Ohio Administrative Code
Title 5160:1 - Eligibility
Chapter 5160:1-6 - Long-Term Care
Section 5160:1-6-07.1 - Medicaid: post-eligibility treatment of income for individuals receiving services through a home and community-based services (HCBS) waiver or the program of all-inclusive care for the elderly (PACE)
Universal Citation: OH Admin Code 5160:1-6-07.1
Current through all regulations passed and filed through September 16, 2024
(A) This rule describes the process for calculating an individual's post-eligibility treatment of income (PETI), commonly referred to as patient liability or share of cost, when the individual is not living in a medical institution. This rule only applies to an individual who is both eligible for medical assistance under the special income level (SIL) as described in rule 5160:1-6-03.1 of the Administrative Code and who is receiving HCBS waiver or PACE services.
(B) The administrative agency will reduce its payment to the HCBS waiver or PACE providers for services provided to the individual by the amount of the individual's patient liability calculated in accordance with this rule.
(C) The individual must pay the patient liability amount to his or her providers identified by the HCBS waiver or PACE administrative agency.
(D) Providers are to collect the full patient liability amount or up to the cost of care, whichever is less.
(E) Patient liability must be recalculated when there is a change in circumstances that affects the patient liability amount.
(F) A patient liability calculated for a child younger than age nineteen shall not increase during the child's continuous eligibility period as described in rule 5160:1-2-14 of the Administrative Code. Any decrease in a child's patient liability results in a new maximum amount, which will not increase for the remainder of the child's continuous eligibility period.
(G) Providers are required to refund to the individual any overpayments of patient liability paid by the individual, such as when retroactive patient liability adjustments are made.
(H) For purposes of this rule, the following definitions apply:
(1) "Assisted living waiver maintenance needs
allowance (ALMNA)" is an amount equal to the current supplemental security
income (SSI) federal benefit rate (FBR).
(2) "Special individual maintenance needs
allowance (SIMNA)" is sixty-five per cent of the special income
level.
(I) For purposes of this rule, patient liability is calculated in the following order:
(1) Total the individual's gross monthly
earned and unearned income, including SSI payments. In the case of an
institutionalized spouse, include any income attributed to the
institutionalized spouse in accordance with rule
5160:1-6-04 of the
Administrative Code.
(2) Exclude
the following payments from the individual's gross monthly income:
(a)
Payments to victims of Nazi
persecution.
(b)
Austrian social insurance payments based, in whole or
in part, on wage credits received under the provisions of the Austrian General
Social Insurance Act, paragraphs 500 through 506 (as in effect October 1,
2022). These payments need to be documented and identifiable separate from
countable insurance.
(c)
Payments from the Dutch government under the
Netherlands' Benefit Act for victims of persecution from 1940-1945 (Dutch
acronym, WUV) (Pub. L. No.
103-286).
(d)
Restitution
payments under the Civil Liberties Act of 1988, to U.S. citizens of Japanese
ancestry and permanent resident Japanese non-citizens who were interned during
World War II, or their survivors, in accordance with
50 U.S.C.
4215 (as in effect October 1,
2022).
(e)
Restitution payments under the Aleutian and Pribilof
Island Restitution Act, in accordance with
50 U.S.C.
4236 (as in effect October 1,
2022).
(f) Agent Orange
settlement fund payments
received on or after January 1, 1989, as a result
of the Agent Orange Compensation Exclusion Act
(Pub. L. No.
101-201)
.
(g) Department of
defense payments to certain persons captured and interned in North Vietnam, in
accordance with the Departments of Labor, Health and Human Services, and
Education, and Related Agencies Appropriations Act of 1998
(Pub. L.
No. 105-78).
(h) Radiation exposure
compensation trust fund payments,
in accordance with the Radiation
Exposure Compensation Act of 1990
(Pub. L. No.
101-426
).
(i) Veterans affairs
payments made to or on behalf of:
(i) Certain
Vietnam veterans' natural children, regardless of
age or marital status, for any
disability resulting from spina bifida suffered by such children
; and
(ii) Certain Korea service veterans' natural
children, regardless of
age or marital status, for any
disability resulting from spina bifida suffered by such children
;
and
(iii)
The natural
children, regardless of
age or marital status,
with
certain birth defects
born to a woman who served in
Vietnam.
