5101:1-39-23 Medicaid: income computations for determining eligibility using the special income level.

(A) This rule defines how the administrative agency shall compute income for purposes of determining medicaid eligibility for coverage of long term care services in a long term care facility, under a home and community-based services (HCBS) waiver program, or under the program of all-inclusive care for the elderly (PACE), using the special income level.

(B) Definitions.

(1) "Administrative agency" is the county department of job and family services, the Ohio department of job and family services (ODJFS), or other entity that determines eligibility for a medical assistance program.

(2) "Community spouse" is an individual who is not in a medical institution or nursing facility and has an institutionalized spouse. Neither of two spouses, married to each other, who both request or receive services under an HCBS waiver program or PACE is considered to meet this definition.

(3) "Home and community-based services (HCBS)" are defined in accordance with rule 5101:1-38-01.6 of the Administrative Code.

(4) "HCBS waiver program" is, in accordance with rule 5101:1-38-01.6 of the Administrative Code, a medicaid program, approved by the centers for medicare and medicaid services(CMS), that waives certain statutory requirements otherwise needed for medicaid coverage of services.

(5) An "individual" is an applicant for or recipient of medicaid.

(6) "Institutionalized" describes an individual who receives long term care services either in a long term care facility, under an HCBS waiver program, or under PACE for at least thirty consecutive days.

(7) A "long term care facility (LTCF)" is a medicaid-certified nursing facility, skilled nursing facility, or intermediate care facility for persons with mental retardation as defined in division-level designation 5101:3 of the Administrative Code.

(8) "Long term care services" are medicaid-funded, institutional or community-based, medical, health, psycho-social, habilitative, rehabilitative, and/or personal care services that may be provided to medicaid-eligible individuals, as defined in rule 5101:3-3-15 of the Administrative Code.

(9) "PACE State Administering Agency (SAA)" is the state agency that has signatory authority on the PACE program agreement with the centers for medicare and medicaid services (CMS) and the PACE organization.

(10) "Program of all-inclusive care for the elderly (PACE)" is a medicaid program, approved by the CMS, for certain elderly individuals.

(11) The "special income level" is an amount, in accordance with rule 5101:1-39-21 of the Administrative Code, equal to three hundred per cent of the current supplemental security income(SSI) payment standard for an individual.

(C) The administrative agency shall:

(1) Determine medical assistance eligibility in accordance with the eligibility rules contained in Chapters 5101:1-37 to 5101:1-42 of the Administrative Code, including the individual's eligibility for medicaid buy-in and low-income medicare assistance programs, in accordance with rules 5101:1-38-03 and 5101:1-39-01.1 of the Administrative Code.

(2) Determine if the individual meets the income criterion for medicaid eligibility for coverage of long term care services in a long term care facility, under an HCBS waiver program, or under PACE, using the special income level by utilizing the following procedure:

(a) Total all gross income, earned and unearned, of the individual, in accordance with Chapter 5101:1-39 of the Administrative Code; then,

(b) Compare the individual's gross income, earned and unearned, to the special income level, in accordance with rule 5101:1-39-21 of the Administrative Code.

(i) The individual meets the income criterion for medicaid eligibility using the special income level if the individual's gross income is equal to or less than the special income level. If the individual meets this income criterion, the administrative agency shall determine the amount of patient liability, if any, in accordance with rule 5101:1-39-24 of the Administrative Code.

(ii) The individual does not meet the income criterion for medicaid eligibility using the special income level if the individual's gross income is greater than the special income level. If the individual's gross income is greater than the special income level, the administrative agency shall compute the individual's countable income in accordance with rule 5101:1-39-20 of the Administrative Code, applying applicable exemptions and disregards in accordance with rules 5101:1-39-18 and 5101:1-39-26 of the Administrative Code, and subtracting the individual's medical insurance premiums, remedial/recurring medical expenses, unpaid past medical expenses and medicaid cost of care in accordance with rule 5101:1-39-10 of the Administrative Code; then, compare the countable income to the medicaid need standard in rule 5101:1-39-21 of the Administrative Code.

(a) The assistance group meets the medicaid need standard income criterion if the countable income is equal to or less than the medicaid need standard. If the assistance group meets the medicaid need standard criterion, the administrative agency shall determine the amount of patient liability, if any, in accordance with rule 5101:1-39-24 of the Administrative Code.

(b) The assistance group does not meet the medicaid need standard income criterion if the countable income exceeds the medicaid need standard. If the assistance group does not meet the medicaid need standard criterion, the administrative agency shall determine medicaid eligibility using the spenddown provisions in accordance with rule 5101:1-39-10 of the Administrative Code. Individuals found eligible under spenddown provisions are not eligible for medicaid coverage of long term care services, including services provided under HCBS waiver programs and PACE.

(3) The administrative agency shall process requests for coverage of long term care services in accordance with this rule and division-level designation 5101:3 of the Administrative Code.

(4) The administrative agency shall issue proper notice and hearing rights as outlined in division-level designation 5101:6 of the Administrative Code.

(D) The ODJFS, or its designee, shall determine, in accordance with this rule and division-level designation 5101:3 of the Administrative Code, if the individual requesting medicaid coverage of long term care services meets the level of care requirements for coverage of long term care services.

Replaces: 5101:1-39-95, 5101:1-39- 22.2

Effective: 07/01/2005
R.C. 119.032 review dates: 07/01/2010
Promulgated Under: 119.03
Statutory Authority: 173.40 , 5111.01 , 5111.871
Rule Amplifies: 173.40 , 5111.01 , 5111.012 , 5111.205 , 5111.87 , 5111.871 , 5111.91
Prior Effective Dates: 6-1-88 (Emer.), 8-1-88 (Emer.), 10-30-88, 1-1-90 (Emer.), 3-1-90 (Emer.), 3-30-90 (Emer.), 4-1-90, 6-29-90, 7-1-90, 10-1-90, 1-1-91 (Emer.), 4-1-91, 1-1-92 (Emer.), 3-20-92, 5-1-92 (Emer.), 7-1-92, 8-14-92 (Emer.), 11-1-92, 5-1-93, 9-1-93, 7-1-94, 1-1-95 (Emer.), 3-20-95, 10-1-95, 4-1-96, 1-1-97 (Emer.), 2-9-97, 12-31-97 (Emer.), 2-1-98, 4-1-99, 1-1-00, 1-1-01, 5/12/02