Chapter 5101:1-40 Medicaid for Families and Children

(A) CFC medicaid is a federal and state financed grant-in-aid program which is administered by ODJFS. CFC medicaid represents a collection of several federal mandatory and optional eligibility categories that cover families, children, and pregnant women who meet the eligibility criteria of the rules in Chapter 5101:1-40 of the Administrative Code.

(B) Federal regulations for the administration of the program are promulgated by the center for medicare and medicaid services (CMS) of the department of health and human services.

(C) When medicaid eligibility under any category is to be terminated or denied continued eligibility for medicaid under all other categories must be explored prior to taking the adverse action. This exploration must ensure that an assistance group or any individual in an assistance group is not denied or terminated from medicaid based on requirements of other programs (such as Ohio works first (OWF) foster care maintenance, food stamps, etc.)

(D) Eligibility for CFC medicaid is determined on an individual basis. Each individual included in the assistance group is to be determined eligible or ineligible according to CFC medicaid requirements. Eligibility factors in general are those eligibility requirements regarding income, resources, residence and citizenship, but not all factors apply nor do they necessarily apply in the same way to all of the various categories of CFC medicaid. The specifics to the various eligibility requirements are addressed in Chapters 5101:1-38, 5101:1-39, and 5101:1-40 of the Administrative Code. If an individual or assistance group does not meet all of the eligibility requirements for a given category of medicaid, then eligibility must be explored for all other categories. This may entail reviewing for other potential assistance groups which contain some, but not necessarily all, of the members of an ineligible assistance group. This means that an individual may have potential eligibility in more than one assistance group, and ineligibility in one of these assistance groups does not necessarily cause ineligibility in the others.

(E) Eligibility for CFC medicaid may exist for individuals/families when they are ineligible for OWF, foster care (IV-E), or adoption assistance solely because of their inability to satisfy an eligibility condition(s) or other requirement not prohibited or not required by title XIX (medicaid). For example, there are federal medicaid prohibitions against deeming of income from stepparents, sibling to sibling, or child to parent, this means that the OWF standard filing unit requirements may not be used as a basis for terminating any category of CFC medicaid.

(F) An individual/family must meet the income and resource eligibility (where applicable) requirements of rules 5101:1-40-20 to 5101:1-40-25 and 5101:1-40-14 to 5101:1-40-17 of the Administrative Code.

(G) Unless otherwise noted in the rules in this chapter of the Administrative Code, the requirements of rules in Chapter 5101:1-38 of the Administrative Code are applicable for verification, application processing, etc. to CFC medicaid applications and redeterminations.

(H) Applicants/recipients of CFC medicaid have the right to a state hearing as stated in division-level 5101:6 of the Administrative Code.

(I) Eligibility for CFC medicaid coverage begins on the first day of the month and ends on the last day. A change in circumstances during the month cannot adversely affect eligibility for the month during which the change occurred. A change in income which can not be reflected in eligibility for the month following the month of change due to prior notice or other administrative requirement shall be effective the first of the second month following the month of change.

(1) The exceptions to monthly coverage are birth and death, expedited medicaid and alien emergency medical assistance (AEMA). CFC medicaid coverage cannot precede a recipient’s date of birth or extend beyond a recipient’s date of death. Expedited medicaid coverage is limited to sixty days from the date all expedited medicaid criteria are met. AEMA coverage consists of only the period of time that services were provided for the emergency medical condition.

(J) The following definitions apply specifically to CFC medicaid:

(1) “Parental responsibility” means the natural or adoptive parent has certain financial responsibility for a child until the child becomes twenty-one if he is living with his parent(s) and was not previously emancipated. However, parents are not financially responsible for a pregnant daughter age eighteen or over who is living with them. If an individual under the age of twenty-one lives outside his parent(s) home, only contributions made by the parent(s) to the child are countable as income to the child.

(2) “Emancipated” means those individuals under age twenty-one who have married or have been (or are) members of the armed forces. Divorced individuals under age twenty-one are also considered to be emancipated. If an individual under age twenty-one has married and subsequently had that marriage annulled, the individual is not considered to be emancipated due to the annulled marriage. An individual under the age of twenty one can also be emancipated by court order.

(3) “Child” for purposes of CFC eligibility varies by the requirements of the specific category that is being explored. For example, for healthy families/LIF and transitional medicaid, “child” is defined as an individual who has not attained age eighteen or an individual who has not attained age nineteen and is a full-time student in a secondary school or in the equivalent level of vocational or technical training. However, an individual is eligible for healthy start as a “child” until age nineteen without regard to school enrollment or attendance.

(4) “Assistance group/family” means the parent(s), natural and adoptive, or in some cases a specified relative, and eligible children living in the home including the unborn child(ren) of a medically verified pregnant woman if provided for under the appropriate program rules. Those individuals included or excluded in the assistance group/family are further discussed in this paragraph.

(a) Individuals who are included in the assistance group for CFC benefits are determined by the category that is being explored, relationship, and financial responsibility. The principles for forming a CFC assistance group are based around whose income (and resources, where applicable) are used to calculate countable income and resources in order to determine eligibility. Because certain individuals have a legal responsibility for support (e.g. spouse to spouse, parent to child) some individuals may be included for assistance group size or for income purposes even though they are not eligible to be covered for benefits in the assistance group. An individual (child or parent) who is determined to be “Temporarily Absent”, as defined in this rule, remains a part of the assistance group/family as though they were physically living in the home. A childless married couple is also considered an assistance group/family.

(b) Individuals who can be, but are not required to be, excluded from the assistance group’s/family’s eligibility are emancipated individuals and individuals age eighteen to twenty-one who are not applying for CFC medicaid, and pregnant women age eighteen or over. Individuals who have income that causes the remaining members of the assistance group to be ineligible shall be excluded if they are individuals subject to medicaid prohibitions against income deeming as defined in paragraph (E) of this rule. Eligibility for the remaining family members shall be determined without consideration of the excluded individual’s need or income.

(c) An exception to inclusion is an assistance group also exists for families containing a child who is receiving SSI who would otherwise qualify for medicaid as a disabled individual under the provisions of Chapter 5101-1-39 of the Administrative Code. If the income or resources of the child’s parent(s) would cause this child to be ineligible for medicaid as a disabled individual or to have a spenddown, then the parent(s) have the option to have the child’s eligibility determined for healthy start. The parent(s) income shall be used in determining the child’s eligibility as well as the child’s own income except for exclusion of the SSI income. Because SSI individuals are prohibited from being part of a healthy families/LIF assistance group, if the remaining family members are receiving healthy families/LIF then the child will have his/her own healthy start assistance group.

(5) “Temporary Absence” means an individual (parent or child) who is otherwise considered part of the assistance group/family is considered to be temporarily absent if all of the following conditions are met:

(a) The location of the absent individual is known;

(b) There is a definite plan for the return of the absent individual to the home;

(c) The absent individual shared the home with the assistance group prior to the onset of the absence;

(d) There is no maximum period of time that an individual may be considered to be temporarily absent provided that the above conditions are met. An exception is in circumstances involving removal of a child(ren) by a public children services agency under the reunification plan. The child(ren) removed are considred temporarily absent as long as they meet the reunification requirements specified in the reunification plan. The individual medicaid eligibility is determined based upon current living arrangements of the child(ren). The remaining assistance group members eligibility is based upon the assistance group size that should include the individual who is temporarily absent.

(e) An individual who has been determined to be temporarily absent remains a part of the assistance group as though he/she were physically present in the household. They remain members of the assistance group throughout the period of temporary absence. An individual who is incarcerated is not considered temporarily absent.

(K) Steps in determining a CFC assistance group:

(1) The assistance group is determined by first deciding for which child(ren) assistance is requested. The child for whom assistance is requested must meet the age requirement for the category being explored.

(2) Add to the assistance group siblings living in the household who also meet the age requirement who are not specifically excluded. “Sibling” means any and all blood-related or adoptive brothers/sisters. Also, include those siblings who meet the temporary absence provision as set forth in this rule.

(3) Add to the assistance group for assistance group size for budgeting purposes the parent(s) living in the household who are not specifically excluded. A parent must not be added to the assistance group unless the child(ren) meets the age requirement for financial responsibility as referenced in paragraph (L)(1)(a) of this rule. “Parents” mean any and all natural and adoptive parents who live in the household and are not specifically excluded. When the child resides with a specified relative, who is in need and has no eligible biological or adoptive children, and has chosen to be part of a healthy families/LIF assistance group, add that individual to the assistance group. These specified relatives are not included in any other CFC assistance groups for benefits or assistance group size with the exception of transitional medicaid. Refer to paragraph (L)(4) of this rule.

(4) This group is considered to be the assistance group. If a person or persons are subject to be included in more than one assistance group within the same household, then the assistance groups containing that individual are first combined and eligibility for this group is determined as a whole. If the largest assistance group is not eligible for benefits, then eligibility for other assistance groups must be explored and determined. Eligibility for each member in that household must be evaluated for medicaid under any potential medicaid category.

(5) Assistance groups or individuals that are eligible for medicaid under more than one category at the same time shall be given the opportunity to make an informed choice as to the category for which they are approved. The goal is to enroll the assistance group for coverage under the category which provides the maximum level of coverage, e.g. healthy families/LIF confers potential eligibility for transitional medicaid if the family later loses healthy families due to earnings and it is, therefore, preferable to enroll a family for healthy families/LIF whenever possible.

(L) Certain additional considerations apply when eligibility is being explored for an assistance group that contains parents as well as children, e.g. healthy families/LIF and transitional medicaid assistance groups. The requirements of the specific eligibility categories are defined elsewhere in this chapter. The following are some principles that apply to certain types of assistance groups:

(1) Determination of the healthy families/LIF assistance group:

(a) An assistance group shall first be explored which includes the natural or adoptive parent(s) and their child(ren). A minor child is an individual who has not attained age eighteen or an individual who has not attained age nineteen and is a full-time student in a secondary school or in the equivalent level of vocational or technical training. The assistance group includes those individuals residing in the same household. An individual who is determined to be temporarily absent from the home as set forth in paragraph (J)(5) of this rule is considered to be residing in the household. Rule 5101:1-40-021(D)(1) of the Administrative Code states the healthy families/LIF assistance group must include a child as defined in this section. An exception to this requirement is in situations where the assistance group only contains the natural, adoptive parent or specified relative because the eligible child is not included due to receipt of SSI assistance.

(b) A minor parent residing with his/her parent(s) who are eligible for healthy families/LIF shall constitute one assistance group containing the parent(s), minor parent, siblings of the minor parent, and the minor parent’s child(ren) unless the income of the minor parent causes the minor’s parents and siblings of the minor parent to be ineligible.