(j) Veterans
administration pensions, including payments for
aid and attendance,
up to the amount of ninety dollars per
month, paid to veterans or their surviving spouse, if any, who are residing in
a nursing facility or are receiving HCBS waiver services. This exclusion
applies to:
(i) A veteran without a spouse or
dependent minor or disabled child; and
(ii) A veteran's surviving spouse without a
dependent minor or disabled child.
(k) Payments made to
Native Americans as listed in section IV of
20 C.F.R.
416 Subpart K Appendix (as in effect
October 1,
2022).
(l)
SSI benefits received under authority of sections 1611(e)(1)(E) and (G) of the
Social Security Act ( SSA) (as in effect October 1,
2022) for
institutionalized individuals during the
first three full months of institutionalization. The administrative agency must
not retroactively redetermine patient liability determinations, made under the
continued benefit provision, if the
individual's actual stay exceeds the expected stay of
ninety days or less.
(m) Residential state
supplement (RSS)
payments to institutionalized individuals, in
accordance with rule
5160:1-5-01 of the
Administrative Code.
(n) Payments
from a state
fund for victims of crime.
(o) Payments made from
any fund established pursuant to a class action settlement in the case of
"Factor VIII or IX concentrate blood products litigation," MDL986, no.
93-C-7452 (N.D. Ill), per section 4735 of the Balanced Budget Act of
1997
(Pub. L. No. 105-33
).
(p)
Payments from the
Ricky Ray Hemophilia Fund Act of 1998 (Pub. L. No. 105-369) or
payments made from any fund established pursuant to a class settlement in the
case of Susan Walker v. Bayer Corporation, 96-C-5024 (N.D.
III).
(q)
Payments made to individuals under the Energy Employees
Occupational Illness Compensation Program Act of 2000 (Pub. L. No.
106-398).
(r) Assistance (other
than wages or salaries) under the Older Americans Act of 1965 under 92 Stat.
1515, 42 U.S.C.
3020a
Pub. L. No.
89-73).
(s) Student financial
assistance
received under the Higher Education Act (HEA) of 1965 (as in effect October 1, 2022) or bureau of Indian
affairs is excluded from income,
regardless of use:
(i)
Pell grants;
(ii)
Student services incentives;
(iii)
Academic
achievement incentive scholarships;
(iv)
Federal
supplemental education opportunity grants;
(v)
Federal
educational loans (Stafford loans, William D. Ford federal direct and direct
PLUS loans, etc.);
(vi)
Upward bound;
(vii)
Gear up
(gaining early awareness and readiness for undergraduate programs);
(viii)
State educational assistance programs funded by the
leveraging educational assistance programs; and
(ix)
Work-study
programs.
(t)
Matching funds
that are deposited into individual development accounts (IDAs), either
demonstration project or TANF-funded, in accordance with
42 U.S.C.
604 (as in effect October 1,
2022).
(u)
Accounts under the Stephen Beck, Jr., Achieving a
Better Life Experience (ABLE) Act of 2014 (Pub. L. No. 113-295). The
following are not considered income to the account holder:
(i)
Contributions to
an ABLE account by another individual or third party.
(ii)
Interest earned
on an ABLE account.
(iii)
Distributions from an ABLE account.
(v)
Federal and
state foster care
payments received under title IV-B or
title IV-E for a child currently living in the household.
(w)
Federal or state
adoption assistance payments received under title IV-B or title
IV-E.
(x)
Payments received under the kinship guardianship
assistance program (KGAP), state KGAP, or kinship guardianship assistance
program connections to twenty-one (KGAP C21).
(y)
Child
care assistance under the Child Care and Development Block Grant Act of
1990
(Pub. L. No.
113-186).
(z) Assistance or
services received through the domestic volunteer service under
42 U.S.C.
66 per
42 U.S.C.
5044(f) (as in effect
October 1,
2022).
(aa)
Payments made for supporting services or reimbursement
of out-of-pocket expenses to volunteers participating in corporation for
national and community service (CNCS, formerly ACTION) programs in accordance
with 42 U.S.C.
1382a (as in effect October 1, 2022):
(i)
AmeriCorps VISTA
program;
(ii)
Special and demonstration volunteer program;
(iii)
Retired senior volunteer program (RSVP);
(iv)
Foster grandparents program; and
(v)
Senior companion
program.
