This website publishes administrative rules on their effective dates, as designated by the adopting state agencies, colleges, and
universities.
| Rule |
Rule 5160:1-3-01 | Medicaid: coverage for the aged, blind, or disabled.
(A) The medicaid program provides
coverage for individuals who meet the aged, blind, or disability status
requirements as set forth in section 1902 of the Social Security Act (as in
effect October 1, 2022). The provisions of Chapter 5160:1-3 of the
Administrative Code establish eligibility criteria, standards, and procedures
that apply to individuals enrolling in an aged, blind, or disabled categorical
coverage group. (B) The rules of this chapter are
organized as follows: (1) Rules under principal
rule 5160:1-3-02 of the Administrative Code set forth base eligibility
requirements of the aged, blind, or disabled eligibility covered
groups. (2) Rules under principal
rule 5160:1-3-03.1 of the Administrative Code set forth income eligibility
requirements. (3) Rules under
principal rule 5160:1-3-05.1 of the Administrative Code set forth resource
eligibility requirements.
Last updated July 27, 2023 at 8:33 AM
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Rule 5160:1-3-02 | Medicaid: criteria for age, blindness, or disability.
Effective:
September 1, 2017
(A) The medicaid program provides coverage for individuals who have been determined to meet the criteria for the limiting physical factors of age, blindness, or disability as set forth in section 1902 of the Social Security Act (as in effect on October 1, 2016). Age is determined by county departments of job and family services (CDJFS). Blindness and disability are determined by either the social security administration (SSA) or the Ohio department of medicaid (ODM) in accordance with rule 5160:1-3-02.9 of the Administrative Code. The criteria are as follows: (1) Age: A person who is age sixty-five years or older meets the age requirement for medicaid. Verification of age is required. (2) Blindness: A person is considered to be blind if he or she has central visual acuity of 20/200 or less in the better eye with correcting glasses, or a limited visual field of twenty degrees or less in the better eye. (3) Disability. Disability is defined differently for adults and children. An individual is disabled if the individual is: (a) An adult who is unable to do any substantial gainful activity by reason of any medically determinable physical or mental impairment or combination of impairments which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than twelve months. (b) A child under the age of eighteen who has a medically determinable physical or mental impairment or combination of impairments that causes marked and severe functional limitations, and that can be expected to cause death or that has lasted or can be expected to last for a continuous period of not less than twelve months. No individual under the age of eighteen who engages in substantial gainful activity may be considered disabled. (B) If SSA makes a finding of presumptive disability based upon the available evidence which reflects a high degree of probability that the individual will meet the disability requirements, the applicant for medical assistance meets the disability requirements necessary to qualify for medical assistance. If it is later determined that the SSA decision was erroneously made and the individual was without fault in the determination, no attempt shall be made to recover payments for medical assistance made on behalf of the individual.
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Rule 5160:1-3-02.1 | Medicare premium assistance programs (MPAP).
Effective:
December 1, 2023
(A) This rule sets forth the eligibility
criteria and benefits for the medicare premium assistance programs (MPAP). The
programs are: qualified medicare beneficiary (QMB), specified low-income
medicare beneficiary (SLMB), qualified individual (QI-1), and qualified
disabled and working individual (QDWI). (B) Definitions. (1) "Eligible,"
for the purpose of this rule, means an individual meets all the requirements to
enroll in MPAP. (2) "Enrolled," for the purpose
of this rule, means an individual is in receipt of benefits under a medicare
health plan. (3) "Entitled,"
for the purpose of this rule, means an individual has coverage under medicare
through the social security administration (SSA). (4) "Family," for the purposes
of MPAP, means the following persons living in the same household as the
individual for whom medicare premium assistance is sought or
received: (a) The individual; and (b) When the individual is a minor, the biological parents,
adoptive parents, step-parents, legal guardians, or legal custodians of the
individual; and (c) The spouse of the individual and of any persons described in
paragraph (B)(4)(b) of this rule; and (d) The minor biological, adopted, or stepchild(ren) of the
individual and of any persons described in paragraphs (B)(4)(b) and (B)(4)(c)
of this rule. (5) "Family of the size
involved" means "family" as defined in paragraph (B)(4) of this
rule. (6) "MPAP" means any or all of
the medicare premium assistance programs: QMB, SLMB, QI-1, and
QDWI. (7) "MPAP resource limit" means
the maximum amount of countable resources allowed under section 1905(p)(1) of
the Social Security Act (as in effect October 1, 2023), as adjusted annually
according to the change in the consumer price index for urban areas
(CPI-U). (8) "Qualified," for the
purpose of this rule, means an individual is eligible to receive benefits under
a medicare health plan, whether or not the individual has applied for those
benefits. (9) "QDWI" means the qualified
disabled and working individual program established by section 1905(s) of the
Social Security Act (as in effect October 1, 2023). This program is sometimes
referred to as the qualified working disabled individuals (QWDI)
program. (10) "QI-1" means the qualified
individual group, described in section 1902(a)(10)(E)(iv) of the Social
Security Act (as in effect October 1, 2023). (11) "QMB" means the qualified
medicare beneficiary group described in section 1905(p)(1) of the Social
Security Act (as in effect October 1, 2023). (12) "SLMB" means the specified
low-income medicare beneficiary group described in section 1902(a)(10)(E)(iii)
of the Social Security Act (as in effect October 1, 2023). (C) The income standards for the medicare
premium assistance programs (MPAP) are as follows: (1) The QMB income
standard is one hundred per cent of the federal poverty level for the family of
the size involved. (2) The SLMB income
standard is greater than one hundred per cent of the federal poverty level and
up to a maximum one hundred twenty per cent of the federal poverty level for
the family of the size involved. (3) The QI-1 income
standard is greater than one hundred twenty per cent of the federal poverty
level and up to a maximum one hundred thirty-five per cent of the federal
poverty level for the family of the size involved. (4) The QDWI income
standard is two hundred per cent of the federal poverty level for the family of
the size involved. (D) To be eligible for a medicare premium assistance program, an
individual must meet all of the following conditions: (1) Be qualified for
coverage under medicare part A (part A). (a) An individual otherwise qualified for QMB must be enrolled in
either part A or medicare part B (part B) for the administrative agency to
provide benefits under this rule. (b) An individual otherwise qualified for SLMB must be enrolled
in part A for the administrative agency to provide benefits under this
rule. (c) An individual otherwise qualified for QI-1 must be enrolled
in part A for the administrative agency to provide benefits under this
rule. (d) An individual otherwise qualified for QDWI must be enrolled
in part A under section 1818A of the Social Security Act (as in effect October
1, 2023). Coverage can be identified as being provided under section 1818A of
the Social Security Act when the individual meets the following
criteria: (i) Has not reached
sixty-five years of age; and (ii) Has lost disability
benefits under Title II of the Social Security Act (as in effect October 1,
2023) solely due to earnings in excess of the substantial gainful activity
(SGA) level established by the SSA; and (iii) Is paying a premium
for part A coverage; and (iv) Has provided no
document or communication from the SSA indicating another basis for part A
coverage. (2) For QMB, SLMB, and
QI-1, have countable resources that do not exceed the MPAP resource limit as
defined in paragraph (B)(7) of this rule for an individual or the MPAP resource
limit for a couple (the individual and the individual's spouse). Countable
resources shall be determined in accordance with Chapter 5160:1-3 of the
Administrative Code. (3) For QDWI, have
countable resources that do not exceed twice the maximum amount of resources
that an individual or couple (the individual and the individual's spouse)
may have under the supplemental security income (SSI) program. Countable
resources shall be determined in accordance with Chapter 5160:1-3 of the
Administrative Code. (4) Have countable income, as determined
in accordance with paragraph (E) of this rule, within the MPAP income standards
as set forth in paragraph (C) of this rule. (5) For QI-1 and QDWI, be otherwise
ineligible for medical assistance in accordance with Chapters 5160:1-3,
5160:1-4, 5160:1-5, and 5160:1-6 of the Administrative Code. (6) Meet the application, conditions of
eligibility, and verification requirements set forth in Chapter 5160:1-2 of the
Administrative Code. (E) Countable income shall be determined in accordance with
Chapter 5160:1-3 of the Administrative Code. (1) The annual cost of
living adjustment (COLA) shall be deducted from the individual's income
beginning in January of each year and continuing through the end of the month
after the month in which the updated federal poverty guidelines are published
in the Federal Register. (2) The income of both
the individual and the individual's spouse shall be determined in
accordance with rule 5160:1-3-03.1 of the Administrative Code and applying all
exclusions listed in rule 5160:1-3-03.2 of the Administrative Code, except that
the twenty-dollar general income exclusion and the exclusion of the first
sixty-five dollars of earned income shall be applied only once to a married
couple in the MPAP eligibility determination. (3) The deeming
provisions set forth in rule 5160:1-3-03.3 of the Administrative Code do not
apply to MPAP eligibility determinations. (F) Application of income standards. (1) When the individual
is a minor, the countable income of the following individuals is combined and
compared to the income standards set forth in paragraph (C) of this rule for
the family of the size involved: (a) The individual; and (b) The individual's biological parents, adoptive parents,
step-parents, legal guardians, or legal custodians; and (c) When married, the individual's spouse. (2) The income of the individual combined
with the income of the individual's spouse is compared to the income
standards set forth in paragraph (C) of this rule for the family of the size
involved. (G) Application of resource
standards. (1) The countable
resources of the individual combined with the countable resources of the
individual's spouse are compared to the resource standards set forth in
paragraphs (D)(2) and (D)(3) of this rule. (2) The deeming
provisions set forth in rule 5160:1-3-05.20 of the Administrative Code do not
apply to MPAP eligibility determinations. (H) Coordination of enrollment. When the individual is eligible
for benefits under this rule, the county department of job and family services
(CDJFS) shall coordinate the individual's receipt of
benefits. (1) When the individual
is or has ever been in receipt of part A or part B benefits, the CDJFS shall
approve MPAP benefits for the individual in the electronic eligibility
system. (2) When the individual has never
received part A or part B benefits, the CDJFS shall: (a) Inform the individual that the Ohio department of medicaid
(ODM) can not pay medicare premiums until the individual has enrolled in part A
or part B through the SSA; and (b) Advise the individual to apply for part A or part B benefits
through the SSA, and advise the individual that the CDJFS will assist upon
request; and (c) Advise the individual to report the approval of part A or
part B benefits to the CDJFS immediately, so payment of premiums can be
approved; and (d) Approve MPAP benefits for the individual in the electronic
eligibility system upon being informed that the individual has been enrolled in
part A or part B by the SSA. (I) Coverage periods. (1) The effective date of
QMB coverage is the first day of the month after the month in which the
administrative agency approves QMB benefits. No retroactive coverage is
available for QMB. (2) Eligibility for SLMB
benefits begins no earlier than the third month prior to the month of
application, provided the individual met all eligibility criteria including
enrollment in part A during the three-month period. (3) Eligibility for QI-1
benefits begins no earlier than the third month prior to the month of
application, provided the individual met all eligibility criteria including
enrollment in part A during the three-month period. (4) Eligibility for QDWI
benefits begins no earlier than the third month prior to the month of
application, provided the individual met all eligibility criteria including
enrollment in part A during the three-month period. (5) Eligibility for payment of medicare
premiums under this rule ends on the earliest of the following
dates: (a) The last day of the month in which the individual dies;
or (b) The last day of the last month in which the individual is
entitled to part B benefits; or (c) The last day of the last month in which the individual meets
the eligibility criteria for MPAP, if notice was provided to the centers for
medicare and medicaid services (CMS) no later than the twenty-fifth day of the
second month of ineligibility; or (d) The last day of the second month before CMS receives notice
the individual was no longer eligible for MPAP, when notice was not provided
within the time limit identified in paragraph (I)(5)(c) of this
rule. (J) Benefits. (1) When the individual
is eligible for QMB, the administrative agency shall pay the
individual's: (a) Premiums for part B and, when a premium is charged, for part
A; and (b) Medicare deductibles; and (c) Medicare co-pays; and (d) Medicare coinsurance costs. (2) When the individual
is eligible for SLMB or QI-1, the administrative agency shall pay the
individual's part B premiums. (3) When the individual
is eligible for QDWI, the administrative agency shall pay the individual's
part A premiums. (4) The medicare
prescription drug benefit program (part D) is not covered by MPAP. (K) Administrative agency responsibilities. The administrative
agency shall: (1) Explore eligibility
for medical assistance and for all MPAP categories when a medical assistance
applicant is qualified for part A. The agency shall advise the
individual: (a) Of the categories of medical assistance or MPAP for which the
individual is eligible, the individual's right to decline payment of
premiums, co-pays, or coinsurance costs, and the effect of declining MPAP
payments; and (b) That when the individual is qualified for benefits under part
A or part B, ODM is prohibited from paying for prescriptions on behalf of that
individual, whether or not a premium would be charged for those
benefits. (2) Determine the
individual's eligibility for QMB and when eligible: (a) Approve QMB benefits effective the month after the
administrative agency approves QMB coverage; and (b) For individuals who are not receiving free part A, but who
could receive part A benefits by paying a premium, coordinate enrollment in
parts A and B with SSA. (3) Determine the
individual's eligibility for SLMB and, when eligible, approve SLMB
benefits in accordance with paragraph (I)(2) of this rule. (4) Determine the
individual's eligibility for QI-1 and, when eligible, approve QI-1
benefits in accordance with paragraph (I)(3) of this rule. (5) Determine the
individual's eligiblity for QDWI and, when eligible, approve QDWI benefits
in accordance with paragraph (I)(4) of this rule. (6) Deny benefits under this rule
when: (a) Any criterion under this rule is not met; or (b) Any of the conditions for denial set forth in rule
5160:1-2-01 of the Administrative Code are met. (7) Discontinue benefits under this rule
when: (a) An individual no longer meets the eligibility criteria
for any covered group under this rule; or (b) Any of the conditions for discontinuance set forth in
rule 5160:1-2-01 of the Administrative Code are met; or (c) The individual was eligible for benefits under QI-1 but
becomes eligible for another category of medical assistance. (8) Coordinate enrollment with the
individual, the SSA, and ODM's buy-in unit. (L) Individual responsibilities. (1) Inform the CDJFS of any actions by
the SSA on the individual's application for part A or part B, or any
changes in the individual's part A or part B coverage. (2) Adhere to the
individual responsibilities set forth in rule 5160:1-2-08 of the Administrative
Code.
Last updated December 1, 2023 at 9:38 AM
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Rule 5160:1-3-02.2 | Medicare buy-in.
Effective:
November 1, 2023
(A) This rule sets forth: (1) The eligibility
criteria for benefits under the medicare part B (part B) buy-in agreement
between the social security administration (SSA) and the Ohio department of
medicaid (ODM), which allows ODM to pay part B (supplemental medical insurance)
premiums for certain individuals even when those individuals are not eligible
for a medicare premium assistance program (MPAP) set forth in rule
5160:1-3-02.1 of the Administrative Code; and (2) The beginning date of
payment of part B benefits under this rule; and (3) The date and effect
of termination of benefits under part B buy-in. (4) The process of
coordinating enrollment with ODM and the SSA. (B) Definitions. (1) "Medicare
buy-in" means the program and process of paying part A and/or part B
benefits on behalf of an eligible individual. (2) "Part B
buy-in" means the agreement under which ODM pays part B premiums on behalf
of an eligible individual. (C) Eligibility criteria. To be eligible
for payment of the part B premium under the medicare buy-in agreement, an
individual must meet all three of the following requirements: (1) Be eligible for part
B. (2) Be eligible for a
category of medical assistance other than: (a) Breast and cervical cancer project as set forth in rules
5160:1-5-02 to 5160:1-5-02.4 of the Administrative Code; or (b) Presumptive eligibility as set forth in rule 5160:1-2-13 of
the Administrative Code. (3) Be receiving at least
one of the following: (a) Medicare premium assistance under rule 5160:1-3-02.1 of the
Administrative Code. (b) One of the following types of cash assistance: (i) Ohio works first
(OWF); or (ii) Supplemental
security income (SSI); or (iii) Residential state
supplement. (c) Four-month extended coverage as set forth in rule 5160:1-4-05
of the Administrative Code. (d) Medical assistance under the grandfathering provisions set
forth in rule 5160:1-3-02.6 of the Administrative Code. (e) Foster care maintenance payments or adoption assistance
payments as set forth in rule 5160:1-2-14 of the Administrative
Code. (f) Medical assistance as a result of section 1619(b) of the
Social Security Act (as in effect October 1, 2023) as set forth in rule
5160:1-3-02.5 of the Administrative Code. (g) Deemed cash assistance under Pub.L.No. 94-48. (h) Long-term care services in a Title XIX certified nursing
facility (NF) or intermediate care facility for individuals with intellectual
disabilities (ICF-IID). (i) Home and community-based services (HCBS), including the
program of all-inclusive care for the elderly (PACE), under a waiver described
in agency 5160 of the Administrative Code. (D) Coordination of enrollment. When an
individual is eligible for benefits under this rule or would be eligible if the
individual was enrolled in part A or part B, the county department of job and
family services (CDJFS) shall coordinate the individual's receipt of
benefits. When the individual: (1) Is or has ever been in receipt of
part A or part B benefits, the CDJFS shall approve part B buy-in benefits for
the individual in the electronic eligibility system. (2) Has never received part A or part B
benefits, the CDJFS shall: (a) Inform the individual that ODM cannot pay medicare premiums
until the individual has enrolled in part A or part B through the SSA;
and (b) Advise the individual to apply for part A or part B benefits,
and advise the individual that the CDJFS will assist upon request;
and (c) Advise the individual to report the approval of part A or
part B benefits to the CDJFS immediately, so payment of premiums can be
approved; and (d) Approve part B buy-in benefits for the individual in the
electronic eligibility system upon being informed that the individual has been
enrolled by the SSA in part A or part B. (E) Coverage period. (1) Start
date. (a) For MPAP benefits under rule 5160:1-3-02.1 of the
Administrative Code, the beginning date for payment of premiums is addressed in
those rules. When an individual is eligible for MPAP benefits under rule
5160:1-3-02.1 of the Administrative Code and also eligible for part B buy-in
under this rule, payment of part B premiums begins on the earlier of the
coverage date under rule 5160:1-3-02.1 of the Administrative Code or the
coverage date under this rule. (b) For individuals eligible for payment of premiums under the
part B buy-in agreement, eligibility begins: (i) The first month an
individual is eligible for both medicare and cash assistance as defined in
paragraph (C)(3)(b) of this rule; or (ii) The first day of the
second month after the administrative agency made the determination the
individual was eligible for medical assistance, when the individual is not in
receipt of cash assistance as defined in paragraph (C)(3)(b) of this
rule. (2) Termination date.