(c) An individual, with no eligible children of his/her own, who resides with child(ren) who meet a degree of specified relationship as defined in paragraph (L)(1)(f) of this rule below may choose to be included in the assistance group with the child(ren) if a natural or adoptive parent of the child(ren) is not in the home. The specified relative’s income would be considered in determining the eligibility of the assistance group, if the specified relative is included. If the specified relative does not choose or is not eligible to be included in the group, then neither their income nor need are considered toward the financial eligibility of the children. When the specified relative has a spouse, the income of the spouse must be evaluated to determine the spouse’s ability to support the specified relative. If the specified relative’s spouse is in need, the spouse cannot be included in the assistance group. To determine whether the specified relative is eligible to be included in the assistance group with the minor child(ren), the allocation process as set forth in rule 5101:1-40-22 of the Administrative Code is applied. The income of the spouse of the specified relative is not countable toward the financial eligibility of the children.

(d) An individual who resides with his or her biological or adoptive children, and children who meet a degree of relationship, as defined in paragraph (L)(1)(f) of this rule shall be included in the assistance group with his or her children. CFC for the assistance group containing the other related children shall be determined separately and independently of the assistance group containing the individual and his or her biological or adoptive children. Income of the specified relative would not be considered in determining eligibility of the assistance group with the related children.

(e) A parent or specified relative in need, who is serving house arrest shall be included in the assistance group, provided that the individual’s confinement is in the household with the minor child(ren).

(f) Specified relative means the following individuals who are age eighteen or older:

(i) The following individuals related by blood or adoption:

(a) Grandparents, including grandparents with the prefix great, great-great, or great-great-great;

(b) Siblings;

(c) Aunts, uncles, nephews, and nieces, including such relatives with the prefix great, great-great, grand, or great-grand;

(d) First cousins and first cousins once removed.

(ii) Stepparents and stepsiblings;

(iii) Spouses and former spouses of individuals named in (f)(i) or (ii) of this paragraph.

(g) Income allotted pursuant to rule 5101:1-40-022 of the Administrative Code affects only individuals for whom the responsible individual has a financial responsibility. This affects eligibility of individual members of the assistance group. The eligibility of remaining members must still be explored.

(2) The following are individuals who would normally be included pursuant to paragraph (A) of this rule but who are excluded due to an ineligibility factor. Although these individuals are not covered by healthy families/LIF for benefits, their income is required to be included if they are a parent or spouse and they are included for purposes of determining assistance group size:

(a) The following are individuals who would normally be included pursuant to paragraph (A) of this rule but who are excluded due to an ineligibility factor. Although these individuals are not covered by healthy families/LIF for benefits, their income is required to be included if they are a parent or spouse and they are included for purposes of determining assistance group size:

(b) Individuals who fail to cooperate with an eligibility requirement such as a failure to cooperate with third party or medical support as defined in rule 5101:1-38-01.4 of the Administrative Code, provide information about a family member required to be included in an assistance group; or failure to comply with an initial eligibility requirement, such as enumeration.

(c) Adults who are ineligible due to a third failure to comply with a work activity as pursuant to rule 5101:1-40-07 of the Administrative Code.

(3) Individuals not eligible to be included in the healthy families/LIF assistance group:

(a) Parents or children receiving SSI. The income of a parent or child who is receiving SSI is not counted toward the healthy families/LIF assistance group containing the other parent and/or children. SSI recipients are also not counted in assistance group size for purposes of financial eligibility determination. A recipient of SSI who wishes to receive healthy families/LIF can choose to terminate their SSI benefits in order to be included in the healthy families/LIF assistance group. The healthy families/LIF eligibility effective date shall not precede the effective date of the SSI termination.

(b) Stepparents, unless there is a common child with the natural or adoptive parent included in the healthy families/LIF assistance group. Stepparents can also be included if the natural/adoptive parent(s) is not in the household and the stepparent is a caretaker in need pursuant to paragraph (L)(1)(c) of this rule.

(c) Parents or children for whom federal, state or local foster care maintenance payments are being made.

(d) Parents or children for whom federal, state or local adoption assistance payments are being made, unless the inclusion of the individual, in whose behalf the payments are being made, allows the family to qualify for healthy families/LIF because the individual increases the assistance group size for financial eligibility budgeting purposes.

(4) Determination of the transitional medicaid assistance group:

Federal regulations require that an individual must be eligible to be included in the state’s section 1931 assistance group (healthy families/LIF) in order to be eligible for inclusion in the transitional medicaid assistance group. Therefore, the individuals who were included in the healthy families/LIF assistance group are the only members eligible to be included in the transitional medicaid assistance group with the following exceptions:

(a) An adult who was ineligible for healthy families/LIF because of a third work activity failure is included in the transitional medicaid assistance group pursuant to rule 5101:1-40-07 of the Administrative Code.

(b) Those individuals whose needs and income would be taken into account in determining healthy families/LIF eligibility of the assistance group if the family were applying in the current month. Under this definition, a child born after healthy families/LIF is terminated, or a child or parent who returns home after healthy families/LIF is terminated, is included in the assistance group for purposes of transitional medicaid.

HISTORY: Eff 6-1-84; 8-1-86 (Emer.); 10-3-86; 2-13-87 (Emer.); 4-25-87; 11-1-87; 1-1-88; 1-1-89 (Emer.); 2-6-89; 1-1-93; 10-31-97 (Emer.); 1-26-98; 11-1-99 (Emer.); 2-1-00; 6-1-02 (Emer); 8-30-02

Rule promulgated under: RC 111.15

Rule authorized by: RC 5111.011, 5111.01

Rule amplifies: RC 5111.01, 5107.02, 5111.011

Replaces: former 5101:1-40-01

R.C. 119.032 review dates: 3/15/2002 and 08/30/2007

To be eligible for covered families and children (CFC) medicaid, a family/individual must be a member of a covered group and meet all applicable eligibility requirements of the rules in chapter 5101:1-40 of the Administrative Code. The three divisions of CFC medicaid covered groups are: families, children, and pregnant women. The financial circumstances of an assistance group and individual members of the assistance group have a major impact on the eligibility criteria applied in the eligibility determination for CFC medicaid. The fact that an assistance group is over income does not necessarily render all members of the group ineligible. The eligibility for each individual must be thoroughly reviewed for other potential assistance groups and/or categories other than the one for which the entire assistance group is not eligible.

(A) Families. This covered group includes families where the eligibility of all members of the family is determined based upon their collective circumstances. The following identifies the families covered by CFC medicaid:

(1) Financially eligible families (healthy families/LIF) with children. This group includes those individuals who are not eligible for OWF cash assistance due to an OWF requirement that is not applicable to medicaid (e.g. signing of a self-sufficiency contract) or prohibited by medicaid (e.g. deeming of sibling income or deeming of income from a child to a parent). This group also includes individuals or families that are OWF cash eligible but decline cash assistance.

(2) OWF recipients. All OWF cash recipients automatically are eligible for healthy families/LIF without a separate eligibility determination. This group includes OWF parents and relatives who are eligible for and receiving OWF only for themselves because the only eligible child(ren) are receiving SSI, or effective February 28, 1994, federal, state, or local foster care maintenance payments or federal, state, or local adoption assistance payments.

(3) Transitional medicaid. Those terminated from healthy families/LIF due to increased earnings from employment.

(4) Four month extended medicaid. Those terminated healthy families/LIF due to the receipt of or increase in spousal or child support.

(5) Healthy start recipients. This includes family situations where a pregnant woman is receiving assistance along with her child(ren) in accordance with rules: 5101:1-40-08 and 5101:1-40-081 of the Administrative Code.

(B) Children. Eligibility for children is often determined independently from the circumstances of their families. Though it is necessary to determine financial eligibility taking into consideration the income of a child’s parents, when the child lives with the parents or is temporarily absent under the provisions of rule 5101:1-40-01(J)(5) of the Administrative Code, the basic nonfinancial eligibility determiner is the child’s circumstances. The following identifies the areas of potential eligibility for children:

(1) Newborns. A child born to a woman eligible for and receiving medicaid under any category at the time of the child’s birth. This includes situations where eligibility was determined retroactively for the period of time which included the child#s date of birth.

(2) Foster care maintenance (FCM) and adoption assistance (AA) cases.

(3) Children in care.

(4) Individuals not eligible for OWF due to deeming of income requirements prohibited by the medicaid program, such as:

(a) Deeming of stepparent to stepchild(ren) income;

(b) Deeming of grandparent income to grandchild(ren);

(c) Deeming of sibling income to other full or half-siblings in household;

(d) Deeming of income from a child to a parent.

Deeming of income prohibitions include all types of income and are not restricted to SSI or other income earmarked by court order or law.

(5) Individuals under age twenty-one living with their parents who are not included because they do not meet an eligibility requirement to be included within an assistance group with their parents (e.g. a 20-year old individual) and individuals who have their own income that would adversely affect the eligibility of other individuals listed in section (B)(4) of this rule.

(6) Individuals under age twenty-one who are not living with a specified relative or who are living by themselves.

(7) Children who are eligible for healthy start whose eligibility is determined pursuant to rules 5101:1-40-08 and 5101:1-40-081 of the administrative code.

(C) Pregnant women. Pregnant women are a covered group for medicaid solely due to the fact the woman is pregnant. These women are determined eligible in accordance with the provisions of healthy start as specified in rules 5101:1-40-08 and 5101:1-40-081 of the Administrative Code. However, they may also be included in an assistance group that receives Medicaid under another category (e.g. healthy families/LIF), but if that assistance group becomes ineligible, the pregnant woman must continue to receive coverage under healthy start throughout her pregnancy and the sixty day postpartum period.

(D) The initial financial eligibility is determined based on the circumstances of the pregnant woman. If the pregnant woman is married and is living with her spouse, his income must be considered in the determination of her initial eligibility. If an unemancipated pregnant woman is under eighteen and living with her parent(s), the income of her parents must be considered in the determination of her initial eligibility. Financial eligibility for healthy start is determined based on the appropriate assistance group size according to the number of fetuses that have been medically verified. Financial eligibility for healthy families/LIF does not count the fetus toward the assistance group size, but does allow a $20 pregnancy allowance (ref. OAC 5101:1-40-26).

HISTORY: Eff 2-15-85 (Emer); 3-12-85 (Emer); 6-10-85 (Emer); 12-30-85; 8-1-86; 9-23-86; 10-3-86; 10-8-86; 1-1-88 (Emer); 6-20-88; 3-6-89; 3-28-89 (Emer); 1-1-90 (Emer); 4-1-90; 10-1-91; 3-1-94 (Emer); 4-18-94; 9-1-94; 9-1-95; 12-31-97 (Emer); 3-9-98; 10-1-98; 8-30-02

Rule promulgated under: RC 111.15

Rule authorized by: RC 5111.011, Section 61.07 Am. Sub.

Rule amplifies: RC 5111.01, 5107.02, 5111.011

Replaces: former 5101:1-40-01.1

R.C. 119.032 review dates: 3/15/2002 and 08/30/2007

All persons who receive OWF assistance are automatically entitled to healthy families/LIFmedicaid. This group encompasses:

(A) All persons included in the assistance group for the OWF program.

(B) Persons included in the OWF assistance group when the cash grant is reduced to zero to adjust for an overpayment.

(C) All persons included in the OWF assistance group and determined eligible for minimum payment are considered OWF cash assistance recipients.

