Chapter 5101:1-40 Medicaid for Families and Children

5101:1-40-01 Covered families and children's (CFC) medicaid: assistance groups and definitions.

(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;

(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.

(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

5101:1-40-01.1 Covered families and children (CFC) medicaid: covered groups.

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);

(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

5101:1-40-02 Covered families and children medicaid: OWF recipients eligible for medicaid.

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

5101:1-40-02.1 Covered families and children medicaid: low-income families (LIF) and OWF covered groups.

(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.

(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

5101:1-40-02.2 Medicaid: coverage for children born to medicaid eligible women.

(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.

(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

(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

5101:1-40-02.3 Covered families and children medicaid: coverage for foster care maintenance and adoption assistance money payment recipients. [Rescinded]

Rescinded eff 1-1-08

5101:1-40-03 Medicaid: children in care and individuals younger than age twenty-one who have aged out of foster care.

(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.

(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

(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

5101:1-40-05 Medicaid: transitional medicaid.

(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,

(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;

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

(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.

(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.

(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.

(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.

(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

5101:1-40-05.1 Medicaid: four-month extended coverage.

(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.

(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.

(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

5101:1-40-05.9 Covered families and children medicaid: four-month extended coverage. [Rescinded]

Rescinded eff 1-1-05

5101:1-40-07 Covered families and children medicaid: medicaid eligibility and OWF sanctions.

(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

5101:1-40-08 Medicaid: coverage for children and pregnant women.

(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.

(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

5101:1-40-08.1 Medicaid: income computations for determining eligibility under the medicaid healthy start covered group.

(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.

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

(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,

(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

5101:1-40-09 Covered families and children medicaid: living arrangements. [Rescinded]

Rescinded eff 5-29-09

5101:1-40-09.2 Covered families and children medicaid: retroactive coverage. [Rescinded]

Rescinded eff 5-22-06

5101:1-40-09.3 Covered families and children medicaid: coverage for an individual added to an ongoing case. [Rescinded]

Rescinded eff 12-1-05

5101:1-40-10 Covered families and children medicaid: county case responsibility for individuals in custody of public children services and private child placing agencies. [Rescinded]

Rescinded eff 1-1-08

5101:1-40-14 Covered families and children (CFC) medicaid: resources: application, definitions, availability, and limitations.

(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

(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.

(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.

(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

5101:1-40-15 ADC-related medicaid: resources: liquid assets.

(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.

(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

5101:1-40-16 ADC-related medicaid: Exempt/nonexempt resources - exchange and transfer - emergency loss/replacement of exempt resources.

(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

5101:1-40-17 ADC-related medicaid: resources: trusts.

(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

5101:1-40-20 Covered families and children (CFC) medicaid: income.

(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 budget adjustment does not become effective until the first day of the month following the month in which the assistance group receives the increased income. Reference rule 5101:1-40-20.3 of the Administrative Code for information regarding unearned income. Reference rule 5101:1-40-20.4 of the Administrative Code for information regarding earned income.

(3) The determination of eligibility for covered families and children medicaid is dependent in part upon the amount of income available to the assistance group. Since covered families and children medicaid is a need-oriented program, there must be an established need for assistance. Those persons who have substantial income in excess of established need are not eligible for covered families and children medicaid even though the other eligibility requirements are met.

(4) It may be necessary in certain instances to apportion income to future months. Such income is current income for the month to which it is apportioned. For example, an employee under a contract of employment shall have the income from such contract averaged over the number of months covered under the contract. This is done regardless of whether the employee chooses to receive the income in fewer months than the contract covers or whether it is paid in fewer months at the convenience of the employer. Income apportioned toward future months is not counted as a current resource. Income apportioned to past months is considered a resource as long as it remains available.

(5) Income received by a member of the covered families and children medicaid assistance group is considered available to all members of the assistance group unless the income is earmarked as defined in rule 5101:1-40-01 of the Administrative Code. Reference rule 5101:1-40-20.7 of the Administrative Code for information regarding earmarked income.

(6) When a Title II beneficiary is a minor, benefits are usually paid through a representative payee. If the beneficiary is a member of the covered families and children medicaid assistance group, it is necessary to determine if the Title II benefits in their entirety are countable as income to the assistance group. Reference rule 5101:1-40-20.7 of the Administrative Code regarding the earmarking of income.

(a) The determination is first made by establishing whether or not the representative payee resides in the same household (i.e., residence) as the assistance group.

(b) If the representative payee resides in the same household, the total amount of Title II benefits received for the beneficiary is countable income.

(c) If the representative payee does not reside in the same household as the beneficiary, only that portion made available to the beneficiary and/or caretaker is countable.

(d) Title II benefits retained by a representative payee who does not reside in the same household as the beneficiary are not considered potential income. The requirement to explore potential income in accordance with paragraph (B) of this rule does not apply.

(7) If income is received jointly by a member of the assistance group and one or more persons not in the assistance group, the assistance group member’s portion to be considered available is the prorated share, unless evidence is produced to the contrary.

(8) The income and resources of a supplemental security income (SSI) recipient who is excluded from a CFC assistance group due to receipt of SSI are not countable to the remaining members of that CFC assistance group as set forth in rule 5101:1-40-01 of the Administrative Code.

(9) The income and resources (when appropriate) of a parent specifically excluded from the CFC assistance group due to non-qualified alien status or third tier work activity failure are counted in determining the assistance group’s eligibility. If the individual who is excluded due to failure to meet the citizenship requirement is a parent, individual’s income, less the disregarded amounts set forth in rule 5101:1-40-20.5 of the Administrative Code, is counted in determining the assistance group’s eligibility.

(10) The income and resources of parents or children for whom federal, state, or local foster care maintenance or adoption assistance payments are made are excluded.

(11) A nonrecurring lump-sum payment of unearned income is a money payment accrued over two or more months or a money payment not related to any time period, such as a death benefit or an inheritance. Such a nonrecurring lump-sum payment is considered unearned income unless otherwise exempted or excluded. It is unearned income only in the month received and as such, does not affect income eligibility as set forth in paragraph (A)(2) of this rule. Any portion of a nonrecurring lump-sum payment remaining in the month(s) following the month of receipt is a resource, countable when appropriate, pursuant to rule 5101:1-40-14 of the Administrative Code.

(B) Exploration of potential income.

(1) The CDJFS must explore with each assistance group the potential development of monthly income.

(a) The assistance group must apply for any monthly benefits to which it is entitled.

(b) It is not appropriate to require the assistance group to apply for lump-sum withdrawals of retirement or pension funds which would negate the drawing of monthly benefits in the near future.

(c) If otherwise eligible for healthy families/LIF, an SSI recipient shall have the choice of continuing to receive SSI or receiving healthy families/LIF, but may not receive SSI and healthy families/LIF at the same time. If an SSI recipient chooses to receive healthy families/LIF, the CDJFS must document that the SSI has been terminated prior to the approval of the individual for healthy families/LIF.

(2) Potential sources of income include, but are not limited to:

(a) Social security insurance, RSDI, railroad retirement, unemployment insurance, disability insurance, workers’ compensation.

(b) Benefits available to veterans, servicemen, and their dependents.

(d) Rights and interests in real and personal property.

(e) Responsible relatives, especially an absent parent, who may be contributing or have a legal liability to contribute.

(f) Other persons who may be contributing, i.e., a cash payment made voluntarily by an individual who is not an assistance group member to the assistance group for its unrestricted use (whether or not the individual who is not a member of the assistance group lives with the covered families and children medicaid assistance group). This does not include situations in which an individual shares a residence with an assistance group and shares responsibility for household expenses through an informal arrangement.

(g) The assistance group’s own capacity for self-help and employment.

(h) Private pension plans, union welfare funds, life insurance disability benefits, other forms of assistance, etc.

(3) The assistance group, including the person responsible for a child, is responsible for giving information necessary to income determinations, and for taking all actions necessary to obtain unconditionally available income.

(a) Income shall be unconditionally available if the assistance group has only to claim or accept the income, or to establish eligibility for the income; e.g., relative’s offer of a contribution, RSDI.

(b) Except for the provision in paragraph (B)(1)(c) of this rule, ineligibility for aid results if the assistance group refuses to accept unconditionally available income.

(1) All income of a member of the assistance group, and the parent living in the home, must be verified. Statements as to the amount and source of income must be verified and documentation contained in the case record. The applicant/recipient and any person whose income affects him are required to submit evidence as requested. The CDJFS shall assist in obtaining the verification if the applicant/recipient requests such assistance or is unable to provide it without the agency’s help.

(2) When there is a response at application or reapplication that no income is received, the CDJFS should review the application forms for inconsistencies which require resolution. There may be reason to question the applicant/recipient’s statement of no income based upon living expenses or retention of resources expensive to maintain. It is the individual’s responsibility to provide evidence to substantiate their claim. However, if it appears verification is not available and the applicant/recipient has cooperated in trying to obtain the verification, the case may be processed based on the individual’s statements as long as there is no evidence or facts to cast doubt on the income allegations.