Eligibility for payment of medicare premiums under this rule ends on the
earliest of the following dates: (a) The last day of the month in which the individual dies;
or (b) The last day of the month in which the individual is
entitled to part B benefits; or (c) The last day of the last month in which the individual
meets the eligibility criteria for part B buy-in benefits, when notice was
provided to the centers for medicare and medicaid services (CMS) no later than
the twenty-fifth day of the second month of ineligibility; or (d) The last day of the second month before CMS received
notice the individual was no longer eligible for part B buy-in benefits, when
notice was not provided within the time limit identified in paragraph (E)(2)(c)
of this rule. (F) Retroactive termination. An
individual's part B premium payment under buy-in can be terminated
retroactively for as many as two months before the state's notice to CMS
that the individual is no longer eligible. (1) After CMS receives
notice from ODM, CMS sends the individual a notice stating the individual is
responsible for paying part B premiums beginning with the month following the
last month of buy-in coverage. Because of administrative delays, an individual
can already be in the third month after buy-in termination and owe three months
of part B premiums before receiving notice that buy-in coverage has been
terminated. (2) The individual may
request equitable relief from CMS under certain conditions specified by CMS in
its notice.
Last updated November 1, 2023 at 8:27 AM
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Rule 5160:1-3-02.3 | Medicaid: coverage for individuals receiving supplemental security income (SSI) benefits.
Effective:
January 1, 2024
(A) This rule describes eligibility for
medical assistance for aged, blind, or disabled individuals who receive SSI
benefits authorized by the social security administration under Title XVI of
the Social Security Act (as in effect October 1, 2023). (B) Eligibility criteria. To be eligible
for coverage under this group an individual must be receiving SSI benefits
based on the social security administration's determination of eligibility
for SSI payments. In addition, certain requirements specific to medical
assistance must be met in order for an individual to be eligible under this
group. Failure to comply with the following requirements will prevent an
individual from being determined eligible under this provision: (1) Consistent with rule
5160:1-2-10 of the Administrative Code: (a) An individual must assign to the state of Ohio any rights to
medical support and payments for medical care from any third party;
and (b) An individual must cooperate with the child support
enforcement agency (CSEA) in establishing the paternity of any child eligible
for medical assistance and in obtaining medical support and payments for
medical care from any third party, in accordance with 42 C.F.R. 433.147 (as in
effect October 1, 2023); and (c) An individual must cooperate with the administrative agency
in identifying and providing information to assist the state with pursuing any
third party who may be liable to pay for care and services. (2) An individual who is
the beneficiary of a trust must provide documentation of the trust as required
by rule 5160:1-3-05.2 of the Administrative Code. (C) Retroactive coverage is available for
this program in accordance with rule 5160:1-2-01 of the Administrative
Code.
Last updated January 2, 2024 at 8:46 AM
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Rule 5160:1-3-02.4 | Medicaid: coverage for the categorically needy.
(A) This rule describes eligibility for
aged, blind, or disabled individuals who meet the income and resource
requirements of the supplemental security income (SSI) program authorized by
the social security administration (SSA) under Title XVI of the Social Security
Act (as in effect October 1, 2022) but who do not receive cash benefits under
the program. Eligibility for this program shall be determined for applications
for medical assistance filed on or after the August 1, 2016 effective date of
this rule. (B) Eligibility criteria. To be eligible
under this group, an individual must meet all of the following
critiera: (1) Be aged, blind, or
disabled; and (2) Determinations of
blindness and disability must be in accordance with SSA policy;
and (3) Have countable income, as determined
under Chapter 5160:1-3 of the Administrative Code, which does not exceed the
income standard described in rule 5160:1-3-03.5 of the Administrative Code;
and (4) Have countable resources, as
determined under Chapter 5160:1-3 of the Administrative Code, which do not
exceed the resource limit described in rule 5160:1-3-05.1 of the Administrative
Code; and (5) Not be receiving cash benefits from
the SSI program; and (6) Meet the conditions of eligibility
outlined in rule 5160:1-2-10 of the Administrative Code. (C) Retroactive coverage is available for
this program in accordance with rule 5160:1-2-01 of the Administrative Code,
but coverage shall not begin prior to the August 1, 2016 effective date of this
rule and shall not provide reimbursement of services rendered prior to the
August 1, 2016 effective date of this rule.
Last updated July 27, 2023 at 8:34 AM
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Rule 5160:1-3-02.5 | Medicaid: supplemental security income (SSI) recipients qualifying under section 1619 of the Social Security Act for continued medical assistance coverage.
(A) This rule describes the eligibility
criteria for continued medical assistance coverage for an individual who is
receving SSI benefits under section 1619 of the Social Security
Act. (B) Section 1619 of the Social Security Act (as in effect October
1, 2022) comprises two basic provisions: (1) Section 1619(a)
extends special SSI cash to individuals whose earnings preclude eligibility for
regular SSI cash benefits. Individuals in 1619(a) status may still receive an
SSI cash benefit in addition to the individual's earned
income. (2) Section 1619(b)
extends medicaid coverage to individuals whose earnings, although high enough
to preclude eligibility for regular SSI cash benefits or special SSI cash
benefits under section 1619(a), may not be enough for medical
care. (C) To determine initial medicaid eligibility for sections
1619(a) and 1619(b), the administrative agency shall verify that the individual
is currently in 1619(a) or 1619(b) status, as determined by the social security
administration. (D) Protection of benefits under 1619 status. (1) An individual who has
been determined eligible for medicaid because of 1619 status is protected from
losing medicaid benefits under this provision as long as the individual remains
in 1619(a) or (b) status. (2) The individual may
have income or resources in excess of the medicaid standards and remain
eligible for medicaid under the 1619 provisions. (3) When the
individual's 1619 status ends, the individual's medicaid protection
is lost.
Last updated July 27, 2023 at 8:34 AM
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Rule 5160:1-3-02.6 | Medicaid: grandfathering provisions and deemed eligibility.
Effective:
December 14, 2020
(A) Various grandfathering provisions
and deemed eligibility requirements were enacted to assure that aged, blind, or
disabled individuals previously eligible for cash assistance and medicaid under
former programs of aid would not be disadvantaged by eligibility conditions
when the supplemental security income (SSI) program was
implemented. (B) Definitions. (1) "Cash
assistance," for the purpose of this rule, means the receipt of at least
one of the following: Ohio works first (OWF), SSI or residential state
supplement (RSS), or the former programs of aid known as aid for dependent
children (ADC), aid for the aged (AFA), aid for the blind (AFB), and aid for
the disabled (AFD). (2) "Essential
spouse" for the purpose of this rule means one who is living with the
individual whose needs were included in determining the amount of cash
assistance and who is determined essential to the individual's
well-being. (C) Under the grandfathering provisions, certain individuals who
were eligible for medicaid in December 1973 are entitled to continued medicaid
eligibility coverage even though they may not meet the medicaid eligibility
requirements imposed beginning in January 1974 for the coverage of the aged,
blind, and disabled. (1) The grandfathered
groups are the following: (a) Individuals receiving mandatory state supplements as
described in 42 C.F.R. 435.130 (as in effect October 1, 2019): an individual
who is the recipient of mandatory state supplement payments (SSP) administered
by the social security administration is automatically eligible for
medicaid. (b) Individuals who are essential spouses as described in 42
C.F.R. 435.131 as in effect October 1, 2019): any individual who was eligible
in December 1973 as an essential spouse remains eligible under the following
criteria: (i) The aged, blind or
disabled spouse continues to meet the December 1973 eligibility requirements of
the applicable cash assistance programs; and (ii) The essential spouse
continues to be the spouse of and lives with the spouse described in paragraph
(C)(1)(b)(i) of this rule; and (iii) The essential
spouse continues to meet the conditions that were in effect in December 1973
under the applicable cash assistance program for having his or her needs
included in computing the payment to the individual described in paragraph
(C)(1)(b)(i) of this rule. (c) Blind or disabled individuals eligible in 1973 as described
in 42 C.F.R. 435.133 (as in effect October 1, 2019): an individual who was
eligible for medicaid in December 1973 because the individual met the
definition of blindness or disability in effect under the former programs of
AFB or AFD and meets the following criteria: (i) The individual meets all current requirements for medicaid
eligibility except for blindness or disability; and (ii) The individual was eligible for medicaid in December 1973 as
blind or disabled, whether or not the individual received cash assistance in
December 1973; and (iii) For each consecutive month after December 1973, the
individual has continued to meet the December 1973 criteria for blindness or
disability; and (iv) For each consecutive month after December 1973, the
individual has continued to meet all other eligibility requirements which were
in effect December 1973. (d) Individuals who lost eligibility for SSI due to an increase
in retirement, survivors and disability insurance (RSDI) as described in 42
C.F.R. 435.134 (as in effect October 1, 2019): individuals eligible despite the
October 1972 twenty per cent general increase: (i) An individual who
would currently be eligible for SSI or cash assistance except for the amount of
increased income resulting from the October 1972 twenty per cent general
increase in RSDI is eligible for medicaid if, for the month of August 1972, the
individual met the following criteria: (a) The individual was eligible for and receiving cash assistance
under the ADC, AFA, AFB, or AFD programs, and (b) The individual received and was entitled to monthly RSDI
benefits. (ii) Only the October
1972 RSDI increase is disregarded. Any subsequent increases in RSDI are not
disregarded. (iii) Although the amount
of the October 1972 RSDI increase is disregarded in determining financial
eligibility, the individual must meet all of the current eligibility
requirements for medicaid. (e) Institutionalized individuals continuously eligible since
1973 as described in 42 C.F.R. 435.132 (as in effect October 1, 2019): an
individual who was eligible for medicaid in December 1973 as an inpatient or
resident of a Title XIX institution and for each consecutive month after
December 1973 meets the following criteria: (i) Continues to meet the
requirements for medicaid eligibility that were in effect in December 1973 for
institutionalized individuals; and (ii) Remains
institutionalized; and (iii) Is determined to
continue to need institutional care. (f) Individuals who would be eligible for SSI but not for RSDI
COLA increases since April 1977 (Pickle Amendment Group) as described in 42
C.F.R. 435.135 (as in effect October 1, 2019): an individual receiving RSDI and
meets the following criteria: (i) Became ineligible for
SSI after April 1977; and (ii) Would continue to be
eligible for SSI if all of the RSDI cost-of-living increases received by the
individual, the individual's spouse or other family member after April
1977 were deducted from current RSDI benefits. (g) Ineligible for SSI due to requirements prohibited by Medicaid
as described in 42 C.F.R. 435.122 (as in effect October 1, 2019): individuals
who would be eligible for SSI or residential state supplements except for an
eligibility requirement used in those programs that is specifically prohibited
under medicaid. (2) Failure to meet any one of the
conditions listed in paragraph (C)(1) of this rule renders the individual
ineligible for grandfathered status under the blind or disabled grandfathering
provisions. (3) An individual described in paragraph
(C)(1)(c) of this rule permanently loses grandfathered status when the
individual fails to meet any December 1973 eligibility requirement for any one
month. (4) Any change in circumstances requires
a redetermination of eligibility based upon all the conditions set forth in
paragraph (C)(1) of this rule. (5) Eligibility under a
grandfathered group does not apply to individuals in a long-term care facility
or enrolled in a home and community-based services waiver. (D) Under deemed eligibility, certain
individuals who were ineligible for SSI, due to receipt of social security
benefits, are entitled to continued medicaid coverage for the aged, blind and
disabled if certain criteria are met. (1) The deemed
eligibility groups are the following: (a) Disabled widows(ers) ineligible for SSI or RSS due to
increase in RSDI as described in 42 C.F.R. 435.137 (as in effect October 1,
2019): disabled widows(ers) who became ineligible for SSI or RSS benefits as a
result of the elimination of the additional reduction factor for disabled
widows(ers) under age sixty and meet all of the following
criteria: (i) Entitled to a monthly
RSDI benefit for December 1983, and (ii) Entitled to and
received a social security widow(er)'s disability benefit in January 1984,
and (iii) Became ineligible
for SSI benefits in the first month in which the increase in social security
disabled widows(ers) benefits, as a result of the elimination of the additional
reduction factor, was received, and (iv) Continuously
entitled to widow(er)'s disability benefits from the first month that the
increase was received, and (v) Would be eligible for
SSI or RSS if the increase in RSDI benefits due to the elimination of the
reduction factor and subsequent cost-of-living adjustments in RSDI benefits
were excluded, and (vi) Filed a medicaid application or renewal on or before June 30,
1988 for deemed eligibility. (b) Disabled adult children as described in section 1634 of the
Social Security Act (as in effect October 1, 2019): disabled individuals who
have attained the age of eighteen and received SSI benefits on the basis of
blindness or disability which began before he or she attained the age of
twenty-two and meet all of the following criteria: (i) Entitled to social
security child's insurance benefits on the basis of disability or an
increase in the amount of the child's insurance benefits which are
payable, and (ii) Became ineligible
for SSI benefits solely because of their receipt of social security
child's insurance benefits or increase in social security child's
insurance benefits, and (iii) Would be eligible
for SSI if the social security child's insurance benefits were
excluded. (c) Disabled widows(ers) ineligible for SSI due to early receipt
of social security as described in 42 C.F.R. 435.138 (as in effect October 1,
2019): disabled widows(ers) at least age sixty who became ineligible for SSI as
a result of the receipt of widows(ers) social security disability benefits and
meet all of the following criteria: (i) Receives widows(ers)
social security disability benefits, and (ii) Became ineligible
for SSI benefits solely because of the receipt of widows(ers) social security
disability benefits, and (iii) Received a SSI
benefit in the month before the month of receipt of widows(ers) social security
disability benefits, and (iv) Not entitled to
medicare part A. (v) Although the amount of the widows(ers) social security
disability benefits is excluded in determining financial eligibility, the
individual must meet all of the current eligibility requirements for medical
assistance. (2) Any changes in
circumstances requires a redetermination of eligibility based upon all
conditions set forth in paragraph (D)(1) of this rule. (3) Eligibility under a deemed group does
not apply to individuals in a long-term care facility or enrolled in a home and
community-based services waiver.
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Rule 5160:1-3-02.9 | Medicaid: disability determination process.
Effective:
December 1, 2023
(A) This rule addresses the process of
determining blindness or disability for non-citizen emergency medical
assistance (NCEMA), medicaid buy-in for workers with disabilities (MBIWD),
retroactive coverage for a deceased individual, or the specialized recovery
services (SRS) program. (B) Definitions. (1) "Administrative
agency," for the purpose of this rule, means the county department of job
and family services (CDJFS). (2) "Current medical
information" means medical records that originated within eighteen months
of the date of initial application. (3) "Deferred"
means the delay in the determination for a disability packet due to incomplete
or an insufficient amount of current medical information for the disability
determination area (DDA) to approve, deny, or continue the blindness or
disability claim. (4) "Disability
begin date" means the date the individual is otherwise eligible for
medical assistance and meets the limiting physical factor. (5) "Disability
determination" is the process by which the DDA determines whether the
individual meets the social security administration's (SSA's)
definition of "blind" or "disabled" for medical assistance
eligibility. The DDA determines blindness and disability in accordance with SSA
policy. (6) "Disability
packet" consists of all required forms specified in paragraph (C) of this
rule and all available current medical information to support the
individual's blindness or disability claim. The disability packet is
submitted by the administrative agency to the DDA for a disability
determination. (7) "Disability
review date" means the date, determined by the DDA, that the
individual's current blindness or disability approval will
expire. (8) "Limiting
physical factor" is a non-financial eligibility criterion consisting of a
physical or mental characteristic or impairment, or a combination of physical
or mental characteristics or impairments, that may limit the individual's
ability to work. An individual meets the limiting physical factor by meeting
the criteria of age, blindness, or disability as set forth in rule 5160:1-3-02
of the Administrative Code. (9) "SSA
disability" means a determination of blindness or disability, as set forth
in section 1902 of the Social Security Act (as in effect October 1, 2023), by
the SSA. (C) Administrative agency
responsibilities. (1) Determine eligibility
for medical assistance in accordance with the eligibility rules contained in
Chapters 5160:1-1 to 5160:1-6 of the Administrative Code. (2) Determine that the
limiting physical factor is met and do not submit a disability packet to the
DDA when the individual: (a) Is sixty-five years of age or older; or (b) Has been approved for SSA disability for the
individual's own blindness or disability. (3) Determine that the
limiting physical factor is not met and submit a disability packet to the DDA
for a disability determination when the individual is potentially eligible for
one of the following: (a) NCEMA, except for routine labor and delivery, as described in
rule 5160:1-5-06 of the Administrative Code; or (b) MBIWD, in accordance with rule 5160:1-5-03 of the
Administrative Code, when an individual has not been determined disabled by the
SSA; or (c) Medical assistance for an individual who has died and
retroactive eligibility is requested in accordance with rule 5160:1-2-01 of the
Administrative Code; or (d) SRS, in accordance with rule 5160:1-5-07 of the
Administrative Code, when an individual has not been determined disabled by the
SSA. (i) The administrative
agency is only required to submit the ODM 03605 "CDJFS Referral to
DDU" (rev. 8/2021) as referenced in paragraph (C)(11) of this rule. No
other forms or documentation listed in this rule are required to be completed
by the administrative agency for an SRS referral to DDA. (ii) DDA will have access
to electronic health records maintained by the recovery manager in order to
make an accurate disability determination. (4) Contact the DDA nurse
manager to request an expedited disability decision from the SSA for an
individual who has an initial disability application that has been pending for
ninety days or longer. The CDJFS shall not submit a disability packet for these
individuals. (5) Presume the limiting physical factor
is met and do not submit a disability packet to the DDA for a disability
determination when the individual is determined to have a presumptive
disability by the SSA and has an application for SSA disability
pending. (6) Upon request, assist the individual
with obtaining medical documentation to support the blindness or disability
claim, including, when necessary, using administrative funds to assist the
individual with receiving a medical, psychological, or eye examination to
determine whether the individual is blind or disabled. (7) Obtain and/or assist the individual
with obtaining all available current medical information that pertains to the
individual's alleged impairment(s) or combination of impairments, as well
as any other information requested by the DDA, and submit the information along
with the disability packet. This includes existing medical information, tests,
services, or records from other entities such as the SSA, opportunities for
Ohioans with disabilities, workers' compensation, etc. (8) Provide the forms listed in this
paragraph to the individual, the individual's legal representative,
another person applying on behalf of the individual, or the treating
physician(s). (a) ODM 07302 "Basic Medical" (rev. 7/2018);
and (b) ODM 07308 "Mental Functional Capacity Assessment"
(rev. 7/2018) when the individual has or appears to have a mental impairment;
and (c) JFS 03606 "Medication Dependencies" (rev. 5/2006)
when applicable. (9) Complete the ODM 07004 "Social
Summary Report for Disability Determination" (rev. 7/2018). (10) Obtain signed copies of form ODM
03397 "Authorization for the Release or Use of Protected Health
Information (PHI)" (rev. 6/2021) from the individual for all providers who
have or may have current medical information. (11) Complete the ODM 03605 "CDJFS
Referral to DDU" (rev. 8/2021). (12) Submit the disability packet to the
DDA for a blindness or disability determination for an individual with
potential eligibility as described in paragraph (C)(3) of this rule.
