5101:1-39-10 Medicaid: eligibility through the spenddown process.

(A) Overview of the spenddown process

This rule sets forth the spenddown process for the medicaid program for the aged, blind or disabled (ABD).

(1) An individual is not eligible for the ABD medicaid program if the individual’s “countable monthly income” as defined in paragraph (C)(2) of this rule exceeds the medicaid need standard applicable to the individual, even though the individual meets all the other eligibility requirements of the ABD medicaid program. However, the individual may be able to become eligible for medicaid for a month through the “spenddown process” as provided in this rule. An individual who is subject to the spenddown process is referred to as a “spenddown assistance group (SAG)” as defined in paragraph (B) of this rule. To assist the SAG in making informed decisions about the spenddown process, the CDFJS should, at every application and redetermination, discuss with the SAG the various ongoing and delayed spenddown medical expenses the SAG may use in the spenddown process, the methods for satisfying spenddown and provide the SAG a copy of JFS 08500.

(a) A SAG may become eligible for medicaid for the entire month, without any monthly spenddown amount, if the SAG and/or family member as defined in paragraph (C)(5) of this rule, has sufficient medical insurance premiums, nursing facility (NF) or intermediate care facility for the mentally retarded (ICF-MR) costs, except as provided in paragraph (E) or past unpaid medical bills (UPMB), as provided in paragraphs (D) to (F) of this rule. If the SAG and/or family member does not have such expenses that are sufficient, the SAG may become eligible for medicaid for all or part of the month by satisfying a “monthly spenddown amount” for the month.

(b) If the SAG has a monthly spenddown amount as calculated under paragraph (D) of this rule, the SAG may become eligible for medicaid for all, or part, of the month by satisfying spenddown for the month. The SAG may satisfy spenddown by using one of two methods. The method the SAG chooses determines whether the SAG is eligible for medicaid for the entire month or for only part of the month.

(i) The SAG may use the “pay-in” method of satisfying spenddown for a month as provided in paragraph (G) of this rule. If the SAG does so, the SAG is eligible for medicaid for the entire month.

(ii) The SAG may use the “current incurred medical expenses (or incurred)” method of satisfying spenddown for a month as provided in paragraph (H) of this rule. If the SAG does so, the SAG is eligible for medicaid for the month starting on the date in the month on which the SAG and/or family member incurred the current medical expense that, combined with any other current incurred medical expenses for the month, equals or exceeds the monthly spenddown amount for the month.

(iii) The CDJFS may permit the SAG to combine the use of both the pay-in method and the incurred method in the same month as provided in paragraphs (G) and (H) of this rule. If the CDJFS permits the SAG to combine methods, and the SAG does so, the SAG is eligible for the month as provided in paragraphs (G)(2)(b) and (H)(2)(b) of this rule.

(iv) If the SAG does not satisfy spenddown for a month, the SAG is not eligible for medicaid for the month but may be eligible for any future month in which the SAG satisfies spenddown.

(d) The spenddown process is subject to the hearing rights and procedures set forth in division level 5101:6 of the Administrative Code.

(2) Any medical expenses of the SAG or family member that the CDJFS actually uses in the spenddown process as a basis for approving medicaid for the SAG for a month remain the obligation of the SAG or family member and shall not be submitted to medicaid for payment and are not payable by the medicaid program as provided in paragraphs (F)(9) and (H)(7) of this rule.

(3) The CDJFS must determine whether the medical expenses and/or pay-in submitted for spenddown have been or may be included as medical expenses in the SAG’s food stamp budget, and whether the SAG is entitled to supplemental and/or increased recurring monthly food stamp benefits as provided in rule 5101:4-4-23(C) and division level 5101:4 of the Administrative Code.

(B) Spenddown assistance group (SAG)

(1) With the exceptions set forth in paragraph (C)(2) of this rule, an individual is subject to the spenddown process if he or she:

(a) Is age sixty-five or older, is blind, or has a disability, as defined in rule 5101:1-39-03 of the Administrative Code; and

(b) Has countable monthly income that exceeds the medicaid need standard applicable to the individual; and

(2) “Spenddown assistance group (SAG)” means an individual in a household who is subject to the spenddown process as provided in paragraph (B)(1) of this rule. The composition of a SAG is determined as follows.

(a) If a household contains a husband and wife both of whom are subject to the spenddown process as provided in paragraph (B)(1) of this rule, the husband and wife together are a two-person (couple) SAG.

(b) If a household contains a husband and wife only one of whom is subject to the spenddown process as provided in paragraph (B)(1) of this rule, the spouse who is subject to the spenddown process is a one-person (individual) SAG.

(c) Except as provided in paragraph (B)(2)(a) of this rule, each individual in a household who is subject to the spenddown process is his or her own separate one-person (individual) SAG. For example, if a household contains a mother and son, both of whom are subject to the spenddown process, the mother is her own one-person individual SAG, and the son, regardless of his age, is his own one-person individual SAG.