(D) Countable income

(1) Countable income is the amount of income which is compared to the appropriate covered families and children medicaid need standard to determine if an individual or family is eligible for covered families and children medicaid.

(2) The amount of countable income is determined by calculating the nonexempt gross unearned income and the gross earned income minus the appropriate income disregards and then totaling the results. The countable income is compared to the appropriate covered families and children medicaid need standard.

(E) Effective date for income changes

(1) Income changes are evaluated to affect eligibility the first day of the month following the month in which the new or increased income is received.

(2) Income changes do not affect eligibility of individuals who are currently receiving medicaid under provisions for pregnant women, deemed eligible newborns, uninsured children, as defined in rule 5101:1-40-08 of the Administrative Code, whose family income is from one hundred fifty one per cent through two hundred per cent of the federal poverty level (FPL), and families in receipt of the initial six months of transitional medicaid.

(3) All other changes in income must be evaluated in compliance with the pre-termination review provisions in rule 5101:1-38-01.1 of the Administrative Code.

HISTORY: Eff 8-1-75; 4-1-86; 8-1-86 (Emer.); 10-3-86; 7-1-89 (Emer.); 9-23-89; 1-1-90 (Emer.); 3-22-90; 10-1-90; 5-1-91; 7-12-91 (Emer.); 9-22-91; 9-1-94; 10-31-97 (Emer.); 1-26-98; 7-1-00; 1-1-03

Rule promulgated under: RC 111.15

Rule authorized by: RC 5111.011, 5111.01

Rule amplifies: RC 5111.01, 5111.011

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

5101:1-40-20.1 Covered families and children (CFC) medicaid: exempt income.

Federal statute and court decisions exclude or exempt certain types of payments or benefits in whole or in part from consideration as income. The exclusions and exemptions vary widely in their effect upon the retention or inclusion of an otherwise eligible person in the assistance group. In some instances, the payments received have no effect on the individual’s eligibility, and the individual remains part of the assistance group.

(A) The monthly earned income of each child receiving covered families and children medicaid, if the child is a full-time student, or a full-time student in a program carried out under the Job Training and Partnership Act (JTPA), is exempt from the one hundred eighty-five per cent and one hundred per cent income tests for a period of time not to exceed six months per calendar year. The six months need not be consecutive but must fall within the twelve-month calendar year. The income of students will be considered as the first disregard of earned income at all times.

(B) Court-ordered child support payments made by a member of the assistance group for a child outside the assistance group are exempt from consideration as income. The actual verified amount paid, up to the amount ordered, is exempt.

(D) A relocation assistance benefit, paid by a public agency to a public assistance recipient who has been relocated as a result of a program of area redevelopment, urban renewal, freeway construction, or any other public development involving demolition or condemnation of existing housing, is exempt income for covered families and children medicaid provided:

(1) The benefit payment is a nonrecurring lump sum; or

(2) If more than one payment is made, such payments are made for a limited time in a manner which does not result in duplication of an allowance in the OWF standard.

(3) Examples are highway relocation assistance paid under sections 163.53 to 163.55 of the Revised Code and any additional relocation payment under Public Law 91-646 (Uniform Relocation Assistance and Real Property Acquisition Policies Act of 1970).

(E) A bona fide loan obtained by a covered families and children medicaid assistance group member from any source is exempt from consideration as countable income or resources. A bona fide loan shall not be considered as income available to the assistance group because the loan is a debt that the assistance group has an obligation to repay. The receipt of a bona fide loan (regardless of the source from which and the reason for which the bona fide loan was secured) by an assistance group shall not adversely affect the assistance group’s eligibility or level of benefits because the loan does not result in a gain to the assistance group that should be considered as countable income.

(1) Only bona fide loans are exempt from consideration as income. In determining whether a bona fide loan exists, any of the situations described in paragraphs (E)(2) to (E)(4) of this rule shall suffice as evidence of a bona fide loan.

(2) A bona fide loan may be established by a written agreement to repay the money within a specified time frame.

(3) A bona fide loan may be established by the existence of evidence to verify that the loan was obtained from an individual or establishment engaged in the business of making loans.

(4) A bona fide loan may be established by the fact that the loan is obtained from an individual or establishment not normally engaged in the business of making loans, if one of the situations described in paragraphs (E)(2) to (E)(4) of this rule exists. The loan may be defined as a bona fide loan if:

(a) The borrower’s acknowledgement of the obligation to repay the loan exists (with or without interest); or

(b) The borrower has expressed intent to repay the loan either by pledging real or personal property, or anticipated income; or

(c) A written statement exists detailing the borrower’s plans to repay the loan when future anticipated income is received (e.g., a timetable and plan for repayment).

(F) Educational grants and scholarships for college expenses.

(1) Educational grants and scholarships from any source for undergraduate and graduate college expenses are exempt from consideration as income or resources.

(2) Educational grants and scholarships are treated in the same manner whether the assistance group member who is the student is an adult or a child.

(3) Educational grants and scholarships are totally exempt as income or resources whether the funds are paid directly to the school or paid to the student.

(4) Educational grants and scholarships that are paid for, or to, a student strictly for educational expenses, or grants and scholarships that include educational and living expenses are exempt regardless of the source from which or the terms under which they are granted, as long as the funds are granted as financial assistance to a student attending an undergraduate or graduate educational institution.

(G) Contributions for shared living expenses.

(1) Cash payments (contributions) received by a covered families and children medicaid assistance group from an individual who is not an assistance group member, but who resides in the same household and shares responsibility for the household expenses through an informal arrangement, shall not be considered unearned income available to the covered families and children medicaid assistance group. The cash contribution given to the covered families and children medicaid assistance group by the individual who is not an assistance group member is not available income to the assistance group because the payment represents the individual’s (who is not an assistance group member) share of the household expenses.

(2) However, if the individual who shares the residence with the assistance group voluntarily gives a cash contribution to the assistance group for its unrestricted use, the cash contribution shall be treated as unearned income to the covered families and children medicaid assistance group.

(H) “Casual or inconsequential income” is income in cash or in kind which is unpredictable as to amount and time of receipt, of short duration, and by itself, of negligible importance in meeting continuing needs under the appropriate aid standard. Casual income remains such as long as it is not recurring and does not exceed thirty dollars per recipient in any quarter, beginning with January, April, July, or October.

(I) “Income in kind” is any benefit received other than in cash.

(J) Income paid by public or private agencies, or community groups, which is either designated by law to be disregarded or given for a special purpose, shall not be deducted. The following are designated by law to be disregarded:

(1) Rural housing loans made by farmers home administration to help individuals and families acquire and/or make needed improvements to a home or other property.

(2) The value of surplus commodities donated by the department of agriculture.

(3) 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 covered families and children medicaid eligibility, ODHS will exclude from income and resources for covered families and children medicaid purposes any payments that are also excluded under the supplemental security income (SSI) program.

(4) Tax-exempt portions of payments received by Alaskan natives as a result of the Alaska Native Claims Settlement Act, Public Law 92-203.

(5) Payments made for supporting services or reimbursement of out-of-pocket expenses to volunteers participating in any program created as a result of Titles II and III, section 418 of Public Law 93-113. These programs include foster grandparents program, senior companions, senior health aides, service corps of retired executives (SCORE), and active corps of executives (ACE).

(6) Benefits received under Title VII, nutrition program for the elderly, of the Older Americans Act of 1965, Public Law 92-258.

(7) The value of supplemental food assistance received under the Child Nutrition Act of 1966, as amended, and the special food service program for children under the National School Lunch Act, as amended, Public Law 92-433 and Public Law 93-150.

(8) Other payments made by a public or private agency for the purpose of supplementing standards, so long as there is no duplication of payment. This includes payments made by an agency providing vocational rehabilitation and payments made to individuals through participation in a JTPA program including all income received from the summer youth employment training program (SYETP). However, any payments made in the form of wages are not exempt under this rule. Payments made in the form of wages, as in the JTPA on-the-job training (OJT) program, cannot be disregarded.

(9) Payments to assistance groups participating in the volunteers in service to America (VISTA) program regardless of the amount of the payments. This disregard does not apply when the director of action determines that the value of all such payments, adjusted to reflect the number of hours such volunteers are serving, is equivalent to or greater than the minimum wage then in effect under the Fair Labor Standards Act of 1938, or the minimum wage under the laws of the states where the volunteers are serving, whichever is greater. (reference: section 404(g) of Public Law 93-113, as amended by section 9 of Public Law 96-143.)

(10) Need-based payments made to a youth under age twenty-two to enable him to participate in training under the JTPA program, Public Law 97-300.

(11) HUD (metropolitan housing authority) payments covering rent/utility bills which exceed the rent payment limitations stipulated by the Brooke amendment.

(12) Retroactive payments paid as a result of a state hearing.

(13) Retroactive payments paid as a result of a reconsideration of SSI benefits.