(bb) Assistance or
services received through
federal food and nutrition
programs:
(i)
Supplemental nutrition assistance program (SNAP);
(ii)
The value of foods donated by the U.S. department of
agriculture commodity supplemental food program;
(iii)
The value of
supplemental food assistance received under the Child Nutrition Act of 1966
(Pub. L. No.
89-642) and the special food service program for
children under the National School Lunch Act (Pub. L. No. 90-302);
(iv)
The special supplemental nutrition program for women,
infants, and children (WIC); and
(v)
Nutrition program
benefits provided for the elderly under Title VII of the Older Americans Act of
1965 (Pub. L. No.
89-73).
(cc)
Assistance received under the Robert T. Stafford Disaster Relief and Emergency
Assistance Act
(Pub. L. No.
100-707) and assistance provided under any federal
statute because of a presidentially-declared disaster.
(dd)
Assistance, with respect to the dwelling unit occupied by such individual (or
such individual and spouse), under the United States Housing Act of 1937
(Pub. L. No. 75-412), the
National Housing Act (Pub. L. No. 73-479),
section 101 of the Housing and Urban Development Act of 1965
(Pub. L. No. 89-117), title
V of the Housing Act of 1949 (Pub. L. No.
81-171), or section 202(h) of the Housing
Act of 1959 (Pub. L. No.
86-372)
.
(ee)
Home energy
assistance provided on the basis of need, in accordance with
20 C.F.R.
416.1157 (as in effect October 1,
2022).
(ff) Relocation
assistance provided under title II of the Uniform Relocation Assistance and
Real Property Acquisitions Policies Act of 1970
(Pub. L. No. 91-646)
provided to individuals displaced by or through
any federal, federally-assisted,
state, state-assisted,
local, or
locally-assisted government
project in the acquisition of real property.
(gg)
The first two thousand dollars per calendar year received as compensation for
participation in clinical trials that meet the criteria detailed in section
1612(b) of the Social Security Act ( as in effect October 1,
2022).
(3) Subtract the applicable personal needs
allowance (PNA) as follows:
(a) For
individuals receiving services under an HCBS waiver, other than the
assisted living waiver, the PNA is the SIMNA.
When the
individual has earned income, subtract up to an additional sixty-five dollars
from the earned income.
(b) For
individuals receiving services under the
assisted living waiver
or in an assisted living facility receiving services
under the mycare waiver, the PNA is the ALMNA.
When the
individual has earned income, subtract up to an additional sixty-five dollars
from the earned income.
(c) For
individuals receiving PACE services and residing in the community, the PNA is
the SIMNA.
(d) For individuals
receiving PACE services and residing in an
assisted
living facility, the PNA is the ALMNA.
(4)
When the individual has a community spouse,
subtract the monthly income allowance (MIA) for the community spouse.
(a) The MIA of the community spouse is
calculated as follows:
(i) Determine the
excess shelter allowance (ESA):
(a) Total and
round down to the nearest dollar the community spouse's expenses for the
principal place of residence, as defined in rule
5160:1-3-05.13 of the Administrative
Code, including any rent or mortgage payment (including principal and
interest), current property taxes, insurance, and any required maintenance
charge for a condominium or cooperative; then
(b)
When the community spouse is responsible for
payment towards the cost of gas, electric, coal, wood, oil, water, sewage, or
telephone service for the residence, add in the standard utility
allowance;
then
(c) Subtract the ESA
standard.
(d) The remainder is the
ESA.
(ii) Add the
calculated ESA to the minimum monthly maintenance needs allowance (MMMNA)
standard to determine the MMMNA. Except in accordance with a hearing decision
under rule
5101:6-7-02 of the
Administrative Code, the MMMNA must not exceed the MMMNA cap which is updated
annually.
(iii) Subtract the
community spouse's gross monthly income from the lesser of the MMMNA,
calculated in paragraph
(I)(4)(a)(ii) of this rule, or the MMMNA cap.
When a
hearing decision under rule
5101:6-7-02 of the
Administrative Code results in a MMMNA that is greater than the MMMNA cap, use
the amount established in the hearing decision. The remainder, rounded down to
the nearest dollar, is the MIA.
(b)
When there is court ordered support that is
greater than the MIA calculated above, the court ordered amount is used as the
MIA.
(c)
When the community
spouse's income is still below the MMMNA after all of the institutionalized
spouse's income is allocated to the community spouse, the community spouse
resource allowance can be increased in accordance with rules
5160:1-6-04 and
5101:6-7-02 of the
Administrative Code, to generate additional income for the community
spouse.