(D) OWF assistance groups who are found eligible for cash assistance, but decline it, as long as they meet the eligibility requirements of the for healthy families/LIF medicaid group as stated in rule 5101:1-40-02.1 of the Administrative Code.

(E) All individuals who meet the temporary absence policy as outlined in rule 5101:1-40-01 of the Administrative Code including the parent or specified relative who is the only remaining assistance group member when a child (or children) has been removed temporarily from the home by a public childrens services agency (PCSA) pursuant to the policy.

(F) It is important to note that P.L. 104-193 broke the automatic tie between medicaid and cash assistance. It is the goal of Ohio’s medicaid program to ensure that all OWF recipients continue to be eligible for medicaid. Therefore, Ohio’s rules must be amended to the extent allowable by federal law to ensure that as OWF rules change, medicaid rules are amended to reflect these changes.

R.C. 119.032 review dates: 04/10/2003 and 04/01/2008

Promulgated Under: 111.15

Statutory Authority: 5111.01

Rule Amplifies: 5111.01

Prior Effective Dates: 9/3/77, 10/26/78, 5/1/79, 9/21/79, 2/21/80, 8/1/86 (Emer.), 1/3/86, 1/1/93, 10/31/97 (Emer.), 12/31/97 (Emer.), 3/9/98, 6/1/02 (Emer.), 8/30/02.

(A) Federal P.L. 104-193, the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) (effective August 22, 1996) eliminated the aid to dependent children (ADC) program and replaced it with a block grant program called temporary assistance for needy families (TANF). PRWORA eliminated the automatic link between the receipt of cash assistance and medicaid. However, states are required to find individuals eligible for medicaid if they would have been eligible for ADC in July 1996 with a few exceptions. This covered group is known as low-income families medicaid (LIF).

(B) Ohio Sub. H.B. 408 created the Ohio works first (OWF) program. It also established the automatic link between cash assistance and medicaid eligibility in Ohio as specified in rules 5101:1-40-01.1 and 5101:1-40-02 of the Administrative Code. This covered group is known as OWF medicaid.

(C) The following definitions apply specifically to the low-income families medicaid (LIF) and OWF covered groups.

(1) LIF medicaid – those individuals found eligible under the July 1996 ADC eligibility requirements.

(2) OWF medicaid – those individuals automatically eligible for medicaid because of their eligibility for OWF cash assistance.

(3) Child – as defined in section 5107.02 of the Revised Code.

(4) Specified relative – as defined in section 5107.02 of the Revised Code.

(5) Income standards – the income standards used to determine financial eligibility for LIF medicaid are the need standard and the payment standard as defined in rule 5101:1-40-26 of the Administrative Code.

(6) Gross countable income – the amount of nonexempt unearned income and earned income (including countable gross earnings from self-employment as defined in paragraph (B) of rule 5101:1-40-20.4 of the Administrative Code) that is compared to the ninety per cent federal poverty level (FPL) standard to determine eligibility for LIF medicaid. Gross countable income is determined by adding all non-exempt unearned income and all earned income without earned income disregards.

(7) Countable income – the amount of income which is compared to the appropriate payment or need standard to determine if a family is eligible for LIF medicaid. Countable income is determined by adding nonexempt gross unearned income and gross earned income minus appropriate earned income disregards.

(D) LIF eligibility requirements

An assistance group making application for LIF medicaid must meet the following eligibility requirements:

(1) The family must include a child as defined in section 5107.02 of the Revised Code.

(2) Family countable income that does not exceed the payment or need standard as defined in rule 5101:1-40-26 of the Administrative Code.

(E) The following provisions apply to the LIF group.

(1) The fifty dollar child support disregard is an allowable disregard in the determination of countable income as set forth in rule 5101:1-40-20.3 of the Administrative Code.

(2) The earned income disregards are applied at the individual level as set forth in rule 5101:1-40-20.5 of the Administrative Code.

(3) The use of the pregnancy allowance in budget calculations remains applicable as set forth in rule 5101:1-40-26 of the Administrative Code.

(F) July 1996 ADC provisions that no longer apply to the LIF group.

(1) Resource limits

(2) Deprivation

(G) OWF provisions that do not apply include, but are not limited to:

(1) The signing of a self-sufficiency contract.

(2) The OWF sanction policy as set forth in section 5107.16 of the Revised Code.

(3) The time-limited participation in OWF as set forth in section 5107.18 of the Revised Code.

(H) OWF medicaid

Individuals who meet the OWF cash assistance eligibility requirements as outlined in Chapters 5101:1-3 and 5101:1-23 of the Administrative Code are automatically eligible for OWF medicaid.

(I) Relationship between LIF, OWF, transitional medicaid and four-month extended medicaid:

(1) Assistance groups who become ineligible for LIF or OWF medicaid due to child or spousal support payments may be eligible for four-month extended medicaid in accordance with Chapter 5101:1-40 of the Administrative Code.

(2) Assistance groups who become ineligible for LIF or OWF medicaid due to income from employment may be eligible for transitional medicaid in accordance with Chapter 5101:1-40 of the Administrative Code.

(3) Assistance groups who lose eligibility for OWF cash due to expiration of the OWF program time- limited participation as set forth in section 5107.18 of the Revised Code shall have their eligibility for LIF medicaid explored prior to the termination of OWF medicaid.

Effective: 01/01/2006

R.C. 119.032 review dates: 10/14/2005 and 01/01/2011

Promulgated Under: 111.15

Statutory Authority: 5111.01

Rule Amplifies: 5111.01 and 5111.019

Prior Effective Dates: 10/31/97 (Emer.), 12/31/97 (Emer.), 3/9/98, 9/01/98, 10/01/99, 07/01/00

(A) This rule defines how the administrative agency shall deem medicaid eligibility to a child born to a woman eligible for and receiving medicaid on the date of the child’s birth.

(B) Definitions

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

(2) “Assistance group” is defined in accordance with rule 5101:1-38-01.2 of the Administrative Code.

(3) “Individual” is the applicant or recipient of a medical assistance program.

(C) Eligibility criteria

(1) A child born to a woman eligible for and receiving medicaid on the date of the child’s birth is deemed to have filed an application and been found eligible on the date of birth and to remain eligible for one year provided:

(a) The child resides continuously in the woman’s household; and

(b) The woman remains eligible for medicaid or would have remained eligible if she were still pregnant.

(2) A child is deemed eligible only within the state in which the woman was eligible on the date of the birth.

(3) No additional eligibility requirements, including income, have to be met in order for medicaid coverage to continue for the child as long as the mother remains eligible for medicaid or would have remained eligible if she were still pregnant.

(D) Application

(1) No application form is necessary for a child born to a medicaid recipient.

(a) The case record must contain written notification of the birth, or

(b) Verbal notification of the birth shall be carefully recorded by the administrative agency in the case record.

(2) The effective date of eligibility shall be the birth date of the child.

(E) Administrative agency responsibilities

(1) If the administrative agency finds that the child is not residing in the mother’s household, or is no longer a resident of the state, the child loses deemed eligibility.

(2) If a mother applies for medicaid after her child is born, and is determined to have retroactive eligibility (in accordance with rule 5101:1-40-08 of the Administrative Code) that includes the date of birth, she is considered to have been eligible for and receiving medicaid at the time of the birth.

(a) The child is deemed eligible at birth and retains that deemed eligibility under the same conditions as a child whose mother applied for and was found eligible for medicaid prior to the birth.

(3) A child eligible for medicaid assistance will be placed on medicaid within five business days from receipt of:

(a) Verbal notification of the birth, or

(b) The JFS 02453 “Inpatient Hospital Admission” form, or

(c) Other written verification.

(4) The administrative agency shall not terminate medical assistance for a member of an assistance group until a pre-termination review (PTR) of continuing medicaid eligibility has been completed in accordance with rule 5101:1-38-01.1 of the Administrative Code.

(5) Prior notice and hearing rights as outlined in division-level designation 5101:6 of the Administrative Code shall be observed.

(F) Individual responsibilities

(1) Continued eligibility after the child’s first birthday requires a reapplication and determination of continued eligibility for medicaid, as described in rule 5101:1-38-01 of the Administrative Code.

Replaces: 5101:1-40-02.2

Effective: 07/01/2005

R.C. 119.032 review dates: 07/01/2010

Promulgated Under: 111.15

Statutory Authority: 5111.01

Rule Amplifies: 5111.01

Prior Effective Dates: 6-1-84, 10-1-84(EMER.), 12-27-84, 1-1-85(EMER.), 4-1-85, 8-1-86(EMER.), 10-3-86, 11-1-91(EMER.), 1-1-92, 5-1-92, 9-1-92, 11-1-99, 2-1-00

Rescinded eff 1-1-08

(A) This rule describes medicaid eligibility requirements for children in care in Ohio and individuals who have aged out of foster care but are younger than age twenty-one.

(B) Definitions.

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

(2) “Authorized representative”, for the purpose of this rule, means a person, eighteen years or older, who stands in place of the individual. The authorized representative may include a legal entity assisting in the application process. The administrative agency may request proper identification from the authorized representative.

(3) “Child” for the purpose of this rule, means a person younger than eighteen years of age.

(4) “Children in care” means, for the purpose of this rule, that a public children services agency (PCSA), private child placing agency (PCPA), or Title IV-E agency has permanent or temporary legal custody of a child as defined in rule 5101:2-1-01 of the Administrative Code.

(5) “Federal adoption assistance” (AA) means the Title IV-E subsidy program as defined by the Adoption Assistance and Child Welfare Act of 1980.

(6) “Foster care maintenance” (FCM) means Ohio’s Title IV-E foster care maintenance program, as defined in rule 5101:2-47-02 of the Administrative Code.

(7) “Independent living services” has the same meaning as in rule 5101:2-42-19 of the Administrative Code.

(8) “Individual”, for the purpose of this rule, means a person who has aged out of foster care at age eighteen and is younger than age twenty-one.

(9) “PCSA” means a public children services agency as defined in section 5153.02 of the Revised Code.

(10) “PCPA” means a private child placing agency as defined in section 5103.02 of the Revised Code.

(11) “State adoption assistance” means the state-only adoption subsidy program as described in rule 5101:2-44-03 of the Administrative Code.

(C) Eligibility criteria.

(1) A child is eligible for medicaid under this rule, regardless of family size, income, or resources, when the child is:

(a) In the custody of a PCSA or a PCPA; or

(b) In receipt of adoption or foster care assistance under Title IV-E of the Social Security Act as in effect January 1, 2008; or

(c) In receipt of state or federal adoption assistance.

(2) An individual younger than age twenty-one, who has aged out of foster care, is eligible for medicaid, regardless of family size, income, or resources, when the individual:

(a) Is at least eighteen but younger than age twenty-one; and

(b) Is in foster care under the responsibility of the state on the individual’s eighteenth birthday; and

(c) Has received FCM payments or independent living services furnished by a program funded under Title IV-E of the Social Security Act of 1935 as in effect January 1, 2008, before the individual reached age eighteen.