(13) Resubmit the initial disability
packet and any additional information to the DDA for a final decision when the
DDA has deferred a disability determination and the administrative agency is
unable to obtain all of the requested additional medical
information. (D) Individual
responsibilities. (1) When the individual
alleges a blindness or disability, the individual shall assist the
administrative agency with obtaining all available current medical information
that supports the blindness or disability claim. (2) As a condition of
eligibility for medical assistance, the individual is required to apply for any
disability benefits to which the individual may be entitled in accordance with
rule 5160:1-2-10 of the Administrative Code. (E) DDA responsibilities. (1) The DDA shall
approve, deny, or defer disability determinations, and shall notify the
administrative agency via the electronic eligibility system. (2) The DDA shall
determine the disability begin date and end date, as appropriate, for approved
blindness or disability claims, and shall inform the administrative agency via
the electronic eligibility system. (3) In accordance with
paragraph (C)(13) of this rule, when the initial disability packet is
resubmitted to the DDA because the administrative agency was unable to obtain
the requested additional medical information, the DDA shall make a final
decision on the case based upon the information available in the initial
disability packet, and shall notify the administrative agency of the decision
via the electronic eligibility system. (F) Discontinuance of an MBIWD DDA-approved individual.
When an MBIWD DDA-approved individual is discontinued from medical assistance
and reapplies: (1) Within twelve months
after the disability begin date, the individual meets the limiting physical
factor for the remainder of the twelve months. The administrative agency shall
not submit a new disability packet to the DDA. The administrative agency shall
apply the existing disability review date. (2) More than twelve
months after the disability begin date, the limiting physical factor is not
met. The administrative agency shall submit a new disability packet to the DDA
for a new disability determination, in accordance with paragraphs (C) to (E) of
this rule. (G) Eligibility for medical assistance when SSA denials are
appealed. (1) When the SSA makes a
decision denying SSA disability, the individual has a right to appeal the SSA
decision. (2) An individual shall
not be eligible for medical assistance programs, where blindness or disability
is an eligibility requirement, during the SSA appeals process.
Last updated December 1, 2023 at 9:38 AM
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Rule 5160:1-3-03.1 | Medicaid: income.
Effective:
January 1, 2024
(A) This rule describes how income, as
defined in rule 5160:1-1-01 of the Administrative Code, is treated for the
purpose of determining eligibility for medical assistance for an aged, blind,
or disabled individual. (B) Treatment of income. (1) Eligibility for
medical assistance is dependent in part upon the amount of monthly income
available to or received by the individual. (a) Gross income, prior to any deductions or exclusions, that can
be reliably anticipated is considered available when calculating countable
income for a month. Thus, when an individual is receiving a pension or is
regularly employed or self-employed, the expected amount of income is
counted. (i) Wages are counted as
earned income in the calendar month in which they are received, even when all
of the work which produced the wages was performed in a prior
month. (ii) When the time of
receipt of the income is at the individual's discretion, the individual
shall promptly request such wages. (iii) When the payment of
wages is deferred at the individual's request, the administrative agency
shall determine when the wages would normally have been paid and allocate them
as income for the month in which the wages would have normally been paid. The
administrative agency shall assume the wages were payable in equal segments
throughout the applicable period and determine eligibility accordingly. When
the payment of wages is deferred due to circumstances beyond the control of the
individual, the administrative agency shall consider the wages as income when
the income is actually received. (b) Receipt of cash, income in-kind, or something of value in a
particular month is considered income to the individual for that month. Any
portion of the income which is retained by an individual into the next month
becomes a resource. (2) All income, except
income excluded in rule 5160:1-3-03.2 of the Administrative Code, shall be
considered when determining the amount of income that is available to an
individual. (3) When an eligible
individual resides with an ineligible spouse or parent(s), a portion of the
ineligible spouse's or parent's income shall be deemed as available
income to the eligible individual. This deeming of income is subject to
conditions and limitations as described in rule 5160:1-3-03.3 of the
Administrative Code. (4) Net earnings from
self-employment are the gross income from any trade or business minus allowable
deductions for that trade or business. (a) When the individual has filed taxes for the previous year,
use all tax forms that were filed with the internal revenue service
(IRS). (b) When the individual has not filed taxes for the previous
year, the following may be used: (i) Business records
including receipts for the costs of doing business, or (ii) Estimated net
income. (5) The monthly income
allowance (MIA) from an institutionalized individual to a community spouse, as
described in rules 5160:1-6-07 and 5160:1-6-07.1 of the Administrative Code,
shall be treated as unearned income to the community spouse in the
determination of the community spouse's eligibility for medical
assistance. (C) Under certain circumstances, the
amount of income determined available to an individual may be greater than the
amount of income that the individual actually receives for personal use. The
following types of income deductions are not subtracted from the
individual's countable income for purposes of determining eligibility for
medical assistance. This list is not all-inclusive. (1) Court-ordered income
deductions. (a) This includes child and/or spousal support, even when such
support is paid directly to the former spouse or child's guardian by the
employer or benefit payer. (b) A division of marital property in a divorce settlement, which
may include a retirement pension, is not considered a court-ordered income
deduction. (2) Deductions due to a repayment of an
overpayment, loan, or other debt, unless the amount being withheld to reduce a
previous overpayment was included when determining the amount of unearned
income for a previous month in the determination of medical assistance
eligibility. (3) Garnishments and
liens placed against earned or unearned income of the individual, regardless of
the purpose for the garnishment or lien. (D) An individual must take all necessary
steps to obtain potential income, as required by paragraph (B)(4) of rule
5160:1-2-10 of the Administrative Code. An individual who does not take the
necessary steps to pursue potential income is presumed to have done so in order
to be eligible for medical assistance. Such non-utilization of income
constitutes ineligibility unless the individual demonstrates good cause. Types
of potential income include, but are not limited to: (1) Retirement,
survivors, disability insurance (RSDI); or (2) Prouty benefits;
or (3) Railroad retirement;
or (4) Veterans benefits;
or (5) Other public/private
retirement benefits. (E) The following items are not considered income, in accordance
with 20 C.F.R. 416.1103 (as in effect October 1, 2023). This list is not
all-inclusive: (1) A personal service
performed for an individual is not income to the individual where the service
is not convertible to cash. (2) Payments made on behalf of an
individual under credit life or credit disability policies directly to loan
companies, mortgage companies, etc. (3) Money an individual borrows or money
received as the repayment of the principal of a bona fide loan. Any interest
received on the money loaned is unearned income. When the proceeds of the loan
are retained in the month following the month of receipt, they are counted as a
resource. (4) A bill paid directly to a creditor or
vendor by a third party on behalf of the individual, unless payment is for food
or shelter, to include: (a) A premium payment for supplementary medical
insurance. (b) Medical insurance premiums. (5) An arrearage of child support which
is payable to an individual on behalf of an adult child unless the individual
retains the income and does not give it to the adult child. (6) Receipts from the
sale, exchange or replacement of a resource are not income but remain
resources. (7) A rebate, refund, or
other return of money an individual has already paid. The money returned is not
income. (8) Any amount refunded
on income taxes already paid. (9) The replacement of an
individual's income that was lost, stolen, or destroyed and was previously
used when determining eligibility. (10) A return of
erroneously received payments. (11) Cash or in-kind
assistance from a governmental or nongovernmental program for medical or social
services that are not food or shelter. (F) Verification of income. (1) The individual's
statements of source and amount of income are subject to verification. At the
time of application and renewal, the income of the individual and household
member(s) whose income affects the individual shall be verified electronically
or documents shall be required to be submitted which verify all sources of
income. When necessary, the administrative agency shall obtain a signed release
of information and contact other sources to verify income. (a) When the administrative agency is unable to verify the income
through electronic sources, the administrative agency will contact the
individual to collect the information needed. When the individual declares the
verifications cannot be accessed or submitted, the individual's statement
shall be accepted. (b) When the administrative agency is unable to make contact with
the individual, a request for information or verification documents shall be
sent electronically, via postal mail, or personally delivered to the individual
as set forth in rule 5160:1-2-01 of the Administrative Code. (2) An individual's
report of income is subject to verification when a review is conducted by the
Ohio department of medicaid (ODM) program integrity compliance
section. (3) The individual has
the burden of verifying the sources and amounts of income, and has the
responsibility of reporting income changes to the administrative agency in
accordance with rule 5160:1-2-08 of the Administrative Code. (4) When an individual
claims to have no income at the time of application or renewal, the
administrative agency shall review the application or renewal for
inconsistencies requiring resolution. The individual is responsible for
supporting the claim of no income; however, when verification is not available
and the individual has cooperated with the administrative agency in trying to
obtain verification, the administrative agency may process the application or
renewal based on the individual's statement unless available information
conflicts with the attestation. Reference rule 5160:1-2-10 of the
Administrative Code for additional information regarding acceptable
verification. (5) When income in-kind
is received, the administrative agency shall determine whether in-kind support
and maintenance is being received in accordance with rule 5160:1-3-03.8 of the
Administrative Code.
Last updated January 2, 2024 at 9:34 AM
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Rule 5160:1-3-03.2 | Medicaid: income exclusions.
(A) When determining eligibility for
medical assistance for the aged, blind, or disabled, certain types of income,
including income from certain sources, are not counted. This rule sets forth
the types of income that are to be excluded, and the order in which they are
excluded from the individual's income. (B) Definitions. (1) "Blind work
expense" (BWE) means the portion of the individual's earned income
used to meet any expenses reasonably attributable to the earning of the income
if the individual is blind; and (a) Is under age sixty-five; or (b) Is age sixty-five or older and received SSI payments
due to blindness for the month before attaining age sixty-five. (2) "Countable income" means
the total earned and unearned income minus the income exclusions set forth in
this rule. Countable income is compared to the appropriate income standard when
determining eligibility for medical assistance. (3) "Exclusion" means an amount
of income which does not count when determining eligibility for medical
assistance. (C) Order of exclusions. Unearned income
exclusions are applied before earned income exclusions. The specific order of
exclusions are described in paragraphs (D) to (F) of this rule. (D) Unearned income exclusions. (1) Unearned income
excluded by federal laws other than the Social Security Act, in accordance with
20 C.F.R 416 subpart K appendix (as in effect October 1, 2020) unless otherwise
noted. The exclusions listed in this paragraph are applied before the
exclusions listed in paragraph (D)(2) of this rule: (a) Agent orange settlement fund payments received on or
after January 1, 1989, as a result of the Agent Orange Compensation Exclusion
Act (Pub. L. No. 101-201). (b) Child care assistance under the Child Care and
Development Block Grant Act (Pub. L. No. 113-186). (c) The first two thousand dollars per calendar year
received as compensation for participation in clinical trials that meet the
criteria detailed in section 1612(b) of the Social Security Act (as in effect
October 1, 2020). (d) Payments made for supporting services or reimbursement
of out-of-pocket expenses to volunteers participating in corporation for
national and community service (CNCS, formerly ACTION) programs in accordance
with 42 U.S.C. 1382a (as in effect October 1, 2020): (i) AmeriCorps VISTA
program; and (ii) Special and
demonstration volunteer program; and (iii) Retired senior
volunteer program (RSVP); and (iv) Foster grandparents
program; and (v) Senior companion
program. (e) Payments made to individuals under the Energy Employees
Occupational Illness Compensation Program Act of 2000 (Pub. L. No.
106-398). (f) Federal food and nutrition programs: (i) Supplemental
nutrition assistance program (SNAP), formerly known as food stamps or food
assistance; and (ii) The value of foods
donated by the U.S. department of agriculture commodity supplemental food
program; and (iii) The value of
supplemental food assistance received under the Child Nutrition Act of 1966
(Pub. L. No. 89-642) and the special food service program for children under
the National School Lunch Act (Pub. L. No. 90-302); and (iv) The special supplemental nutrition program for women,
infants, and children (WIC); and (v) Nutrition program benefits provided for the elderly
under Title VII of the Older Americans Act of 1965 (Pub. L. No.
89-73). (g) Student financial assistance received under the Higher
Education Act of 1965 (as in effect October 1, 2020) or bureau of Indian
affairs is excluded from income and resources, regardless of use: (i) Pell grants;
and (ii) Student services
incentives; and (iii) Academic
achievement incentive scholarships; and (iv) Federal supplemental
education opportunity grants; and (v) Federal educational
loans (Stafford loans, William D. Ford federal direct and direct PLUS loans,
etc.); and (vi) Upward bound;
and (vii) Gear up (gaining
early awareness and readiness for undergraduate programs); and (viii) State educational
assistance programs funded by the leveraging educational assistance program;
and (ix) Work-study
programs. (h) Home energy assistance provided on the basis of need,
in accordance with 20 C.F.R. 416.1157 (as in effect October 1,
2020). (i) Matching funds that are deposited into individual
development accounts (IDAs), either demonstration project or TANF-funded, in
accordance with 42 U.S.C. 604 (as in effect October 1, 2020). (j) Restitution payments under the Civil Liberties Act of
1988, to U.S. citizens of Japanese ancestry and permanent resident Japanese
non-citizens who were interned during World War II, or their survivors, in
accordance with 50 U.S.C. 4215 (as in effect October 1, 2020). (k) Restitution payments under the Aleutian and Pribilof
Island Restitution Act in accordance with 50 U.S.C. 4236 (as in effect October
1, 2020). (l) Payments to victims of Nazi persecution. (m) Payments from the Dutch government under the
Netherlands' Benefit Act for victims of persecution from 1940-1945 (Dutch
acronym, WUV) (Pub. L. No. 103-286). (n) Department of defense payments to certain persons
captured and interned in North Vietnam, in accordance with the Departments of
Labor, Health and Human Services, and Education, and Related Agencies
Appropriations Act of 1998 (Pub. L. No. 105-78). (o) Radiation exposure compensation trust fund payments, in
accordance with the Radiation Exposure Compensation Act of 1990 (Pub. L. No.
101-426). (p) Veterans affairs payments made to or on behalf
of: (i) Certain Vietnam
veterans' natural children, regardless of age or marital status, for any
disability resulting from spina bifida suffered by such children;
and (ii) Certain Korea
service veterans' natural children, regardless of age or marital status,
for any disability resulting from spina bifida suffered by such children;
and (iii) The natural
children, regardless of age or marital status, with certain birth defects born
to a woman who served in Vietnam. (q) Austrian social insurance payments based, in whole or
in part, on wage credits received under the provisions of the Austrian General
Social Insurance Act, paragraphs 500 to 506 (as in effect October 1, 2020).
These payments are to be documented and identifiable from countable
insurance. (r) Payments made to Native Americans as listed in section
IV of 20 C.F.R. 416 subpart K appendix (as in effect October 1,
2020). (s) Payments from the Ricky Ray Hemophilia Relief Fund Act
of 1998 (Pub. L. No. 105-369) or payments made from any fund established
pursuant to a class settlement in the case of Susan Walker v. Bayer
corporation, 96-C-5024 (N.D. Ill). (t) Accounts under the Stephen Beck, Jr., Achieving a
Better Life Experience (ABLE) Act of 2014 (Pub. L. No. 113-295). The following
are not considered income to the account holder: (i) Contributions to an
ABLE account by another individual or third party. (ii) Interest earned on
an ABLE account. (iii) Distributions from
an ABLE account. (2) Unearned income
excluded by the Social Security Act, in accordance with 20 C.F.R. 416.1124 (as
in effect October 1, 2020) unless otherwise noted. The exclusions listed in
this paragraph are applied after the exclusions listed in paragraph (D)(1) of
this rule, and in the following order: (a) Any public agency's refund of taxes on real
property or food. (b) Assistance based on need which is provided under a
program which uses income as a factor of eligibility and is wholly funded by a
state or political subdivision. Residential state supplement (RSS) payments are
included in this category. (c) Grants, scholarships, fellowships, or gifts used for
paying educational expenses are either excluded or countable, depending upon
their use: (i) Any portion of a
grant, scholarship, fellowship, or gift used for paying tuition, fees, or other
necessary educational expenses at any educational institution, including
vocational or technical education, is excluded from income. (ii) Any portion of such
educational assistance that is not used to pay current tuition, fees, or other
necessary educational expenses but is set aside to be used for paying this type
of educational expense at a future date is excluded from income in the month of
receipt. If these funds are not spent after nine months, they become a
countable resource as of the tenth month following receipt. (iii) Any portion of a grant, scholarship, fellowship, or
gift that is not used or set aside for paying tuition, fees, or other necessary
educational expenses is income in the month received and a resource the month
after the month of receipt, if retained. (d) Food which an individual or his/her spouse grows or
raises if it is consumed by the household. (e) Assistance received under the Robert T. Stafford
Disaster Relief and Emergency Assistance Act (Pub. L. No. 100-707) and
assistance provided under any federal statute because of a
presidentially-declared disaster. (f) The first sixty dollars of infrequent or irregular
unearned income received in a calendar quarter. (g) Alaska senior benefits program payments. (h) Foster care payments. (i) Any interest earned on an excluded burial fund and any
appreciation in the value of an excluded burial arrangement which are left to
accumulate and become a part of that burial fund. (j) Support and maintenance assistance based on
need: (i) Provided in-kind by a
private non-profit agency; or (ii) Provided in cash or
in-kind by a supplier of home heating oil or gas, or by a private or municipal
utility company. (k) One-third of child support payments made by an absent
parent. (l) Twenty dollar general income exclusion. This exclusion
does not apply to income/assistance based on need that uses income as a factor
of eligibility and is wholly or partially funded by the federal government or
by a non-governmental agency, in accordance with 20 C.F.R. 416.1124(c)(12)(as
in effect October, 1, 2020). Catholic charities and the salvation army are
non-governmental agencies. (m) Unearned income used to fulfill an approved plan to
achieve self-support (PASS). (n) Federal housing assistance, in accordance with
1612(b)(14) of the Social Security Act (as in effect October 1, 2020), provided
by: (i) The office of housing
and urban development (HUD); or (ii) The U.S. department
of agriculture's rural housing service (RHS), formally known as the
farmers home administration (FHA). (o) Any interest earned on an excluded burial space
purchase agreement if left to accumulate as part of the value of the
agreement. (p) The value of any commercial transportation ticket which
is received as a gift and is not converted to cash. (q) Payments from a state compensation fund for victims of
crime. (r) Relocation assistance provided under title II of the
Uniform Relocation Assistance and Real Property Acquisitions Policies Act of
1970 (Pub. L. No. 91-646) provided to individuals displaced by or through any
federal, federally-assisted, state, state-assisted, local, or locally-assisted
government project in the acquisition of real property. (s) Combat fire pay received from the uniformed
services. (t) Interest on a dedicated account in a financial
institution for an individual under the age of eighteen, that is maintained by
a representative payee, the sole purpose of which is to receive and maintain
past-due supplemental security income (SSI) benefits which are 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 (as in effect October 1,
2020). (u) Gifts to children with life-threatening conditions, in
accordance with section 1612(b)(22) of the Social Security Act (as in effect
October 1, 2020), from an organization described in section 501(c)(3) of the
Internal Revenue Code of 1986, within the following limitations: (i) In-kind gifts not
converted to cash; and (ii) The first two
thousand dollars of any cash gifts within a calendar year. (v) Interest and dividend income from a countable resource
or from a resource excluded under a federal statute other than section 1613(a)
of the Social Security Act (as in effect October 1, 2020). (w) A state annuity paid by a state, to an individual
and/or the individual's spouse, on the basis of the state's
determination that the individual is a veteran and is blind, disabled, or
aged. (E) Earned income excluded by the Social Security Act, in
accordance with 20 C.F.R. 416.1112 (as in effect October 1, 2020) unless
otherwise noted. The exclusions listed in this paragraph are applied after the
unearned income exclusions, and in the following order: (1) Earned income tax
credit payments and child tax credit payments. (2) The first thirty
dollars of infrequent or irregular earned income received in a calendar
quarter. (3) Student earned income
exclusion (SEIE): (a) Earned income of blind or disabled student children
under the age of twenty-two, up to the SEIE monthly limit, and not more than
the SEIE yearly limit. The SEIE monthly and yearly limits are updated and
published annually in a medicaid eligibility procedure letter that includes
standards and limits that have been updated due to the social security
administration's cost of living adjustment (COLA). (b) Available to a student attending school to include
college, university, or a course of vocational or technical training designed
to prepare students for gainful employment. (4) Any portion of the twenty-dollar
monthly general income exclusion which has not been excluded from unearned
income in that same month. (5) The first sixty-five dollars of
earned income in a month. (6) Earned income of disabled individuals
used to pay impairment-related work expenses (IRWEs), as described in 20 C.F.R.
