5160:1-2-11 Medicaid: treatment of qualified long-term care insurance policies.

(A) This rule describes the qualified long-term care partnership (QLTCP) program under which an individual's resources are disregarded in eligibility determinations and at estate recovery in the amount of benefits paid to or on behalf of the consumer by a QLTCP policy.

(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 administering the medicaid program.

(2) "Estate recovery" means the program set out in rule 5101:1-38-10 of the Administrative Code.

(3) "Qualified long-term care partnership (QLTCP)" means the program established under section 5111.18 of the Revised Code, under which an individual's resources are disregarded in eligibility determination(s) and at estate recovery in the amount of benefits paid to or on behalf of the consumer by a QLTCP policy.

(4) "Third party" is defined in rule 5101:1-38-02.2 of the Administrative Code.

(C) A QLTCP policy is one that meets all of the following requirements.

(1) On the date the policy was issued, the state in which the insured resided had in place an approved state plan amendment which provides, pursuant to 42 U.S.C. 1396p(b) (as in effect on May 1, 2007), for the disregard of resources in an amount equal to the insurance benefit payments made to or on behalf of an individual who is a beneficiary of a QLTCP policy; and

(2) The policy is a qualified long-term care insurance policy, as defined in section 7702B(b) of the Internal Revenue Code of 1986; and

(3) The policy meets the requirements set forth by the Ohio department of insurance or, if purchased outside Ohio, meets the requirements of an approved state plan amendment, as described in paragraph (C)(1) of this rule, in the state of purchase.

(D) At application or reapplication (as established in Chapter 5101:1-39 of the Administrative Code) for long-term care services, a home and community-based services (HCBS) waiver, or the program of all inclusive care for the elderly (PACE), an individual's resources will be disregarded up to the dollar amount of benefits paid to or on behalf of the individual by a QLTCP policy.

(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) An individual may apply for long term care services before exhausting the benefits of a QLTCP policy. If an individual applies for and is eligible to receive medicaid coverage before the QLTCP policy is exhausted, the QLTCP insurer must make payment for medical care to the maximum extent of their liability before medicaid funds may be used to pay providers for covered services as established in rule 5101:1-38-02.2 of the Administrative Code.

(3) If an individual has applied for and been found eligible to receive medicaid, and then receives additional resources, the individual continues to be eligible for medicaid to the extent the total value of all disregarded resources does not exceed the individual's QLTCP disregard plus the applicable resource allowance.

(4) A QLTCP disregard does not affect post-eligibility income calculations under Chapters 5101:1-38 to 5101:1-41 of the Administrative Code; the disregard cannot reduce patient liability or cost of care.

(E) Transfers of resources.

(1) If an individual becomes eligible for medicaid through the application of a QLTCP disregard, then makes a transfer (of disregarded resources) that would otherwise be considered an improper transfer (under rule 5101:1-39-07 of the Administrative Code), no restricted medicaid coverage period applies. The disregarded value of the transferred resource continues to be considered part of the individual's QLTCP disregard.

(2) If an individual becomes eligible for medicaid through the application of a QLTCP disregard after making a transfer that would otherwise be considered an improper transfer (per rule 5101:1-39-07 of the Administrative Code):

(a) If the individual's QLTCP disregard plus resource limit equals or exceeds the individual's countable resources plus the value of the transferred resource, no restricted medicaid coverage period applies. The disregarded value of the transferred resource is considered part of the individual's QLTCP disregard.

(b) If the individual's QLTCP disregard plus resource limit is less than the individual's countable resources plus the value of the transferred resource:

(i) The individual's available QLTCP disregard is determined by adding the individual's QLTCP disregard to the individual's resource limit, then subtracting the individual's current countable resources and any amounts that have previously been transferred without a restricted medicaid coverage period as a result of a QLTCP disregard.

(ii) The individual's available QLTCP disregard is subtracted from the amount that would otherwise have been considered improperly transferred. The remainder is the amount improperly transferred; a restricted medicaid coverage period is calculated for the remainder as per rule 5101:1-39-07 of the Administrative Code.

Effective: 09/01/2007
R.C. 119.032 review dates: 09/01/2012
Promulgated Under: 119.03
Statutory Authority: 5111.11 , 5111.18
Rule Amplifies: 5111.11 , 5111.18