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(A) This rule describes the eligibility criteria for a child from birth until the individual reaches nineteen years of age in accordance with 42 C.F.R. 435.118 (as in effect October 1, 2025) for applications for medical assistance.
(B) Definition. "Child" means an individual younger than nineteen years of age.
(C) Eligibility criteria for coverage because a newborn child was born to a medicaid-eligible woman (deemed newborn). In accordance with 42 C.F.R. 435.117 (as in effect October 1, 2025), a child is automatically eligible for medical assistance as of the child's date of birth, and remains eligible until the child reaches the age of one, provided the birth mother has applied for, been determined eligible for, and is receiving medical assistance on the date of the child's birth.
(1) Coverage under this paragraph also applies to newborns under the following circumstances:
(a) When labor and delivery services were furnished prior to the date of application and the birth mother's medicaid eligibility is based on retroactive coverage in accordance with 42 C.F.R. 435.915 (as in effect October 1, 2025).
(b) When the birth mother is receiving non-citizen emergency medical assistance (NCEMA) in accordance with rule 5160:1-5-06 of the Administrative Code.
(c) When the birth mother is residing in a public institution and is:
(i) Restricted from payment of services as referenced in rule 5160:1-1-03 of the Administrative Code; and
(ii) Within twelve months of the date of her most recent medicaid application or renewal.
(d) When the birth mother is in the custody of a public children services agency (PCSA) or private child placing agency (PCPA).
(e) When the birth mother is in receipt of adoption or foster care assistance under Title IV-E.
(f) When the birth mother is in receipt of state or federal adoption assistance.
(g) When the birth mother loses medicaid eligibility after the birth of the newborn.
(h) When the birth mother is no longer a member of the newborn's household at any time prior to the newborn reaching the age of one.
(2) For newborns described in this paragraph, the administrative agency must:
(a) Upon verbal or written notification of the newborn's birth from any individual or entity reporting the birth:
(i) Verify, in the electronic eligibility system, that the birth mother was eligible for and received medicaid on the date of the child's birth, and
(ii) Approve the child's eligibility for medicaid without delay and without consideration of household composition or income.
(b) Not require an application for the child or a renewal of eligibility prior to the month of the child's first birthday.
(c) Not require verification of U.S. citizenship or identity.
(d) Complete a renewal of eligibility when the child reaches the age of one.
(D) Eligibility criteria for coverage because an individual is a child under nineteen years of age.
(1) A child's family size and household income shall be calculated as described in rule 5160:1-4-01 of the Administrative Code.
(2) When the child is not covered by other creditable coverage, the child's household income must not exceed two hundred six per cent of the federal poverty level for the family size.
(3) When the child is covered by other creditable coverage, the child's household income must not exceed one hundred fifty-six per cent of the federal poverty level for the family size.
(4) A child receiving medical coverage under this paragraph remains eligible:
(a) Through the end of the month in which the child turns nineteen years of age, if the child remains otherwise eligible in accordance with rule 5160:1-2-10 of the Administrative Code, and the individual responsibilities described in rule 5160:1-2-08 of the Administrative Code are met; or
(b) Until the end of an inpatient stay during which inpatient services are being furnished, if the child is found eligible under this paragraph on or after his or her eighteenth birthday and turns nineteen years of age during the inpatient stay.
Last updated June 1, 2026 at 8:48 AM