404.1576 (as in effect October 1, 2020). (7) One-half of remaining earned income
in a month. (8) BWEs, as defined in paragraph (B) of
this rule. (9) Earned income used to fulfill an
approved plan to achieve self-support (PASS). (F) As a state-selected option under
section 1902(r)(2) of the Social Security Act (as in effect October 1, 2020),
exclude all income received from temporary employment with the decennial
census. (G) Unused exclusions. (1) Exclusions never
reduce earned or unearned income below zero. (2) Unused portions of a
monthly exclusion cannot be carried over for use in subsequent
months. (3) Unused earned income
exclusions are never applied to unearned income. (4) Other than the
twenty-dollar general income exclusion, no unused unearned income exclusion may
be applied to earned income. (H) The twenty-dollar general and
sixty-five-dollar earned income exclusions are applied only once to an eligible
couple, even when both members have income, since the couple's earned
income is combined in determining eligibility for medical
assistance.
Last updated July 1, 2021 at 9:50 AM
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Rule 5160:1-3-03.3 | Medicaid: deeming of income.
(A) This rule describes the process for
calculating the amount of income to deem from an ineligible spouse, ineligible
parent, or sponsor when determining eligibility for medical assistance for an
eligible spouse, eligible child, or sponsored alien. (1) When an eligible
spouse resides in the same household with his or her ineligible spouse, or an
eligible child under age eighteen resides in the same household with his or her
ineligible parent(s), a portion of the income and resources of such spouse or
parent are included in determining the eligible spouse's or eligible
child's financial eligibility for medical assistance for the aged, blind,
or disabled. For spouse-to-spouse deeming to apply, the eligible spouse must be
eligible based on his or her own income. (2) If a sponsored alien
is sponsored by his or her ineligible spouse or ineligible parent(s), apply
spouse-to-spouse or parent-to-child deeming calculations. (3) If a sponsored alien
has a sponsor and also has an ineligible spouse or ineligible parent(s) who is
not his or her sponsor, apply both sponsor-to-alien and spouse-to-spouse (or
parent-to-child) deeming calculations. (B) Definitions: (1) "Allocation," for the purpose of this rule,
means an amount deducted from income subject to deeming, which is considered to
be set aside for the support of certain individuals other than the eligible
individual. (2) "Child,"
for deeming purposes, means an individual under age eighteen who lives in a
household with one or both parents and who is neither married nor head of
household. The deeming of parental income applies through the month in which
the child becomes eighteen years old. An eligible or ineligible child's
income and/or resources are never deemed to parent(s) or
sibling(s). (3) "Deemed
income" means income attributed to another person whether or not the
income is actually available to the person to whom it is deemed. (4) "Eligible
child" means a child in the household who has applied for medical
assistance for the blind or disabled, and who meets all the applicable
non-financial eligibility criteria for medical assistance. (5) "Eligible
parent" means a parent in the household who has applied for medical
assistance for the aged, blind, or disabled, and who meets all the applicable
non-financial eligibility criteria for medical assistance. (6) "Eligible
spouse" means the member of the married couple who has applied for medical
assistance for the aged, blind, or disabled, and who meets all the applicable
non-financial eligibility criteria for medical assistance. (7) "Household" means the
eligible spouse, the ineligible spouse, and any of the couple's children
or the children of either member of the couple; or the eligible child, the
eligible child's parent(s), and other children of the
parent(s). (a) A household does not exist if an individual or a group
of individuals does not have a residence. In such a case, only the eligible
individual's income is used to determine eligibility for medical
assistance. (b) If a child is born in an institution (e.g., a
hospital), the child is a member of the household at the time of birth unless
the parents have completed the required paperwork to give the child up for
adoption or the child has been placed in the temporary custody of a public
children's services agency. (c) An eligible individual or an ineligible spouse or
ineligible parent who is temporarily absent, as defined in rule 5160:1-1-01 of
the Administrative Code, is still considered to be a member of the household
for deeming purposes. (8) "Ineligible child" means a
child in the household who has not applied for medical assistance for the blind
or disabled. (9) "Ineligible parent" means
an eligible child's parent who has not applied for medical assistance for
the aged, blind, or disabled. (10) "Ineligible spouse" means
an eligible spouse's husband or wife who has not applied for medical
assistance for the aged, blind, or disabled. (11) "Parent" means a natural or
adoptive father or mother living in the same household as the eligible child.
The income of a step-parent who lives with the eligible child is deemed to the
child only when the natural or adoptive parent also lives in the household with
the step-parent and the child. If the natural or adoptive parent divorces a
step-parent and the child is living with the step-parent, the step-parent is
not a parent or spouse for deeming purposes. (12) "Sponsor" means an
individual who signs an affidavit of support agreeing to support an alien as a
condition of the alien's admission for permanent residence in the U.S. A
sponsored alien may have more than one sponsor. For deeming purposes, a sponsor
does not include an organization such as the congregation of a church or a
service club, or an employer who only guarantees employment for an alien upon
entry but does not sign an affidavit of support. (13) "Sponsored alien," for
purposes of this rule, means an individual lawfully admitted for permanent
residence in the U.S. who is supported by a sponsor(s). Such an individual has
applied for medical assistance for the aged, blind, or disabled, and meets all
the applicable non-financial eligibility criteria for medical
assistance. (14) "Spouse" means a person who
is legally married to another under Ohio law. (C) In accordance with 20 C.F.R. 416.1161
(as in effect on October 1, 2018), when determining the income of an ineligible
spouse, ineligible parent, or sponsor of an alien, or of an ineligible child in
the household, the following items shall not be considered income: (1) Income excluded by
federal laws other than the Social Security Act as described in paragraph
(D)(1) of rule 5160:1-3-03.2 of the Administrative Code; (2) Items not considered
income as described in paragraph (E) of rule 5160:1-3-03.1 of the
Administrative Code; (3) Any public
income-maintenance (PIM) payments, as defined in 20 C.F.R. 416.1142(a) (as in
effect on October 1, 2018), received by the ineligible spouse, ineligible
parent(s), or ineligible child in the household, and any income which was
counted or excluded in figuring the amount of that payment; (4) Any of the income of
the ineligible spouse or ineligible parent that is used to determine the amount
of a PIM payment to someone else; (5) Any portion of a
grant, scholarship, fellowship, or gift used or set aside to pay tuition, fees,
or other necessary educational expenses; (6) Money received for
providing foster care to an ineligible child; (7) The value of food
assistance and the value of foods donated by the department of
agriculture; (8) Food raised and
consumed by members of the household; (9) Tax refunds on
income, real property, or food purchased by the family; (10) Income used to
fulfill an approved plan to achieve self-support (PASS), as defined in 20
C.F.R. 416.1181 (as in effect on October 1, 2018); (11) The amount of
court-ordered child support payments paid by a household member for a child
outside the home; (12) The value of in-kind
support and maintenance; (13) Alaska longevity
bonus payments made to an individual who is a resident of Alaska and who, prior
to October 1, 1985, met the twenty-five-year residency requirement for receipt
of such payments in effect prior to January 1, 1983, and was eligible for
supplemental security income (SSI); (14) Disaster assistance
as described in 20 C.F.R. 416.1150 and 416.1151 (as in effect on October 1,
2018); (15) Income received
infrequently or irregularly, as defined in 20 C.F.R. 416.1112(c)(2) and
416.1124(c)(6) (as in effect on October 1, 2018); (16) Blind work expenses,
as defined in rule 5160:1-3-03.2 of the Administrative Code, of the ineligible
spouse or parent; (17) Income of the
ineligible spouse or ineligible parent which was paid under a federal, state,
or local government program to provide the eligible individual with chore,
attendant, or homemaker services; (18) Certain support and
maintenance assistance as described in 20 C.F.R. 416.1157(c) (as in effect on
October 1, 2018); (19) The value of a
commercial transportation ticket as described in 20 C.F.R. 416.1124(c)(16) (as
in effect on October 1, 2018); however, if such a ticket is converted to cash,
the cash is income in the month the ineligible spouse or ineligible parent
receives the cash; (20) Refunds of federal
income taxes and advances made by an employer relating to an earned income tax
credit, as described in 20 C.F.R. 416.1112(c) (as in effect on October 1,
2018); (21) Payments from a fund
established by a state to aid victims of crime, as described in 20 C.F.R.
416.1124(c)(17) (as in effect on October 1, 2018); (22) Combat pay received
from one of the uniformed services pursuant to 37 U.S.C. 310 (as in effect on
October 1, 2018); (23) Impairment-related
work expenses, as described in 20 C.F.R. 404.1576 (as in effect on October 1,
2018), incurred and paid by an ineligible spouse or ineligible parent, if the
ineligible spouse or ineligible parent receives disability benefits under title
II of the act; (24) Interest earned on
excluded burial funds and appreciation in the value of excluded burial
arrangements which are left to accumulate and become part of separate burial
funds, and interest accrued on and left to accumulate as part of the value of
agreements representing the purchase of excluded burial spaces, as described in
20 C.F.R. 416.1124(c)(9) and (15) (as in effect on October 1,
2018); (25) Interest and
dividend income from a countable resource or from a resource excluded under a
federal statute other than section 1613(a) of the Social Security Act, in
accordance with 20 C.F.R. 416.1124(c)(22) (as in effect on October 1,
2018); (26) Earned income of a
student as described in 20 C.F.R. 416.1112(c)(3) (as in effect on October 1,
2018); (27) Any additional
increment in pay, other than any increase in basic pay, received while serving
as a member of the uniformed services if: (a) The ineligible spouse or ineligible parent received the
pay as a result of deployment to or service in a combat zone; and (b) The ineligible spouse or ineligible parent was not
receiving additional pay immediately prior to deployment to or service in a
combat zone. (D) If the eligible spouse or eligible parent(s) is/are
receiving Ohio works first (OWF) or SSI payments, then the payments themselves
and any of the OWF- or SSI-eligible individual's own income that was used
to compute eligibility for such payments are not considered available for
deeming. (E) When an eligible spouse is living in the same household
with an ineligible spouse who has income, perform the following steps to
calculate the amount of income to deem to the eligible spouse: (1) Determine the
ineligible spouse's income, applying any appropriate exclusions listed in
paragraph (C) of this rule; (2) Deduct the
appropriate allocation for each ineligible child in the household: (a) There is no allocation for an ineligible child
receiving PIM payments as described in paragraph (C)(3) of this
rule. (b) The allocation amount is the current SSI federal
benefit rate (FBR), as published annually in the Federal Register, for a couple
minus the current SSI FBR for an individual. (c) The allocation for each ineligible child in the
household is reduced by the amount of that ineligible child's income,
minus any appropriate exclusions listed in paragraph (C) of this
rule. (d) The ineligible child allocation(s) must first be taken
from the ineligible spouse's unearned income; any remaining allocation
amount will be subtracted from the ineligible spouse's earned
income. (3) If the ineligible
spouse's remaining income after subtracting the ineligible child
allocation(s) is less than or equal to the current SSI FBR for a couple minus
the current SSI FBR for an individual: (a) Do not deem any income to the eligible
spouse. (b) Combine the eligible spouse's unearned and earned
income, applying the appropriate exclusions listed in rule 5160:1-3-03.2 of the
Administrative Code. (c) If the eligible spouse's countable income is less
than or equal to the current income standard for an individual, the eligible
spouse is financially eligible for medical assistance. (4) If the ineligible
spouse's remaining income after subtracting the ineligible child
allocation(s) is greater than the current SSI FBR for a couple minus the
current SSI FBR for an individual, treat the spouses as if they were an
eligible couple: (a) Combine both the ineligible spouse's
post-allocation unearned and earned income and the eligible spouse's
unearned and earned income, applying any appropriate exclusions listed in rule
5160:1-3-03.2 of the Administrative Code; (b) Subtract the twenty-dollar general exclusion from the
couple's combined unearned income; if there is less than twenty dollars of
unearned income, subtract the remainder of the exclusion from the couple's
combined earned income; (c) Subtract sixty-five dollars from the couple's
combined earned income, then subtract one-half of the remaining earned
income. (d) If the couple's countable income is less than or
equal to the current income standard for a couple, the eligible spouse is
financially eligible for medical assistance. (F) When an eligible child(ren) reside(s) with an
ineligible parent(s), perform the following steps to calculate the amount of
income to deem to the eligible child(ren): (1) Determine the income
of each ineligible parent, applying any appropriate exclusions listed in
paragraph (C) of this rule; (2) Deduct the
appropriate allocation for each ineligible child in the household: (a) There is no allocation for an ineligible child
receiving PIM payments as described in paragraph (C)(3) of this
rule. (b) The allocation amount is the current SSI federal
benefit rate (FBR), as published annually in the Federal Register, for a couple
minus the current SSI FBR for an individual. (c) The allocation for each ineligible child in the
household is reduced by the amount of that ineligible child's income,
minus any appropriate exclusions listed in paragraph (C) of this
rule. (d) The ineligible child allocation(s) must first be taken
from the ineligible parent(s) combined unearned income; any remaining
allocation amount will be subtracted from the ineligible parent(s)'s
combined earned income. (3) Subtract the
twenty-dollar general exclusion from the combined unearned income of the
ineligible parent(s); if there is less than twenty dollars of unearned income,
subtract the remainder of the exclusion from the combined earned income of the
ineligible parent(s); (4) Subtract sixty-five
dollars from the combined earned income of the ineligible parent(s), then
subtract one-half of the remaining earned income; (5) Combine the
ineligible parent(s)' remaining earned and unearned income; (6) Subtract the
appropriate parental living allowance for each ineligible parent; (a) There is no parental living allowance deducted for an
ineligible parent who receives PIM payments as described in paragraph (C)(3) of
this rule. (b) If one ineligible parent resides in the household with
the child(ren), subtract the current SSI FBR for an individual. (c) If two ineligible parents (or one ineligible parent and
an ineligible step-parent) reside in the household with the child(ren),
subtract the current SSI FBR for a couple. (d) If both ineligible natural or adoptive parents and an
ineligible step-parent reside in the household with the child(ren), subtract
both the current SSI FBR for a couple and the current SSI FBR for an
individual. (7) Divide the remaining
income by the number of eligible children in the household, and the resulting
amount (rounded to the second decimal place) is deemed to each eligible
child. (8) Any income deemed to
an eligible child from an ineligible parent is added to the eligible
child's own unearned income. (9) Combine the eligible
child's unearned and earned income, applying any appropriate exclusions
listed in rule 5160:1-3-03.2 of the Administrative Code. (10) If the eligible
child's resulting countable income is less than or equal to the current
income standard for an individual, the eligible child is financially eligible
for medical assistance. (G) When a household is comprised of an ineligible spouse,
an eligible spouse, and one or more eligible children, the ineligible
spouse's income is deemed first to the eligible spouse and the remainder
deemed to the eligible child(ren). (1) Determine the income
of the ineligible spouse, applying any appropriate exclusions listed in
paragraph (C) of this rule; (2) Deduct the
appropriate allocation for each ineligible child in the household, as described
in paragraph (E)(2) of this rule. (3) If the ineligible spouse's
remaining income after subtracting the ineligible child allocation(s) is less
than or equal to the current SSI FBR for a couple minus the current SSI FBR for
an individual: (a) Do not deem any income to the eligible spouse or
eligible child(ren); and (b) Compare the eligible spouse's and each eligible
child(ren)'s own countable income, applying any appropriate exclusions
listed in rule 5160:1-3-03.2 of the Administrative Code, to the current income
standard for an individual. (c) If the eligible spouse's and/or each eligible
child(ren)'s own income is less than or equal to the current income
standard for an individual, the eligible spouse and/or each eligible child(ren)
is financially eligible for medical assistance. (4) If the ineligible spouse's
remaining income after subtracting the ineligible child allocation(s) is
greater than the current SSI FBR for a couple minus the current SSI FBR for an
individual: (a) Combine both the ineligible spouse's
post-allocation unearned and earned income and the eligible spouse's
unearned and earned income, applying any appropriate exclusions listed in rule
5160:1-3-03.2 of the Administrative Code; (b) Subtract the twenty-dollar general exclusion from the
couple's combined unearned income; if there is less than twenty dollars of
unearned income, then subtract the remainder of the exclusion from the
couple's combined earned income; (c) Subtract sixty-five dollars from the couple's
combined earned income, then subtract one-half of the remaining earned
income. (d) If the couple's countable income is less than or
equal to the current income standard for a couple, the eligible spouse is
financially eligible for medical assistance and no income is deemed to the
eligible child(ren). (e) If the couple's countable income is greater than
the current income standard for a couple, the eligible spouse is not
financially eligible for medical assistance. (f) The amount of the couple's income in excess of the
need standard for a couple is divided by the number of eligible children in the
household and the resulting amount (rounded to the second decimal place) is
deemed to each eligible child. (5) Any income deemed to
an eligible child under paragraph (G)(4)(f) of this rule is added to the
eligible child's own unearned income. (6) Combine each eligible
child's unearned and earned income, applying any appropriate exclusions
listed in rule 5160:1-3-03.2 of the Administrative Code. (7) If each eligible
child's resulting countable income is less than or equal to the current
income standard for an individual, the eligible child is financially eligible
for medical assistance. (H) Sponsor-to-alien deeming shall apply
regardless of whether the sponsor and the sponsored alien live in the same
household or whether the sponsor actually provides the sponsored alien any
support. (1) Determine the income
of the sponsor and the sponsor's spouse (if applicable), applying unearned
income excluded by federal laws other than the Social Security Act, in
accordance with 20 C.F.R. 416 Subpart K appendix (as in effect on October 1,
2018), unless otherwise noted; (2) Deduct the
appropriate allocation for each sponsor, each sponsor's spouse, and child
of each sponsor. (a) The allocation amount for each sponsor is the current
SSI FBR for an individual. (b) The allocation amount for each sponsor's spouse
and child of each sponsor is one-half of the current SSI FBR for an
individual. (3) The remaining amount
is deemed to the sponsored alien as unearned income. (4) If there are multiple
sponsored aliens who are sponsored by the same sponsor, the deemed amount is
applied in full to each sponsored alien. (5) Combine the sponsored
alien's unearned and earned income, applying any appropriate exclusions
listed in rule 5160:1-3-03.2 of the Administrative Code. (6) If the sponsored
alien's resulting countable income is less than or equal to the current
income standard for an individual, the sponsored alien is financially eligible
for medical assistance.
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Rule 5160:1-3-03.5 | Medicaid: application of income standards.