(5)
When the
individual has dependent family members, subtract either the family allowance
(FA) or the family maintenance needs allowance (FMNA). The FA does not apply
when there is
an FMNA.
(a)
Subtract
an FA
when the institutionalized individual has family
members residing with his or her spouse in the community.
The FA is calculated as follows:
(i) For each family member, multiply the
MMMNA standard by one-third; then
(ii) Subtract that family member's gross
monthly income; then
(iii) Round
the result down to the nearest dollar.
(iv) The remainder is the allowance amount
for that family member.
(v) The
allowances for each family member are added together to determine the
FA.
(b)
Subtract
an FMNA
when the
institutionalized individual has dependent family members who resided with the
institutionalized individual immediately before the individual was admitted to
a medical institution. The FMNA does not apply
when there is a
spouse in the community. The FMNA is calculated as
follows:
(i)
The
FMNA standard is the Ohio works first (OWF) payment standard for the same
number of applicable dependent family members.
(ii) Subtract the
combined monthly income of the dependent family members from the FMNA standard;
then
(iii) Round the result
down to the nearest dollar.
(iv) The remainder is
the FMNA.
(6)
The following types of health care costs shall be subtracted from the
institutionalized individual's patient liability. Any requests for subtraction
of these costs must include documentation that clearly shows the type of
medical expense, the amount the individual is responsible for paying, and the
date the service or item was provided to the individual.
(a) Health insurance premiums (including
medicaid and medicare premiums) and coinsurance, insurance deductibles and
copayments, that are incurred by:
(i) The
institutionalized individual;
(ii)
The institutionalized individual's spouse; or
(iii) The institutionalized individual's
minor or disabled child.
(b) The cost of any of the institutionalized
individual's incurred expenses for medical care, recognized under Ohio law, but
not covered by medicaid and not subject to third-party payment. The unpaid past
medical expenses, and any request to subtract such expenses from the patient
liability, must meet the following criteria:
(i) The service
was
medically necessary as determined by the administrative agency.
(ii) Expenses for medical care
were not incurred while serving a restricted medicaid
coverage period (RMCP) per rule
5160:1-6-06.5 of the Administrative Code.
Expenses that were incurred while serving an RMCP shall not count as unpaid
past expenses and shall not be subtracted from the patient liability
calculation.
(iii)
Unpaid patient liability shall not count as unpaid past
medical expenses and shall not be subtracted from the patient liability
calculation.
(iv) The request for
the subtraction of incurred expenses for medical care can only be initiated by
either the institutionalized individual or person or entity who has the legal
ability to act on the individual's behalf, including the institutionalized
individual's authorized representative. A request for a deduction cannot be
initiated by a medical services provider or supplier, unless such provider or
supplier is also the institutionalized individual's authorized
representative.
(7) Subtract the payment
in an amount up
to fifteen dollars per month, or the amount approved by the administrative
agency, to administer a qualified income trust (QIT) account in accordance with
rule 5160:1-6-03.2 of the Administrative
Code.
(8) The remainder, rounded
down to the nearest dollar, is the individual's monthly patient liability, for
a full month of HCBS or PACE services.
(9) The individual's patient liability will
be prorated
when the individual is enrolled in an HCBS waiver or
PACE program for less than a full month. Prorated patient liability
amounts
are calculated as follows:
(a) Determine
the per diem patient liability amount by dividing the patient liability for a
full month of institutionalization by the number of days in the month for which
the prorated payment is to be determined.
(b) Determine the actual number of days of
institutionalization in the month for which the prorated payment is to be
determined, including the first date of institutionalization in the month. The
date of discharge or the date of death is not included in this
calculation.
(c) Multiply the
actual number of days of institutionalization by the per diem patient liability
amount and round this number down to the nearest dollar. This is the
individual's prorated patient liability.
(J) The individual will receive written notification of the amount of patient liability for which he or she is responsible. Such notice will explain how the individual can request a hearing if he or she disagrees with the patient liability amount.
(K) When applicable, the individual will receive written notification of the MIA, FA, or FMNA that were calculated in accordance with this rule. Such notice will explain how the individual can request a hearing if he or she disagrees with those amounts.
Disclaimer: These regulations may not be the most recent version. Ohio may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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