(D) Child, individual, or authorized representative responsibilities. The child, the individual, or the authorized representative must:

(1) Sign and date the application;

(2) Cooperate in establishing eligibility which includes verifying citizenship, as described in rule 5101:1-38-02 of the Administrative Code, upon turning age eighteen and leaving care; and

(3) Report any changes in eligibility criteria.

(E) Administrative agency responsibilities. The administrative agency must:

(1) Determine medicaid eligibility in accordance with the eligibility rules as described in Chapters 5101:1-37 to 5101:1-42 of the Administrative Code;

(2) Not require a face-to-face interview for application;

(3) Redetermine eligibility every twelve months;

(4) Not terminate an individual’s eligibility until a pre-termination review (PTR) of continuing medicaid eligibility has been completed in accordance with Chapter 5101:1-38 of the Administrative Code; and

(5) Issue proper notice and hearing rights as outlined in division 5101:6 of the Administrative Code.

Replaces: 5101:1-40-03, 5101:1-40-02.3, 5101:1-40-10,

Effective: 01/01/2008

R.C. 119.032 review dates: 01/01/2013

Promulgated Under: 111.15

Statutory Authority: 5111.01, 5111.0111

Rule Amplifies: 5111.01, 5111.0111

Prior Effective Dates: 7/10/80, 1/1/83, 10/14/83 (Temp.), 12/22/83, 2/15/85 (Emer.), 3/12/85 (Emer.), 6/10/85, 8/1/86 (Emer.), 10/3/86, 10/1/87, 4/1/90 (Emer.), 6/1/90, 3/1/94 (Emer.), 4/18/94, 11/1/99 (Emer.), 2/1/00, 7/1/00, 2/1/02, 6/1/02 (Emer.), 8/30/02

(A) Transitional medicaid is a category of continuing medicaid available to certain assistance groups that lose healthy families/low income families (LIF) eligibility.

(B) Definitions.

(1) “Transitional medicaid assistance group” includes:

(a) The healthy families/LIF assistance group at the time of loss of healthy families/LIF eligibility,

(b) Individuals who would be included in the healthy families/LIF assistance group if the assistance group applied in the month of loss of healthy families/LIF eligibility,

(c) Child(ren) born or a child(ren) or parent(s) who return home after termination of healthy families/LIF eligibility,

(d) Specified relative because the natural parent is not in the home (pursuant to paragraph (L)(1)(f) of rule 5101:1-40-01 of the Administrative Code),

(e) Individual(s) not receiving healthy families/LIF medicaid because of a third tier work activity sanction (pursuant to rule 5101:1-40-07 of the Administrative Code),

(f) Individual(s) not receiving healthy families/LIF benefits because of failure to cooperate in establishing paternity and/or obtaining or pursuing medical support (pursuant to rule 5101:1-38-02.2 of the Administrative Code), and

(g) Parents or specified relatives of children for whom federal, state, or local foster care maintenance payments are made, who are otherwise eligible for healthy families/LIF.

(2) “Administrative agency” means the county department of job and family services (CDJFS), Ohio department of job and family services (ODJFS), or other entity that determines eligibility for a medical assistance program.

(3) “Child” is defined as “an individual who has not attained age eighteen or an individual who has not attained age nineteen and is a full-time student in a secondary school or in the equivalent level of vocational or technical training,” pursuant to paragraph (J)(3) of rule 5101:1-40-01 of the Administrative Code.

(4) “Countable income” means the amount of income compared to the appropriate payment or need standard to determine if an individual is eligible for medicaid. Countable income is determined by adding all of a family’s nonexempt unearned income to nonexempt earned income after subtracting all appropriate disregards.

(5) “Family” has the same meaning as in rule 5101:1-40-01 of the Administrative Code.

(6) “Income” has the same meaning as in rule 5101:1-40-20 of the Administrative Code.

(7) “Individual” means an applicant for or recipient of a medical assistance program.

(8) “Quarter” is defined as three months of transitional medicaid coverage.

(a) “First quarter” is defined as the first, second, and third months of transitional medicaid coverage;

(b) “Second quarter” is defined as the fourth, fifth, and sixth months of transitional medicaid coverage;

(c) “Third quarter” is defined as the seventh, eighth, and ninth months of transitional medicaid coverage;

(d) “Fourth quarter” is defined as the tenth, eleventh, and twelfth months of transitional medicaid coverage.

(C) The first six month period of transitional medicaid.

(1) Eligibility criteria.

(a) The assistance group must have been eligible for and received healthy families/LIF in the state of Ohio in at least three of the six months immediately preceding the month in which the assistance group became ineligible for healthy families/LIF. Receipt of medicaid benefits under another state’s program does not count toward meeting this requirement.

(b) The transitional medicaid assistance group must have lost healthy families/LIF eligibility due to earned income which caused countable income to exceed ninety per cent of the federal poverty level.

(c) The assistance group must have earned income. Verification of income is not required.

(d) The transitional medicaid assistance group must include either:

(i) A child, or

(ii) Parent(s) or specified relative whose child(ren) receives medicaid benefits in a separate assistance group due to receipt of adoption assistance, foster care maintenance, or SSI.

(e) Individuals must not have a conviction(s) of medicaid fraud by a court of competent jurisdiction within the six month period prior to becoming ineligible for healthy families/LIF.

(2) Eligibility period.

If the administrative agency determines the healthy families/LIF assistance group is eligible for transitional medicaid, a notice advising the assistance group of their reporting responsibilities, will be issued. The notice must advise the assistance group that healthy families/LIF will stop on the date indicated on the notice. The notice will also state “Your Medicaid health card will stop on _________.” The date entered in this space will be the last day of the twelfth month of potential medicaid coverage. When the last day of the twelfth month is indicated on the notice, the following statement is included: “see information enclosed.”

(a) Eligibility for the first six month period of transitional medicaid is for six months, provided the eligibility criteria in paragraph (C)(1) of this rule are met.

(b) Eligibility for the first six month period of transitional medicaid begins the month immediately following the last month of healthy families/LIF eligibility. If healthy families/LIF continues beyond the last month of healthy families/LIF eligibility, the months of coverage beyond eligibility are counted as months of the transitional medicaid period of eligibility.

(3) Quarterly income reports

(a) The administrative agency must send a quarterly report form to the transitional medicaid assistance group no later than the third Friday of the third and sixth months of traditional medicaid coverage.

(i) These reports are for, respectively, the first and second quarters of transitional medicaid coverage.

(ii) The quarterly report form will notify the transitional medicaid assistance group of the requirement to report the assistance group’s gross earned income and costs of child care for each of the three preceding months.

(b) The transitional medicaid assistance group must complete the quarterly report form(s) and return it to the administrative agency by the fifth day of the month following the end of the quarterly reporting period, which would be, respectively, the fourth and seventh months of the transitional medicaid coverage period.

(c) The administrative agency must determine eligibility for continued transitional medicaid coverage upon the timely receipt of a quarterly report.

(i) Upon the timely receipt of the first quarterly report, the administrative agency must determine eligibility based upon the eligibility criteria delineated in paragraph (C)(1) of this rule.

(4) Termination of transitional medicaid.

(a) Eligibility for transitional medicaid ends if:

(i) The assistance group no longer meets the eligibility criteria delineated in paragraph (C)(1)(d) of this rule;

(ii) The transitional medicaid assistance group regains eligibility for healthy families/LIF;

(iii) The transitional medicaid assistance group fails, without good cause, to return a required first quarterly report in accordance with this rule, the transitional medicaid assistance group will lose eligibility for transitional medicaid for the second six month period of eligibility;

(b) The administrative agency shall not terminate medicaid for any assistance group or members(s) of an assistance group until a pre-termination review (PTR) of continuing medicaid eligibility has been completed in accordance with rule 5101:1-38-01.1 of the Administrative Code.

(c) Hearing rights as outlined in division 5101:6 of the Administrative Code must be observed.

(D) The second six month period of transitional medicaid.

(1) Eligibility criteria.

(a) The assistance group must have received transitional medicaid continuously for the entire first six-month period.

(b) The assistance group must meet the eligibility criteria of paragraph (C)(1) of this rule.

(c) The assistance group must meet the quarterly income reporting requirements as defined in paragraphs (C)(3)(b), (C)(3)(c), (D)(3)(b), and (D)(3)(c) of this rule.

(d) The assistance group’s average gross monthly earned income (less child care costs as is necessary for employment of the parent or specified relative) must not exceed the transitional medicaid standard, as set forth in rule 5101:1-40-26 of the Administrative Code.

(i) When a change in the transitional medicaid assistance group composition is reported during the three month period covered by the quarterly report, the average assistance group size (rounded up) is used for the period covered by the quarterly report.

(2) Eligibility period.

(a) An assistance group’s potential eligibility for the second six month period of transitional medicaid begins the month immediately following the completion of the first six months of transitional medicaid. If healthy families/LIF continued beyond the last month of healthy families/LIF eligibility, the months of coverage beyond eligibility are counted as months of the transitional medicaid period of eligibility.

(3) Quarterly income reports.

(a) The administrative agency must send a quarterly report form to the transitional medicaid assistance group no later than the third Friday of the ninth month of transitional medicaid coverage.

(i) This report is for the third quarter of transitional medicaid coverage.

(ii) The quarterly report form will notify the transitional medicaid assistance group of the requirement to report the assistance group’s gross earned income and costs of child care for each of the three preceding months.

(b) The transitional medicaid assistance group must complete the quarterly report form and return it to the administrative agency by the fifth day of the month following the end of the quarterly reporting period, which would be the tenth month of the transitional medicaid coverage period.

(c) The administrative agency must determine eligibility for continued transitional medicaid coverage upon the timely receipt of a quarterly report.

(i) Upon timely receipt of the second and third quarterly reports, the administrative agency must determine eligibility based on the eligibility criteria delineated in paragraph (D)(1) of this rule.

(ii) If the parent’s or specified relative’s child care costs bring the transitional medicaid assistance group’s gross monthly earned income to within the transitional medicaid standard as defined in rule 5101:1-40-26 of the Administrative Code, the child care costs must be verified.

(4) Termination of transitional medicaid.

(a) Eligibility for transitional medicaid ends if:

(i) The transitional medicaid assistance group no longer meets the eligibility criteria delineated in paragraphs (C)(1) and (D)(1) of this rule;

(ii) The transitional medicaid assistance group regains eligibility for healthy families/LIF;

(iii) The transitional medicaid assistance group fails to return a required quarterly report in accordance with this rule;

(iv) The parent or specified relative in the transitional medicaid assistance group reports no earnings in one of the three months of the second or third quarterly reporting period (unless the lack of earnings is due to involuntary loss of employment, illness, or the administrative agency establishes that there was other good cause); or

(v) The transitional medicaid assistance group’s gross monthly earned income, less child care costs, exceeds the transitional medicaid standard as defined in rule 5101:1-40-26 of the Administrative Code.

(b) The administrative agency shall not terminate medicaid for a members(s) of an assistance group until a pre-termination review (PTR) of continuing medicaid eligibility has been completed in accordance with rule 5101:1-38-01.1 of the Administrative Code.