(d) There may be more than one SAG in a household.

(3) The CDJFS must determine whether a SAG is eligible for medicaid under any other medicaid category. If a SAG is eligible for medicaid under any other category, the SAG has the option to choose which category to accept. The CDJFS must explain and discuss this option with the SAG so that the SAG may make an informed decision.

(4) The monthly spenddown amount of a SAG, if any, is determined pursuant to paragraph (D) of this rule.

(5) For a SAG that must satisfy a monthly spenddown amount in order to become eligible for medicaid for a month as determined pursuant to paragraph (D) of this rule the following applies:

(a) The CDJFS shall not deny ABD medicaid for a SAG who is applying for medicaid and does not anticipate satisfying spenddown in the month of application, or in one or more future months. Instead, the CDJFS shall authorize the SAG as open/fail in CRIS-E, changing the SAG to open/pass in CRIS-E for any month in which the SAG satisfies spenddown.

(b) The CDJFS shall not propose to terminate ABD medicaid for a SAG that does not satisfy spenddown for one or more months. Instead, the CDJFS shall maintain the SAG as open/fail in CRIS-E, changing the SAG to open/pass for any month in which the SAG satisfies spenddown.

(1) “Aged, blind or disabled (ABD) medicaid program” means the program set forth in Chapter 5101:1-39 of the Administrative Code. In CRIS-E the medicaid categories applicable to SAGs are: MA-A (medicaid for the aged); MA-B (medicaid for the blind); and MA-D (medicaid for the disabled). The spenddown process only applies to those categories of medicaid.

(2) “Countable monthly income” means the income of the SAG as determined under Chapter 5101:1-39 of the Administrative Code.

(a) As provided in rule 5101:1-39-41 of the Administrative Code:

(i) A supplemental security income (SSI) recipient (including an SSI recipient who is no longer in receipt of SSI cash payments) who is eligible for medicaid under Section 1619 of the Social Security Act (1619-eligible person) is not subject to the spenddown process. The 1619-eligible person shall not have a spenddown amount, and cannot be a SAG, regardless of the amount of his or her countable monthly income.

(ii) When a 1619-eligible person lives with a spouse, neither the 1619-eligible person nor his or her spouse is subject to the spenddown process. The 1619-eligible person and his or her spouse shall not have a spenddown amount, and cannot be a SAG, regardless of the amount of their countable monthly income.

(b) As provided in rule 5101:1-39-38 of the Administrative Code:

(i) The RSDI income of certain adult disabled children is not included in countable monthly income.

(ii) The RSDI income of certain disabled widows or widowers is not included in countable monthly income.

(3) “Current incurred medical expenses” is defined in paragraph (H) of this rule.

(4) “Delayed spenddown eligibility” refers to the medicaid eligibility established under paragraphs (D)(4)(b), (G) and (H) of this rule.

(5) “Family member” means:

(a) If the SAG is a child who is under age eighteen, family member means any person:

(i) Who is a natural or adoptive parent of the SAG unless a court has eliminated such parent’s duty of medical support to the SAG; or

(ii) Who lives with the SAG and is a sibling or half-sibling under age eighteen of the SAG; or

(iii) Who is a deceased parent of the SAG, provided the parent who lives with the SAG had a duty of medical support of the deceased parent at the time of his or her death; or

(iv) Who is a deceased sibling of the SAG, provided the sibling lived with the SAG at the time of his or her death, and a parent who lives with the SAG had a duty of medical support to the deceased sibling at the time of his or her death.

(b) If the SAG is a person age eighteen or older, family member means any person:

(i) Who is (or, if deceased, was) the spouse of the SAG unless a court has eliminated the SAG’s duty of medical support to such spouse; or

(ii) Who is (or, if deceased, was) the natural or adopted child under age eighteen of the SAG unless a court has eliminated the SAG’s duty of medical support to such child; or

(iii) Who is (or, if deceased, was) the former spouse of the SAG, provided a court has imposed on the SAG a duty of medical support to the former spouse.

(i) Who is (or, if deceased, was) the former spouse of a SAG provided a court has imposed on the SAG a duty of medical support to such former spouse; or

(ii) Who is (or, if deceased, was) the natural or adopted child under age eighteen of a SAG member unless a court has eliminated such SAG member’s duty of medical support to such child.

(d) Family member does not include a step-parent, a step-child or a step-sibling.

(6) “Incurred” means that the SAG or family member has paid a medical bill or expense, or is liable for the bill or expense.

(7) “Incurred method of satisfying spenddown” is defined in paragraph (H) of this rule.

(8) “Incurred spenddown medical expense” and “delayed spenddown medical expense” refer to a current incurred medical expense as provided in paragraphs (D)(4)(b) and (H) of this rule.