(14) Foster care payments, made by a state, a political subdivision, or a tax-exempt child placement agency, for a qualified foster-care child boarded in the home.

(15) Experimental housing allowance program payments made under annual contributions contracts entered into prior to January 1, 1975, under section 23 of the U.S. Housing Act of 1937, as amended. This program is designed to aid low-income families to secure adequate housing.

(16) HUD community development block grant funds received by an assistance group. Funds for this program are paid from Title I of the Housing and Community Development Act of 1974 (Public Law 93-383 and Public Law 95-128). The primary purpose of this program is to prevent the deterioration of property occupied and owned by persons with low and moderate income. rehabilitation projects made possible by this program do not include routine repairs and maintenance, but consist of major repairs or improvements such as complete renovation of the exterior or interior of a house. Funds from this program cannot be used for support and maintenance.

(17) Cash or in-kind assistance provided for supportive services that are necessary to enable program participation to a youth under age twenty-two eligible for training under the job training partnership act but who cannot pay for required supportive services. Supportive services may be required for transportation, temporary shelter, meals, health care, etc. (Public Law 97-300).

(18) Compensation provided in lieu of wages to any youth under age twenty-two participating in tryout employment under JTPA at a private-for-profit work site or at a public and private nonprofit work site when private-for-profit work sites are not available. Individuals in tryout employment may not participate more than twenty hours per week during the school year or two hundred fifty hours per assignment (Public Law 97-300).

(19) Home energy assistance (HEA) or support and maintenance assistance (SMA) paid to clients in cash or in kind per Public Law 97-377, Public Law 97-424, or Public Law 98-21.

(a) “Home energy assistance” means any assistance related to home energy.

(b) “Support and maintenance assistance” means in-kind (non-cash) assistance from a private nonprofit organization recognized by ODHS; to meet food, clothing, or shelter needs; or cash or in-kind assistance from a rate-of-return entity providing home energy, a supplier of home heating oil or gas, or a municipal utility providing home energy.

The assistance is only in-kind and is provided by a private nonprofit organization; or it is cash or in-kind assistance furnished by a supplier of home heating oil or gas, an entity providing home energy whose revenues are primarily derived on a rate-of-return basis regulated by a state or federal governmental body, or a municipal utility providing home energy; and the assistance is provided on the basis of need for such support.

(20) 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.

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

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

(23) Payments received under the provisions of the child care and development block grant (section 5082 of Public Law 101-508).

(24) 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.

(25) Basic health insurance, child care or child care allowances, auxiliary aid and services for disabled individuals and the national service educational award provided for individuals participating in a national service program established under the National and Community Service Trust Act of 1993 (Public Law 103-82). Payments received as a living allowance shall be considered earned income.

(K) Effective January 1, 1991, any earned income tax credit (EITC) received, whether added to the individual’s wages or as part of an income tax refund, is exempt from consideration as income in the determination of eligibility or level of benefits.

(L) SSI Income.

(M) Income tax refunds received by a member of the assistance group or by an individual whose income is considered in determining eligibility are exempt.

(N) 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 in determining eligibility and/or patient liability.

Interest received as a result of payments from this settlement is not excluded for income and resource purposes.

(O) P.L. 101-610, Nnational and Community Service Act (NCSA) of 1990, section 177(d), November 16, 1990, provides that section 142(b) of the JTPA applies to projects conducted under Title I of the NCSA as if such projects were conducted under the JTPA. Title I includes three acts: (a) Serve-America: the Community Service Schools and Service-Learning Act of 1990, (b) the American Conservation and Youth Service Corps Act of 1990, and (c) the National and Community Service Act. There are about forty-seven different NCSA programs and they vary by state. Most of the payments are made as a weekly stipend or for educational assistance. The higher education service-learning program and the americorps umbrella program come under this title. The National Civilian Community Corps (NCCC) is a federally managed Americorps program. The summer for safety program is an Americorps program under which participants earn a stipend and a one thousand-dollar postservice educational award. The National and Community Service Trust Act of 1993, P.L. 103-82, September 23, 1993, amended the National and Community Services Act of 1990 but it did not change the exclusion.

(P) Compensation received for services by an individual appointed to a temporary position within the bureau of census established for purposes relating to the 2000 decennial census of the United States as specified in section 3 of the Decennial Census Improvement Act of 1999 shall not cause a reduction in benefits provided through any program such as medicaid which is financed in whole or in part by federal funds. This income exemption applies only with respect to compensation for services performed during the calendar year 2000 and does not apply if the individual performing the service involved is appointed (or first appointed to any other temporary census position) prior to January 1, 2000.

(Q) 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.

HISTORY: Eff 11-1-76; 12-31-77; 12-1-79; 5-29-80; 9-7-81; 3-1-84; 6-1-84; 7-1-84 (Temp); 9-1-84; 9-10-84; 10-1-84 (Emer.); 12-27-84; 1-1-85 (Emer.); 4-1-85; 1-1-86 (Emer.); 1-2-86; 2-23-86; 8-1-86 (Emer.); 10-3-86; 10-1-87; 7-1-89; 9-23-89; 10-1-89 (Emer.); 11-1-89 (Emer.); 12-16-89; 1-29-90; 6-1-90; 7-12-91 (Emer.); 9-22-91; 10-1-91 (Emer.); 12-20-91; 4-1-92; 10-1-92 (Emer.); 12-21-92; 3-1-95; 10-30-95; 10-31-97 (Emer.); 1-26-98; 2-1-99; 5-1-00 (Emer.); 8-6-00; 1-1-03; 1-1-03

Rule promulgated under: RC 111.15

Rule authorized by: RC 5111.011, 5111.01

Rule amplifies: RC 5111.01, 5111.011

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

5101:1-40-202 ADC-related medicaid: non-exempt income.

(A) Unless specifically listed as exempt income in rule 5101:1-40-201 of the Administrative Code, all income is considered as nonexempt income and is to be deducted from the need allowance. In the determination of financial need, the amount of gross monthly income must first be established. Deductions, when applicable, are then made from monthly gross income.

(B) In calculating gross nonexempt income (both earned and unearned), the amount shall be rounded down to the nearest whole dollar by dropping all cents. All cents in gross weekly, biweekly, or semimonthly income shall be dropped prior to applying the conversion factors to convert the income into a standard month. All cents shall be dropped before and after multiplying by the appropriate conversion factor, prior to applying the earned income disregards. Hourly rates which contain cents are not rounded but are converted in the exact amount.

(C) Gross nonexempt income (both earned and unearned) which is received in a frequency other than monthly must be converted to a standard month rather than adjusting income each month.

Conversion shall be performed using the following factors:

(1) Income received on a weekly basis is multiplied by 4.3.

(2) Income received biweekly (every two weeks) is multiplied by 2.15.

(3) Income received semimonthly (twice a month) is multiplied by 2.

(D) In situations in which an individual has fluctuating income, the income must first be averaged (as set forth in rule 5101:1-40-204 of the Administrative Code) to arrive at a figure to be converted into monthly income.

(E) In calculating the expenses which may be subtracted from gross nonexempt income, the actual amount of each expense shall be used in the calculation. The sum of these expenses shall be deducted from the individual’s rounded-down monthly income prior to rounding down in the determination of countable income.

(F) If there are different categories of allowable expenses, the actual amount of the expenses are added by category. The sum of each category of expenses shall be deducted from the corresponding category of rounded-down gross monthly income.

HISTORY: Eff 11-1-76; 5-14-77; 4-5-79; 10-1-81; 12-1-82; 3-1-84; 10-1-84 (Emer.); 12-27-84; 8-1-86 (Emer.); 10-3-86; 10-1-88 (Emer.); 12-20-88; 10-1-89 (Emer.); 12-16-89; 5-1-91; 10-30-95; 10-31-97 (Emer.); 1-26-98

Rule promulgated under: RC 111.15

Rule authorized by: RC 5111.01, 5111.011

Rule amplifies: RC 5111.01, 5111.01

REPLACES PART OF FORMER RULE 5101:1-23-03

REVIEW DATE: 1/26/03

5101:1-40-20.3 Covered families and children (CFC) medicaid: unearned income.

Unearned income is all income that is not wages or net earnings from self-employment. Thus, all income which does not meet the definition of earned income is considered unearned income.

(A) Eligibility for an unearned income payment does not, by itself, affect the amount of unearned income to be counted; actual receipt is the key factor. The assistance group must pursue potential income but the individual must actually be receiving the payment in order to have it included as income.

(B) The amount of unearned income to be established is dependent upon the amounts and frequency with which the income is actually received. However, sometimes there are deductions or withholding taxes deducted from certain types of unearned income. If the deductions are mandatory, only the net income is to be considered. If the deduction is voluntary, the gross amount must be considered as income.

(C) The entire payment from mortgage and land contract payments is unearned income. The verified amounts paid for taxes and insurance on the property are allowable expenses. Any amount the individual pays on the property such as the mortgage payment itself is deducted.

