3701-43-16 Financial eligibility requirements for payment for treatment for children with medical handicaps.

(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: 10/28/2013 and 10/28/2018
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