(9) “Individual” means an individual or a married couple who is subject to the spenddown process in this rule.

(10) “Medicaid need standard” means the standard set forth in rule 5101:1-39-21 of the Administrative Code that is applicable to the SAG. The standard (“individual need standard” or “couple need standard”) applicable to the SAG is determined as follows.

(a) If a household contains a husband and wife both of whom are subject to the spenddown process, the husband and wife together are a two-person (couple) SAG as provided in paragraph (B)(2)(a) of this rule: the couple need standard is applicable to the SAG.

(b) If a household contains a husband and wife only one of whom is subject to the spenddown process, the spouse who is subject to the spenddown process is a one-person (individual) SAG as provided in paragraph (B)(2)(b) of this rule: the individual need standard is applicable to the SAG.

(c) Except as provided in paragraph (B)(2)(a) of this rule, each individual in a household who is subject to the spenddown process is his or her own separate individual SAG: the individual need standard is applicable to each SAG. For example, if a household contains a mother and son each of whom is subject to the spenddown process, each is an individual SAG, so the individual need standard is applicable to each of them.

(11) “Medical expense” or “medical bill” means an expense or bill for a medical item or service provided to the SAG or family member.

(a) The CDJFS may accept that medical expenses and bills submitted in the spenddown process are usually for items or services that were medically necessary. In an unusual situation a question may arise about whether an item or service was medically necessary. In such a situation the CDJFS will need to determine whether the item or service was medically necessary by following these steps:

(i) In order to make the determination the CDJFS must contact the SAG and assist the SAG in gathering relevant information from the medical provider and other appropriate persons about the medical necessity of the item or service.

(ii) If the medical provider of the item or service indicates that item or service was not medically necessary, the CDJFS may decline to use the item or service in the spenddown process in accordance with paragraph (A)(2)(d) of this rule.

(iii) If the medical provider of the item or service indicates that the item or service was medically necessary the CDJFS may use the item or services in the spenddown process in accordance with the other provisions of this rule. However, in an unusual situation, the CDJFS may question the provider’s statement regarding medical necessity. In that case, the CDJFS must ask the ODJFS prior authorization unit (PAU) to determine whether the item or service was medically necessary.

(iv) If the PAU decides that the item or service was medically necessary, the CDJFS must use the item or services in the spenddown process in accordance with the other provisions of this rule. The PAU decision is for the sole purpose of determining whether the item or service was a medically necessary expense or bill in the spenddown process. The PAU decision is not for the purpose of determining whether to prior authorize the item or service under rule 5101:1-39-31 of the Administrative Code nor for the purpose of determining whether the item or service is payable by the medicaid program.

(v) If the PAU decides that the item or service was not medically necessary, the CDJFS may decline to use the item or service in the spenddown process in accordance with paragraph (A)(2)(d) of this rule.

(vi) The CDJFS must fully document the provider’s statement, PAU decision, and all other information related to the CDJFS’s decision in CRIS-E running record comments (CLRC) as well as in the hard copy record.

(b) Medical insurance premiums as defined in paragraph (C)(12) of this rule, and NF and ICF-MR costs of care that meet the requirements of paragraph (E) of this rule, are always considered medically necessary.

(12) “Medical insurance premiums” means payments or costs for insurance coverage for medical items or services such as health, dental, vision, long term care, hospital, prescriptions, etc.

(13) “Medically necessary” is defined in rules 5101:1-3-01 and 5101:1-3-011 of the Administrative Code.

(14) “Ongoing spenddown eligibility refers to the medicaid eligibility established under paragraphs (D)(2) to (D)(4)(a) of this rule.

(15) “Ongoing spenddown medical expense” refers to a medical insurance premium, NF or ICF-MR cost, or unpaid medical bills (UPMB) as provided in paragraphs (D) to (F) of this rule.

(16) “Pay-in method of satisfying spenddown” is defined in paragraph (G) of this rule.

(17) “Qualified individual-1 (QI-1)” means the program described in rule 5101:1-39-53.1 of the Administrative Code. The medicaid program pays the monthly medicare part B premium for a person who is eligible for QI-1.

(18) “Qualified medicare beneficiary (QMB)” means the program described in rule 5101:1-39-53.1 of the Administrative Code. The medicaid program pays the medicare cost-sharing expenses of a person who is eligible for QMB. The medicare cost-sharing expenses include the monthly medicare part A and part B premiums, annual coinsurance and all deductibles.

(19) “Satisfying spenddown” is defined in paragraphs (G) and (H) of this rule.

(20) “Specified low-income medicare beneficiary (SLMB)” means the program described in rule 5101:1-39-53.1 of the Administrative Code. The medicaid program pays the monthly medicare part B premium for a person who is eligible for SLMB.