(D) Sick leave payments received in the form of an insurance benefit are unearned income. Benefits received in the form of wages are earned income.

(E) The income received from the rental of real property where the property is managed by a management firm or other company is considered unearned income to the family.

(1) Management of rental property would entail the actual functions of upkeep of property, collection of rent payments, payment of operation costs, bookkeeping and rental procedures such as credit analysis, and filling of vacancies.

(2) A relative, friend or tenant that provides services on a custodial basis would not be considered a property manager.

(3) When a management firm or other company manages the rental property and the assistance group is forwarded an amount (less management expenses), that amount is to be considered unearned income. When the assistance group receives the total amount of income from rental property, the unearned income would be the amount remaining after deducting operating expenses and management fees.

(4) Regardless of who receives the total income from the rental property, operating and management expenses are to be deducted from the total income.

(5) If the individual receives income from his efforts as manager of rental property, that situation would be considered self-employment and as such earned income. Only in situations where the individual directly manages the rental property will this be considered self-employment.

(F) A maximum of fifty dollars in current child support collections each month may be disregarded for an assistance group.

(1) Ohio court-ordered child support with an effective date prior to December 1, 1986 and received by the assistance group or by the CSEA shall have the first fifty dollars disregarded in the financial eligibility determination for CFC medicaid.

(2) New or modified Ohio court-ordered child support with an effective date on or after December 1, 1986 shall be paid through the local CSEA. A fifty dollar disregard is applied in the financial eligibility determination of these assistance groups.

(3) Any income received by the assistance group from the absent parent shall be considered a gift and no fifty dollar disregard shall be applied in the assistance group’s CFC medicaid financial eligibility determination.

(4) The fifty dollar disregard of child support is applied by assistance groups rather than by family or household.

(5) 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 form consideration as income or resources in the financial eligibility determination for CFC medicaid.

(G) Verification of unearned income is required at initial application, at reapplication, when the income amounts change, and when discrepancies in income information are discovered. Special attention should be paid to those types of unearned income which periodically are increased due to cost of living increases that are issued across the board to all recipients of specific benefits.

(1) When an individual alleges unearned income sufficiently high to make him clearly ineligible for CFC medicaid, there is no need for further verification if some other factor of eligibility, such as age or citizenship is clearly not met. Whenever such factor is only questionable and is not yet resolved, unearned income should be verified.

(2) Most forms of unearned income may be verified by a written statement from the agency, organization, or a person administering payment. The verification must show the monthly amount of the benefit, the amount of deductions, and must confirm whether or not the deductions are mandatory.

(H) A portion of the income of aliens who fail to meet citizenship requirements and sanctioned individuals is counted in determining the assistance group’s eligibility. The portion of income of these specifically excluded individuals that remains after application of appropriate disregards shall be treated as unearned income to the assistance group in the determination of the assistance group’s eligibility for CFC medicaid.

HISTORY: Eff 11-1-76; 5-14-77; 4-5-79; 10-1-81; 12-1-82; 3-1-84; 10-1-84 (Emer.); 12-27-84; 1-2-86; 4-1-86; 10-3-86; 10-1-87 (Emer.); 12-24-87; 7-1-89 (Emer.); 9-23-89; 5-1-93; 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

5101:1-40-20.4 ADC-related medicaid: earned income.

(A) Earned income

(1) “Earned income” is payment received by an individual for services performed as an employee or as a result of the individual being engaged in self-employment or as a result of providing room and board or board.

(2) Earned income includes wages, salary, commissions, or profit from activities such as business enterprise, farming, etc., in which the recipient is engaged as a self-employed individual or as an employee.

(3) Generally, wages include all remunerations from employment. The verified amount which is being garnisheed is excluded from determination of gross earnings.

(4) “Earned income with respect to self-employment” means the total profit from a business enterprise resulting from a comparison of the gross receipts with the business expenses directly related to producing the goods or services. Where the individual is both employed and self-employed, the individual’s gross earned income will consist of his or her wages plus the proceeds from self-employment minus operating expenses.

(5) State temporary disability insurance and temporary worker’s compensation payments are considered earned income when such payments are employer funded; made to an individual who remains employed during recuperation from a temporary illness or injury pending return to the job; and are specifically characterized under state law as temporary wage replacements. Short-term disability benefits paid under public employees retirement system, state teachers retirement system, school employees retirement system and highway patrol retirement system meet these conditions.

(6) The county department of job and family services (CDJFS) shall determine the monthly gross amount of earnings, i.e., the amount of earnings before taxes and other deductions and apply the appropriate income disregards to determine the monthly net earned income.

(7) If the employed individual works a set number of hours per pay period, that set number of hours shall be used in computing the individual’s gross monthly earned income. The gross monthly income shall be computed by either using the gross earnings listed on the individual’s pay stubs or by multiplying the set number of hours per pay period by the hourly rate of pay as the figure to be used in converting the income into a standard month.

(8) If the employed individual has fluctuating hours, the pay shall be averaged to arrive at a figure to be used in converting the income into a standard month. In these fluctuating income situations, the CDJFS shall use actual pay stubs for at least four weeks, when possible, in arriving at a figure to use in converting the income into a standard month.

(9) Averaging the previous four weeks of earned income is suggested as a guide in determining a representative figure in situations involving fluctuating income. Sometimes, the earned income from the prior four week period is not representative of current or future income. In situations when the prior four week period is not representative of future income, the CDJFS shall project countable income for a pay period based on a best estimate. The best estimate shall be determined based on a number of variables which may affect the determination. The variables that may need to be considered include situations when:

(a) There are more than four weeks of pay stubs available and the assistance group member advises the CDJFS representative that an average of a longer period of time would be more representative of the individual’s average earnings because the most recent four weeks of earnings were less or greater than average. In the event that more than four weeks of pay stubs are available at the time that the CDJFS is making the determination, the CDJFS shall use all income related information within three months of the estimate that is available in order to arrive at a representative figure to be subsequently converted into a standard month. This includes situations when the assistance group member disagrees with the use of earnings from the past four week period as indicative of future earnings. Also, when there are more than four weeks of pay stubs available, but the assistance group member advises the CDJFS that the earned income that is expected in the future is going to be less than that in the most recent (four weeks) past, the CDJFS shall use all income related information that is available (including the individual’s projection of future earnings) to determine a representative figure. Additionally, some pay stubs reflect year-to-date earnings. This is an acceptable method of determining average income for longer than the four week period prior to the eligibility determination.

(b) Conversely, if there are fewer than four weeks of pay stubs available at the time of the eligibility determination, the CDJFS shall use all income information that is available in order to arrive at a representative figure. This includes situations when the employed assistance group member disagrees with the use of earnings from the past four week period as indicative of future earnings.

(c) If there are no pay stubs available because the employment is new, the CDJFS shall project an estimated amount for a pay period based on the CDJFS’ best estimate of the individual’s income and circumstances. In this situation, the CDJFS’ best estimate shall be based on projected wages from and hours of employment as reported by the individual. The CDJFS’ best estimate for the pay period shall be converted into a standard month as set forth in rule 5101:1-40-20.2 of the Administrative Code. The CDJFS must remind the individual of their reporting responsibilities, especially in regard to its earnings.

(10) The computed average (and the subsequent conversion to a standard monthly figure) shall remain unchanged until a change in income occurs or until the next reapplication. A reported change in income will require a recomputation of the budget.

(11) All changes in income, resources and circumstances must be reported to the CDJFS in accordance with the provisions set forth in rule 5101:1-2-07.3 of the Administrative Code whenever a change in income is reported (including increases in hourly wages, a change from fluctuating hours to set hours, change in employer, part-time to full-time employment or vice versa), the monthly income must be recomputed according to the policy set forth in this rule and in rule 5101:1-40-02.2 of the Administrative Code to determine continued eligibility.

(12) In calculating the gross nonexempt income (both earned and unearned), the monthly amount shall be rounded down to the nearest whole dollar by dropping all cents. All cents in gross weekly, biweekly, or semi-monthly income shall be dropped prior to applying the conversion factors to convert the income into a standard month. Hourly rates which contain cents are not to be rounded, but are converted in the exact amount. The rounding down to the nearest whole dollar does not occur until the weekly income is computed. The cents are dropped when the weekly income is determined and again when the monthly income is computed by the use of the conversion factors.

(13) In calculating the expenses which may be subtracted from gross nonexempt income, the actual amount of each expense shall be used in the computation. The sum of these expenses shall be deducted from the assistance group’s (rounded down) monthly income prior to dropping cents, in the determination of countable income. An assistance group may have allowable expenses which fall into different categories. The expenses are added and totaled by category. The sum of each category of expenses is deducted from the corresponding category of gross income. The balance remaining after expenses are deducted shall be rounded down prior to adding the categories of income.

(B) Definition of self-employment and gross earnings

(1) An individual who operates his or her own business has earnings from self-employment. The gross earnings and the amount and type of operating expenses must be determined.