(c) Hearing rights as outlined in division 5101:6 of the Administrative Code must be observed.

(E) Transitional medicaid assistance groups that have coverage terminated prior to the completion of the twelfth month of transitional medicaid may potentially reestablish transitional medicaid coverage.

(1) Assistance groups which lose transitional medicaid eligibility in accordance with paragraph (C)(4)(a)(ii) or paragraph (D)(4)(a)(ii) of this rule will be eligible for a new period of transitional medicaid upon meeting all requirements in paragraph (C)(1) of this rule.

(2) Assistance groups which lose transitional medicaid eligibility in accordance with paragraph (C)(4)(a)(ii) or paragraph (D)(4)(a)(ii) of this rule will be eligible for the remaining span of transitional medicaid upon meeting eligibility requirements in paragraphs (C)(1)(b) to (C)(1)(e) of this rule.

Effective: 01/01/2008

R.C. 119.032 review dates: 10/12/2007 and 01/01/2013

Promulgated Under: 111.15

Statutory Authority: 5111.01

Rule Amplifies: 5111.01, 5111.019

Prior Effective Dates: 4/1/90 (Emer.), 6/22/90, 10/1/90, 1/1/93, 4/21/94, 10/31/97 (Emer.), 1/26/98, 6/1/02, 8/30/02, 8/4/03

(A) This rule defines four-month extended coverage for purposes of determining medicaid eligibility. Four-month extended coverage is for certain individuals who lose medicaid eligibility under the covered group of healthy families/low-income families (LIF) wholly or partly as a result of new or increased receipt of child or spousal support.

(B) Definitions.

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

(2) “Assistance group” for the purposes of this rule means an individual or individual(s) and may include the following:

(a) The healthy families/LIF assistance group at the time of loss of healthy families/LIF eligibility;

(b) Individuals who would be included in the healthy families/LIF assistance group if the assistance group applied in the month of loss of healthy families/LIF eligibility;

(c) Specified relative because the natural parent is not in the home in accordance with rule 5101:1-40-01 of the Administrative Code;

(d) A child born after healthy families/LIF is terminated or an individual who returns home after healthy families/LIF is terminated; and

(e) Parents or specified relatives of children for whom federal, state, or local foster care maintenance payments are made, who are otherwise eligible for healthy families/LIF.

(3) “Individual” is the applicant or recipient of a medical assistance program.

(C) Eligibility criteria.

(1) The assistance group must meet the medicaid eligibility criteria in accordance with the eligibility rules contained in Chapters 5101:1-37 to 5101:1-42 of the Administrative Code.

(2) The assistance group must have become ineligible to receive healthy families/LIF wholly or partly as a result of new or increased receipt of child or spousal support under title IV-D of the Social Security Act.

(3) The assistance group must have been eligible for and received healthy families/LIF in the state of Ohio in at least three of the six months immediately preceding the month in which the assistance group became ineligible for healthy families/LIF.

(D) Eligibility period.

(1) The eligibility period is four calendar months beginning with the first month of ineligibility for healthy families/LIF.

(2) There is no eligibility redetermination for assistance groups that receive four-month extended coverage.

(3) If an individual loses eligibility for four-month extended coverage during the four-month period, the individual cannot become eligible for four-month extended coverage during the same four-month period. However, the individual may be found eligible during the same four-month period under another category of medicaid.

(E) Administrative agency responsibilities.

(1) The administrative agency shall determine medicaid eligibility in accordance with the eligibility rules contained in Chapters 5101:1-37 to 5101:1-42 of the Administrative Code.

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

(3) The administrative agency shall not terminate medical assistance for a member(s) of an assistance group until a pre-termination review (PTR) of continuing medicaid or medical assistance eligibility has been completed in accordance with rule 5101:1-38-01.1 of the Administrative Code.

HISTORY: Replaces former rule 5101:1-40-05.9; Eff. 1-1-05

Promulgated Under: 111.15

Statutory Authority: 5111.01

Rule Amplifies: 5111.01, 5111.012

R.C. 119.032 review dates: 01/01/2010

Rescinded eff 1-1-05

(A) In accordance with section 5107.16 of the Revised Code, an adult member of an OWF assistance group who is subject to an OWF sanction as a result of a self-sufficiency contract failure does not lose eligibility for healthy families/LIF medicaid as a result of a first or second failure to comply without good cause.

(B) An adult member of an OWF assistance group who is sanctioned as a result of her/his own third or subsequent failure to comply with a provision of an OWF self-sufficiency contract related to a work activity as defined in division (D) of section 5107.40 of the Revised Code loses eligibility for healthy families/LIF medicaid until he/she complies with the work activity as described in paragraph (C) of this rule. Before proposing to terminate the sanctioned adult’s medicaid eligibility under this paragraph, the CDJFS must complete a pre-termination review (PTR) of continuing medicaid eligibility for the sanctioned adult under every other medicaid category as described in rule 5101:1-38-01.1 of the Administrative Code.

(C) There is no minimum sanction period for the sanctioned adult member of the assistance group who has lost eligibility under the provisions outlined in paragraph (B) of this rule. The sanctioned adult immediately regains medicaid eligibility by complying with the work activity. The CDJFS must permit the sanctioned adult to comply immediately without any delay due to the OWF minimum sanction period. Immediately upon compliance, the sanctioned adult shall be eligible for healthy families/Lif medicaid as described in rule 5101:1-40-02.1 of the Administrative Code beginning the first day of the month in which he/she complies.

(D) The eligibility for covered families and children medicaid of a pregnant woman (Including a woman in her sixty-day postpartum period), a non-sanctioned adult, or minor child who is a member of an OWF assistance group subject to an OWF sanction is not affected at any tier.

HISTORY: Eff 7-1-00; 10-1-01

Rule promulgated under: RC 111.15

Rule authorized by: RC 5111.011

Rule amplifies: RC 5107.16, 5111.01, 5111.011

RC 119.032 REVIEW DATES: 7/1/2005

(A) This rule describes two medicaid covered groups:

(1) Pregnant women; and

(2) Low income children with income no more than two hundred per cent of the federal poverty level (FPL), including children with no creditable insurance, from birth until the individual reaches age nineteen, who are not eligible under any other category of medicaid.

(B) Definitions.

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

(2) “Countable income” means the amount of income compared to the appropriate payment or need standard to determine if an individual is eligible for medicaid. Countable income is determined by adding all of a family’s nonexempt unearned income to nonexempt earned income after subtracting all appropriate disregards.

(3) “Creditable insurance” means health insurance coverage as defined in 42 U.S.C. 300gg (a) to (c) as in effect on January 1, 2008.

(a) This includes, but is not limited to, coverage under a group health plan, either group or individual health insurance, the federal employee health benefit program, and a public health plan.

(b) Creditable insurance does not include coverage consisting solely of expected benefits, including but not limited to coverage only for accidents, disability income insurance, liability insurance, supplemental policies to liability insurance, worker’s compensation insurance, automobile medical payment insurance, credit-only insurance, coverage for on-site medical clinics, or limited-scope dental, vision, or long-term care insurance.

(4) “Family” has the same meaning as in rule 5101:1-40-01 of the Administrative Code.

(5) “Income” has the same meaning as in rule 5101:1-40-20 of the Administrative Code.

(6) “Individual”, for the purpose of this rule, means a child younger than age nineteen or a pregnant woman.

(7) “Medical verification of pregnancy” means a written statement signed by a doctor or nurse verifying pregnancy and the expected date of delivery or confinement as well as the number of fetuses.

(8) “Postpartum coverage” means a span of medicaid eligibility that begins on the last day of a pregnancy (if the woman was eligible for and receiving medicaid on that date) and ends on the last day of the month in which the sixtieth day (after the last day of the woman’s pregnancy) falls.

(C) Eligibility criteria.

(1) Countable income must be no more than two hundred per cent of the FPL for the appropriate family size.

(2) There is no resource limit.

(3) Eligibility for low income children.

(a) There are two standards for children with income no more than two hundred per cent:

(i) A child whose family’s countable income is no more than one hundred fifty per cent of the FPL remains eligible for medicaid even if the child is covered by creditable insurance;

(ii) A child whose family’s countable income is more than one hundred fifty per cent but no more than two hundred per cent of the FPL is only eligible for medicaid if the child is not covered by creditable insurance as per paragraph (B)(3) of this rule.

(b) Children already in receipt of medicaid under this program at age eighteen, will remain eligible through the end of the month in which he or she turns nineteen.

(4) Eligibility for pregnant women.

(a) Determination of income at initial eligibility during pregnancy:

(i) If a pregnant woman is married and living with her spouse, his income must be considered.

(ii) If a pregnant woman is younger than eighteen, unemancipated, and living with her parents, the income of her parents must be considered.

(b) Income eligibility for pregnant women:

(i) A pregnant woman with countable income of no more than one hundred fifty per cent of the FPL for her family size is financially eligible for medicaid.

(ii) If a pregnant woman has countable income of more than one hundred fifty per cent but no more than two hundred per cent of the FPL for her family size:

(a) Income is disregarded in the amount of the difference between two hundred per cent and one hundred fifty per cent of the FPL for her family size; and

(b) She is financially eligible for medicaid.

(c) Eligibility for a pregnant woman, once established, continues throughout pregnancy and the postpartum period without redetermination and regardless of changes in her family income.

(i) An individual may have retroactive eligibility for up to three prior months during which she was pregnant.

(ii) To be eligible for postpartum coverage, an individual must be receiving medicaid on the date her pregnancy ends.

(d) Family size. When determining an individual’s eligibility for medicaid as a pregnant woman, the family size includes the unborn child or children.

(i) If the number of fetuses is not on the medical verification of pregnancy, eligibility shall be determined using an assumption there is one fetus.

(ii) A pregnant woman found ineligible due to excess income must be informed that the number of fetuses may affect eligibility and be given an opportunity to verify the number of fetuses.

(D) Individual responsibilities. The individual must:

(1) Cooperate in establishing eligibility and provide verification in accordance with Chapter 5101:1-38 of the Administrative Code;

(2) Provide medical verification of pregnancy, if applying for medicaid as a pregnant woman; and

(3) Inform the administrative agency of any available health insurance coverage according to rule 5101:1-38-02.2 of the Administrative Code.

(E) Administrative agency responsibilities. The administrative agency must:

(1) Determine medicaid eligibility in accordance with the eligibility rules contained in Chapters 5101:1-37 to 5101:1-42 of the Administrative Code;

(2) Not require an individual to complete a face-to-face interview;

(3) Perform a redetermination of the eligibility of low income children every twelve months;

(4) Explore eligibility for other categories of medicaid under low income families or medicaid for the aged, blind, and disabled, as described in Chapters 5101:1-37 to 5101:1-42 of the Administrative Code, before approving coverage as a pregnant woman or child under two hundred per cent of the FPL;

(5) Not terminate medicaid for a member of an assistance group until a pre-termination review (PTR) of continuing medicaid or medical assistance eligibility has been completed in accordance with rule 5101:1-38-01.1 of the Administrative Code; and

(6) Issue proper notice and hearing rights as outlined in division 5101:6 of the Administrative Code.