(21) “Spenddown amount” or “monthly spenddown amount” means the dollar amount, if any, a SAG must satisfy in order to become eligible for medicaid for all or part of a month as provided in paragraphs (D)(4)(b), (G), and (H) of this rule.

(22) “Spenddown assistance group (SAG)” is defined in paragraph (B)(2) of this rule.

(23) “Subject to the spenddown process” is defined in paragraph (B)(1) of this rule.

(24) “Transportation expense” means a reasonable expense incurred by a SAG or family member for transportation that is needed to obtain a medically necessary item or service such as appointments with a doctor, clinic, hospital, mental health agency, or therapist, or a trip to a pharmacy for prescriptions or to a medical supplier for durable medical goods, etc.

(a) Transportation may be by public or private transportation, for example, private motor vehicle, bus, taxi, etc.

(b) Transportation expenses include but are not limited to the following:

(i) Charges for public transportation such as bus and/or taxi fare.

(ii) Standard mileage expense shall be the current state mileage reimbursement rate for the use of a private motor vehicle owned by the SAG or family member; or, the actual expense incurred by the SAG or family member for transportation by a private motor vehicle not owned by the SAG or family member. Reference CRIS-E table TMEP for the current state mileage reimbursement rate.

(iii) Expenses related to the transportation such as parking fees and tolls.

(iv) Overnight lodging expenses if overnight travel is needed to obtain the medical item or service. Actual expenses for meals when overnight travel is required; however, the meal allowance cannot exceed thirty dollars per person per day.

(v) Attendant care costs and/or the costs of a companion if a medical provider verifies that an attendant and/or companion is required due to the age, physical, and/or mental condition of the SAG or family member.

(vi) Expenses related to delivering a medical service or item to the SAG or family member such as a charge by a pharmacy for the delivery of prescriptions to the home of the SAG or family member, a charge by a medical supplier for delivery and set-up of air supplies in the home of the SAG or family member, a charge by a therapist for traveling to the home of the SAG or family member to provide therapy, etc.

(c) Transportation expenses do not include the cost of transportation actually provided to the SAG or family member through the CDJFS’s enhanced medicaid transportation (EMT) program.

(d) Transportation expenses do not include any transportation expenses actually deducted from income as an “impairment-related work expense (IRWE)” as set forth in rule 5101:1-39-18 of the Administrative Code.

(e) The CDJFS may accept that transportation expenses submitted in the spenddown process are usually for transportation that was needed to obtain a medical service or item and that the cost is reasonable. In an unusual situation, a question may arise about whether a transportation expense was needed and/or reasonable. In such a situation, the CDJFS must determine whether the expense was needed and/or reasonable. In order to make the determination, the CDJFS must contact the SAG, and, if necessary, assist the SAG in gathering relevant information from the medical provider and other appropriate persons, concerning all of the relevant circumstances, including the following:

(i) The age, physical and mental condition and transportation needs of the person; and

(ii) The medical item or service for which the person needed the transportation; and

(iii) The suitability of the transportation alternatives reasonably available to the person; and

(iv) The reasonableness of the expense based on the circumstances; and

(v) Any other relevant factors.

(vi) After considering all of the above factors, if the CDJFS determines that the expense or a portion of the expense was not needed and/or not reasonable, the CDJFS may decline to use the expense, or the portion of the expense, determined to be unneeded and/or unreasonable in the spenddown process in accordance with paragraph (A)(2)(d) of this rule. The CDJFS must fully document its determination in CRIS-E running record comments (CLRC) and in the hard copy record.

(25) “Unpaid past medical bills (UPMB)” is defined in paragraph (F) of this rule.

(D) Determining monthly spenddown amount:

(1) Whenever the countable monthly income of a SAG exceeds the medicaid need standard applicable to the SAG, the CDJFS must follow paragraphs (D)(2) to (D)(5) of this rule to determine whether the SAG is eligible for medicaid without any spenddown amount and, if not, to calculate the monthly spenddown amount of the SAG.

(2) Determine the total amount of all monthly medical insurance premiums of the SAG and family members. Do not round down. Subtract that amount from the countable monthly income of the SAG. Round down the subtotal to the nearest whole dollar.

(a) If the remainder is equal to or less than the medicaid need standard applicable to the SAG, the SAG is eligible for medicaid for the entire month without any monthly spenddown amount.

(b) If the remainder exceeds the medicaid need standard applicable to the SAG, continue to the next step.

(c) A SAG who is eligible for QMB, SLMB or QI-1 has the option to decline such eligibility. If the individual accepts QMB, SLMB or QI-1 eligibility then the individual’s medicare premium(s) is not deducted after the CDJFS obtains verification that the medicaid program has actually begun paying the premium(s). If the individual declines eligibility then the individual’s medicare premium(s) is deducted at this step. The CDJFS must explain and discuss this option with the SAG so that the SAG may make an informed decision.

