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 an 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) 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.
(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.
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
guidelines, 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 of
two thousand dollars.
(B) The director shall determine the
applicant or recipient to be financially eligible for payment for treatment
services if 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
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 medical 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: 10/01/2005