Replaces: 5101:1-40-08

Effective: 01/01/2008

R.C. 119.032 review dates: 01/01/2013

Promulgated Under: 111.15

Statutory Authority: 5111.01, 5111.012, 5111.013

Rule Amplifies: 5111.01, 5111.012, 5111.013, 5111.014

Prior Effective Dates: 10/1/89 (Emer.), 12/16/89, 10/1/90, 4/4/98, 11/19/99 (Emer.), 1/1/98 (Emer.), 1/1/00, 7/1/00, 9/20/03

(A) This rule defines how the administrative agency shall compute income for purposes of determining medicaid eligibility under the healthy start covered group.

(B) Definitions.

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

(2) “Assistance group” is defined in accordance with rule 5101:1-38-01.2 of the Administrative Code.

(C) Administrative agency responsibilities.

(1) The administrative agency shall determine medicaid eligibility in accordance with the eligibility rules contained in Chapters 5101:1-37 to 5101:1-42 of the Administrative Code.

(2) The administrative agency shall determine if the assistance group meets the income criteria for medicaid eligibility under the healthy start covered group by utilizing the following procedure:

(a) Total all gross income, earned and unearned, of the assistance group, in accordance with Chapter 5101:1-40 of the Administrative Code; then

(b) Exclude all appropriate income exemptions in accordance with Chapter 5101:1-40 of the Administrative Code; then,

(c) Subtract all appropriate income disregards in accordance with Chapter 5101:1-40 of the Administrative Code.

(d) The remainder is the countable income.

(i) The assistance group meets the healthy start income criterion if the assistance group’s countable income is equal to or less than the appropriate healthy start standard, as stated in rule 5101:1-40-26 of the Administrative Code.

(ii) The assistance group does not meet the healthy start income criterion if the assistance group’s countable income is greater than the appropriate healthy start standard, as stated in rule 5101:1-40-26 of the Administrative Code.

HISTORY: Eff 10-3-86; 1-1-88 (Emer.); 3-28-88; 1-1-89 (Emer.); 3-6-89; 4-5-89 (Emer.); 6-18-89; 10-1-90; 4-4-98; 2-3-00; Replaces: 5101:1-40-08.1, eff. 1-1-05

Rule promulgated under: RC 111.15

Rule authorized by: RC 5111.01, 5111.013

Rule amplifies: 5111.01, 5111.012, 5111.013

R.C. 119.032 review dates: 12/01/2009

(A) To be eligible for CFC, an otherwise eligible individual must live in an appropriate living arrangement as defined within this rule. Living in an appropriate living arrangement does not confer any specific status regarding whether the individual meets the other CFC eligibility requirements, nor does it address whether the individual’s financial eligibility is as an individual or if the individual is to be considered temporarily absent from another assistance group under the provisions of rule 5101:1-40-01(J)(5) of the Administrative Code. An exception exists for a child(ren) born to or living with an inmate of a public institution, correctional facility, or other inappropriate living arrangement. Unless the child is detained or otherwise committed to the facility, the child is not considered to be an inmate and shall be treated as though living in an independent living arrangement. The following are the eligible living arrangements for CFC medicaid:

(1) A certified private nonprofit child care institution:

A “certified private nonprofit child care institution” is one which has been certified by ODJFS. The term does not include detention facilities, forestry camps, training schools, or any other facility operated primarily for the detention of children who are determined to be delinquent.

(2) A certified private foster family home.

(3) A residential community group home. A “residential community group home” is defined as a residence where a number of individuals reside and receive room, board, and some limited personal care and supervision. It is not considered a medical or institutional facility and does not include correctional or holding facilities for individuals who are prisoners, or facilities that are operated to serve children as the majority of its residents.

(4) A subsidized adoption placement.

(5) Living in the individual’s own home.

(6) Living with nonrelative adults.

(7) Living with a specified relative.

(8) A private nonprofit group home.

(9) A certified public child care institution:

A “certified public child care institution” is one which has been certified by ODJFS and accommodates no more than twenty-five children. The term does not include detention facilities, forestry camps, training schools, or any other facility operated primarily for the detention of children who are determined to be delinquent.

(B) Individuals placed or residing in public facilities are not eligible for covered families and children medicaid because they are inmates of a public institution. A “public facility” is defined as any institution, group home, foster home, or other facility that is the responsibility of a governmental unit, or over which a governmental unit has responsibility or administrative control.

(C) A public institution does not include a medical institution. An individual is not considered an inmate of a public facility until he has resided therein for a full calendar month.

(D) A public institution does not include a publicly operated community residence. Individuals placed in publicly operated community residential facilities are eligible for covered families and children medicaid coverage if all other eligibility factors are met. A “publicly operated community residential facility” is one that is designed or has been changed to serve no more than sixteen residents. The facility must provide some services beyond food and shelter such as social services, help with personal living activities, or training in socialization and life skills. the facility may provide occasional medical or remedial care. Residential facilities located on the grounds of, or immediately adjacent to, any large institution or multiple-purpose complex are not included in this definition even though they serve sixteen or fewer residents. The nature of a residential facility is residential and not institutional; also, its residents need not be children.

A “publicly operated community residential facility” does not include correctional or holding facilities for individuals who are prisoners.

(E) An individual who is committed by the court to a correctional institution for detention in connection with a violation of the law is considered an inmate of a penal institution and is not eligible for covered families and children medicaid.

(F) Children who remain in the custody of the court or the Ohio department of youth services for reasons other than detention as a delinquent but have been placed in one of the living arrangements described in paragraph (A) of this rule by the court may be eligible for covered families and children medicaid.

HISTORY: Eff 6-1-84; 8-1-86 (Emer.); 10-3-86; 3-1-94 (Emer.); 7-1-00; 6-1-02 (Emer); 8-30-02

Rule promulgated under: RC 111.15

Rule authorized by: RC 5111.01, 5111.011

Rule amplifies: RC 5111.01, 5111.011

R.C. 119.032 review dates: 7/1/2005

Rescinded eff 5-22-06

Rescinded eff 12-1-05

Rescinded eff 1-1-08

(A) Application of resource policy

The resource policy stated in this chapter do not apply to the following covered families and children (CFC) medicaid covered groups:

(1) Healthy families/low-income families (LIF) assistance groups.

(2) Transitional medicaid assistance groups.

(3) Healthy start assistance groups.

(4) Expedited medicaid assistance groups.

(5) Four-month extended medicaid assistance groups.

(B) Resources: definitions, principles, and availability

(1) Resources are those possessions belonging to members of an assistance group that may be used for their support. Resources include personal property, real property, and liquid assets as well as assets not in a liquid form. All resources belonging to members of an assistance group must be considered in order to determine their value and availability. The resources of certain individuals whose needs are not included in the assistance group are also considered and applied toward the resource limit, as defined in paragraph (C) of this rule. The resources of the following individuals are counted:

(a) Individuals who are ineligible due to the individual’s third failure without good cause to participate in an OWF work activity

(b) Individuals who are non-qualified aliens; and

(c) Individuals who are ineligible for medicaid due to failure to cooperate with medical support requirements.

(2) Ownership of a resource must be clearly established to evaluate availability.

(a) A resource owned solely by a member of the assistance group (or an individual excluded in paragraph (B)(1) of this rule) is considered to be available in its entirety to the assistance group.

(b) A resource owned in common with an individual other than a member of the assistance group (or individual excluded in paragraphs (B)(1)(a) to (B)(1)(c) of this rule) is considered to be available to the assistance group on a prorated basis unless documentation is provided to the contrary. When ownership is shared unequally, the CDJFS must determine the amount of the resource that is available to the assistance group.

(c) Only resources in which the assistance group has a legal interest and the legal ability to use or dispose of are to be counted.

(d) If the ownership of the resource is shared, the assistance group’s ability to use or dispose of the resource must be determined.

(e) When a member of the assistance group shares ownership of a resource with another person who is not a member of the assistance group, it is assumed that the ability to use and dispose of the resource exists unless the assistance group can provide documentation to the contrary. If the owner who is not the assistance group member (or an individual excluded in paragraph (B)(1) of this rule) indicates the intention of blocking the assistance group’s use or disposal of the resource, the assistance group should be referred to available legal services. If legal means of pursuit are available, the assistance group is required to take any and all necessary action to make the resource available. If the assistance group is unwilling to take action to make the resource available, the application must be denied or the assistance terminated. If the assistance group is unable to make the resource available because one of the owners cannot be located, the cost of legal action is prohibitive, etc., the resource is not considered to be available to the assistance group. When there is good cause for being unable to obtain all necessary verification related to availability, an application must be approved pending the receipt of the verification. Availability of the resource must be reviewed at each reapplication.

(3) The CDJFS must consider whether the individual resides with the parent(s) or a spouse. Resources of the parent(s) or a spouse are not considered when determining eligibility if:

(a) A natural or adoptive parent or a spouse is in receipt of SSI; or

(b) An individual does not live in the same household as his parent(s).

(4) For a resource to be considered in determining CFC medicaid eligibility, it must be available to the assistance group. Available is defined as accessible. A resource is considered to be available to the assistance group as long as the owner of the resource (who is a member of the assistance group), or any other member of the assistance group (or any of the specifically excluded individuals identified in paragraph (B)(1) of this rule) is aware, or has reason to be aware of the resource. If the recipient convinces the CDJFS that all members of the assistance group were unaware of the resource and had no reason to be aware of the resource, then the resource shall be considered to have been unavailable. The assistance group has the burden of proving that each member of the assistance group (including the specifically excluded individuals identified in paragraph (B)(1) of this rule) was unaware of and had no reason to be aware of the resource. The resource will be considered to have been unavailable only for the period of time the assistance group can demonstrate that they had no reason to be aware of the resource. Once any member of the assistance group (or any of the individuals identified in paragraph (B) of this rule) becomes, or has reason to become aware of the existence of the resource, the resource will be considered available to the assistance group. The assistance group must have the legal right to control and dispose of the property for it to be counted as a resource.

(5) A resource must be both liquid and available to be considered in determining eligibility for assistance.

(6) The assistance group must have the legal right to dispose of the resource being considered.

(7) The resources of a parent who is living in the home but is not included in the assistance group are counted against the resource limitation on the following basis:

(a) All resources held by the natural parent are available to the child(ren) in their entirety except as specified in paragraph (B)(3) of this rule.

(b) All resources owned solely by the stepparent are not considered available to the natural parent and/or the natural parent’s child(ren).

(c) If a resource is jointly owned and listed with the names connected by “and,” the resource is divided equally between the couple. If a resource is jointly owned but is listed with the names connected by “or,” the resource is considered available in its entirety to the natural parent. All of the resource is then available to the natural parent’s child(ren).

