(A) Non-financial eligibility requirements. The individual must complete a JFS 07120 "Residential State Supplement Referral" (rev. 3/2003) and meet all of the following criteria to be enrolled into the RSS program:
(1) A county department of job and family services (CDJFS) must have determined the individual to be eligible for medicaid.
(2) The individual must currently reside in a skilled nursing facility or need at least a protective level of care as defined in rule 5101:3-3-08 of the Administrative Code.
(3) The individual must not require more than one hundred twenty days of skilled nursing care, as defined in section 3721.01 of the Revised Code, during any twelve month period unless the individual resides in a licensed residential care facility authorized to provide skilled nursing care in accordance with section 3721.011 of the Revised Code.
(4) The individual must not have a cognitive impairment which requires the presence of another person on a twenty-four hour a day basis for the purpose of supervision to prevent harm.
(5) The individual must be accepted for placement or residing in an approved community living arrangement, and a residential state supplement administrative agency must have determined that the facility is appropriate for the individual's needs in accordance with section 5119.69 of the Revised Code. The appropriate living arrangements are:
(a) An "adult foster home" certified under section 5119.692 of the Revised Code;
(e) A residential facility of the type defined in section 5119.22 of the Revised Code, that is licensed by the Ohio department of mental health; or
(f) An apartment or room that is used to provide community mental health services, is certified by the Ohio department of mental health under section 5119.611 of the Revised Code, and is approved by a board of alcohol, drug addiction, and mental health services in accordance with section 340.03 of the Revised Code.
(6) The individual must not be related to the owner or caregiver of the RSS living arrangement.
(7) The individual must not be a participant in any federal 1915C waiver program.
(8) The individual must not be a participant in ODJFS' program of all-inclusive care for the elderly (PACE).
(9) The individual must not be enrolled in a medicare or medicaid-certified hospice program.
(10) The residential state supplement administrative agency must have funds available to make another RSS placement.
(11) The individual must agree to participate in the development of a plan of care that includes residential needs and supports, and must sign the RSS resident agreement.
(12) The individual must execute a release of information form permitting exchange of information between the RSS provider and other care providers and key contacts as needed for continuity of care and eligibility determination.
(13) An individual who has been selected by the residential state supplement administrative agency for an RSS enrollment eligibility determination, or the individual's authorized representative, must apply for medicaid if he or she is not currently a medicaid recipient. The application for medicaid must be filed with the CDJFS within thirty days of the day the individual is notified of the selection.
(B) Financial eligibility requirements.
(1) The definitions of earned and unearned income in Chapter 5101:1-37 of the Administrative Code are applicable to the RSS program.
(2) When a husband and wife reside in the same RSS facility and both have appropriate levels of care, the CDJFS shall determine their RSS financial and resource eligibility collectively utilizing the appropriate couple need standards.
(3) When a husband and wife reside in the same RSS facility and only one of them has an appropriate level of care, the CDJFS shall determine RSS financial and resource eligibility utilizing the appropriate individual need standard. The spouse who does not have the necessary level of care shall have medicaid eligibility determined in accordance with Chapter 5101:1-39 of the Administrative Code as an individual with one exception: income cannot be deemed to or from the RSS-eligible spouse.
(4) The financial eligibility methodologies for medicaid and RSS are the same, with three exceptions:
(a) SSI income is countable income in the RSS program, except that all SSI cost-of-living adjustments after October 1, 1982, are disregarded for all RSS assistance groups with SSI income.
(b) The medicaid spenddown provision does not apply in the RSS program. If an individual has countable income equal to or in excess of the financial need standard for the appropriate RSS living arrangement, the individual is ineligible for RSS.
(c) The RSS program has no deeming provision. For an RSS spouse and a non-RSS spouse residing in the same living arrangement, there is no deeming to or from the RSS spouse. They are both treated as individuals for purposes of determining RSS eligibility. If applicable, the non-RSS spouse shall have medicaid eligibility determined as an individual in accordance with Chapter 5101:1-39 of the Administrative Code with no deemed income allocation from the RSS spouse.
(5) Twenty dollars of any income, earned or unearned other than income from SSI, is disregarded. Only one twenty dollar disregard is applied per couple if both husband and wife are eligible for RSS.
(6) The disregard allowed from an eligible individual's earned income is sixty-five dollars plus one-half of the remaining income.
(7) Earnings which are used to pay for blind work expenses and/or impairment-related work expenses may be deducted from the earned income in accordance with Chapter 5101:1-39 of the Administrative Code.
(8) If the RSS individual's countable income is less than the financial need standard for the appropriate RSS living arrangement, but the individual's RSS enrollment is not yet completed, the CDJFS shall pend the RSS application until the RSS enrollment determination is completed.
(9) If the RSS individual's countable income is less than the financial need standard for the appropriate RSS living arrangement, the individual is eligible for an RSS payment.
(10) The CDJFS shall determine retroactive medicaid eligibility in accordance with Chapter 5101:1-38 of the Administrative Code for coverage of non-RSS medicaid services.
(11) Qualified medicare beneficiary (QMB) and specified low-income medicare beneficiary (SLMB) eligibility determinations.
(a) QMB and SLMB eligibility determinations shall be made upon application for all programs, including RSS. If eligible, the CDJFS shall approve QMB or SLMB unless the individual, after having been fully informed of the benefits of each covered group, chooses not to have QMB or SLMB approved.
(b) If QMB or SLMB eligibility does not exist, the CDJFS shall deny QMB or SLMB. If RSS eligibility is subsequently approved, the CDJFS shall enroll the individual in the state buy-in only.
(c) QMB and SLMB financial eligibility is determined for the husband and wife as a couple even if only one has an appropriate level of care.
Replaces: 5101:1-17-02, 5101:1-17-04
R.C. 119.032 review dates: 09/01/2016
Promulgated Under: 111.15
Statutory Authority: 5111.011
Rule Amplifies: 5111.01 , 5111.011 , 5119.69
Prior Effective Dates: 12/1/82, 7/1/83 (temp.), 9/24/83, 9/1/84, 1/1/89 (Emer.), 3/6/89, 9/12/91 (Emer.), 12/2/91, 11/1/93 (Emer.), 1/30/94, 5/1/94 (Emer.), 7/24/94, 7/1/95 (Emer.), 9/24/95, 4/1/96, 10/1/02, 7/1/11 (Emer.)