(3) Determine the total amount of the nursing facility (NF) or intermediate care facility for the mentally retarded (ICF-MR) cost of care of the SAG as provided in paragraph (E) of this rule. Do not round down. Subtract that amount from the remainder calculated in paragraph (D)(2) of this rule. Round down the subtotal to the nearest whole dollar.

(a) If the remainder is equal to or less than the medicaid need standard applicable to the SAG, the SAG is eligible for medicaid for the entire month without any monthly spenddown amount.

(b) If the remainder exceeds the medicaid need standard applicable to the SAG, continue to the next step.

(4) Determine the amount of the unpaid past medical bills (UPMB) of the SAG and family members as provided in paragraph (F) of this rule. Do not round down. Subtract that amount from the remainder calculated in paragraph (D)(3) of this rule. Round down the subtotal to the nearest whole dollar.

(a) If the remainder is equal to or less than the medicaid need standard applicable to the SAG, the SAG is eligible for medicaid for the entire month without any monthly spenddown amount.

(b) If the remainder exceeds the medicaid need standard applicable to the SAG, the remainder is the monthly spenddown amount of the SAG. In order to become eligible for medicaid for all or part of the month, the SAG must satisfy the monthly spenddown amount for the month as provided in paragraphs (G) and (H) of this rule.

(E) NF or ICF-MR cost of care used in determining monthly spenddown amount

(1) For the purposes of paragraph (D)(3) of this rule, the cost of care of a SAG who resides in a licensed NF or ICF-MR is determined as follows. The cost of care of a family member cannot be used in the spenddown process.

(a) If the facility is certified for the medicaid program, the SAG may use as a medical expense in the calculation at paragraph (D)(3) of this rule the medicaid per diem rate for the cost of care.

(b) If the facility is not certified for the medicaid program, the SAG may use as a medical expense in the calculation at paragraph (D)(3) of this rule the amount the facility requires the SAG to pay for the care received (private pay rate) when all of the following conditions are met:

(i) The facility has a current license from the Ohio department of health; and

(ii) The SAG’s attending physician has provided a written statement to the CDJFS that care in the facility is medically necessary.

(2) If the SAG is subject to a period of restricted coverage due to an improper transfer of assets as provided in rule 5101:1-39-07 of the Administrative Code, the CDJFS shall not compute the following for the SAG:

(a) Patient liability budget, nor

(b) Monthly income allowance (MIA), nor

(d) Family maintenance needs allowance (FMNA).

(F) Unpaid past medical bills (UPMB) used in determining monthly spenddown amount

(1) For the purposes of paragraph (D)(4) of this rule, the amount of unpaid UPMB to be subtracted is determined as follows.

(2) UPMB means an unpaid past medical bill, or a portion of a medical bill, as defined in paragraph (C)(11) of this rule, that:

(a) Is for a medical item or service provided to the SAG or a family member; and

(b) Is still owed, and is not subject to payment by a third party who is legally obligated to pay the bill (for example, private insurance, medicaid, medicare, or a person who is court-ordered to pay the expense, etc.); and

(d) Has not been used in a previous month to meet the spenddown amount or as a UPMB as provided in paragraph (F)(9) of this rule; and

(e) Meets one of the criterion in paragraphs (F)(3) to (F)(7) of this rule.

(3) A UPMB is considered to have been “incurred” :

(a) In the month during which the provider supplied the item or service to the SAG or family member; and

(b) By the SAG or family member to whom the provider supplied the item or service.

(4) The SAG is not required to pay, or provide evidence of paying, the UPMB.

(5) The UPMB that a SAG may apply in the spenddown process are:

(a) A UPMB incurred during a month in which the person receiving the item or service was not eligible for medicaid. If the SAG incurred the UPMB:

(i) The CDJFS must determine whether the SAG is retroactively eligible for medicaid for the month in which the SAG incurred the UPMB. The CDJFS shall explore retroactive eligibility (including eligibility through the spenddown process) under rule 5101:1-38-01.3 of the Administrative Code.

(ii) If the SAG is not retroactively eligible (even through the spenddown process) for the month in which the SAG incurred the UPMB, the SAG may apply the UPMB in the spenddown process.

(iii) If the SAG is retroactively eligible for medicaid (whether or not through the spenddown process) for the month in which the SAG incurred the UPMB, the SAG may apply the UPMB in the spenddown process only if the UPMB satisfies paragraph (F)(5)(c) of this rule.

(b) A UPMB incurred during a month in which the SAG did not satisfy the monthly spenddown amount even with the application of the bill.

(c) A UPMB for a medical item or service that was not paid, or payable, by medicaid regardless of whether the individual receiving the item or service was eligible for medicaid during the month in which the UPMB was incurred because the UPMB is for an item or service:

(i) That was not covered by medicaid; or

(ii) That was supplied by a provider who was not participating in medicaid; or

(iii) That was supplied by a medicaid provider who did not accept medicaid for UPMB; or

(iv) Items or services not covered by medicaid include, but are not limited to, state psychiatric hospital charges, transportation expenses, etc.