(A) The purpose of this rule is to set forth the application of income standards used in medicaid eligibility determinations for aged, blind, or disabled individuals. (B) Definitions. (1) "Income standard" means the income limit above which an individual is ineligible for a given category of medicaid for the aged, blind or disabled. (2) "Couple income standard" is equal to the current supplemental security income (SSI) benefit rate for a couple. The updated figure is published annually by the social security administration. (3) "Individual income standard" is equal to the current supplemental security income (SSI) benefit rate for an individual. The updated figure is published annually by the social security administration. (C) Application of income standards. (1) For an individual, countable income is compared to the appropriate individual income standard. (2) For a married couple: (a) If both members of the married couple are categorically eligible, countable income is compared to the appropriate couple income standard. (b) If only one member of the married couple is categorically eligible, countable income may be compared to either the individual income standard or the couple income standard, in accordance with the deeming provisions set forth in rule 5160:1-3-03.3 of the Administrative Code.
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Rule 5160:1-3-03.6 | Medicaid: treatment of rental income.
Effective:
December 14, 2020
(A) The purpose of this rule is to
describe the calculation and treatment of rental income and expenses for
medical assistance eligibility determinations. (B) Definitions. (1) "Net rental income" means
gross rent less the ordinary and necessary expenses paid in the same taxable
year. Net rental income is treated as unearned income unless the individual is
in the business of renting properties, in which case the income is treated as
earned income from self-employment. (2) "Ordinary and necessary
expenses" are those expenses necessary for the production or collection of
rental income. In general, these expenses include interest on debts, state and
local taxes on real and personal property, state and local taxes on motor fuel,
general sales taxes, and expenses for managing or maintaining
property. (3) "Rent"
means a payment which an individual receives for the use of real or personal
property, such as land, housing, or machinery. (C) To determine net rental income: (1) Identify countable
rental income. (a) Rental deposits. (i) Rental deposits are
not income to the landlord while subject to return to the tenant. (ii) Rental deposits used
to pay rental expenses become income to the landlord at the point of
use. (b) Do not consider rents received in months prior to the
individual's eligibility for medical assistance. (2) Calculate allowable
expenses. (a) Deductible expenses include: (i) Interest and escrow
portions of a mortgage payment (at the point the payment is made to the
mortgage holder). (ii) Real estate
insurance. (iii) Repairs (i.e.,
minor correction to an existing structure). (iv) Property
taxes. (v) Lawn
care. (vi) Snow
removal. (vii) Advertising for
tenants. (viii) Utilities. (b) Nondeductible expenses include: (i) Depreciation or
depletion of property. (ii) Principal portion
of a mortgage payment. (iii) Capital
expenditures (i.e., an expense for an addition or increase in the value of
property which is subject to depreciation for income tax
purposes). (c) Proration to determine allowable amount of
expenses. (i) In multiple family
residences, if the units in the building are of approximately equal size,
prorate allowable expenses based on the number of units designated for rent
compared to the total number of units. If the units are not of approximately
equal size, prorate allowable expenses based on the number of rooms in the
rental units compared to the total number of rooms in the building. The rooms
do not have to be occupied. (ii) For rooms in a
single residence, prorate allowable expenses based on the number of rooms
designated for rent compared to the number of rooms in the house. Do not count
bathrooms as rooms in the house. Basements and attics are counted only if they
have been converted to living spaces (e.g., recreation rooms). (iii) For rented land,
prorate expenses based on the percentage of total acres that are for
rent. (d) Do not consider expenses paid in months prior to the
individual's eligibility for medical assistance. (e) Expenses are deducted when paid, not when
incurred. (3) Subtract the
deductible expenses paid in a month from gross rent received in the same
month. (a) If deductible expenses exceed gross rent in a month, subtract
the excess expenses from the next month's gross rent and continue doing
this as necessary until the end of the tax year in which the expenses are
paid. (b) If there are still excess expenses, subtract them from the
gross rent received in the month prior to the month the expenses were paid and
continue doing this as necessary to the beginning of the tax year
involved. (c) Do not carry excess expenses over to other tax years or use
them to offset other income. (4) Use evidence from the
previous months to estimate net rental income for the next twelve months;
however, deduct only predictable expenses (e.g., utilities, interest payments,
taxes, etc.). (5) If an unpredictable expense is
reported at a later date (e.g., a repair), deduct the expense in the month
paid. If the expense exceeds the rent for that month, recalculate the rest of
the estimated period in accordance with paragraph (C)(3) of this
rule. (6) Absent evidence to the contrary,
apportion net rental income in proportion to the percentage of ownership. If
the gross rent is split between the individual and another joint owner before
expenses are paid, deduct expenses paid by the individual from the
individual's portion of the gross rent. (D) Verification of income and expenses.
Use documents in the individual's possession (e.g., bills, receipts, etc.)
to verify the gross rent and the dates received, and expenses and the dates
paid. The individual's most recent federal income tax return including
"Schedule E" may assist with identifying past expenses and estimating
future rental income. (1) The administrative
agency will contact the individual to collect the information needed. If the
individual declares the verifications cannot be accessed or submitted, the
individual's statement is to be accepted. (2) If the administrative
agency is unable to make contact with the individual, a written (electronic or
paper) request for the necessary information or verification documents is to be
sent as set forth in rule 5160:1-2-01 of the Administrative Code. (3) If a determination cannot be made
regarding whether an expense is allowable (e.g., whether the expense is an
incidental repair or a capital expenditure), the administrative agency may
contact the internal revenue service (IRS) for assistance.
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Rule 5160:1-3-03.7 | Medicaid: treatment of sick pay and sick leave.
Effective:
August 1, 2016
(A) The purpose of this rule is to set
forth the treatment of sick pay and sick leave for eligibility for medical
assistance. (B) Definitions. (1) "Sick pay"
means a payment made to or on behalf of an employee by an employer or a private
third party for sickness or accident disability. (2) "Sick
leave" means a paid absence from duty for personal or family medical
reasons and considered a continuation of salary. (C) Treatment of sick pay. (1) Sick pay is treated
as earned income (wages) if the individual receives sick pay within six months
after stopping work and the income is not attributable to the employee's
own contributions toward a sick pay plan. (2) Sick pay is treated
as unearned income if: (a) The individual receives sick pay within six months
after stopping work and the income is attributable to the employee's own
contributions toward a sick pay plan; or (b) The individual receives sick pay more than six months
after stopping work. (3) To determine the six months'
period after stopping work, begin with the first day of non-work, include the
remainder of that calendar month, and include the next six full calendar
months. (D) Treatment of sick leave. (1) Sick leave payments are treated as earned
income. (2) Sick leave that is donated to the individual
is treated the same as if it were the individual's own leave.
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Rule 5160:1-3-03.8 | Medicaid: in-kind support and maintenance.
Effective:
August 1, 2016
(A) This rule sets forth how in-kind
support and maintenance is valued for purposes of determining eligibility for
medical assistance. (B) Definitions. (1) "Actual
value" is the dollar amount that an individual paid for an item or
service, or for his/her share of an item or service. (2) "Current market
value" is the dollar amount for which an item would sell on the local open
market. (3) "Household"
is a personal place of residence in which individuals share common living
quarters and function as a single economic unit. (4) "Household of
another income standard" is equal to two-thirds of the income standard for
an individual or couple as applicable. (5) "In-kind support and
maintenance" is unearned income in the form of food or shelter, or
something that can be used to get food or shelter, that a person is given or
receives because someone else pays for it. (6) "Living in household of
another" means that the individual does not live in his/her own household
as defined in paragraph (B)(7) of this rule. (7) "Living in own household"
means that: (a) The individual has ownership interest or life estate in
the home; or, (b) The individual is liable for payment of any part of a
rental charge; or, (c) The individual pays a pro-rated share of living
expenses; or, (d) The individual lives in a non-institutional care
situation. (8) "Non-institutional care
situation" means that: (a) The individual has been placed by a public or private
agency under a specific program of protective placement; and, (b) The placement is in a private household that is
licensed or otherwise approved by the state to provide protective care;
and, (c) The placing agency retains responsibility for
continuing supervision of the need for placement and of the services provided;
and, (d) The individual, the placing agency, or some other party
pays for the services provided, or has a written agreement to pay for the
services provided. (9) "Presumed maximum value" is
one-third the value of the individual income standard, as set forth in rule
5160:1-3-03.5 of the Administrative Code, plus twenty dollars. (10) "Public assistance
household" is a household in which all individuals receive some type of
public income-maintenance payments, including but not limited to Ohio works
first (OWF), supplemental security income (SSI), disaster relief and emergency
assistance, or state or local government assistance programs based on
need. (11) "Shelter" means living
quarters for an individual in the individual's permanent living
arrangement. (12) "Shelter costs" means rent,
mortgage payments, real property taxes, heating fuel, gas, electricity, water,
sewerage, and garbage collection services. (C) In-kind support and maintenance
received by an individual is excluded if: (1) It is identified as
excluded in accordance with rule 5160:1-3-03.2 of the Administrative Code;
or, (2) It is received from
another member of a public assistance household; or, (3) The individual
receives SSI and the social security administration does not reduce the
individual's SSI benefit because of in-kind support and
maintenance. (D) In-kind support and maintenance
received by an individual is valued by applying the household of another income
standard when: (1) The individual is a
recipient of SSI benefits and receives the one-third reduction in the SSI
benefit; or, (2) The individual lives
for an entire month in another person's household, and receives both food
and shelter for the entire month from someone living in that
household. (E) In-kind support and maintenance
received by an individual is valued by treating the in-kind support and
maintenance as countable unearned income, using the presumed maximum value if
the individual: (1) Receives in-kind
support and maintenance but lives in his own household, or (2) Does not live for the
entire month in another person's household, or (3) Does not receive all
his food and shelter from another person in that household for the entire
month, or (4) Receives in-kind
support and maintenance from someone outside the household. (F) In-kind support and maintenance
received by an individual is valued by treating the in-kind support and
maintenance as countable unearned income, using the current market value or
actual value, whichever is less, when the individual demonstrates
that: (1) The current market
value of any in-kind support and maintenance received, minus any payment the
individual makes for them, is less than the presumed maximum value;
or, (2) The actual amount
someone else pays for the individual's in-kind support and maintenance is
less than the presumed maximum value. (G) The administrative agency shall, for
purposes of determining eligibility for medical assistance, determine the value
of in-kind support and maintenance received by an individual in accordance with
this rule.
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Rule 5160:1-3-03.10 | Medicaid: retirement funds.
Effective:
August 1, 2016
(A) This rule describes how retirement
funds are treated for purposes of determining medical assistance
eligibility. (B) Definition. "Retirement
funds" are plans designed to provide unearned income to supplant or
supplement earned income. Retirement funds may include, but are not limited to
such plans as: public and private pension, disability, or retirement plans;
defined benefit employer pension plans, profit sharing pension plans, 403(b)
pension plans, money purchase pension plans, employee stock ownership plans,
individual retirement accounts (IRA); KEOGH pension plans, Roth IRAs,
simplified employee pension plans (SEP-IRA), and 401k pension plans; or any
other pension or retirement plans authorized under 401, 403, 408 of the
Internal Revenue Code (IRC) as outlined in 26 U.S.C. (as in effect on February
1, 2016), or any other enacted IRC provisions providing for a pension or
retirement plan or any other similar financial vehicles administered by an
individual, employer, or union. A retirement fund converted into an annuity
shall be considered in accordance with rule 5160:1-3-05.3 of the Administrative
Code. (C) Retirement funds treated as
income. (1) A retirement fund in
which an individual has the legal ability to receive regular guaranteed
lifetime payments will be treated as a source of unearned income rather than as
a resource. A defined benefit employer pension plan is an example of this type
of retirement. (2) The individual is
required to obtain the maximum available amount of payment from the plan. If
the maximum available amount of payment requires the individual's spouse
to consent to a waiver of the spouse's survivor benefits, the individual
must document a good faith attempt to obtain that consent, and whether consent
was obtained or refused. If consent is not obtained, the individual must elect
the minimum spousal survivor benefit required by the plan. (3) If allowed in the
plan, the individual may elect a lesser payment in favor of retaining a minimum
survivor benefit for a child who can be documented to be blind or disabled, as
defined in rule 5160:1-3-02 of the Administrative Code. (4) If the retirement
fund is determined to not be income, then the retirement fund shall be
evaluated as a potential resource. (D) Retirement funds treated as a
resource. (1) The retirement fund
shall be evaluated as a potential resource only after it is determined to not
be income. (2) A retirement fund is
a countable resource if the individual or the individual's spouse has an
ownership interest in the retirement fund and the legal ability to convert it
to cash. (a) The value of a retirement fund is the amount an
individual can currently withdraw from the fund. (b) This determination shall be made by reference to
documentation describing the retirement fund and/or a letter from the plan
administrator. (c) Self-defined retirement plans such as an IRA or KEOGH
plan are examples of this type of retirement fund. (3) If there is a
financial penalty imposed by the plan administrator in order to convert the
account to cash, the amount of the countable resource is the net amount payable
to the individual after deducting the penalty. The amount payable may not be
further reduced by the amount of any tax incurred by the individual as a result
of the conversion of the account to cash. (4) A retirement fund is
not a resource if an individual must terminate employment in order to obtain
any lump sum or payment. (5) A retirement fund
determined to be a resource in accordance with paragraph (D) of this rule,
which is owned by an ineligible spouse or parent or spouse of an ineligible
parent, shall not be considered for deeming purposes described in rule
5160:1-3-03.20 of the Administrative Code. (E) Administrative agency
responsibilities. (1) The administrative
agency must evaluate any retirement fund of which the individual is a
beneficiary. (2) The administrative
agency shall obtain the summary plan description or other document describing
the rights and benefits under the retirement fund. A letter from the plan
administrator may also be obtained to make the determinations required under
this rule. (F) Individual responsibilities. An
individual is required to provide all available documentation to aid the
administrative agency in evaluating any retirement fund of which the individual
is a beneficiary.
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Rule 5160:1-3-05.1 | Medicaid: resource requirement.
(A) This rule describes how resources are
treated for purposes of determining eligibility for medical
assistance. (B) Definitions. (1) "Countable
resources" mean those resources remaining after all exclusions have been
applied. (2) An
"encumbrance" means a claim, lien, charge, or liability attached to
and binding on an identified piece of real or personal property. (3) "Equity
value" means the fair market value of a resource minus any encumbrance on
it. (4) "Fair market value" of a
resource means the going price, for which real or personal property can
reasonably be expected to sell on the open market, in the particular geographic
area involved. (5) "Geographic
area" means the area covered by radio, television, newspaper, and other
media serving the area where the individual lives and where the property is
located. (6) "Personal property" means
any property that is not real property. The term includes, but is not limited
to, such things as cash, jewelry, household goods, tools, life insurance
policies, automobiles, promissory notes, etc. (7) "Real property" means land,
including buildings or immovable objects, attached permanently to the
land. (8) "Resources"
is defined in rule 5160:1-1-01 of the Administrative Code. (9) "Resource limit" means the
maximum combined value of all resources an individual can have an ownership
interest in and still qualify for medical assistance. (a) For an individual, the resource limit is two thousand
dollars. (b) For a married couple, whether both are eligible or one
is ineligible, the resource limit is three thousand dollars. (c) A child living with a parent is considered to be an
individual and has a resource limit of two thousand dollars. (10) "Trust" is defined in rule
5160:1-3-05.2 of the Administrative Code. (C) Treatment of non-excluded resources and determination
of resource availability. The administrative agency shall evaluate and
calculate the value of all resources held by an individual and the
individual's spouse. An individual is ineligible for medical assistance
when he or she has an ownership interest in resources with an aggregate or
total countable value greater than the resource limit. The following provisions
govern that process. (1) Receipt and retention
of cash or in-kind items. (a) An individual or the individual's spouse may
receive cash or in-kind items during a calendar month (the "month of
receipt"). The administrative agency must treat the cash or in-kind items
as a potential source of countable income for the month of receipt under the
rules governing income. (b) When the individual or the individual's spouse
retains the cash or in-kind items beyond the month of receipt, the
administrative agency shall determine the availability of the cash or in-kind
items as a potential countable resource under the rules governing
resources. (c) Receipt of cash or in-kind items from the sale or
exchange of timber, minerals, or other like items that are part of the land
must be governed by this provision. (d) When the individual or the individual's spouse
receives cash or in-kind items as the result of an exchange, sale, replacement,
or conversion of a resource, the administrative agency must consider the
availability of the cash or in-kind items effective the month following the
month of receipt under the rules governing the treatment of
resources. (2) Changes in the value
of resources. (a) The administrative agency shall review any change
(increase or decrease) in the total value of an individual's resources
when the change may affect the individual's eligibility for medical
assistance. (b) The review shall be initiated by the administrative
agency based upon information derived from any reliable source indicating the
value of an individual's available resources has increased or
decreased. (c) The administrative agency shall conduct the review of
any changes in the value of resources upon discovery of the
changes. (3) Discovery of
previously unknown ownership interests. (a) Any individual alleging lack of knowledge of an
ownership interest in a resource must provide a signed statement attesting to
the lack of knowledge and explaining the circumstances resulting in its
discovery. (b) The individual shall obtain supporting documentation,
which may include signed statements from other individuals who are familiar
with the individual's situation, confirming the individual's
claim. (c) When the administrative agency obtains both the signed
statement and adequate supporting documentation from the individual, the
administrative agency shall not count an individual's ownership interest
as an available resource during any period in which the individual was unaware
of the ownership interest. (d) The administrative agency shall evaluate the value of
previously unknown ownership interests, including any monies (interest,
dividends, or other earnings) that have accumulated on it, under
income-counting rules for that item. (e) When the signed statement or the supporting
documentation is not provided, the administrative agency shall count an
individual's ownership interest as an available resource during any period
in which the individual claimed to be unaware of the ownership interest. When
appropriate, the administrative agency shall evaluate the individual for
overpayment or potential fraud in accordance with rule 5160:1-2-04 of the
Administrative Code. (4) Shared
ownership. (a) When the individual shares ownership with another
person (co-owner) and the individual is unable to make the resource available
because one of the owners cannot be located, the cost of a legal action is
prohibitive, or the individual was unsuccessful in a legal action, the resource
is not countable. Availability of the resource shall be reexamined at each
eligibility review. (b) When the co-owner is the individual's spouse,
parent (when the individual is under age eighteen), or child under age
eighteen, the ability to use or dispose of the resource exists for the
individual unless he or she provides documentation to the
contrary. (5) Continuing
verification. (a) The administrative agency shall verify the value of
real and personal property with each application or renewal and any time
information is provided indicating a change in the individual's resources
may have occurred. (b) The administrative agency shall record the verification
and place all supporting documents in the case record. (6) Property that has not
been sold. (a) This provision governs real and personal property that
has not been sold. When an individual owns property affecting his or her
eligibility for medical assistance and the property has not been sold, it will
not be counted as an available resource as long as the individual continues to
list the property for sale at an amount equal to the fair market value
determined by the county auditor, where available, or any other knowledgeable
source. (b) Real property that was the principal place of residence
must first be considered in accordance with rule 5160:1-3-05.13 of the
Administrative Code before the provisions of this paragraph are
applied. (c) The inability to sell property may result from legal
technicalities, general economic conditions in the community, or the inability
to find a buyer. In order for property to be excluded as a countable resource,
the individual has the burden of producing reliable documentation establishing
one of the following: (i) The individual may
produce documentation from two different types of knowledgeable sources in the
geographic area who agree that although the property is listed for sale, the
property has not been sold due to an attribute of the property or the market or
both. (a) In the case of real
property, knowledgeable sources are limited to the following entities who have
experience in the sale or valuation of the type of real property in question:
county auditors, real estate brokers, real estate agents, real estate
appraisers, United States department of agriculture (USDA) rural development
service center offices, USDA farm service agency service center offices, banks,
savings and loan associations, mortgage companies and similar lending
institutions, and the county extension service offices. (b) In the case of
personal property, knowledgeable sources are limited to the following: any
professional, business owner or operator, or expert who has experience in the
sale, trade, restoration, or valuation of the type of personal property in
question. (ii) The individual may
produce documentation showing an actual but unsuccessful sale attempt has been
made. (a) In the case of real
property, the documentation must show that the property has been, and is
currently, listed for sale in a newspaper or with a for sale by owner website,
real estate agent, real estate broker, or real estate firm in the geographic
area. The documentation may include a listing agreement with a real estate
agent, broker, or firm, or a written statement signed by a real estate agent,
broker, or firm confirming that the real property has an active status with the
multiple listing service (MLS). The property is a countable resource until it
is listed for sale. (b) The property must be
listed for sale at an amount equal to the fair market value determined by the
county auditor, where available, or any other knowledgeable
source. (c) The real estate
agent, broker, or firm must verify that no reasonable offer to purchase the
property has been declined. An offer is reasonable when it is not less than
ninety per cent of the fair market value established by the county auditor,
where available, or any other knowledgeable source. (d) When the individual
receives an offer for the property that is less than ninety per cent of the
fair market value established by the county auditor, where available, or any
other knowledgeable source, the low offer may be an indication that the value
is incorrect. (e) When it appears that
the stated market value is incorrect, either the individual or the
administrative agency may obtain an appraisal from a second source to set a
more accurate value. A second appraisal is not necessary when the purchase
offer is so low that it is obviously unreasonable. (f) The individual has
the right to rebut the value of the property by obtaining an appraisal of the
property. (iii) The individual may
produce documentation showing good cause. (a) A good cause
exception may be requested by the individual or the individual's
authorized representative. (b) Good cause exists
when the individual was prevented by circumstances beyond his or her control
from listing the property for sale. (D) Resources of family members, households, and
non-citizens. (1) The resources of
spouses residing together are addressed in accordance with the deeming of
resources in rule 5160:1-3-05.20 of the Administrative Code. (2) The administrative
agency shall apply the resource limit for an individual effective the month
following the month a married couple separates or divorces or one member
dies. (3) The resources of a
child under the age of eighteen are addressed in accordance with the deeming of
resources in rule 5160:1-3-05.20 of the Administrative Code. (4) The resources of a
non-citizen and sponsor(s) are addressed in accordance with the
sponsor-to-non-citizen deeming requirements in accordance with rule
5160:1-3-05.20 of the Administrative Code. (E) Resources that are determined to be excluded from the
applicable resource limit for medical assistance remain excluded at the time of
the individual's death. Excluded resources are part of the deceased
individual's estate and are subject to the estate recovery provisions in
accordance with section 5162.21 of the Revised Code. (F) The entrance fee for individuals residing in a
continuing care retirement community or a life care community must be
considered an available resource in accordance with rule 5160:1-6-02.3 of the
Administrative Code.