(2) An individual who performs managerial duties or puts forth efforts to operate and rent his or her own real property has earnings from self-employment. Only in situations where the individual directly manages his or her own rental property will this be considered self-employment.

(3) “Gross earnings from self-employment” means the total proceeds or gross receipts from self-employment minus operating expenses. Operating expenses are deducted from the total proceeds or gross receipts to determine gross earned income to be applied to the one hundred eighty-five per cent and ninety per cent federal poverty levels. Earned income disregards are deducted from the calculated gross earned income.

“Operating expenses” are the identifiable costs of producing goods or services and without which the goods or services could not be produced. Verified costs of certain items necessary for the operation of a self-employment business/farm are appropriately deducted from the total business income to determine gross earnings.

(1) The following are those items which may be deducted as operating expenses:

(a) The cost of renting land, buildings, machinery, and equipment necessary for the operation of the business or farm.

(b) The cost of utilities for business or farm buildings.

(d) The amount of real property taxes (except special assessment taxes that increase the value of the property) on business or farm land owned or being purchased by the individual.

(e) The cost of employees” wages and benefits and the employer’s share of the employees’ social security taxes.

(f) The costs of repairs and maintenance of business or farm property (including buildings, machinery, equipment, trucks, etc.) owned or being purchased by the individual, if such expenditures do not appreciably add to the value of the property.

(g) The interest portion of business and farm loans or mortgages.

(h) Insurance on business and farm property (including buildings, machinery, livestock, cars, trucks, etc.).

(i) Business licenses.

(j) The cost of gas and oil for business or farm vehicles.

(k) The cost of feed, fertilizer, seeds, plants, and farm supplies.

(l) The cost of breeding fees, veterinary fees, and livestock medicines.

(m) The cost of advertising.

(n) Postage.

(o) The cost of tools purchased for the business.

(p) Attorney fees related to the business.

(q) The cost of tax return preparation.

(r) Wholesale cost of products sold.

(s) Business-related travel expenses.

(t) The cost of business transportation (including parking expenses). Travel expenses to and from the individual’s home to place of employment are not deductible. Travel expenses while at work (such as going to pick-up materials required for the business) are considered a business expense. Personal use of a motor vehicle is not an allowable expense. All transportation expenses must be prorated according to how the motor vehicle is used.

(2) Deductions from gross receipts from self-employment may not be made for any of the following:

(a) Monies paid to purchase capital assets, equipment, machinery, and other durable goods.

(b) Payments on the principal of mortgages on income-producing real property.

(d) Any amount claimed as a net loss sustained in any prior period.

(e) Any amount claimed as the applicant/recipient’s own federal, state, local, and social security taxes.

(f) Any amount claimed as personal business and entertainment expenses and personal transportation.

(3) Standard deduction for operating expenses for home day-care providers: a flat fifty per cent deduction from gross earnings from self-employment related to being a home day-care provider may be used in lieu of determining and verifying actual operating expenses. If an assistance group is able to document acceptable operating expenses (as set forth in paragraph (C) of this rule) that exceed the fifty per cent standard deduction, the actual expenses may be used in the determination of gross earned income.

(D) Establishing annual gross earned income from self-employment.

(1) Generally, it will be necessary for the self-employed individual to provide copies of their tax return from the previous year and the individual’s current business records in order for a projection of annual gross income to be determined. Additionally, the self-employed individual’s estimate of expected income and expenses must be secured.

(2) The amount of annual gross earned income from self-employment shall be determined by subtracting the allowable annual operating expenses (or, if applicable, the standard deduction as set forth in paragraph (C)(3) of this rule) from the annual gross receipts. The amount of the gross annual self-employment earnings shall then be distributed into all months of the taxable year.

(E) Distributing monthly income from self-employment earnings.

(1) The CDJFS must determine the countable monthly income of a self-employed individual based on an estimate of the individual’s gross earnings.

(2) Whenever possible, the CDJFS must secure a copy of the self-employed individual’s previous year’s tax return. The income listed on the previous year’s tax return should be used to estimate the expected earnings for the current and future months.

(3) Unless the individual contests the determination of expected income, the estimate of income for the current taxable year shall be based on the previous year’s tax return. The individual’s gross monthly income should be determined to be one-twelfth of the gross earnings as shown on the tax return for the preceding year. The applicable earned income disregards must subsequently be applied to determine eligibility and level of benefits. This method of estimating the self-employed individual’s income should be applicable in situations in which the individual has been self-employed for some time, his gross earnings from self-employment have remained fairly constant (as evidenced by tax returns from previous years) and there is no anticipated change in circumstances.

(4) If the individual contests the estimate of his or her income from self-employment based solely on information on the previous year’s tax return, the individual must provide a projected estimate of his or her gross earnings for the current taxable year, based upon his or her current business records to support his or her contention.

(a) When the individual can estimate their gross earnings for the current taxable year based on current business records, the CDJFS shall accept the individual’s best estimate. Using the individual’s best estimate of income for the current taxable year, the CDJFS shall allocate one-twelfth of the gross annual income equally into each month of the taxable year. The CDJFS shall subsequently use the one-twelfth figure as the individual’s gross monthly income to which all applicable earned income disregards are applied to arrive at the countable monthly income that shall be compared to the payment standard in the determination of eligibility.

(b) If the individual contests the CDJFS’ estimate of his income from self-employment (based solely on information on his previous year’s tax return) but does not provide a projected estimate of gross earnings for the taxable year based on current business records to support his or her contention, the CDJFS shall project his or her earnings based on the gross earnings listed on his or her previous year’s tax return.

(5) In the event that the individual does not have a tax return from the previous year because the business is a new one, (or because the individual’s records have been destroyed or are unavailable and all attempts to recover the records have been exhausted) the CDJFS shall project an estimate of the individual’s countable annual income based on the individual’s current business records. The CDJFS shall base its decision on the individual’s business records for the current year unless the individual contests this determination and provides a reasonable explanation as to why the current business records do not reflect the income (and expenses) that he expects to receive in the future. If the individual contests the determination by providing a reasonable explanation as to why the CDJFS projection is not satisfactory and provides a written estimate of his projected annual income and expenses, the CDJFS shall use the individual’s written estimate on which to base the eligibility determination. The CDJFS shall determine that one-twelfth of the projected gross earnings shall be allocated as the individual’s gross monthly income.

(6) In some situations the previous year’s tax return of a self-employed individual is not representative of the expected earnings/income for the current year. There are some situations in which it will be difficult to project future earnings from the individual’s self-employment. Projecting income will be especially difficult in these situations on a monthly basis because the allowable expenses may be higher or even exceed the gross receipts, for a particular month. The previous year’s tax return or current business records may not be considered to be accurate indicators of the individual’s expected earnings for a variety of reasons.

(a) The business may be a new one for which there is no previous year’s tax return;

(b) The individual may not have record keeping expertise;

(d) The individual may not have the time, ability, or assistance necessary to develop the necessary data from his records; or

(e) There are other circumstances as explained by the individual, which preclude the use of the previous year’s tax return or business records as an accurate means of projecting future income.

(7) In the absence of both the previous year’s tax return and current business records, the CDJFS shall require the individual to provide a written best estimate of his or her projected annual income and expenses. The CDJFS shall then determine that one-twelfth of the projected annual income (less expenses) shall be allocated as the individual’s gross monthly income.

(F) When income is received from room and board (or board only), a standard operating expense equal to the zero income level food stamp coupon allotment for the number of boarders in the household is deducted from total income. The remainder is gross earned income.

(G) The National and Community Service Trust Act of 1993 (NCSTA) establishes educational opportunities for individuals who participate in national service programs. Participants could qualify for a living allowance, basic health insurance, child care services or a child care allowance, aid and services for disabled individuals, and a national service educational award.

(1) The monthly living allowance received by participants (including minor parents who are specified relatives in an OWF assistance group) under NCSTA shall be treated as earned income, with appropriate earned income disregards applied.

(2) The basic health insurance, child care services or the child care allowance, aid and services, and the national service educational award shall be treated as complementary payments and services to the extent that the funds are used to meet the expenses necessary for participation in a NCSTA program.

(H) Earned income may be treated specially under certain case situations. The case situations and their special treatment are listed in paragraphs (h)(1) and (h)(2) of this rule.

(1) Earned income of an individual included in the assistance group as a dependent child is excluded (not deducted) in determining eligibility provided the following occur:

(a) If the individual is enrolled in and physically attending a full-time (as certified by the school or institute attended) program of study or training leading to a certificate, diploma, or degree.

(b) If the individual is enrolled in and physically attending at least part time (as certified by the school or institute attended) a program of study or training leading to a certificate, diploma, or degree and is regularly employed in or available for and actually seeking part-time employment.

(c) If the individual is enrolled in and physically attending at least part time (as certified by the school or institute attended) a program of study or training leading to a certificate, diploma, or degree and is precluded from full-time attendance or part-time employment because of a verified physical handicap.