(6) For a SAG residing in a NF or ICF-MR:

(a) Any unpaid NF or ICF-MR costs incurred while the SAG was in a period of restricted coverage as the result of an improper transfer of assets as provided in rule 5101:1-39-07 of the Administrative Code cannot be used as a UPMB until the period of restricted coverage has expired.

(b) Any NF or ICF-MR costs that were used to satisfy spenddown liability during a period of restricted coverage, and that remain unpaid after the period of restricted coverage has expired, shall not be used as a UPMB. For example, the spenddown amount, not including the cost of care as a recurring medical expense, would be five hundred dollars and the individual does not pay any of the monthly cost of care during the period of restricted coverage. A statement is then presented showing the SAG owes the full amount of the cost of care for the month. The allowable past medical expense would be the cost of care less the five hundred dollars that had already been used in the spenddown budget as part of the ongoing medical expense.

(7) The CDJFS shall assist the SAG in choosing the amount of the UPMB to apply, and the month(s) for which to apply the UPMB, in the calculation at paragraph (D)(4) of this rule. To assist the SAG in making an informed decision, the CDJFS shall determine the minimum number of months for which the UPMB might be applied. To make this determination, the CDJFS shall:

(a) First, determine the combined total of all the UPMB of the SAG and family members;

(b) Then, divide the total UPMB by remainder calculated in paragraph (D)(3) of this rule;

(c) The quotient is the minimum number of months the UPMB would allow the SAG to obtain medicaid eligibility through the spenddown process without having to satisfy any monthly spenddown amount, assuming no changes in the countable monthly income, current incurred medical expenses of the SAG, the medicaid need standard applicable to the SAG, etc.

(8) The amount of the UPMB the CDJFS must subtract in the calculation in paragraph (D)(4) of this rule is:

(a) The amount of the UPMB the SAG chooses to subtract, or

(b) If the SAG does not choose an amount to subtract, the difference between the remainder calculated in paragraph (D)(3) of this rule and the medicaid need standard applicable to the SAG.

(9) A UPMB, or portion of a UPMB, that a CDJFS actually uses in the spenddown process as a basis for approving medicaid eligibility for the SAG for a month, cannot be used again in the spenddown process. However, a UPMB, or portion of a UPMB, that the CDJFS does not actually use in the spenddown process as a basis for approving medicaid eligibility for the SAG, can be used in a future month in the spenddown process.

(10) For each UPMB, the CDJFS shall document in the CRIS-E case record (CLRC) and in the hard copy case record:

(a) The name of the provider; the item or service provided; the date item or service was provided; the name of the SAG or family member, to whom the item or service was provided; the amount still owed for the item or service; and

(b) The month(s) for which the UPMB, or a portion of the UPMB, was actually used in the calculation in paragraph (D)(4) of this rule as a basis for approving medicaid eligibility for the SAG for a month.

(G) The pay-in method of satisfying monthly spenddown amount

This subsection applies if the SAG has a monthly spenddown amount as calculated in paragraph (D)(4) of this rule.

(1) At the SAG’s option, the SAG may use the pay-in method of satisfying spenddown, described in paragraph (G) of this rule, for a month and use the incurred method of satisfying spenddown, described in paragraph (H) of this rule, for another month. At the CDJFS’s option, the CDJFS may permit the SAG to combine the two methods in a single month as follows:

(a) After the SAG and/or family member have incurred an amount of current medical expenses for a month that is less than the SAG’s spenddown amount for the month, the CDJFS may permit the SAG to pay-in the difference between the spenddown amount and the current incurred medical expenses (spenddown balance for the month).

(b) If the SAG pays-in the spenddown balance for the month, the SAG is eligible for medicaid for the month starting on the date in the month on which the SAG or family member incurred the last current medical expense for the month.

(c) To assist the SAG in making an informed decision about which method(s) to use, the CDJFS shall, at every application and reapplication, provide to, and review with, the SAG a copy of JFS 08500 as well as the CDJFS policies and procedures related to the spenddown process.

(2) At the SAG’s option, the SAG may satisfy spenddown for a month by paying (or paying in) to the CDJFS the dollar amount of the spenddown amount for the month (pay-in spenddown). If the SAG does so, the SAG is eligible for medicaid for the entire month.

(3) A third-party (an individual, organization, agency, etc.) may pay-in on behalf of the SAG, or a group of SAGs, by making payments from the third party’s funds, or other funds, directly to the CDJFS. Such payments are not considered income, are not included in countable monthly income to the SAG, and do not affect the medicaid eligibility of a SAG.