Last updated April 1, 2022 at 8:23 AM
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Rule 5160:1-3-05.2 | Medicaid: trusts.
(A) This rule defines the treatment of a
trust for the purposes of determining eligibility for medical assistance
programs. This rule is only enforceable to the same extent as section 5163.21
of the Revised Code. (B) Definitions. (1) "Beneficiary" means any
person benefiting in some way from the trust. The beneficiary can be the
grantor or another person. There may be more than one beneficiary of a
trust. (2) "Grantor" means any person
who creates a trust. For purposes of this rule, the term grantor
includes: (a) An individual; (b) An individual's spouse; (c) A person, including a court or administrative body, with
legal authority to act in place of, or on behalf of, an individual or the
individual's spouse; and (d) A person, including a court or administrative body, acting at
the direction or upon the request of an individual or the individual's
spouse. (3) "Irrevocable trust" means a
trust that cannot be revoked by the grantor or terminated by a court. A trust
terminating only upon the occurrence of an event outside the control or
direction of the beneficiary or the grantor is irrevocable. (4) "Legal instrument or device
similar to a trust" means any legal instrument, device, or arrangement
that is not called a trust under state law, but is similar to a trust. This
includes, but is not limited to, escrow accounts, investment accounts,
partnerships, contracts, and other similar arrangements. To constitute a legal
instrument or device similar to a trust, all of the following must be
present. (a) There must be a person holding, managing, retaining, or
administering the property. For the purpose of this rule, the person holding,
managing, retaining or administering the property is referred to as the
trustee. (b) The trustee must have an equitable, legal, or fiduciary duty
to hold, manage, retain, or administer the property for the benefit of another
person. For the purpose of this rule, this other person is referred to as the
beneficiary. (c) The trustee must hold identifiable property for the
beneficiary. (5) "Payment" means any
disbursal from the principal or income of the trust. A payment may include
actual cash, non-cash or property disbursements, or the right to use and occupy
real property. (6) "Payments to or for the benefit
of the individual" means any payment to any person resulting in any direct
or indirect benefit to the individual. (7) "Person" has the same
meaning as set forth in section 1.59 of the Revised Code and includes an
individual, corporation, business trust, estate, trust, partnership, and
association. (8) "Revocable trust" means a
trust that can be revoked by the grantor or the beneficiary. For the purposes
of the medicaid program, the following trusts are "revocable trusts"
even when the terms of the trust state it is irrevocable: (a) A trust providing the trust can be terminated only by a
court; or (b) A trust terminating upon the happening of an event, when the
event can occur at the direction or control of the grantor, the beneficiary, or
the trustee. (9) "Testamentary trust" means
a trust that is established by a will. This type of trust does not take effect
until after the death of the person (testator) who created the
trust. (10) "Trust," for the purpose of
this rule, means any arrangement in which a grantor transfers property (real or
personal) to a trust with the intention that it be held, managed, or
administered by a trustee(s) for the benefit of the grantor or certain
designated individuals (beneficiaries). In this rule, the term trust includes
any legal instrument or device that is similar to a trust. (11) "Trustee" means any person
who manages a trust. A trustee manages a trust's principal and income for
the benefit of the beneficiaries. (C) The five categories of
trusts. (1) Category one:
self-settled trusts established before August 11, 1993, also referred to as
medicaid qualifying trusts. (a) A trust, or legal instrument or device similar to a trust,
falls under this category when it meets all the following
criteria: (i) The trust was
established before August 11, 1993; (ii) The trust was not
established by a will; (iii) The trust was
established by the individual; (iv) The individual is or
may become the beneficiary of all or part of the trust; and (v) Payment from the
trust is determined by one or more trustees who are permitted to exercise any
discretion with respect to the distribution to the individual. (b) The amount of the trust deemed to be an available resource to
the individual is the maximum amount of payments that may be permitted under
the terms of the trust to be distributed to the individual, assuming the full
exercise of discretion by the trustee or trustees. The maximum amount includes
only amounts that may be, but are not, distributed from either the income
(interest) or principal of the trust. (c) Amounts actually distributed to the beneficiary for any
purpose are treated under the rules governing income. (d) The availability of a trust in this category shall be
considered whether or not: (i) The medicaid
qualifying trust is irrevocable or is established for purposes other than to
enable a grantor to qualify for medicaid, or medicare premium assistance
programs described in rule 5160:1-3-02.1 of the Administrative Code;
and (ii) The trustee actually
exercises discretion. (2) Category two:
self-settled trusts established on or after August 11, 1993. (a) A trust, or legal instrument or device similar to a trust,
falls under this category when it meets all of the following
criteria: (i) The trust was
established on or after August 11, 1993; (ii) The assets of the individual were used to form all or part of
the corpus of the trust; (iii) The trust was not established by a will; and (iv) The trust was established by the individual, the spouse of
the individual, a person, including a court or administrative body, with legal
authority to act in place of or on behalf of the individual or on behalf of the
spouse of the individual, or a person, including a court or administrative
body, acting at the direction or upon the request of the individual or the
spouse of the individual. (b) Revocable trusts in this category are treated as
follows. (i) The corpus of the
trust is considered a resource available to the individual. (ii) Payments from the
trust to, or for the benefit of, the individual are considered unearned
income. (c) Irrevocable trusts in this category are treated as
follows. (i) When there are any
circumstances under which payment from the trust could be made to, or for the
benefit of, the individual, the portion from which payments could be made is
considered a resource available to the individual. The administrative agency
shall not take into account when payments can be made. A payment that can be
made only in the future satisfies this provision. (ii) Any payments
actually made to, or for the benefit of, the individual from either the corpus
or income are considered unearned income. (d) Where a trust is funded with assets of another person or
persons, as well as assets of the individual, the rule provisions governing
this category of trust applies only to the portion of the trust attributable to
the individual. (e) The availability of a trust in this category is considered
without regard to: (i) The purpose for which
a trust is established; (ii) Whether the trustees
have or exercise any discretion under the trust; (iii) Any restrictions on
when or whether distributions may be made from the trust; or (iv) Any restrictions on
the use of distributions from the trust. (3) Category three:
exempt trusts. The principal or income from any one of these trusts is exempt
from being counted as a resource. (a) Special needs trusts are not countable resources. A trust
qualifies as a special needs trust when the following conditions are
met. (i) The trust contains
the assets of an individual under age sixty-five. The trust may also contain
the assets of other individuals. (a) When such a trust was
established for a disabled individual under age sixty-five, the exception for
the trust continues even after the individual becomes age sixty-five, provided
the individual continues to be disabled as defined in rule 5160:1-3-02 of the
Administrative Code. (b) The trust cannot be
added to or otherwise augmented after the individual reaches age sixty-five,
with the exception of income earned by the trust. (ii) The individual is
disabled as defined in rule 5160:1-3-02 of the Administrative
Code. (iii) The trust is
established for the benefit of the individual. (iv) The trust is
established by one of the following: (a) The individual, if
established on or after December 13, 2016; (b) A parent;
(c) A
grandparent; (d) A legal guardian of
the individual; or (e) A court. (v) The trust requires, upon the death of the individual, the
state will receive all amounts remaining in the trust, up to an amount equal to
the total amount of medical assistance paid on behalf of the
individual. (vi) Cash distributions to the individual are counted as unearned
income. All other distributions from the trust are treated under the rules
governing in-kind income. (vii) Distributions from
an individual's special needs trust to the same individual's own
achieving a better life experience (ABLE) account shall be treated in
accordance with rule 5160:1-3-05.14 of the Administrative Code. (b) Qualified income trusts (QIT) are not countable resources. A
trust qualifies as a QIT when the trust meets the requirements in rule
5160:1-6-03.2 of the Administrative Code. (c) Pooled trusts are not countable resources. A trust qualifies
as a pooled trust only when all of the following conditions are
met. (i) The trust contains
the assets of an individual of any age who is disabled as defined in rule
5160:1-3-02 of the Administrative Code. (ii) A separate account
is maintained for each beneficiary of the trust but, for purposes of investment
and management of funds, the trust pools the funds in these
accounts. (iii) Accounts in the
trust are established by the individual, the individual's parent,
grandparent, or legal guardian, or a court solely for the benefit of
individuals who are disabled. (iv) To the extent that
any amounts remaining in the beneficiary's account upon the death of the
beneficiary are not retained by the trust, the trust pays to the state the
amount remaining in the account equal to the total amount of medical assistance
paid on behalf of the beneficiary. To meet this requirement, the trust must
include a provision specifically providing for such payment. (v) Cash distributions to
the individual are counted as unearned income. All other distributions from the
trust are treated under the rules governing in-kind income. (vi) Distributions from
an individual's pooled trust to the same individual's own achieving a
better life experience (ABLE) account shall be treated in accordance with rule
5160:1-3-05.14 of the Administrative Code. (d) Supplemental services trusts are not countable resources. A
trust qualifies as a supplemental services trust only when it meets the
requirements of section 5815.28 of the Revised Code. (i) Any person may
establish a trust under section 5815.28 of the Revised Code only for another
person who is eligible to receive services through one of the following
agencies: the department of developmental disabilities; a county board of
developmental disabilities; the department of mental health and addiction
services. (a) The administrative agency shall not determine eligibility for
another agency's program. (b) An individual must provide documentation from one of these
agencies establishing that the individual was determined to be eligible for
services from that agency at the time of the creation of the
trust. (c) An individual may provide an order from a court of competent
jurisdiction that states the individual was eligible for services from one of
the agencies at the time of the creation of the trust. (ii) At the time the
trust is created, the trust principal does not exceed the maximum amount
permitted. In 2006, the maximum amount permitted was two hundred twenty-two
thousand dollars. The maximum amount each year thereafter is the prior
year's amount plus two thousand dollars. (iii) The administrative
agency shall review the trust to determine whether it complies with the
remaining provisions of section 5815.28 of the Revised Code. (iv) Payments from
supplemental services trusts are exempt as long as the payments are for
supplemental services as defined in section 5815.28 of the Revised Code. All
supplemental services shall be purchased by the trustee, not through direct
cash payments to the beneficiary. (e) When a trust is represented to be an exempt trust, but the
administrative agency determines that it does not meet the requirements for one
of the exempt trusts, then it is not an exempt trust and will fall under one of
the four other categories of trusts. (4) Category four: trusts
established by someone else for the benefit of the individual. (a) A trust, or legal instrument or device similar to a trust,
falls under this category when it meets the following criteria: (i) The trust is created
by someone other than the individual; (ii) The trust names the
individual as a beneficiary; and (iii) The trust is funded
with assets or property that the individual never held an ownership interest in
prior to the establishment of the trust. (b) Any portion of a trust in this category is an available
resource only when the trust permits the trustee to expend principal, corpus,
or assets of the trust for the individual's medical care, care, comfort,
maintenance, health, welfare, general well-being, or a combination of these
purposes. The trust is still considered an available resource even when the
trust contains any of the following types of provisions: (i) Any provision
prohibiting the trustee from making payments that would supplant or replace
medicaid or public assistance, or other government assistance; (ii) Any provision
prohibiting the trustee from making payments that would impact or affect the
individual's right or ability or opportunity to receive medicaid, or
public assistance, or other government assistance; or (iii) Any provision
attempting to prevent the trust or its corpus or principal from counting as an
available resource under this rule. (c) A trust in this category normally considered as an available
resource is not counted as an available resource under the following
circumstances. (i) When the trust
contains a clear statement requiring the trustee to preserve a portion of the
trust for another beneficiary or remainderman, then that portion of the trust
is not counted as an available resource. Terms of a trust granting discretion
to preserve a portion of the trust do not qualify as a clear statement
requiring the trustee to preserve a portion of the trust. (ii) When the trust
contains a clear statement requiring the trustee to use a portion of the trust
for a purpose other than the medical care, care, comfort, maintenance, welfare,
or general well-being of the individual, then that portion of the trust is not
counted as an available resource. Terms of a trust that grant discretion to
limit the use of a portion of the trust do not qualify as a clear statement
requiring the trustee to use a portion of the trust for a particular
purpose. (iii) When the trust
contains a clear statement limiting the trustee to making fixed periodic
payments, then the trust is not counted as an available resource; however, the
payments are treated under the rules governing income. Terms of a trust that
grant discretion to limit payments do not qualify as a clear statement
requiring the trustee to make fixed periodic payments. (iv) When the trust
contains a clear statement requiring the trustee to terminate the trust if it
is counted as an available resource, then it is not counted as an available
resource. Terms of a trust granting discretion to terminate the trust do not
qualify as a clear statement requiring the trustee to terminate the
trust. (v) When any person
obtains a judgment from a court of competent jurisdiction expressly preventing
the trustee from using part or all of the trust for the medical care, care,
comfort, maintenance, welfare, or general well-being of the individual, then
the trust or that portion subject to the court order is not counted as a
resource. (vi) When the trust is
specifically exempt from counting as an available resource by this rule,
another rule, the Revised Code, or the U.S. Code, it is not counted as a
resource. (vii) When the individual
presents a final judgment from a court demonstrating that he or she was
unsuccessful in a civil action against the trustee to compel payments from the
trust, then it is not counted as an available resource. (viii) When the
individual presents a final judgment from a court demonstrating that in a civil
action against the trustee the individual was only able to compel limited or
periodic payments, then it is not counted as an available resource; however,
the payments are treated under rules governing income. (ix) When the individual
provides written documentation showing the cost of a civil action brought to
compel payments from the trust are cost prohibitive, then it is not counted as
an available resource. (d) For trusts under this category, even when the trust is not
counted as an available resource, any actual payments from the trust to the
individual are treated under the rules governing income. (5) Category five: trusts
established by will for the benefit of a surviving spouse. (a) A trust, or legal instrument or device similar to a trust,
can be established by the will of a deceased spouse. (i) When there are any
circumstances under which payment from the trust could be made to, or for the
benefit of, the surviving spouse, the portion from which payments could be made
is considered an available resource. The administrative agency shall not take
into account when payments can be made. A payment that can be made only in the
future satisfies this provision. (ii) Any payments
actually made to, or for the benefit of, the surviving spouse from either the
corpus or income are considered unearned income. (D) This rule supersedes all previous
rules governing trusts and the administrative agency shall apply it
prospectively to all determinations and renewals of eligibility for all
individuals. Any determination or renewal made in accordance with this rule
shall not be affected by or governed by any prior eligibility determinations
made under former rules governing trusts nor shall this rule be applied
retroactively to determine an individual's eligibility or liability for
any prior period.
Last updated March 1, 2024 at 8:12 AM
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Rule 5160:1-3-05.3 | Medicaid: annuities.
Effective:
September 1, 2017
(A) This rule describes the treatment of annuities for the purposes of determining eligibility for medical assistance. (B) Definition. An "annuity" provides fixed, periodic payments, either for life or a term of years. When an individual purchases an annuity, he or she generally pays the entity issuing the annuity a lump sum of money, in return for which the issuing entity promises regular payments in a specified amount to the individual or designated beneficiary. These payments may continue for a fixed period of time or for the lifetime of the individual or designated beneficiary. The annuity typically contains a remainder clause under which, if the annuitant dies, the contracting entity converts whatever is remaining in the annuity into a lump sum and pays it to a designated beneficiary. (C) Treatment of annunities in the determination of eligibility for medical assistance. (1) Any resource meeting the definition of an annuity in paragraph (B) of this rule shall be considered an excluded resource. (2) Any payments from an annuity shall be considered as unearned income to the individual or designated beneficiary.
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Rule 5160:1-3-05.4 | Medicaid: cash and checking and savings accounts and time deposits.
