Rule 5160:1-4-04 | MAGI-based medicaid: coverage for pregnant individuals.

(A) This rule describes eligibility for pregnant individuals as described in 42 C.F.R. 435.116 (as in effect on October 1, 2023) for applications for medical assistance.

(B) Eligibility criteria for coverage because an individual is pregnant.

(1) The individual must be female and pregnant.

(2) A statement from the individual, a physician, or managed care organization (MCO) is sufficient verification of pregnancy, unless the administrative agency has information contradicting the individual's statement. Self-attestation of pregnancy is acceptable unless available information conflicts with the attestation or the woman is pregnant with more than one fetus.

(3) The individual's household income must not exceed two hundred per cent of the federal poverty level for the family size. For the purpose of this rule, family size includes the number of fetuses.

(4) An individual who is in her postpartum period, as defined in rule 5160:1-1-01 of the Administrative Code, is also eligible under the criteria described in this rule.

(C) Eligibility span for pregnant individuals.

(1) Once established, eligibility for a pregnant individual continues throughout the pregnancy and postpartum period.

(2) An individual is eligible for postpartum coverage if she was eligible for medical assistance on the date the pregnancy ended. This includes a birth mother whose labor and delivery services were furnished prior to the date of application and who is determined eligible for retroactive coverage of labor and delivery services as described in rule 5160:1-2-01 of the Administrative Code.

(D) Administrative agency responsibilities. The administrative agency must:

(1) Calculate a pregnant individual's family size and household income as described in rule 5160:1-4-01 of the Administrative Code.

(2) When a pregnant woman attests to carrying more than one fetus and the increased family size makes her income eligible for medical assistance, the administrative agency shall require the woman to provide verification of pregnancy, including the expected date of delivery and the number of unborn fetuses, from a licensed medical professional.

(3) Not discontinue eligibility for a pregnant individual during the pregnancy or postpartum period, unless the individual dies, moves out of state, or requests that coverage be discontinued.

(E) Individual responsibilities. A pregnant woman must provide verification of pregnancy from a licensed medical professional, including the expected date of delivery and the number of unborn fetuses, only when requested by the administrative agency.

Last updated March 1, 2024 at 8:12 AM