(d) “Full-time attendance” and “part-time attendance” are defined as follows:

(i) In a secondary school, “full-time” is the completion of four carnegie units per year. A “carnegie unit” is a measure of counting course credits in secondary education. The completion of one hundred twenty clock hours per year for an individual course equals one carnegie unit. “Part-time” is the completion of two carnegie units per school year.

(ii) In a college or university, “full-time” is generally twelve semester or eighteen quarter hours and “part-time” is considered to be anything less than eighteen quarter hours or twelve semester hours.

(iii) In a technical school in a program with shop practice, “full-time” is thirty clock hours per week. With no shop practice, “full-time” is twenty-five clock hours per week. “Part-time,” without shop practice, is twelve hours per week. With shop practice, “part-time” is fifteen hours per week.

(iv) In a secondary education program of cooperative training or in apprenticeship training, “full-time attendance” is thirty clock hours per week, or six clock hours per day.

(v) In a vocational school, required attendance varies from eighteen to twenty-two and one-half hours per week.

(2) Workforce Investment Act of 1998 earnings received by a dependent child who is not a full-time student are exempt from consideration as income in the one hundred eighty-five per cent and one hundred per cent need tests for six months within a twelve-calendar-month period.

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: 8/1/75, 7/1/76, 11/1/76, 5/14/77, 12/31/77, 10/26/78, 4/5/79, 9/21/79, 2/3/80, 10/1/81, 5/1/82, 12/1/82, 12/10/82, 12/29/82, 1/13/83, 3/1/84, 10/1/84 (Emer.), 12/27/84, 1/2/86, 8/1/86 (Emer.), 10/3/86, 10/1/87, 1/1/89 (Emer.), 4/1/89, 7/1/89 (Emer.), 9/23/89, 1/1/90, 3/2/90, 4/1/90, 9/1/90 (Emer.), 5/1/91, 11/1/94, 3/1/95, 10/30/95, 10/31/97 (Emer.), 1/26/98

5101:1-40-205 Covered families and children medicaid: disregards of earned income.

(A) For each individual whose needs are included in the eligibility determination and for each individual whose needs are not included due to the application of a sanction for the individual’s failure to fulfill an eligibility requirement, there are certain disregards allowed in order to determine the countable income.

(1) The disregards are deducted from the gross earnings of each employed individual included in the assistance group and for each employed individual whose needs are not included due to the application of a sanction for the individual’s failure to fulfill an eligibility requirement, in the order listed in paragraphs (B) to (D) of this rule.

(2) For self-employed individuals, these disregards are also deducted from gross earnings as defined in paragraph (B) of rule 5101:1-40-204 of the Administrative Code. These disregards are not allowed when comparing the gross income to the one hundred eighty-five per cent standard.

(3) These disregards are not all applicable when computing the countable income of the grandparents in the minor caretaker budgeting process, and in the determination of countable income to be allocated when there is a parent who is ineligible due to citizenship status.

(B) The monthly earned income of each dependent child who is a full-time student, a full-time student from a JTPA program, or a part-time student who is not a full-time employee is totally disregarded when determining the countable income of the covered families and children medicaid assistance group. There is no time limit on this total disregard for participants in a JTPA program or national service program established under the Nationaland Community Service Trust Act of 1993, (i.e., Americorps, youth corps).

The cost of care for a dependent child or incapacitated adult is an allowable deduction after the two hundred fifty dollars and one-half of the remainder of earned income disregard as described in paragraph (F)(3) of this rule or the thirty dollars and/or one-third disregards as determined in paragraph (E) of this rule. An amount equal to the actual cost but not to exceed one hundred seventy-five dollars per child or two hundred dollars if the child is under age two, for the care of each dependent child or incapacitated adult living in the home and receiving covered families and children medicaid or LIF if the employed caretaker is employed full time.

(1) If the caretaker is employed part time, an amount equal to the actual cost, but not to exceed one hundred twenty dollars per child may be deducted. “Full-time employment” is defined as thirty-five hours or more per week. “Part-time employment” is defined as less than thirty-five hours per week.

(2) The cost of care for a dependent child or incapacitated adult may be disregarded even though the provider is a household member or relative. The disregard does not apply if the dependent care provider is an assistance group member, a parent of the child receiving dependent care, or a legal guardian of the child receiving dependent care.

(3) Documentation of the incapacitated adult’s need must be contained in the assistance group record to support the allowance of the disregard. There is no disregard allowed for the cost of care for an incapacitated adult living in the home who is not also a member of the assistance group.

(4) The caretaker shall have the following options with respect to child care costs:

(a) The caretaker may elect to have the actual monthly child care costs (up to the applicable maximums of one hundred seventy-five dollars per child, or two hundred dollars if the child is under age two, for full time or one hundred twenty dollars for part-time) disregarded in the covered families and children medicaid/LIF medicaid budget calculation. This includes any mandatory family fee that may be charged when there is a social service vendor payment for child care.

(b) The caretaker may elect to have the monthly child care costs met through social service vendor payment. This option is contingent upon the availability of a vendor payment provider and sufficient title XX funds. Dependent care costs that are being met through vendor payment shall not be allowed as an earned income disregard.

(D) Ninety dollars standard work allowance

For those assistance groups that are not eligible to receive the two hundred fifty dollars and one-half of the remainder of earned income disregard as described in paragraph (F) of this rule, the first ninety dollars of monthly earned income of each employed individual whose needs are included in the assistance group and of each employed individual whose needs are not included due to the application of a sanction for the individual’s failure to fulfill an eligibility requirement.

(E) Additional disregards for covered families and children medicaid covered groups other than low-income families (LIF) medicaid and OWF medicaid.

(1) Thirty dollars and one-third of the remaining income for individuals found other wise eligible or who have received OWF in one of the prior four months. An assistance group which did not receive an OWF cash payment due to the minimum payment requirement is considered to be receiving OWF.

(2) The thirty dollars and one-third of the remaining income shall be applied to earnings for a period of four consecutive months. After the four month period, the thirty dollars disregard continues to be applied for a maximum of eight additional months to the assistance group member’s earned income. The one-third disregard is limited to four months.

(3) The four consecutive month period begins with the first month in which both the thirty dollars disregard and the one-third disregard are allowed in the computation of eligibility for covered families and children medicaid.

(4) Any month in which the one-third disregard is allowed in an overpayment calculation is part of the four consecutive month period.

(5) The four consecutive month period is considered to be uninterrupted when a penalty is applied for a month in which the assistance group member or sanctioned individual would have been eligible for the one-third disregard.

(6) In some instances there may be a break in the four consecutive month period because the assistance group member lost the earnings or lost covered families and children medicaid eligibility due to an eligibility factor. If the assistance group becomes eligible again for covered families and children medicaid and is eligible for the thirty dollars and the one-third disregards, the four consecutive month period begins again.

(7) After the individual has received the thirty dollars disregard for the eight additional months, the individual does not become eligible again for the application of the thirty dollars disregard until he is once again eligible to receive the one-third disregard.

(a) The eight month period begins with the month following the fourth consecutive month in which the thirty dollars and one-third disregards were applied and ends with the eighth consecutive month regardless of whether the thirty dollars disregard is actually applied to the assistance group member’s earned income.

(b) When an assistance group member becomes ineligible for covered families and children medicaid before the thirty dollars and one-third disregards have been applied for four consecutive months, but before eight additional months of the thirty dollars disregard have been available, the assistance group member or sanctioned individual is eligible for the remaining months of the thirty dollars disregard if he becomes eligible for covered families and children medicaid during that time. The thirty dollars disregard is available to assistance group members who lost eligibility because of the thirty dollars and one-third disregards and become applicants during this eight-month period, even if such applicants were not recipients during one of the four prior months.

(8) The one-third disregard may only be applied for a period of four consecutive months. After the four month period, the one-third disregard is no longer deducted from the assistance group member’s or sanctioned individual’s earned income. The assistance group member does not become eligible for the use of the one-third disregard in the determination of eligibility for covered families and children medicaid until twelve months have expired.

(F) Additional disregards for low-income families (LIF) medicaid and OWF medicaid

(1) Disregards as described in paragraphs (B) to (C)(4) of this rule.

(2) The first two hundred fifty dollars and one-half of the remainder of monthly earned income of each employed individual in the assistance group.

(3) An assistance group which did not receive an OWF cash payment due to the minimum payment requirement is considered to be receiving OWF.

(4) The use of the thirty dollars and one-third disregards as described in paragraph (E) of this rule does not preclude the use of the two hundred fifty dollars and one-half of the remainder of earned income disregard when determining LIF medicaid or OWF medicaid eligibility.

(5) Eligibility for LIF medicaid can be determined for an assistance group who would be eligible for OWF but declines cash assistance.

(G) The remaining income after the deductions set forth in paragraphs (A) to (F) of this rule is countable earned income.