Effective:
December 14, 2020
(A) This rule describes the treatment of
cash, checking and savings accounts, and time deposits for purposes of
determining eligibility for medical assistance. (B) Definitions. (1) "Cash"
means money on hand or available in the form of currency or coins. Foreign
currency or coins are cash to the extent that they can be exchanged for U.S.
currency. (a) Monthly income is not counted when evaluating cash on
hand. (b) The individual's statement of actual cash on hand is
accepted without verification. (2) "Checking
account" or "savings account" is the same as having cash on hand
because deposits are payable on demand. An individual should be able to
withdraw money from a checking account or savings account on the same day the
individual requests it. (3) "Dedicated
account" means an account in a financial institution, the sole purpose of
which is to receive and maintain supplemental security income (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
(as in effect October 1, 2019). (4) "Depository
account", for the purpose of this rule, means a checking account, savings
account, or time deposit at a financial institution that allows money to be
deposited and withdrawn by the account owner. (5) "Depository
account signature card" means a contract with the financial institution
that shows who has access to the depository account and whether or not the
signatures of more than one owner of the depository account are needed to
withdraw funds. (6) "Passbook"
means a financial institution record which shows deposits, withdrawals, and
interest. (7) "Past-due
benefits" mean any of the following: (a) SSI benefits due but unpaid which accrue prior to the month
payment was effectuated; or (b) SSI 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; or (c) Any adjustment to SSI benefits that results in an accrual of
unpaid benefits. (8) "Time
deposit" means a contract between an individual and a financial
institution whereby the individual agrees to leave funds on deposit for a
specified period and the financial institution agrees to pay interest at a
specified rate for that period. (a) Certificates of deposit (CDs) and saving certificates are
common forms of time deposits. (b) Withdrawal of a time deposit before the specified period
expires incurs a penalty, which usually is imposed against the principal. This
penalty does not prevent the time deposit from being a resource, but does
reduce its value as a resource. On rare occasions, the terms of a time deposit
will prohibit early withdrawal. (C) Access to depository accounts. (1) When the individual
is: (a) The account owner and has the legal right to withdraw
funds from the account, all of the funds in the account are a resource to the
individual. (b) A co-owner of the account with another individual who
is applying for or in receipt of medical assistance, the funds in the account
are equally divided and a resource to each of the co-owners. (c) A co-owner of the account with someone who is not
applying for or in receipt of medical assistance, all of the funds in the
account are a resource to the individual. (2) The depository
account signature card identifies who has access to the funds. In the absence
of the depository account signature card, a statement from the financial
institution is acceptable documentation. (3) In situations where a depository
account is shared with others and the amount of funds has an effect on the
individual's eligibility for medical assistance, the administrative agency
shall inform the individual that if he or she has restricted access to the
depository account according to the contract with the financial institution or
if a portion of the depository account was contributed by another person, the
individual must provide documentation to support his or her statements
regarding the account situation. (4) When the individual provides
documentation showing that access to the depository account is restricted
through the need for the signature of other owners, all of the funds are still
considered a resource of the individual unless documentation is provided of the
percentage the other owners have contributed. (a) When the other owners refuse to allow the individual to
withdraw funds from the depository account, the individual must provide
documentation that the resource is unavailable and take any action necessary to
obtain the resource. (b) When the individual is institutionalized, a determination of
whether an improper transfer has occurred must be completed in accordance with
rule 5160:1-6-06.5 of the Administrative Code. If the individual's
signature is all that is needed to access the depository account, then the
depository account is his or hers in its entirety unless documentation is
provided that indicates which percentage of the funds the other person(s)
deposited. (5) When the individual provides
documentation showing that another person, who is not applying for or in
receipt of medical assistance, has an ownership interest in and contributed to
the depository account, then only the portion contributed by the individual
shall be considered as a resource. (a) Interest accrued on the depository account shall be allocated
according to the portions of ownership. (b) Documentation necessary to show the individual does not own
the funds in the depository account includes: (i) A statement from the
individual giving his or her allegation regarding ownership of the funds, the
reason for establishing the co-owned depository account, who made deposits to
and withdrawals from the depository account, how withdrawals were spent, etc.;
and (ii) Corroborating
statements from the other depository account holder(s); and (iii) Where ownership for
prior periods needs to be established, the evidence must include a financial
institution record or income statement. This may result in determinations that
the individual owned varying dollar amounts for the prior period. (6) When the co-owner of the depository
account is incompetent or a minor, it is unnecessary to obtain a corroborating
statement from that person. That person's incompetency or age may be the
reason why the claimant is listed as a depository account co-owner. In the
event this occurs, the administrative agency shall: (a) Obtain a corroborating statement from a third party who has
knowledge of the circumstances surrounding the establishment of the co-owned
depository account. (b) Make the decision without a corroborating statement if there
is no third party and document the basis for the decision and why no
corroborating statement was obtained. (7) When, following the evaluation of
ownership, it is determined that the individual's share of the resource is
within the allowable limit, medical assistance is to be approved or continued.
The individual shall: (a) Remove his or her assets from the co-owned depository account
within sixty days from the date his or her eligibility is approved;
and (b) Provide documentation that the change has been
made. (8) The name and address of the financial
institution, the depository account number, the name(s) on the depository
account, and the amount of money in the depository account must be documented
in the individual's case record. If the authority to withdraw money from
the depository account does not belong to those whose names are shown on the
depository account, that fact must also be documented. (D) The checking or savings account is
not a resource when: (1) The account restricts
the right to withdraw funds from the account to a specific account owner;
or (2) Withdrawals from the
account require authorization from a third party; or (3) Use is restricted by
a court order; or (4) The account is
restricted to a special purpose. (E) Time deposits. (1) When the owner of a
time deposit cannot under any circumstances withdraw funds before the time
deposit matures, it is not a resource. The time deposit becomes a resource (not
income) on the date of maturity, and may affect countable resources in the
month in which the time deposit matures. If the owner has no access to the
interest before the time deposit matures, accrued interest is not a resource
and is income in the month the deposit matures. (2) When an individual
has transferred his or her resources into a time deposit in which early
withdrawal is prohibited, a determination of whether an improper transfer has
occurred must be completed in accordance with rule 5160:1-6-06.5 of the
Administrative Code. The determination shall include consideration of the
length of the period of inaccessibility, the individual's life expectancy,
and the amount of the time deposit. (3) A time deposit for
which early withdrawal is prohibited is still considered a countable resource
for the purposes of determining a community spouse resource allowance for an
institutionalized individual as described in rule 5160:1-6-04 of the
Administrative Code. (4) A time deposit's
resource value at any given time, if early withdrawal is permitted, is the
amount the owner would receive upon withdrawing it at that time, excluding
interest paid that month. Generally, this is the amount originally deposited;
plus accrued interest for past months; minus any penalty specified on the time
deposit certificate for early withdrawal. (F) Verifying depository accounts. (1) A checking account is
verified by examining the printout from online banking or the last monthly bank
statement and the checkbook record to arrive at the current bank balance. A
copy of the monthly bank statement and checkbook record shall be retained in
the case record. (a) When the printout or statement shows deposit and withdrawal
activity or cash flow inconsistent with the individual's stated financial
situation, the administrative agency shall investigate fully to establish the
source of income. (b) When the printout, bank statement, or checkbook record is not
available or there is some reason to doubt the accuracy of the checkbook
record, verification shall be obtained by contact with the financial
institution after obtaining the individual's written
authorization. (2) A savings account is
verified by examining the printout from online banking, last monthly bank
statement, or current balance of the passbook. (a) The administrative agency shall retain a copy of the page(s)
that show activity in the last sixty days. When the printout, bank statement,
or passbook shows deposit and withdrawal activity inconsistent with the
individual's stated financial situation, the administrative agency shall
investigate fully to establish the source of income. (b) When the printout, bank statement, or passbook is not
available or appears to have been materially altered, the administrative agency
shall obtain verification by contact with the financial institution after
securing the individual's written authorization. (c) All the information obtained shall be retained in the
individual's case record. (3) A time deposit is verified by viewing
the time deposit certificate or document and the account records of interest
accrual. The administrative agency may also obtain verification of the time
deposit or early withdrawal provisions by contacting the financial institution
after securing the individual's authorization. All the information
obtained shall be retained in the individual's case record. (4) The administrative
agency will contact the individual to collect the information needed. If the
individual declares the verifications cannot be accessed or submitted, the
individual's statement is to be accepted. (5) If the administrative
agency is unable to make contact with the individual, a written (electronic or
paper) request for the necessary information or verification documents is to be
sent as set forth in rule 5160:1-2-01 of the Administrative Code. (G) Dedicated account. (1) Past-due benefits
deposited into a dedicated financial institution account and any accrued
interest or other earnings on such an account are excluded from income and
resources. (2) 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. (a) An exception is when the financial institution requires the
individual to deposit money to open an account, such as a minimum deposit, a
small amount of other funds can be used to open the dedicated
account. (i) The funds that were
used to open the account are not excluded as a resource and must be removed
from the account once the account has been established and the past-due
benefits paid into it. (ii) 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) Funds other than those described in paragraph (G)(2)(a) of
this rule shall not be deposited into a dedicated account. (3) The individual must provide
verification that a dedicated account has been established. The verification
must include the name and address of the financial institution, account number,
account title, type of account, and the amount of money in the
account. (4) 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 social security
administration determines to be appropriate provided that such expense benefits
the individual and, in the case of personal 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. (5) 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. (a) The exclusion of the funds in the account from the
individual's countable resources continues to apply until SSI eligibility
is terminated. (b) Once an individual's SSI 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. Any remaining funds are a countable
resource. (c) Reopening of a prior period of SSI eligibility following
termination is not a new period of eligibility and, therefore, the exclusion
may be reapplied. (6) When an individual receives past-due
benefits that may be, but have not yet been, deposited into a dedicated
account, the payment is excluded from resources for nine months until the payee
deposits the payment into a dedicated account. Such payments are not required
to be deposited into a dedicated account at the option of the representative
payee.
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Rule 5160:1-3-05.5 | Medicaid: promissory notes, property agreements, and loans.
Effective:
September 1, 2017
(A) This rule describes the treatment of promissory notes, property agreements, and loans for purposes of determining eligibility for medical assistance. (B) Definitions. (1) "Promissory note" means a written, unconditional promise signed by a person to pay a specified sum of money at a specified time, or on demand, to the person, corporation, or institution named on the note. It may be given in return for goods, money loaned, or services rendered. A promissory note making periodic payments is not considered an annuity. (2) "Property agreement" means a pledge or security of particular property for the payment of a debt or the performance of some other obligation within a specified period. (a) Property agreements on real estate generally are referred to as mortgages but also may be called real estate or land contracts, contracts for deed, deeds of trust, etc. (b) Personal property agreements (e.g., pledges of crops, fixtures, inventory, etc.) are commonly known as chattel mortgages. (C) Promissory notes or property agreements held by an individual. (1) A promissory note or property agreement is an available resource. (a) The resource value is its outstanding principal balance unless the individual furnishes evidence that it has a lower cash value. (b) The property itself is not a resource. (2) Payments received by an individual toward the principal balance of a promissory note or property agreement are not income. The interest portion of payments received is unearned income to the individual. (3) A copy of the property agreement must be recorded with the county auditor, county recorder, or other appropriate government agency charged with the responsibility of recording property agreements. (a) For the purposes of this rule, a property agreement is not considered effective until the date it is recorded with the county auditor, county recorder, or other appropriate government agency charged with the responsibility of recording property agreements. The administrative agency shall disregard any property agreement that is not properly recorded and shall consider the entire property as an available resource to the individual. (b) For the purposes of this rule, the property agreement recording date held by the appropriate government agency is considered the date of transfer. (4) Documentation must be provided by the individual verifying his or her proportionate share of the note or agreement if ownership of the note or agreement is shared. (5) A promissory note or property agreement has no value if the individual adequately documents the obligations under the promissory note or property agreement were discharged by order of a bankruptcy court. (D) Loans held by an individual. (1) Money an individual borrows or money received as the principal repayment of a bona fide loan is not considered income. (a) Any interest received on money loaned is unearned income. (b) Retained proceeds of a loan in the month following the month of receipt are counted as a resource. (2) The value of the loan is the outstanding balance due as of the individual's application date for medical assistance.
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Rule 5160:1-3-05.6 | Medicaid: burial funds and contracts.
Effective:
September 1, 2017
(A) This rule describes the treatment of burial funds and burial contracts for purposes of determining eligibility for medical assistance. (B) Definitions. (1) "Burial funds" are revocable burial contracts, revocable burial trusts, other revocable burial arrangements (including the value of certain installment contract for burial spaces), cash, financial accounts (checking or savings accounts), or other financial instruments with a definite cash value (e.g. stocks, bonds, etc.). (2) "Prepaid burial contract" means an agreement whereby the buyer pays in advance for a burial that the seller agrees to furnish upon the death of the buyer or other designated individual. (C) Burial funds exclusion. (1) Up to one thousand five hundred dollars for each person can be excluded in burial funds set aside for: (a) The burial expenses of the individual; and (b) The burial expenses of the individual's spouse. (2) Burial funds must be clearly designated for the individual's or the individual's spouse's burial and must be kept separate from nonburial-related assets in order to be excluded. (3) The burial funds exclusion is separate from and in addition to the burial space exclusion described in rule 5160:1-3-05.7 of the Administrative Code. (4) Any accural of interest or appreciation in the value of excluded burial funds is excluded from resources and income, even if the total value of the burial funds exceeds one thousand five hundred dollars. (5) Expenses included for burial funds purposes are generally those related to preparing a body for burial and any services prior to burial to include transportation of the body, embalming, cremation, flowers, clothing, services of the funeral director and staff, etc. (6) Any burial funds that exceed the burial funds exclusion are combined with all other countable resources and compared to the resource limit described in rule 5160:1-3-05.1 of the Administrative Code. (D) Irrevocable prepaid burial contracts. (1) Irrevocable prepaid burial contracts are not a resource. (2) Any portion of the contract that represents burial funds reduces the amount available under the burial funds exclusion described in paragraph (C) of this rule. (3) Any portion of the contract that represents the purchase of burial spaces has no effect on the burial funds exclusion. (E) Revocable or salable prepaid burial contracts. (1) If a prepaid burial contract is revocable or salable it is a countable resource and treated as a burial fund. (2) Any portion of the contract that clearly represents the purchase of a burial space is excludable as a countable resource if it meets the requirements of rule 5160:1-3-05.7 of the Administrative Code. (3) The value of a revocable or salable burial contract is: (a) The amount payable to the buyer upon revocation; or (b) If the contract is not revocable but is salable, its current market value. (F) Burial space contract. (1) The burial space exclusion described in rule 5160:1-3-05.7 of the Administrative Code is applied to any single-purpose burial space contract if: (a) The contract lists all of the burial spaces and either includes a value for each space or the total value of all the spaces combined; and (b) The seller's obligations to provide those items is not contingent on further payment, as in certain installment contracts (ie. the items are actually being held for the individual's future use). (2) Treat the burial space contract as burial funds when: (a) The unidentified portion of a contract that implies it covers only burial spaces but does not identify some or all of the spaces or does not include either a value for each burial space or the total of all the spaces combined; or (b) The amount paid on an installment contract for burial spaces if the contract does not entitle the individual to the spaces until the full purchase price has been paid. (G) Life insurance funded burial contracts. (1) A life insurance funded burial contract involves an individual owning/purchasing a life insurance policy on his or her own life and then assigning, revocably or irrevocably, either the ownership or proceeds of the policy to a third party, generally a funeral provider. The purpose of the assignment is to fund a burial contract. (a) Assignment of ownership. (i) Revocable assignment of ownership. (a) The burial space exclusion described in rule 5160:1-3-05.7 of the Administrative Code does not apply because the funeral provider has not received payment and no purchase of burial spaces has been made. The provider has no obligation to provide any spaces until the individual dies and, therefore, no spaces are being held for the individual. (b) The resource value of the burial contract is equal to the cash surrender value (CSV) of the life insurance policy, subject to the burial funds exclusion described in paragraph (C) of this rule. (ii) Irrevocable assignment of ownership. (a) The burial space exclusion described in rule 5160:1-3-05.7 of the Administrative Code may apply if the burial space contract with a funeral service company for specified burial spaces represents current right to the use of the items at the amount shown. Any portion of the burial contract that represents the purchase of a burial space has no effect on the burial funds exclusion described in paragraph (C) of this rule. (b) The life insurance policy and burial contract are not resources. The face value (FV) of the burial funds portion of the contract is subject to the burial funds exclusion described in paragraph (C) of this rule. (b) Assignment of proceeds. (i) Revocable assignment of proceeds. (a) The burial space exclusion described in rule 5160:1-3-05.7 of the Administrative Code does not apply to the CSV of the life insurance policy because the funeral provider has not received payment and no purchase of burial spaces has been made. The provider has no obligation to provide any spaces until the individual dies and, therefore, no spaces are being held for the individual. (b) The resource value of the burial contract is equal to the CSV of the life insurance policy. (i) If the FV of all life insurance policies on the individual's life is one thousand five hundred dollars or less, the CSV is excluded under the life insurance exclusion described in rule 5160:1-3-05.12 of the Administrative Code. (ii) If the FV of all life insurance polices exceeds one thousand five hundred dollars, treat the CSV of the policy according to the burial funds exclusion described in paragraph (C) of this rule. (ii) Irrevocable assignment of proceeds. The irrevocable assignment of proceeds is not premitted without requiring the irrevocable assignment of ownership. (2) When an individual irrevocably transfers ownership of a revocable life insurance policy that funds a burial contract to a trust, the CSV of the policy is evaluated under the trust rule 5160:1-3-05.2 of the Administrative Code. (3) Life insurance funded burial contracts are not burial insurance. (4) Dividend accumulations of a life insurance policy as part of the value of the policy or the prepaid burial contract are not excluded. Dividend accumulations are separate resources and must be designated separately in order to qualify for the burial funds exclusion. (H) Burial insurance. (1) Burial insurance is a contract whose terms prevents the use of its proceeds for anything other than payment of the insured's burial expenses. (2) Treat burial insurance as burial funds described in paragraph (C) of this rule. (3) The value of the burial insurance policy is the FV of the policy. (I) Contracts for both burial spaces and burial funds. If a contract does not indicate which amounts represent the purchase of burial spaces and which amount represents burial funds, and which parts, if any, are irrevocable, the entire contract shall be considered a resource in the form of burial funds.
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Rule 5160:1-3-05.7 | Medicaid: burial spaces.
