Current through all regulations passed and filed through September 16, 2024
(A) As used in this rule:
(1) "Income guidelines" means the guidelines,
as established by the director on April first of each year, for use in
determining financial eligibility for payment for treatment. The income
guidelines shall be equal to one hundred eighty-five per cent of the poverty
income for each size family, as reported in the "Federal Register" by the
United States department of health and human services, rounded up to the
nearest five hundred dollars.
(2)
A "family unit" means the group consisting of the following persons:
(a) The applicant or recipient;
(b) The applicant's or recipient's spouse;
(c) The applicant's or recipient's
parent(s) or custodian(s); and
(d)
Other persons who, for federal income tax purposes, are considered dependents
of the individual who claims the applicant or recipient as a dependent or who
are considered dependents of the applicant or recipient, except for a spouse
who is not the biological parent.
A family unit consists only of the applicant or recipient if
the applicant or recipient is self-supporting and has no spouse or dependents,
or if the applicant or recipient is in the custody of a government or private
agency.
(3)
"Family income" means the current year's projected adjusted gross earnings
based on current gross earnings as reported on pay stubs and/or the sum of the
annual adjusted gross incomes, as reported to the United States internal
revenue service for federal income tax purposes for the previous year, of each
member of the family unit, except for the incomes of a custodian who is not the
applicant's or recipient's natural or adoptive parent and the custodian's
dependents. In the case of an applicant or recipient who is eighteen or more
years of age and self-supporting or twenty-one or more years of age, the family
income shall include only the adjusted gross income of the applicant or
recipient.
For the purposes of this rule, family income shall not include
educational scholarships, loans, and grants; amounts spent by the family unit
for child care expenses; amounts spent by the family unit for respite care
(with appropriate verification from a qualified respite care provider); and
lump-sum death benefits.
(4) "Maximum ability to pay for medical care"
means the difference between the amount a family unit spends, including payroll
deductions, for health-related insurance coverage and the sum of the following
amounts:
(a) Ten per cent of the first
fifteen thousand dollars by which the family income exceeds the applicable
income guideline, as defined in paragraph (A)(1) of this rule;
(b) Twenty-five per cent of the next
twenty-five thousand dollars by which the family income exceeds the applicable
income guideline, as defined in paragraph (A)(1) of this rule; and
(c) Thirty-seven and one half per cent of the
remaining amount by which the family income exceeds the applicable income
guideline, as defined in paragraph (A)(1) of this rule.
(5) "Service level credit" means a credit
against the maximum ability to pay for medical care as determined by the
director based upon the applicant's or recipient's need for treatment services.
The need for treatment services is determined by reference to the services
requested by the managing physician on the medical application, to the extent
that those services are eligible for authorization under paragraph (E) of rule
3701-43-18 of the Administrative
Code. Service levels and service level credits are the following:
(a) Service level one is based on the
applicant's or recipient's need for routine physician visits or routine
outpatient hospital care. The service level credit for this service level is
five hundred dollars.
(b) Service
level two is based on the applicant's or recipient's anticipated need for brief
hospitalizations, minor surgical procedures, medications, durable equipment, or
medical supplies. The service level credit for this service level is one
thousand dollars.
(c) Service
level three is based on the applicant's or recipient's documented need for
multiple hospitalizations, major surgical procedures, medications or supplies
costing more than five hundred dollars per month, or medical services for more
than one child with special health care needs. The service level credit for
this service level is two thousand dollars.
(B) The director shall determine the
applicant or recipient to be financially eligible for payment for treatment
services either of the following apply:
(1)
Family income of the applicant's or recipient's family unit, as defined in
paragraph (A)(3) of this rule, is less than or equal to the applicable income
guideline, as defined in paragraph (A)(1) of this rule; or
(2) The service level credit for the
applicant or recipient, as defined in paragraph(A)(5) of this rule, equals or
exceeds his or her family unit's maximum ability to pay for medical care, as
defined in paragraph (A)(4) of this rule.
(C) Notwithstanding paragraph (B) of this
rule, in order to assure that services to a medically eligible applicant will
not be interrupted, the director may determine that such an applicant is
financially eligible for payment for treatment services if the applicant's
family unit provides satisfactory evidence of both of the following:
(1) During the twelve-month period before the
date of application, the family unit paid for unreimbursed medical, vision,
therapy services and dental services that were provided to any member of the
family unit, or the family unit has contracted in writing to pay for any such
services during the twelve months after the date of application; and
(2) The total dollar amount that the family
unit spent or is contracted to pay equals or exceeds the difference between the
maximum ability to pay for medical care, as defined in paragraph (A)(4) of this
rule, and the applicable service level credit, as defined in paragraph (A)(5)
of this rule.
(D)
Applicants or recipients who are receiving services from the special
supplemental food program for women, infants, and children (WIC), supplemental
security income (SSI) benefits, or medicaid benefits, except for delayed
medicaid spend-down cases as defined in rule 5101:1-39-10 of the Administrative
Code, are financially eligible for payment for treatment by the program.
R.C. 119.032 review dates:
09/15/2010 and
09/01/2013
Promulgated
Under: 119.03
Statutory Authority: 3701.021
Rule
Amplifies: 3701.023
Prior Effective Dates: 1/1/1975, 12/29/80,
7/14/86, 1/2/89, 4/1/92, 4/1/94, 12/1/01, 10/13/03, 10/1/05