(H) Earned income disregard penalties

The two hundred fifty dollars and one-half of the remainder of earned income disregard, the ninety dollars standard work allowance, the dependent care costs, and the thirty-dollars and one-third disregards are not deducted from the earned income of the assistance group or individual for the month in which any of the following situations exist. Any month in which the one-third disregard is not applied due to one of the following situations is considered as one of the four consecutive months periods.

(1) The individual terminated his/her employment or reduced his/her earned income without good cause within the preceding month. The penalty is applied to the earned income of the individual in the month following the month of termination of employment or reduction in earnings.

(2) The individual refused without good cause within the preceding month to accept a bona fide offer of employment. The penalty is applied to the earned income of the individual in the month following the month of the refusal to accept an offer of employment.

(3) The individual voluntarily requests assistance to be terminated for the purpose of avoiding the receiving of the one-third disregard for four consecutive months.

(4) The individual failed without good cause to make a timely report of earnings. This penalty is applied if an individual does not report a change in a timely manner.

HISTORY: Eff 11-1-76; 5-14-77; 4-5-79; 10-1-81; 12-1-82; 3-1-84; 10-1-84 (Emer.); 12-27-84; 1-1-85 (Emer.); 4-1-85; 1-2-86; 4-1-86; 4-1-88 (Emer.); 6-30-88; 1-1-89 (Emer.); 4-1-89; 7-1-89 (Emer.); 9-23-89; 10-1-89 (Emer.); 12-16-89; 4-23-90; 7-12-91 (Emer.); 9-12-91; 9-1-94; 10-1-97 (Emer.); 1-26-98; 7-1-00

Rule promulgated under: RC 111.15.

Rule authorized by: RC 5111.01, 5111.011

Rule amplifies: RC 5111.01, 5111.011

REPLACES: FORMER 5101:1-40-205

RC 119.032 REVIEW DATES: 7/1/2005

5101:1-40-21 Covered families and children medicaid: Initial eligibility test. [Rescinded]

Rescinded eff 1-6-05

5101:1-40-22 Covered families and children (CFC) medicaid: allocating income to members of an assistance group.

(A) Income must be allocated to certain CFC assistance group members from responsible individual(s) living with but not a member(s) of the CFC assistance group. Responsible individuals are spouses and/or natural or adoptive parent(s) who have spouses or children for whom they have legal and/or financial responsibility. Examples of such responsible individuals include, but are not limited to:

(1) Natural or adoptive parent(s) of an unemancipated minor caretaker of a CFC medicaid eligible child,

(2) Natural or adoptive parent(s) of an unemancipated nineteen or twenty year old,

(3) Spouse of a nineteen or twenty year old,

(4) Spouse of a specified relative in need (as defined in rule 5101:1-40-01 of the Administrative Code), and

(5) Natural or adoptive parent(s) who do not meet citizenship requirements.

(B) The allocation allowance is the amount or portion of the income of a responsible individual that must be considered as unearned income to a member(s) of a CFC assistance group.

(C) The same method is used to determine the allocation allowance in any of the situations identified in paragraph (A) of this rule. The allocation allowance is calculated using the following steps:

(1) Determine the gross monthly countable income of the responsible individual. Income exempted pursuant to rule 5101:1-40-20.1 of the Administrative Code is not counted toward the countable gross income.

(a) The responsible individual(s) must provide verification of monthly gross income.

(b) If the responsible individual(s) refuses or is unable to verify income, the CDJFS must explore or provide assistance in obtaining verification prior to denying or removing the affected individual(s) from the CFC assistance group.

(c) If the income of the responsible individual cannot be determined and/or verified pursuant to rule 5101:1-38-01 of the Administrative Code, only the eligibility of individual(s) subject to the allocation of income is affected. The eligibility of any remaining assistance group member(s) is not affected.

(2) Subtract disregards appropriate to the responsible individual circumstances.

(a) The first ninety dollars of the responsible individual’s gross earned income for the month.

(b) The amount equal to the one hundred per cent need standard for the responsible individual from whom the income is being allocated and any other individuals who meet the following conditions:

(i) Who are living in the home; and,

(ii) Whose needs are not included in the CFC assistance group; and

(iii) Who are claimed or could be claimed by the responsible individual as a spouse or dependent for federal personal income tax liability under the internal revenue service rules.

(c) The actual amount of payments, up to the one hundred per cent need standard, made by the responsible individual from whom the income is being allocated for individuals who are not living in the home but are claimed or could be claimed by the individual as dependents for federal personal income tax liability under the internal revenue service’s rules.

(d) The amount paid by the individual from whom the income is being allocated as court ordered alimony or child support for individuals not living in the home.

(3) The remaining income of the responsible individual is the allocation amount and is to be considered as unearned income in determining financial eligibility of the affected member(s) of the CFC assistance group.

(4) The need of the individual toward whom the income is allocated is defined by the difference between the standard of the assistance group including the individual minus the standard of the assistance group excluding the individual.

(a) Standards presented in rule 5101:1-40-26 of the Adminstrative Code are used for the calculation of the need of the individual.

(i) The payment standard is used to calculate the need of nineteen and twenty year old individuals.

(ii) The ninety per cent federal poverty level is used to calculate the need of a natural or adoptive parent.

(iii) The one hundred fifty per cent healthy start standard is used to calculate the need of minor caretakers.

(b) If the allocated income equals or exceeds the need of the individual, then the affected individual is not eligible for inclusion in the assistance group.

(c) If the affected individual is not eligible for inclusion in the assistance group, but the CDJFS must explore eligibility for other potential medicaid categories prior to denying or terminating for this individual.

(D) Situations in which income is not allocated to member(s) of the CFC assistance group.

(1) The income of a stepparent is not counted in the determination of his stepchild(ren)’s eligibility for CFC medicaid.

(2) The income of a grandparent is not counted in the determination of a minor caretaker’s child(ren)’s eligibility for CFC medicaid.

(3) Only the income of the minor caretaker’s natural or adoptive parent(s) is used when determining a minor caretaker’s eligibility; the income of the stepparent of the minor caretaker is not allocated to the minor caretaker.

(4) When a child receives a state adoption subsidy because of special needs pursuant to rule 5101:1-40-03 of the Administrative Code.

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: 8/01/86 (Emer.), 10/03/86, 10/01/88 (Emer.)12/20/88, 10/01/89 (Emer.), 12/16/89, 3/0194 (Emer.), 4/18/94, 6/01/02 (Emer.), 8/30/02

5101:1-40-25 Covered families and children medicaid: low income families (LIF).

(A) This rule describes the budgeting methods and eligibility standards for low income families (LIF) medicaid.

(B) Definitions.

(2) “Countable income”, for the purposes of this rule, means the amount of income compared to the payment standard and is determined by adding all of a family’s nonexempt unearned income to nonexempt earned income after subtracting all appropriate disregards.

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

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

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

(1) Non-financial criteria:

(a) The individual must be the parent of a child younger than nineteen, and reside with the child.

(b) The individual must not be eligible for another category of medicaid.

(2) Financial criteria:

(a) There is no resource limit.

(b) There are two income standards. An individual is financially eligible for medicaid if either:

(i) The individual’s gross income is no more than ninety per cent of the federal poverty level for the appropriate family size; or

(ii) The individual’s countable income is no more than the payment standard for the appropriate family size.

(D) Individual responsibilities. The individual must:

(1) Provide verification in accordance with Chapter 5101:1-38 of the Administrative Code.

(2) Inform the administrative agency of any available health insurance, as provided in 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) Calculate the family’s countable income in accordance with Chapter 5101:1-40 of the Administrative Code.

(3) Not terminate medical assistance 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.

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

Replaces: 5101:1-40-25

Effective: 01/01/2008

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

Promulgated Under: 111.15

Statutory Authority: 5111.01

Rule Amplifies: 5111.01, 5111.019

Prior Effective Dates: 10/31/97 (Emer.), 1/26/98, 10/1/99, 7/1/00, 1/1/06

5101:1-40-25.1 Medicaid: budgeting methodology for individuals under the age of twenty-one not living with a parent or spouse.

(A) This rule outlines the budgeting process when determining covered families and children medicaid eligibility for individuals under the age of twenty-one not living in the same household as a parent or spouse. For the purpose of this rule, only the individual’s income is considered.

(B) Definitions

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

(2) “Countable income” is: the amount of income which is compared to the appropriate payment or need standard to determine if an individual is eligible for medicaid. Countable income is determined by adding nonexempt gross unearned income and gross earned income minus all appropriate disregards.

(3) “Gross countable income” is determined by adding all non-exempt unearned income and all earned income without earned income disregards.

(4) An “individual” is:

(a) An applicant or recipient of a medical assistance program; and,

(b) For the purposes of this rule, an individual under the age of twenty-one not living with a parent or spouse.

(1) The administrative agency shall total all gross countable income.

(2) The administrative agency shall subtract the following disregards if appropriate:

(a) The first ninety dollars of monthly earned income.

(b) Thirty dollars and one-third of the remaining income in accordance with Chapter 5101:1-40 of the Administrative Code.