(4) The CDJFS must implement, and make available in writing, reasonable policies and procedures for administering the pay-in spenddown method. For example, the CDJFS policies and procedures must:

(a) Permit, and provide reasonable methods of accepting, payments by third parties (for example, individuals, agencies, programs, etc.) on behalf of individual SAGs and groups of SAGs.

(b) Ensure that, at the SAG’s option, the SAG will receive a medicaid card for a month on or about the first day of the month by making its pay-in payment by a date chosen by the CDJFS near the end of the preceding month.

(i) If the CDJFS receives the SAG’s pay-in payment before the CRIS-E cutoff date in the preceding month, the CDJFS will authorize the issuance of the medicaid card in CRIS-E (release the card) within two business days after the CRIS-E cutoff date; or

(ii) If the CDJFS receives the SAG’s pay-in payment on or after the CRIS-E cutoff date in the preceding month, the CDJFS will release the card within two business days after the CDJFS received the SAG’s pay-in payment.

(c) Ensure that, at the SAG’s option, the SAG may pay-in for a month at anytime during the same month and that the CDJFS will release the card for the month within two business days after the CDJFS received the SAG’s pay-in payment.

(d) Establish reasonable methods for accepting and accounting for pay-in payments, including for example: accepting cash payments, any necessary conditions for accepting checks or money orders, provisions for refunding or crediting unused pay-in amounts, etc.

(e) Establish provisions for refunding a SAG’s pay-in payment for a month in the event the SAG:

(i) Becomes eligible for medicaid for the month other than through the spenddown process;

(ii) Becomes ineligible for medicaid for the month even through the spenddown process; or

(iii) Paid in a higher spenddown amount than required or the CDJFS made an error in calculating the monthly spenddown amount.

(f) In accordance with rule 5101:1-38-02 of the Administrative Code, issue a receipt to all SAGs and to third-parties who make pay-in payments stating:

(i) The date of receipt of the payment; and

(ii) The name of the person or entity from whom the payment was received; and

(iii) The name and case number/category/sequence number (case/cat/seq) of the SAG for whom the payment was made; and

(iv) The month of medicaid eligibility for which the pay-in payment will be used and the effective date of medicaid for the month; and

(v) The amount of the pay-in and the form in which it was paid (e.g., cash money order, check, etc.).

(5) The CDJFS must document in the CRIS-E running record comments (CLRC) and in the hard copy record the information required in paragraph (G)(5)(f) of this rule.

(H) The current incurred medical expenses (or, incurred) method of satisfying monthly spenddown amount

This subsection applies if the SAG has a monthly spenddown amount as calculated in paragraph (D)(4) of this rule.

(1) At the SAG’s option, the SAG may use the incurred method of satisfying spenddown, described in paragraph (H) of this rule, for one month, and the pay-in method of satisfying spenddown, described in paragraph (G) of this rule, for another month. At the CDJFS’s option, the CDJFS may permit the SAG to combine the two methods in a single month as follows:

(a) After the SAG and/or family member has incurred an amount of current medical expenses for the month that is less than the SAG’s spenddown amount for the month, the CDJFS may permit the SAG to pay-in the difference between the spenddown amount and the current incurred medical expenses (spenddown balance for the month).

(c) To assist the SAG in making an informed decision about which method(s) to use, the CDJFS shall at every application and reapplication provide to, and review with, the SAG a copy of JFS 08500 as well as CDJFS policies and procedures related to the spenddown process.

(2) At the SAG’s option, the SAG may satisfy spenddown for a month by incurring a dollar amount of current medical expenses that equals the spenddown amount for the month (incurred spenddown). If the SAG does so, the SAG is eligible for medicaid for the month starting on the date in the month on which the SAG and/or family members incurred the current medical expenses that, combined with all other current incurred medical expenses for the month, equaled or exceeded the SAG’s monthly spenddown amount for the month.

(3) “Current incurred medical expense” means a medical bill or a portion of a medical bill as defined in paragraph (C)(11) of this rule that meets the following requirements:

(a) It is for a medical item or service provided to the SAG or family member during the month for which the SAG is seeking to obtain medicaid eligibility through the spenddown process; and

(b) It is a bill the SAG or family member has already paid, or is liable for the payment; and

(d) A medical expense, or portion of an expense, that is “written off” by the provider is a current incurred medical expense for the month in which the item or service was provided even though the expense is written-off by the provider later in the same or a subsequent month.

(e) A medical expense, or a portion of a medical expense that is paid, or subject to payment, by a third party (such as HCAP, private or personal charity, etc.) that is not legally obligated to pay the expense, or the portion of the expense, for the SAG or family member is a current incurred medical expense for the month in which the item or service was provided even though the expense, or the portion of the expense, is paid by the third party later in the same or a subsequent month.

(f) A medical expense, or a portion of a medical expense, that is paid or subject to payment by a third party (such as private insurance, medicaid, medicare, or a person who is court-ordered to pay the expense, etc.) that is legally obligated to pay the expense, or a portion of the expense, for the SAG or family member is not an incurred medical expense.