(8) On occasion, an assistance group cannot liquidate nonexempt personal property which causes ineligibility because of legal technicalities, general economic conditions in the community, or the inability to find a buyer. When a bona fide effort as specified in paragraph (B) of rule 5101:1-39-32.1 of the Administrative Code is made to dispose of a resource and evidence shows there is not a current market for the personal property, then the personal property is not counted.

(a) Unavailability of the personal property must be reevaluated at every reapplication.

(b) When personal property has been declared unavailable due to a lack of purchase offers, the assistance group must continue attempts to sell the personal property.

(c) When personal property has been declared unavailable due to a specified condition, the CDJFS must confirm from the assistance group that the specified condition which made the personal property unavailable still exists.

(C) Resources: limitations

(1) The total equity value of all countable real property, personal property, and liquid assets owned by members of the assistance group cannot exceed one thousand dollars for an assistance group of any size. “Equity value” means fair market value minus liens or encumbrances (legal debts). “Fair market value” means the price an item of a particular make, model, size, material, or condition will sell for on the open market in the geographic area involved.

(2) The one thousand dollar resource limit does not include:

(a) Homestead property which is the usual residence of the assistance group.

(i) Homestead property includes one home and all adjoining land.

(ii) “Adjoining land” means land which is not separated by intervening property owned by someone else. Land which is separated by roads, rivers, streams, etc., is considered to be adjoining.

(b) One motor vehicle, the value of which does not exceed one thousand five hundred dollars with consideration of liens or encumbrances.

(i) If this vehicle has any excess value over the one thousand five hundred dollar limit, the excess is applied to the overall one thousand dollar resource limitation.

(ii) The value of all other motor vehicles, with consideration of liens or encumbrances, is counted toward the one thousand dollar resource limitation.

(c) Items or personal property owned by members of the assistance group that are considered as household goods and personal effects.

(d) The resources of an SSI recipient.

(e) Funeral agreements valued at one thousand five hundred dollars or less for each member of the assistance group. Equity value for funeral agreements that exceed one thousand five hundred dollars per assistance group member shall be counted toward the one thousand dollar resource limitation.

(f) One burial space for each member of the assistance group.

(g) Bona fide loans from any source.

(h) Educational grants and scholarships from any source for undergraduate and graduate college expenses.

(i) Payments received by individuals of Japanese ancestry under section 105 of Public Law 100-383, and payments received by Aleuts under section 206 of Public Law 100-383.

(j) Payments received under the provisions of the Agent Orange Compensation Exclusion Act (Public Law 101-201) received on or after January 1, 1989.

(k) Earned income tax credit (EITC) payments received after December 31, 1990 in the form of a refund of federal income taxes or in the form of an advance payment by an employer must be disregarded in the month of receipt of such payment and in the month following. When an applicant has received the EITC refund in the month prior to application, any remaining portion of the EITC payment will be considered an exempt resource in the month of application.

(l) Effective May 1, 1991, the resources of an individual on whose behalf federal, state or local foster care maintenance payments are made.

(m) Effective May 1, 1991, the resources of an individual who is excluded from the OWF assistance group on whose behalf federal, state or local adoption assistance payments are made.

(n) Payments received under the provisions of the Radiation Exposure compensation Act (Public Law 101-426) received on or after October 15, 1990.

(o) Many federal statutes provide for the exclusion from income and resources of certain payments made to members of Indian tribes and groups. Due to the number of statutes that affect CFC medicaid eligibility, ODJFS will exclude from income and resources for CFC medicaid purposes any payments that are also excluded under the supplemental security income (SSI) program.

(p) Payments received under the provisions of the “Child Care and Development Block Grant” (Section 5082 of Public Law 101-508).

(q) Escrow accounts established and credited as the direct result of the assistance group’s involvement in the “Family Self-Sufficiency Program” on or after May 13, 1992. These escrow accounts are only considered available when the assistance group is no longer receiving any federal, state, or other public assistance for housing.

(r) Effective February 28, 1994 the resources of an individual for whom federal, state or local foster care maintenance or adoption assistance payments are being made.

(s) As a result of the settlement contained in H.B. 2015, none of the payments made from any fund established pursuant to a class settlement in the case of “Susan Walker v. Bayer Corporation,” et al., 96-C-5024 N.D. Ill.) shall be considered income or resources when determining eligibility. Interest received as a result of this settlement is not excluded for resource purposes.

(t) Assistance payments in the month in which they are received.

(u) Child support payment distributions made by ODJFS pursuant to division (C) of Section 1 of Am. S.B. 170 of the 124th General Assembly and rules 5101:1-29-31.1 and 5101:1-29-31.2 of the Administrative Code shall be excluded from consideration as income or resources in the financial eligibility determination for CFC medicaid.

(3) The one thousand dollar resource limit does include:

(a) The equity value of real property not used as the residence of the assistance group, assessed according to its equity value. Any income received from income-producing property is counted as income to the case.

(b) The equity value of any burial spaces in excess of one per person.

(c) The cash value of life insurance policies.

(d) Household goods and personal effects not considered as exempt resources.

HISTORY: Eff 6-1-76; 12-31-77; 2-3-80; 5-29-80; 1-1-81; 10-1-81; 5-7-82; 7-15-84; 10-1-84 (Emer.); 12-27-84 (Emer.); 1-1-85 (Emer.); 4-1-85 (Emer.); 4-1-88; 6-30-88; 4-1-89 (Emer.); 5-28-89; 7-1-89 (Emer.); 9-23-89; 12-1-89 (Emer.); 6-1-90; 5-1-91 (Emer.); 7-11-91 (Emer.); 9-22-91; 4-1-92; 9-1-92; 10-1-92 (Emer.); 9-1-94; 8-1-95; 10-31-97 (Emer.); 1-26-98; 1-1-03

Rule promulgated under: RC 111.15

Rule authorized by: RC 5111.01, 5111.011

Rule amplifies: RC 5111.01, 5111.011

R.C. 119.032 review dates: 04/05/2002 and 01/01/2008

(A) “Personal property” consists of those resources that are available for the support or maintenance of a person’s needs. It consists of those items which are easily transported and stored, such as cash, bonds, life insurance, motor vehicles, etc.

(B) All liquid assets are countable resources. “Liquid assets” are those resources which are in cash or payable in cash upon demand. The most common types of liquid assets are cash on hand, savings accounts, checking accounts, trusts, stocks, and mortgages. The value of such items must be assessed, combined with the value of all other countable resources, and counted toward the one thousand dollar resource limitation.

(C) Checking and savings accounts are considered as cash since deposits are payable on demand.

(1) In a joint account, all funds in the account are a resource to the individual if he has unrestricted access to them.

(2) When an account is shared with others and the amount of funds has an effect on the individual’s eligibility, the CDHS shall inform the individual that if he has restricted access to the account by the contract with the financial institution or if a substantial portion of the account was contributed by another person, he must provide documentation to support his contention.

(a) A depository account/signature card will show who has access to the funds. This is the contract with the financial institution and it shows whether or not the signatures of more than one owner of the account are needed to withdraw from the fund. A statement from the financial institution is also acceptable documentation.

(i) If the documentation indicates access is restricted to the account through the need for the signature of other owners, then the account is considered to be owned by the recipient in proportion to the number of other owners.

(ii) If the applicant’s signature is all that is needed to access the account, the account is his in its entirety unless documentation is provided that indicates another person deposited a substantial portion of the funds and claims ownership of his share.

(iii) When an individual provides documentation that shows the other person(s) has a substantial interest in the account, only the portion the applicant/recipient contributed shall be considered a resource. Interest accrued on the account shall be allocated according to the portions of ownership. Documentation which explains the reason for the joint account, who made the deposits/withdrawals as well as corroborating statements from the co-owner(s) of the account must be obtained by the CDHS.

(iv) If it is determined the individual’s share of the resource is within the allowable limit, assistance can be approved or continued and the individual shall be required to remove his assets from the joint account within sixty days from the date his eligibility is established.

(v) If the co-owner(s) of the joint account is incompetent or a minor, a corroborating statement from the co-owner(s) is not necessary. A corroborating statement from a third party who has knowledge of the circumstances surrounding the joint account is necessary. If there is no third party, the CDHS shall make a determination whether or not assistance can be approved/continued and document the basis of that decision in the case record.

(b) A checking account is verified by examining the last monthly bank statement and the checkbook record to arrive at the current account balance. If the statement shows deposit/withdrawal activity which is inconsistent with the individual’s stated financial situation further investigation as well as documentation for the case record may be necessary.

(c) A savings account is verified by examining the last monthly bank account statement or the passbook. Photocopies of page(s) showing activity during the last sixty days should be maintained for the assistance group record. If the statement shows deposit/withdrawal activity which is inconsistent with the individual’s stated financial situation, further investigation as well as documentation for the record may be necessary.

(3) Past-due benefits and other underpayments that exceed six times the monthly SSI payment deposited into a dedicated financial institution account and any accrued interest or other earnings on such an account are excluded from income and resources.

(a) For any month that funds other than accrued interest or other earnings on the account are commingled in this account, the exclusion does not apply to any funds in the account. Exception: if the financial institution requires the individual to deposit money to open an account, e.g., minimum deposit, a small amount of other funds can be used to open the dedicated account. However, the funds that were used to open the account are not exempt as a resource and must be removed from the account once the account has been established and the past-due benefits paid into it. The funds that were used to open the account must be withdrawn before the end of the month following the month that the past-due benefits are paid.

(b) A dedicated account is an account in a financial institution, the sole purpose of which is to receive and maintain SSI past-due benefits which are required or allowed to be paid into such an account and the use of which is restricted by section 1631(a)(2)(F) of the Social Security Act. Funds other than those described above may not be deposited into a dedicated account.

(c) Past-due benefits are SSI benefits due but unpaid which accrue prior to the month payment was effectuated, benefits due but unpaid which accrue during a period of suspension from SSI payments for which the individual was subsequently determined to have been eligible, and any adjustment to SSI benefits which results in an accrual of unpaid benefits.

(d) The individual’s representative payee shall use funds in the account to pay for the following allowable expenses: education or job skills training, personal needs assistance, special equipment, housing modification, medical treatment, therapy or rehabilitation, or any other item or service that the commission for social security determines to be appropriate provided that such expense benefits the individual and, in the case of personals needs assistance, special equipment, housing modification, therapy or rehabilitation or other approved item, is related to the impairment (or combination of impairments) of the individual. These expenditures do not affect an individual’s income or resources.

(e) Restrictions on the use of funds in a dedicated account continue to apply during a period of suspension from SSI payments, non-pay status, and SSI eligibility but no payment. The exclusion from resources of the funds in the account continues to apply until SSI eligibility is terminated. Once an individual’s eligibility has been terminated, the exclusion of the funds in a dedicated account cannot be carried over if the individual establishes a new period of SSI eligibility by filing a new application for SSI. Reopening of a prior period of eligibility following termination is not a new period of eligibility and, therefore, the exclusion may be reapplied. Any remaining funds are a countable resource.

(f) The individual must provide verification that a dedicated account has been established. The verification should include the name and address of the financial institution, account number, account title, type of account, and the amount of money in the account.

