Current through all regulations passed and filed through September 16, 2024
(A) As used in this
rule:
(1) "Adjusted family income" means a
balance after credits for child care expenses or educational expenses not
reimbursed by a third party, estimated annual expenditures for health insurance
not reimbursed by a third party, and service level are subtracted from family
income.
(2) "Assistance" means
reimbursement to the eligible participant or legal representative for premiums
paid by the eligible participant or legal representative for health insurance
coverage for the eligible participant. Assistance may include payments for
premiums for an eligible participant's single coverage under a health insurance
plan or payments for premiums for the dependent portion of an insurance plan
when the eligible participant is one of a group of dependents who is covered
under a health insurance plan.
(3)
"Eligible participant" means a person twenty-one years of age or older with
hemophilia or a related bleeding disorder, who is under the care of a BCMH
approved hemophilia treatment center, and who also meets the conditions for
eligibility for insurance premium payment assistance set forth in paragraph (B)
or (C) of this rule.
(4)
"Estimated annual expenditure for health insurance" means the estimated amount
for which a family unit spends on insurance premiums.
(5) "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 the eligible participant.
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.
(6) "Family
unit" means the group consisting of the following persons:
(a) The eligible participant;
(b) The eligible participant's spouse, if
married;
(c) The eligible
participant's parents, if participant is considered a dependent by parents for
federal income tax purposes;
(d)
Other persons who, for federal income tax purposes are considered dependents of
the eligible participant.
(7) "Service level" means a credit against
the family income as determined by the director based upon the eligible
participant's need for treatment services. Service level credits are the
following:
(a) Service level one is based on
the eligible participant'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 eligible participant's 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 eligible participant's documented need for
medication and supplies costing more than five hundred dollars per month. The
service level credit for this service is two thousand dollars.
(B) The director may
authorize assistance to an applicant who meets the definition of an eligible
participant under paragraph (A) of this rule, has health insurance coverage and
meets all the following criteria:
(1) The
applicant's adjusted family income is less than or equal to the income
guidelines as defined in paragraph (A)(1) of rule
3701-43-16 of the Administrative
Code.
(2) The cost of the
applicant's or family unit's annual health insurance premiums exceed seven and
one half per cent of the family unit's gross annual earnings and assistance
with the premiums is cost-effective as determined by the director; and (3)
There are funds available in the hemophilia insurance premium program
encumbrance to cover the eligible participant.
(C) If an applicant is found ineligible for
assistance under paragraph (B) of this rule, the director may deem the
applicant eligible if the applicant meets the definition of an eligible
participant under paragraph (A) of this rule, has health insurance coverage and
meets all the following criteria:
(1) The
applicant's annual health insurance premiums exceed fifteen per cent of the
family unit's gross annual earnings and assistance with the premiums is
cost-effective as determined by the director;
(2) The applicant's adjusted family income
does not exceed 300% of the federal poverty level;
(3) The director determines that the cost of
the annual premiums constitutes a hardship to the applicant; and
(4) There are funds available in the
hemophilia insurance premium program encumbrance to cover the eligible
participant.
(D) The
director shall require that the following written documentation be submitted to
determine the applicant's eligibility for assistance:
(1) The BCMH medical application form signed
by the applicant or legal representative, and the treating physician or
authorized representative of the BCMH approved hemophilia treatment center.
(2) Combined program application
and supporting documentation to determine financial eligibility;
(3) Documentation showing the annual
insurance premium amount;
(4)
Documentation of annual health care costs of the applicant that has been
covered by the insurance; and
(5)
Any other documentation requested by the director.
(E) The director shall notify the applicant
in writing of his decision to provide assistance within thirty days of the
receipt of all the required documentation. Assistance with health insurance
premium payments will not begin prior to the first day of the month in which
all the required documentation is received.
(F) The director shall establish an initial
period of eligibility for assistance not to exceed twelve months. The director
may renew the eligibility on an annual basis as long as the requirements of
paragraph (B) or (C) is met and funds are available.
(G) The eligible participant or legal
representative shall submit, within thirty days of the date of the change,
documentation of any changes to income that result in an increase in annual
gross earnings, changes to the eligible participant's medical condition or
treatment thereof, changes to the eligible participant's health insurance
coverage, or documentation of any other changes that would affect the eligible
participant's eligibility for assistance.
(H) The director may discontinue assistance
or change the terms of assistance if:
(1) The
eligible participant or legal representative fails to meet the requirements set
forth in paragraphs (B) and (C) of this rule: or
(2) The eligible participant or legal
representative fails to pay the health insurance premiums; or
(3) The funding for the hemophilia insurance
premium payment program has been expended.
(I) The director shall provide the eligible
participant or legal representative written notice of the decision to
discontinue or change the terms of assistance. Any such discontinuation or
change will become effective no sooner than thirty calendar days from the date
of the written notice.
R.C. 119.032 review dates:
09/15/2010 and
09/01/2013
Promulgated
Under: 119.03
Statutory Authority: 3701.021
Rule
Amplifies: 3701.021, 3701.022, 3701.023, 3701.024, 3701.025, 3701.026,
3701.027, 3701.028
Prior Effective Dates: 1/30/2004