(g) A medical expense, or portion of an expense, that is paid, or is subject to payment, by a public or private agency or program (for example, HCAP, local levy funds, etc. except medicaid or medicare) is a current incurred medical expense for the month in which the item or service was provided even if it is paid by the agency or program later in the same or a subsequent month.

(h) If an agency or program provides a direct medical service based on an “ability-to-pay” fee scale, or “sliding” fee scale, only the amount the SAG or family member is liable to pay the agency or program is a current incurred medical expense.

(i) A medicaid-covered expense that the CDJFS actually uses in the spenddown process as a basis for approving medicaid eligibility for a SAG for a month will not be paid, and is not payable, by the medicaid program but remains the legal obligation of the SAG.

(j) A current incurred medical expense includes a transportation expense as defined in paragraph (C)(24) of this rule incurred by the SAG or family member during the month for which the SAG is seeking to obtain medicaid eligibility through the spenddown process.

(k) A current incurred medical expense does not include any expense actually deducted from earned income as an “impairment-related work expense (IRWE)” as provided in rule 5101:1-39-18 of the Administrative Code.

(l) A current incurred medical expense does not include a “possible future medical expense,” that is, an expense the SAG or family member has not yet incurred for a medical item or service that has not yet been provided to the SAG or family member.

(4) Current medical expenses covered by medicare.

The following criteria apply to each current medical expense covered by medicare that is incurred by a SAG or family members, who have medicare part A and/or part B coverage (person).

(a) If the medicare expense is one for which the individual does not have supplemental medicare coverage (for example, QMB, nationwide, American family, etc.), the amount of the current incurred medical expense shall be:

(i) One hundred per cent of each such medicare expense until the person’s medicare deductible is met; and

(ii) Twenty per cent of the medicare approved rate if it is known, or if it is not known, twenty percent of the charge for each such expense after the person’s medicare deductible is met.

(b) If the medicare expense is one for which the person has supplemental medicare insurance, the expense shall not be considered a current incurred medical expense.

(5) The SAG may apply the total dollar value of all current incurred medical expenses of the SAG and family members against the SAG’s spenddown amount for the month.

(6) A current incurred medical expense for a month that the CDJFS actually uses in the spenddown process as a basis for approving medicaid eligibility for the SAG for a month, cannot be used again in the spenddown process. However, a current incurred medical expense for a month that the CDJFS does not actually use in the spenddown process as a basis for approving medicaid eligible for the month, can be used as a UPMB in the future in the spenddown process as long as the expense remains unpaid and meets the other requirements of paragraph (F) of this rule.

(7) Procedural requirements:

(a) The SAG must submit monthly to the CDJFS, by mail, facsimile, or in person, verification of the current incurred medical expenses the SAG wishes to apply against the SAG’s spenddown amount for the month. Verifications may include, for example, unpaid bills, statements, invoices, paid receipts, etc.

(b) For each expense, the SAG must verify the name of the provider, the item or service provided, the date item or service was provided, the name of the SAG or family member to whom the item or service was provided, and the amount the SAG or family member paid or is liable to pay for the item or service.

(c) The CDJFS shall authorize the issuance of a medicaid card (release the card) for the month in CRIS-E within two business days after the SAG submits verification showing that current incurred medical expenses for the month satisfy the SAG’s spenddown amount for the month.

(d) The CDJFS must document in CRIS-E running record comments (CLRC), and in the hard copy record, on a month-by-month basis:

(i) The information required by paragraph (H)(8)(b) of this rule concerning the current incurred medical expenses for the month; and

(ii) The date the CDJFS authorized the medicaid card for the month in CRIS-E, or the specific reason(s) the CDJFS did not authorize a medicaid card for the month.

HISTORY: Eff 9-3-77; 12-31-77; 3-1-79; 10-1-79; 12-7-79; 2-21-80; 10-10-84 (Emer.); 12-29-84; 4-1-86; 8-1-86 (Emer.); 10-3-86; 11-1-86 (Emer.); 12-22-86; 10-1-88; 12-20-88; 1-1-89 (Emer.); 4-1-89; 10-1-89 (Emer.); 12-16-89; 1-1-90 (Emer.); 4-1-90; 9-28-90 (Emer.); 12-24-90; 10-1-91; 1-1-93 (Emer.); 3-18-93; 9-10-93 (Emer.); 12-10-93; 12-1-97 (Emer.); 2-1-98; 10-1-02

Rule promulgated under: RC 111.15

Rule authorized by: RC 5111.01, 5111.011

Rule amplifies: RC 5111.01

Replaces: 5101:1-39-10, 5101:1-39-10.1, 5101:1-39-10.2, 5101:1-39-10.3

R.C. 119.032 review dates: 10/01/2007