(g) When an individual receives past-due benefits that may be, but have not yet been, deposited into a dedicated account, the payment is excluded for the lesser of six months or until the payee deposits the payment into the dedicated account. Past due benefits that are less than or equal to the amounts described above may be, but are not required to be, deposited in the account at the option of the representative payee.

(D) Stocks. The value of a stock is determined by the demand for it when it is bought and sold. As the result of constant trading, the value of stocks frequently varies from day to day. The value of stock is the closing price published in a newspaper. The value of stocks traded over the counter is expressed on a “bid” and “asked” basis. The bid price is used to determine the value of a stock. If the closing or bid price of a stock is not shown, a local securities firm must determine its value. If the ownership of the stock is shared, i.e., more than one name is on the face of the stock certificate, it is jointly owned and each person’s share is equal.

Shares of stock in an Alaskan native regional or village corporation are exempted from resources.

(E) Bonds. A U.S. savings bond is an obligation of the federal government but unlike other government bonds, it is not transferrable; that is, it can only be sold back to the government. Several series of U.S. savings bonds E, G, I, J, H can be quickly converted into cash at local banks; however, some bonds, including series E bonds, must be held at least sixty days from the date of issuance before they can be cashed. Other than those bonds which must be held at least sixty days from the date of issuance before being converted into cash, most savings bonds are convertible within one to two days.

(1) U.S. savings bonds are usually registered in the name of the owner(s) shown on the front of the bond and may be redeemed by the owner by completing a form on the back of the bond. If ownership of the bond is shared (more than one name is on the face of the bond), it is jointly owned and each person’s share is equal, but any one of them can dispose of the bond.

(2) In establishing the value of a U.S. savings bond, the date of issuance on the face of the bond is controlling. The value of the bond depends on the time elapsed from the date of issue. Although many U.S. savings bonds have a table of values on the reverse of the bond, this table is often inaccurate since the interest rate on U.S. bonds may have changed since the bond was issued. A bank can determine the current value. The CDHS must document the name and title of the person from the bank who provided the information, and the current value of the bond.

(F) Mortgages. A mortgage is a pledge of a particular property for the payment of a debt or the performance of some other obligation within a prescribed time period. A mortgage may generally be discounted or sold. The amount for which the mortgage could be discounted or sold is the amount of the countable resource. A bank, savings and loan company, or real estate broker is contacted to determine whether a mortgage can be discounted or sold and the amount for which it can be discounted or sold.

(G) Dividends and interest. Accrued dividends and interest on savings accounts, certificates, stocks, bonds, etc., are added to the principle and the total evaluated as a liquid asset. Dividends and interest which are paid directly to the family and are not added to the value of the resource are unearned income.

(H) Retirement plans. The amount of funds which an assistance group member is able to withdraw from KEOGH plans, 401k plans, individual retirement accounts (IRAs), or the Ohio deferred compensation program shall be considered as resources. No portion of the funds withheld for payment of any penalty for early withdrawal (such as taxes, fees, interest, charges, etc.) shall be considered as part of the resource. The funds shall be considered as a resource as of the date that the assistance group member actually receives the funds.

(I) Life insurance. The cash value of all life insurance of any member of the assistance group is a resource. In order for the value of any life insurance policy to be considered in the total amount of resources, it is necessary that the policy be owned by the applicant/recipient or a member of the assistance group. The cash value of any life insurance must be assessed, combined with the value of all other countable resources, and counted toward the one thousand dollar resource limitation.

(1) The CDHS must verify the cash value of life insurance policies and record the information in the assistance group record. The policy itself generally provides all information needed to determine any cash value that may be available.

(2) The CDHS must contact the insurance company or local agent if the policy does not provide the information needed to establish the cash value of the policy.

(J) Motor vehicles. Motor vehicles include automobiles, trucks, campers, buses, vans, motorcycles, trailers, boats, snowmobiles, and airplanes. One motor vehicle is exempt as a resource if its value does not exceed one thousand five hundred dollars with consideration of liens and encumbrances. If this vehicle has any excess value over the one thousand five hundred dollar limit, the excess value is applied to the overall one thousand dollar resource limitation.

(1) The “net value” of a motor vehicle is its current market value minus any liens or encumbrances. The market value is determined from the current month’s “NADA Official Used Car Book”, using the column headed “average trade in,” for the particular year and model, taking into consideration all options on the vehicle and its high or low mileage. Verification of the vehicle’s description (year, make, model) and of liens or encumbrances must be secured. For vehicles not listed in the “NADA Official Used Car Book,” the CDHS shall assist the applicant/recipient in obtaining an appraisal of the current market value from a recognized dealer.

(2) There may be instances when an individual will dispute the “NADA” book value of the vehicle for reasons, such as damage or inoperability. The individual shall be given the opportunity to acquire an independent verification of the value, at his own expense, from a recognized dealer. The individual shall be advised that the CDHS’ final determination of value is not bound by such an appraisal but that it will be considered in the evaluation.

(3) If a vehicle is no longer listed in the “NADA” book, the individual’s independent estimate of the value shall be accepted, unless there is reason to believe that the estimate is incorrect. If it appears that the vehicle’s value will affect eligibility, the individual shall obtain an appraisal or produce other evidence of its value, such as tax assessment, insurance company estimate, or newspaper advertisement indicating the sale price of similar vehicles. The individual shall provide verification of the value of licensed antique, custom made, or classic vehicles.

(K) Funeral agreements. A “funeral agreement” is defined as a preneed (prepaid) funeral contract, written agreement, contract or series of contracts to provide funeral services and/or funeral goods to be used in connection with the funeral or final disposition of human remains. Payment for these goods or services is made outright or on an installment basis prior to the death of the person so purchasing them or for whom they are purchased.

(1) All payments for funeral goods and services made under a preneed funeral contract remain intact as a fund held by a financial institution or in a common or pooled trust fund until the death of the person for whose benefit the agreement is made or until the goods or services are delivered.

(2) Any deposit may be released upon demand of the person for whose benefit such deposit was made or upon the demand of the seller for its share of the deposited funds and earned interest if the contract has been canceled.

(3) Funeral agreements with equity value of fifteen hundred dollars or less for each family member are excluded from the resource limitation. If the equity value of funeral agreements exceeds fifteen hundred dollars, the excess value is counted toward the one thousand dollar resource limitation. Prior to determining whether the excess value is available to the applicant/recipient, the contract will have to be reviewed to determine whether it is revocable or irrevocable.

(L) Burial plots. The value of burial space held for the purpose of providing a place for burial for each member included in the assistance group is excluded and does not count toward the resource limitation. The equity value of any burial spaces in excess of one per person is countable toward the resource limitation.

(M) Household goods. Household goods are all personal property customarily found in the home and used in connection with the maintenance, use, and occupancy of the premises.

(N) Personal effects. Personal effects are other items of personal property normally held and recognized as incidental items intended for personal use by one or more household members.

HISTORY: Eff 6-1-76; 12-31-77; 2-3-80; 5-29-80; 1-1-81; 10-1-81; 5-7-82; 7-15-84; 10-1-84 (Emer.); 12-27-84; 1-1-85 (Emer.); 4-1-85; 5-3-85 (Emer.); 8-1-85; 1-2-86; 11-1-87; 10-1-90; 10-30-95; 10-1-97; 10-31-97 (Emer.); 1-26-98; 3-1-98 (Emer.); 5-1-98

Rule promulgated under: RC 111.15

Rule authorized by: RC 5111.01

Rule amplifies: RC 5111.01

REVIEW DATE: 1/26/03

(A) When an exempt resource is exchanged for another exempt resource of equal value, the resulting resource is exempt. When an exempt resource is exchanged for a nonexempt resource of any value, the nonexempt resource is a countable resource.

(B) When an exempt resource is sold, the resulting cash is an exempt resource for six months only if it will be used to purchase an exempt resource.

(C) A payment of disaster assistance, casualty insurance, or other settlement specifically designated to replace a resource lost due to a disaster is considered as a resource in the same manner as the exempt resource for a period of six months. When the individual intends to replace or repair the exempt resource but circumstances beyond his control prevent replacement or repair within a six month period, an extension of up to an additional six months may be granted. Any portion of the payment not used within the applicable period to make the replacement or repair of the item is considered to be a liquid asset subject to the resource limitation of one thousand dollars.

(D) When a nonexempt resource is replaced because of loss due to theft, accident, or disaster, the replacement amount of the replacement item is considered to be a nonexempt resource and is counted toward the one thousand dollar resource limitation.

(E) If a nonexempt resource is exchanged for another resource of the same type and of equal value, the new resource remains nonexempt. If a nonexempt resource is sold, the amount received can be considered as a nonexempt resource only if it is used to purchase the same type of nonexempt resource of equal value within a thirty day period of the sale. Otherwise, the amount received from the sale of the nonexempt resource is considered as income.

HISTORY: Eff 7-15-94; 10-31-97 (Emer.); 1-26-98

Rule promulgated under: RC 111.15.

Rule authorized by: RC 5111.01

Rule amplifies: RC 5111.01

REPLACES RULE 5101:1-3-056

REVIEW DATE: 1/26/03

(A) A trust is a right of property held by one party for the benefit of another. The person who holds the legal title to property for the benefit or use of another is the trustee.

(B) The CDHS should not automatically consider a trust unavailable. In some instances the beneficiary may petition the court to have funds released early in order to meet current needs. The applicant/recipient must attempt to make the resource available by consulting a legal aid service or the county prosecutor’s office. If the applicant/recipient is unable to make the resource available or the cost of legal action is prohibitive, the trust is considered unavailable. Unavailability must be reviewed at each reapplication.

(C) If the person who created the trust is the eligible applicant/recipient, the trust is considered a resource if he has the legal ability to dissolve it and to use the money.

(D) If an eligible applicant/recipient is a beneficiary of a trust, the trust is not considered as a resource to him when he cannot convert it to cash. Any payment he receives from the trust is unearned income.

(E) A person who is appointed a trustee generally cannot use any of the funds within the trust for his own benefit. Therefore, an individual may be a trustee of a valuable trust and not be able to receive money from it since he has no access to the funds for his personal use. Under such circumstances, it is not a resource to him. If an individual is acting as a trustee for a trust he created, the trust is a resource.

(F) Rule 5101:1-39-271 of the Administrative Code covering the treatment of medicaid trusts is applicable to all ADC-related medicaid assistance groups.

HISTORY: Eff 2-1-95; 10-31-97 (Emer.); 1-26-98

Rule promulgated under: RC 111.15.

Rule authorized by: RC 5111.012.

Rule amplifies: RC 5111.01

REPLACES RULE 5101:1-3-059

REVIEW DATE: 1/26/03

(A) Availability of income

(1) Income received by the covered families and children medicaid assistance group must be considered in determining need. Certain types of income are excluded from consideration and there are some disregards of income.

(2) “Income” is any benefit which is received by the individual during a calendar month as a result of current or past labor or services, business activities, interests in real or personal property, or as a contribution from persons, organizations, or assistance agencies. While an increase in income must be reported within ten calendar days from the date of the increase, the budg