Lawriter - OAC - 5160:1-5-07 Medicaid: specialized recovery services (SRS) program.

5160:1-5-07 Medicaid: specialized recovery services (SRS) program.

(A) This rule sets forth the eligibility criteria for a state plan home and community-based services (HCBS) benefit authorized under section 1915(i) of the Social Security Act (as in effect on October 1, 2017). Section 1915(i) of the act allows states the flexibility to provide HCBS to individuals who require less than an institutional level of care (LOC) and who would, therefore, not be eligible for HCBS under the more restrictive criteria of section 1915(c) waivers. The specialized recovery services (SRS) program provides targeted services to the following individuals described in rule 5160-43-02 of the Administrative Code:

(1) Individuals with severe and persistent mental illness (SPMI); or

(2) Individuals who are active on the solid organ or soft tissue waiting list; or

(3) Individuals with certain diagnosed chronic conditions.

(B) Eligibility for the SRS program state plan HCBS benefit. An individual shall meet all of the following criteria to be eligible for the SRS program state plan HCBS benefit:

(1) Be at least twenty-one years of age.

(2) Have been determined to meet the definition of disability used by the social security administration (SSA) for purposes of supplemental security income (SSI) or social security disability insurance (SSDI) benefits.

(a) A disability determination is not required for individuals over the age of sixty-five years old who are active on the solid organ or soft tissue waiting list, or who have certain diagnosed chronic conditions.

(b) A disability determination is not required for individuals under age sixty-five years old who are enrolled in the medicare end-stage renal disease program.

(3) Meet the clinical diagnostic, needs assessment, and risk criteria described in rule 5160-43-02 of the Administrative Code.

(4) Reside in a home and community-based setting consistent with the qualities identified in 42 C.F.R. 441.710 (as in effect on October 1, 2017).

(5) Meet the financial and nonfinancial eligibility requirements of one of the following groups:

(a) Group one.

(i) Be in receipt of medical assistance, as described in Chapters 5160:1-1 to 5160:1-5 of the Administrative Code; and

(ii) Have countable income that does not exceed one hundred fifty per cent of the federal poverty level (FPL), as determined using the same rules used for determining the individual's medical assistance eligibility.

(b) Group two.

(i) Meet the conditions of eligibility outlined in rule 5160:1-2-10 of the Administrative Code; and

(ii) Not be otherwise eligible for medical assistance; and

(iii) For the purpose of determining whether an individual is income eligible for the SRS program, the administrative agency shall compare the individual's countable income to one hundred fifty per cent of the FPL, as determined in accordance with Chapter 5160:1-3 of the Administrative Code.

(a) If the individual's countable income exceeds one hundred fifty per cent of the FPL, apply additional disregards in the following order:

(i) Twenty dollar personal needs disregard; then

(ii) Disregard income in the amount of the difference between one hundred fifty per cent of the FPL for an individual and three hundred per cent of the current supplemental security income (SSI) federal benefit rate (FBR) for an individual.

(b) If the amount determined in paragraph (B)(5)(b)(iii) of this rule is no more than one hundred fifty per cent of the FPL, the individual meets the income eligibility requirement for the SRS program.

(iv) There is no resource limit for individuals described in paragraph (B) (5)(b) of this rule.

(C) There is no retroactive eligibility for the SRS program state plan HCBS benefit. Coverage under this rule cannot begin prior to the first day of the month in which all financial, nonfinancial, and programmatic criteria are met.

(D) An individual who is receiving the state plan HCBS benefit cannot be concurrently enrolled in another HCBS authority, such as a section 1915(c) waiver. Subject to the individual's choice, he or she will be enrolled in the HCBS authority best meeting the totality of his or her needs regardless of the order in which the individual applied for or became eligible for HCBS.

(E) Eligibility for this program shall be determined for applications for medical assistance filed on or after the effective date of this rule.

Effective: 7/1/2018
Five Year Review (FYR) Dates: 8/1/2021
Promulgated Under: 111.15
Statutory Authority: 5162.03, 5163.02
Rule Amplifies: 5162.03, 5163.02
Prior Effective Dates: 08/01/2016, 09/11/2017