(3) The administrative agency shall then compare the countable income to the Ohio works first (OWF) payment standard.

(a) If the individual’s countable income is equal to or less than the OWF payment standard, eligibility exists.

(b) If the individual’s countable income is greater than the OWF payment standard, eligibility does not exist.

Replaces: 5101:1-40:251

Effective: 01/01/2006

R.C. 119.032 review dates: 01/01/2011

Promulgated Under: 111.15

Statutory Authority: 5111.01

Rule Amplifies: 5111.01

Prior Effective Dates: 8/1/1986 (Emer.), 10/3/1986, 3/1/1994 (Emer.), 4/18/1994, 7/1/2000

5101:1-40-26 Medicaid: standards of need.

(A) This rule describes the need standards used to determine financial eligibility for medicaid coverage of families, pregnant women, and children.

(B) Definitions.

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

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

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

(C) There are six need standards which are used in computing eligibility for covered families and children medicaid. They are the one-hundred per cent need standard, the payment standard, the ninety per cent federal poverty level (FPL), the one hundred fifty per cent healthy start standard, the two hundred per cent healthy start standard and the transitional medicaid standard. All six standards are used at various times throughout the eligibility and budget calculations.

(D) When determining the appropriate AG size/household size for an AG containing a pregnant woman, the unborn child(ren) is counted as if the child(ren) had been born and was living in the household. The increased AG/household size is used only for expedited medicaid and healthy start financial determinations.

(E) Need standards.

(1) The one hundred per cent need standard is the amount determined necessary to meet the minimum requirements for food, clothing, housing, utilities, transportation and personal/incidental items. This standard is used as the basis for calculation of the low income families LIF payment standard.

The one hundred per cent need standard is used in calculations as an allowance for the needs of a non-recipient individual. An example is in the stepparent budget or minor caretaker budget where an allowance must be made for the individual’s needs which are not being included in the AG.

(2) The payment standard is a ratable reduction of the one hundred per cent standard. The payment standard is the figure used to calculate the actual cash payment and from which all countable income is deducted.

(3) The one hundred per cent healthy start standard is the basis for the calculation of the one hundred fifty per cent healthy start standard and the one hundred eighty-five per cent transitional medicaid standard.

(4) For pregnant women the AG’s countable income may not exceed one hundred fifty per cent of the federal poverty level for the appropriate AG. 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, 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, as described in rule 5101:1-40-08 of the Administrative Code.

(5) For children from birth through age eighteen, the AG’s countable income may not exceed one hundred fifty per cent of the federal poverty level for the appropriate AG size.

(6) For children from birth through age eighteen, the AG’s countable income may not exceed two hundred per cent of the federal poverty level for the appropriate AG size.

(7) For low income families, the AG’s countable income may not exceed the standards described in rule 5101:1-40-25 of the Administrative Code.

(8) The federal poverty level is the basis of income eligibility for transitional medicaid. The transitional medicaid standard is the standard used to determine eligibility for the second six month period of transitional medicaid coverage.

Effective: 03/01/2008

R.C. 119.032 review dates: 10/12/2007 and 03/01/2013

Promulgated Under: 111.15

Statutory Authority: 5111.01

Rule Amplifies: 5111.01, 5111.013, 5111.014, 5111.019

Prior Effective Dates: 1/1/89 (Emer.), 3/6/89, 5/1/89 (Emer.), 7/1/89 (Emer.) 7/8/89, 9/23/89, 4/2/90 (Emer.), 6/22/90, 10/1/90, 4/1/91 (Emer.), 6/30/92, 1/1/93 (Emer.), 3/18/93, 6/20/94, 10/31/97 (Emer.), 1/26/98, 11/19/99, 1/1/00, 7/1/00, 6/1/03 (Emer.), 9/20/03, 1/1/06

5101:1-40-60 Expedited medicaid eligibility determinations.

(A) Expedited medicaid must be explored for all pregnant women listed on any application for assistance.

(1) The CDHS shall identify individuals who are potentially eligible for expedited medicaid at the time of the individual’s request for assistance. An employee of the CDHS shall be responsible for screening all applications as they are received by mail or screening individuals as they come in to apply in person.

(2) Individuals who are found to be potentially eligible for expedited medicaid should be referred to a caseworker to determine financial eligibility.

(3) The CDHS shall also screen the applications to determine if the pregnant woman currently has a pending application for regular program eligibility or is currently on expedited medicaid.

(4) Once an individual has passed the screening process, a caseworker shall review the application to determine income eligibility.

(5) If the individual applied for assistance by completing an ODHS 7200 “Application for Cash, Medical and Food Stamp Assistance”, either an ODHS 7216 “Combined Programs Application” (CPA) or ODHS 7100 “Application for Income, Medical, and Food Assistance” (CAF) must be completed by the individual.

(B) To be eligible for expedited medicaid, a pregnant woman must meet the following criteria:

(1) Pregnancy must be medically verified by a statement signed by a doctor or a nurse, and;

(2) The assistance group’s countable income must be equal to or less than the appropriate healthy start standard.

(a) Verification of income is not mandatory at this point; the individual’s statement on the application is sufficient.

(b) The healthy start eligibility requirements as described in rule 5101:1-40-08 of the Administrative Code for income determinations apply to these individuals. Although the income of the woman’s family (if any), is taken into account to determine eligibility, expedited medicaid is available to the pregnant woman only.

(C) The regular medicaid and covered families and children medicaid eligibility requirements for citizenship and residency as described in rule 5101:1-38-02 of the Administrative Code apply to these individuals.

(D) When the CDHS receives either a CAF, APPL, or CPA that indicates that there is a pregnant woman in the household, and the criteria listed above has not been met, the ODHS 7220 “Application/Reapplication Verification Request Checklist for Healthy Start/Expedited Medicaid” must be completed immediately, indicating the specific verification still needed in order to establish eligibility.

(E) Within ten days of the date of application, the ODHS 7227 “Application Follow-Up Letter for Healthy Start/Expedited Medicaid,” must be mailed or personally delivered to the applicant, to inform her of the verification that was requested, but had not yet been received.

(F) The following also apply to expedited medicaid:

(1) No face-to-face interview requirement.

(2) No resource limit,

(3) No retroactive medicaid.

(4) Authorized representatives may apply for expedited medicaid on behalf of another individual.

(5) The provisions regarding a recipient-caused medicaid overpayment determination and recovery apply.

(6) There is no automatic assignment of third party and medical support payments for expedited medicaid.

(G) Concurrent determination of benefits.

(1) In addition to determining eligibility for expedited medicaid, the CDHS must concurrently determine eligibility for one of the following: healthy start, low-income families medicaid or regular medicaid for the aged, blind or disabled. The policy and procedure for completion of the application and the application process shall be in accordance with the rules in Chapters 5101:1-38, 5101:1-39 and 5101:1-40 of the Administrative Code pertaining to the appropriate programs, including a face-to face interview for those medicaid programs that require a face-to-face. Additionally, retroactive medicaid eligibility may be explored, if appropriate.

(2) In all instances except for healthy start or low income families only applications, an APPL or CAF must be completed. For healthy start and low income families applications, either a CPA or CAF may be completed.

(H) Eligibility span and limited medicaid coverage.

(1) An expedited medicaid card will be authorized, for all pregnant women, the day all eligibility criteria in accordance with this rule is met, but not later than the following work day. The expedited medicaid card is time-limited and does not replace a regular medicaid card.

(2) Expedited medicaid coverage is limited to sixty days from the date all expedited medicaid criteria are met.

(3) One expedited medicaid card will be issued for the entire eligibility span (sixty days).

(4) A pregnant woman may only receive one expedited medicaid card per pregnancy.

(5) Medicaid coverage under expedited medicaid is restricted to all medicaid covered services (e.g., doctor’s visits, prescriptions) except in-patient hospital services. However, since medicaid coverage under low income families, healthy start, or medicaid for the aged, blind, or disabled is being explored concurrently, inpatient hospitalization may be covered if the individual is subsequently found eligible for one of these programs.

(I) Notices.

(1) Notice of approval for expedited medicaid is required; all other approval and denial notices for the concurrent eligibility of regular program eligibility (i.e., low income families, healthy start, or medicaid for the aged, blind or disabled) shall be provided in accordance with the rules in division-level 5101:6 of the Administrative code.

(2) Termination of expedited medicaid upon expiration of the span of coverage is exempt from the normal notice requirements as described in division-level 5101:6 of the Administrative Code.

HISTORY: Eff 4-1-91 (Emer.); 6-1-91; 9-1-92; 9-1-93; 7-1-00

Rule promulgated under: RC 111.15

Rule authorized by: RC 5111.01, 5111.011

Rule amplifies: RC 5111.01, 5111.011

REPLACES FORMER RULES: 5101:1-39-96, 5101:1-39-961, 5101:1-39-962, 5101:1-39-963, 5101:1-39-964

R.C. 119.032 REVIEW DATES: 7/1/2005