Effective:
August 1, 2016
(A) This rule describes the treatment of
burial spaces for the purposes of determining eligibility for medical
assistance. (B) Definitions. (1) "Agreement," for the purpose of this rule,
means a contract with a burial provider for a burial space held for the
individual or a member of the individual's immediate family. (2) "Burial
space," means a burial plot, gravesite, crypt, mausoleum, casket, urn,
niche, or other repository customarily and traditionally used for the
deceased's bodily remains. The term also includes a contract for care and
maintenance of the gravesite, sometimes referred to as an endowment or
perpetual care and necessary and reasonable improvements or additions to such
spaces, including but not limited to vaults, headstones, markers, or plaques,
burial containers (e.g., for caskets) and arrangements for the opening and
closing of the gravesite. (3) "Immediate
family" includes the individual's: (a) Parents, including adoptive parents; (b) Minor or adult children, including adoptive and
stepchildren; (c) Siblings, including adoptive and stepsiblings;
or (d) Spouses of immediate family if the marriage is in
effect at the time of determination or renewal of eligibility for medical
assistance. (C) A burial space or burial space
contract, described in rule 5160:1-3-05.6 of the Administrative Code which
represents the purchase of a burial space held for the burial of the
individual, the individual's spouse, or any other member of the
individual's immediate family is an excluded resource, regardless of
value. (D) A burial space is held for an
individual when someone currently has: (1) Title to and/or
possesses a burial space intended for the individual's use (e.g., has
title to a burial plot or owns a burial urn stored for his own use);
or (2) A contract with a
funeral service company for specified burial spaces for the individual's
burial (i.e., an agreement which represents the individual's current right
to the use of the items at the amount shown). (E) Until the purchase price is paid in
full, a burial space is not held for an individual under an installment sales
contract or similar device and the installment payments shall be considered
burial funds in accordance with rule 5160:1-3-05.6 of the Administrative
Code. (F) Administrative agency
responsibilities. The administrative agency shall: (1) Determine whether the
burial space is held for the individual or member of the individual's
immediate family if the agreement shows the purchase of a specified burial
space at a specified price. (2) Of items that serve
the same purpose, exclude only one per person. For example, exclude a cemetery
lot and a casket for the same person, but not a casket and an urn. (3) If the agreement
calls for installment payments, determine whether the value of the burial space
must be treated as burial funds in accordance with rule 5160:1-3-05.6 of the
Administrative Code.
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Rule 5160:1-3-05.8 | Medicaid: lump-sum payments.
Effective:
January 1, 2024
(A) This rule describes the treatment of
lump-sum payments for purposes of determining eligibility for medical
assistance. (B) Definition. "Lump-sum
payment" means income which is accrued over two or more months or a money
payment which is not related to any time period, such as a death benefit or
inheritance. (C) An anticipated nonrecurring lump-sum
payment is considered unearned income unless otherwise excluded. It is unearned
income in the month received and a countable resource in the month following
the month of receipt. The following are some types of anticipated lump-sum
payments that are considered unearned income: (1) Gifts, prizes, or
awards. (2) Retirement or pension
funds. (3) Judgments and
out-of-court settlements. (4) Proceeds received as
the beneficiary of a life insurance policy, including social security lump-sum
death benefits. (5) Workers compensation
payments when received as a lump-sum. (D) An unanticipated nonrecurring
lump-sum payment is not considered unearned income in the month of receipt and
is a resource in the month following the month of receipt. The following are
some types of unanticipated lump-sum payments that are considered resources,
that are not unearned income: (1) Proceeds received from the surrender
or maturing of insurance policies. (2) Proceeds received for the sale of
real property. (3) Replacement of income that was lost,
destroyed or stolen if the original income was used to determine
eligibility. (E) Retroactive payments from supplemental security income (SSI)
or retirement, survivors, disability insurance (RSDI) are unearned income in
the month received and excluded as countable resources for nine months
following the month of receipt. The source, amount, and the date of receipt of
the retroactive payment must be verified and the information recorded in the
case record. (1) As long as the funds
from the retroactive payment are not spent, they are excluded for the full nine
month period. Unspent money must be identifiable from other resources for this
exclusion to apply. The money may be commingled with other funds, but if this
is done in such a fashion that the retroactive amount can no longer be
separately identified, that amount will count toward the resource
limit. (2) Once the money is
spent, this exclusion does not apply to items purchased with the money even if
the nine month period has not expired. However, other exclusions may
apply. (F) Federal income tax refunds, and
advance payments with respect to refundable income tax credits, are not
considered income and are excluded as a countable resource for a period of
twelve months beginning the month after the month of receipt, in accordance
with 26 U.S.C. 6409 (as in effect October 1, 2023). (G) Medicaid buy-in for workers with
disabilities (MBIWD) premium refunds, as described in rule 5160:1-5-03 of the
Administrative Code, are not considered unearned income in the month of receipt
and are excluded as a countable resource for a period of twelve months
beginning the month of receipt. (H) When an individual eligible for medical assistance
receives a lump-sum payment, he or she may increase his or her personal
property holdings up to the maximums allowed. Then the administrative agency
compares the amount received to the amount of medicaid payments made on behalf
of the individual. (1) When the lump-sum is
equal to or less than medicaid payments, the individual is given a choice
of: (a) Purchasing household goods or personal effects, as
described in rule 5160:1-3-05.10 of the Administrative Code, to ensure that
resources remain within allowable limits; or (b) Using some or all of the lump-sum payment to pay
personal debts; or (c) Using some or all of the lump-sum payment for his or
her own personal care, including but not limited to hygiene products,
toiletries, and assistance with daily living activities; or (d) Repaying the medicaid program for medicaid payments
made on his or her behalf in order to preserve continuing eligibility for
medical assistance. The amount paid by medicaid for past care can be recovered
only when the individual agrees and when the repayment amount will continue to
ensure the individual's resources remain within the allowable limits;
or (e) Requesting that his or her medical assistance be
discontinued. (2) When the lump-sum is
in excess of medicaid payments for the individual, the excess amount shall be
counted as an available resource. When the amount exceeds the maximum resource
limit, medical assistance shall be discontinued and the individual will not be
required to use any of the lump-sum as repayment of past medicaid
payments.
Last updated January 2, 2024 at 9:34 AM
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Rule 5160:1-3-05.9 | Medicaid: dividends and interest.
Effective:
August 1, 2016
(A) This rule describes the treatment of
dividends and interest for the purposes of determining eligibility for medical
assistance. (B) Definitions. "Dividends"
and "interest", for the purpose of this rule, are returns on
financial institution accounts. A cash gift or incentive payment to open an
account is considered interest. (C) If the resource that produced the
dividends or interest is: (1) A countable resource,
the dividends and interest are excluded. (2) Excluded under a
federal statute other than the Social Security Act, the dividends and interest
are excluded. (3) Excluded under
section 1613(a) of the Social Security Act as described in rule 5160:1-3-05.14
of the Administrative Code, the dividends and interest may or may not be
excluded, depending on the specific resource.
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Rule 5160:1-3-05.10 | Medicaid: household goods and personal effects as resources.
Effective:
August 1, 2016
(A) This rule describes the treatment of household goods and
personal effects for the purposes of determining eligibility for medical
assistance. (B) Definitions. (1) "Encumbrance" means a claim, lien,
charge, or liability attached to and binding on an identified piece of real or
personal property. (2) "Household goods", for the purpose
of this rule, are all personal property customarily found in or near the home
and used on a regular basis in connection with the maintenance, use and
occupancy of the premises. This encompasses items necessary for an adequate
standard of sustenance, accommodation, comfort, information and entertainment
of occupants and guests. Such items include furniture, household appliances,
carpets, dishes, cooking and eating utensils, televisions and personal
computers. (3) "Personal effects, for the purpose of
this rule, are other personal property normally held and recognized as
incidental items intended for personal use by one or more household members.
Such items include clothing, personal jewelry, pets, personal care items
musical instruments, books, or items of cultural or religious
significance. (C) Household goods and
personal effects are excluded as resources. (D) Items acquired or are held for their value or as an
investment are not considered personal effects and are countable resources.
Such items can include but are not limited to gems, jewelery that is not worn
or held for family significance, collectibles, or animals for investment
purposes. (1) The current market value is the countable
resource amount. (2) If there is an encumbrance on the items, the
equity value is the countable resource amount.
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Rule 5160:1-3-05.11 | Medicaid: automobiles and other modes of transportation as resources.
(A) This rule describes the treatment of
automobiles and other modes of transportation for purposes of determining
eligibility for medical assistance. (B) Definition. "Automobile", for the purpose of this
rule, means any vehicle used for transportation. It can include, in addition to
cars and trucks: motorcycles, boats, snowmobiles, animal-drawn vehicles, and
animals. (C) One automobile is excluded for the individual, regardless of
value, if a member of the individual's household uses the automobile for
transportation. (1) For the purpose of
determining the community spouse resource allowance for couples when one spouse
is institutionalized, one automobile is considered totally excluded, regardless
of its use and value in accordance with rule 5160:1-6-04 of the Administrative
Code. (2) If an automobile is
not excluded, count the equity value of the automobile as a
resource. (3) Any automobile an
individual owns in addition to the one wholly excluded and which cannot be
excluded under another rule (e.g., property essential for self-support) is a
resource in the amount of its equity value. (4) If one of two
automobiles can be excluded because of one of the reasons listed above, and the
other is a countable resource, the exclusion applies to the automobile with the
greater equity value regardless of which automobile is actually
used. (5) The equity value for
all additional automobiles, regardless of the type of vehicle, is counted as a
resource. (6) The equity value for
all vehicles that are not used for transportation (e.g., pleasure boats,
snowmobiles, etc.) or excluded under another rule (e.g., necessary for
self-employment) is counted as a resource. These vehicles are considered
countable personal effects. (D) For the purpose of determining whether a vehicle is used for
transportation, accept the individual's account of its use. If a vehicle
is not being used for transportation, determine the reason why. (1) A temporarily
broken-down vehicle normally used for transportation still qualifies as an
automobile. One that has been junked or that is used only as a recreational
vehicle (e.g., a boat used weekends on the lake) does not qualify as an
automobile. (2) Vehicles that do not
meet the definition of an automobile are personal effects. The value they have
as a resource is their equity value, and the personal effects exclusion,
described in rule 5160:1-3-05.10 of the Administrative Code, does not apply to
them. (E) The fair market value of an automobile is determined by the
average trade-in value shown for the vehicle in the most recently published
"National Automobile Dealers Association (NADA) Guide". The
description of the car must be complete enough to enable the administrative
agency to locate it in the appropriate NADA guide. The description is to
include the year, make, model, number of doors, equipment, etc. Absent evidence
to the contrary, assume the vehicle to be in average condition. (1) If the NADA guide
cannot be used (e.g., animal-drawn vehicle), obtain a fair market value
estimate from a disinterested knowledgeable source. (2) An individual who
disagrees with the value of the vehicle can rebut the value by obtaining a
written appraisal of the vehicle's fair market value from a disinterested
knowledgeable source, such as a used car or truck dealer or an automobile
insurance company. The administrative agency is not bound by this appraisal but
the appraisal is to be considered in the evaluation of the
vehicle. (3) Always verify the
collector value of an antique or other collectible vehicle.
Last updated June 1, 2021 at 10:12 AM
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Rule 5160:1-3-05.12 | Medicaid: life insurance.
Effective:
September 1, 2017
(A) This rule describes how life insurance policies are treated for purposes of determining medical assistance eligibility. (B) Definitions of terms contained within life insurance policies. (1) "Accelerated life insurance payments" means some or all of the proceeds from the life insurance policy are paid out to the policy owner prior to the death of the insured. (2) "Beneficiary" means an individual or entity named in the contract to receive the policy proceeds upon the death of the insured. (3) "Cash surrender value (CSV)" means a form of equity value that the policy acquires over time. The owner of a policy can obtain its CSV only by turning the policy in for cancellation before it matures or the insured dies. A loan against a policy reduces its CSV. The value usually increases with the age of the policy. (4) "Dividend accumulations" are dividends which accrue in an account that the insurance company controls for the policy owner. The policy owner can access the funds without penalty at any time without affecting the policy's face value (FV) or CSV. Dividend accumulations cannot be excluded from resources under the life insurance exclusion, even if the policy that pays the accumulations is excluded from resources. Unless they can be excluded under another provision, they are a countable resource. (5) "Dividend additions" are amounts of insurance purchased with dividends and added to the policy, increasing its death benefit and CSV. The table of CSV's that comes with a policy does not reflect the added CSV of any dividend additions. (6) "Dividends", for the purpose of this rule, means periodically (annually, as a rule), the insurer may pay a share of any surplus company earnings to the policy owner as a dividend. Depending on the life insurance company and type of policy involved, dividends can be applied to premiums due, paid by check to the owner, or by an addition or accumulation to an existing policy. (7) "Face value" (FV) means the amount of basic death benefit contracted for at the time the policy is purchased. It is the amount to be paid out when the insured dies. (8) "Insured" means the individual whose life is covered by the life insurance policy. (9) "Insurer" means the company or association which contracts with the owner. (10) "A life insurance policy" means a contract under which the insurer agrees to pay a specified amount to a designated beneficiary upon the death of the insured. (11) "Owner" means the individual with the right to change such policy. It is normally the person who pays the premiums. (12) "Term life insurance" means an insurance policy that provides coverage for a specified period at a guaranteed rate. Usually does not have a CSV. Policy owners have the option of converting some term life policies into universal life or whole life insurance policies. (13) "Universal life insurance" means an insurance policy that provides insurance over a specified period with greater flexibility on premium payment and potential for higher internal rates of return and builds CSV for policy owners over time. (14) "Whole life insurance" means an insurance policy that applies part of the premium payments to build CSV for the policy owner. (C) A life insurance policy is a countable resource to the policy owner for medical assistance purposes if it generates a CSV. Its value as a resource is the amount of the CSV. (1) The total CSV of all life insurance policies for an individual is excluded if the total face value of the policies is equal to or less than one thousand five hundred dollars for any one individual. If the total face value of all life insurance policies for any one individual is more than one thousand five hundred dollars, then the total CSV of all the policies for that individual is counted toward the applicable resource limit. Policies in which a CSV has not yet accrued are still considered available when determining the total face value of the individual's life insurance policies. (2) Life insurance policies in which no CSV will ever accrue (e.g., term life insurance), are not considered in determining the face value of the insurance policies, and are excluded from all computations. In addition, burial insurance policies are not considered in computing face value. Burial insurance is insurance which by its terms can only be used to pay the burial expense of the insured and will not accrue any CSV. (3) When the face value of all countable life insurance policies on an ineligible individual exceeds one thousand five hundred dollars and deeming is required, the cash value of the policies is combined with the ineligible individual's other countable resources and appropriately deemed to the eligible individual. (D) The individual must submit all policies that the individual and spouse own. The following information must be recorded in the case record: (1) Name of insured; (2) Name of owner; (3) Type of insurance (whole life, universal life, or term life); (4) Date the policy was purchased; (5) Maturity date of policy, if specified; (6) Face value; (7) Cash surrender value, if applicable; (8) Amount of loans outstanding against the policy, if applicable; (9) For term insurance, amount of premium and frequency; (10) Contact information for the insurance company to include address and phone number; and (11) Policy number; (E) Factors to consider when determining whether a life insurance policy is a resource: (1) If the policy does not have a CSV due to the type of policy, further examination is not necessary. If the policy does have a CSV, the administrative agency must distinguish between the owner of the policy and the insured. (2) The owner of the policy is the only individual who can receive the proceeds under the cash surrender provisions of the policy. Therefore, it is not material that the individual (or spouse) is the insured individual if the individual is not also the owner of the policy. If this is the case, there is no resource available. (3) A life insurance policy is an available resource only when the policy is owned by the individual or person whose resources are deemed to the individual. If the consent of another person is needed to surrender a policy for its full CSV, the policy is available as a resource after the individual has obtained the consent. The individual must make a reasonable effort to obtain consent. If the consent cannot be obtained, the policy is not available. Any doubt about possible availability is resolved by contacting the insurance company. A determination would need to be made as to whether an improper transfer had occurred. (4) The exclusion of a total of one thousand five hundred dollars face value of countable insurance policies applies to each individual separately and does not mean an average of one thousand five hundred dollars per person. An individual and spouse are each allowed one thousand five hundred dollars but not any combination of values for a three thousand dollar total for both. (5) CSV of a policy is determined by contacting the insurance company whenever there is any question regarding the current value. (6) The insurance exclusion does not apply to a matured endowment policy since the owner may elect to receive the total face value at any time. If the individual leaves the matured policy on deposit with the insurance company, it is no longer classified as insurance but is considered an investment at interest (the same as money in a savings account). (F) Evaluating the insurance policy. (1) Face value. The face value on the insurance policy may be labeled the "face amount," "sum insured," "amount of insurance" or "amount of this policy." (a) The face value does not include additional benefits payable because of special conditions such as double indemnity riders, which apply in the event of accidental death. (b) If the face value cannot be determined, the insurance company or local agent must be contacted for clarification. For example, the insurance company must be contacted to clarify the value when there has been a lapse in the policy because of nonpayment of premiums which results in some other insurance option becoming effective. If the information is obtained by telephone, the name, title and telephone number of the person contacted, and the name and address of the insurance company and the details of the conversation are documented in the case record. (2) Cash surrender value. To compute the cash surrender value of a life insurance policy, it is necessary to know whether the premiums are up-to-date or in default (have not been paid) and to read the conditions in the policy affecting cash surrender. The anniversary date of a policy is the same day and month as the date of issuance. Verification of the cash surrender value must be obtained from the insurance company if the CSV, on its own, or in conjunction with other resources is close to the applicable resource limit. (3) Dividends. (a) Dividend additions. (i) The FV of dividend additions are not included when determining whether a life insurance policy is countable or excluded as a resource. (ii) If the life insurance policy is a countable resource, include the CSV of dividend additions when determining the resource value of the policy. (iii) If the life insurance policy is an excluded resource, the CSV of the dividend additions is not included when determining the individual's countable resources. (b) Dividend accumulations. (i) Dividend accumulations are not excluded under the life insurance provision, even if the life insurance policy that pays the dividend accumulation is excluded. (ii) Unless the dividend accumulations are excluded under another provision, dividend accumulations are countable as a resource, even if the life insurance policy is excluded because the policy's FV is one thousand five hundred dollars or less. (c) Dividends count as income if the total FV of all the life insurance policies on any one person does not exceed one thousand five hundred dollars. Dividends are excluded as income if the life insurance policy is countable as a resource. (4) An owner's failure to pay the premiums on the life insurance policy or failure to elect an option within a certain period of time after defaulting on the premiums generally causes an option to apply automatically. The CSV is usually applied by the company along with any dividends to buy extended life insurance. Under these circumstances, the face amount of the life insurance is uncertain and there is a possibility that a certain option or options have come into play. It is necessary for the insurance company to compute the actual CSV before a determination of eligibility can be made. The current face value and CSV must be obtained from the insurance company. (5) When an individual has borrowed on a life insurance policy, the amount of the CSV depends upon the outstanding loan. Under these circumstances, the administrative agency must contact the insurance company to determine the amount of the CSV. (G) Treatment of accelerated life insurance payments. (1) Most accelerated payment plans fall into three basic types, depending on the circumstances which cause or trigger the payments to be accelerated. These types are the following: (a) Long term care model, which allows the policyholders to access their death benefits should they require extended confinement in a care facility or, in some instances, health care services at home; (b) Dread disease or catastrophic illness model, which allows policyholders to access their death benefits if they contract or acquire one of a number of specified covered conditions; and (c) Terminal illness model, which allows policyholders to access their death benefits following a diagnosis of terminal illness where death is likely to occur within a specified number of months. (2) Some companies refer to these types of payments as "living needs" or "accelerated death" payments. (3) Depending on the type of accelerated payment plan, receipt of accelerated payments may reduce the policy's face value by the amount of the payments and may reduce the CSV in a manner proportionate to the reduction in face value. In some cases, a lien may be attached to the policy in the amount of the accelerated payments and a proportionate reduction in CSV results. (4) Accelerated payments are not "benefits" for purposes of exploring potential income. It is not required that a policyholder apply for accelerated payments as a condition of obtaining or retaining medical assistance eligibility. (5) Since accelerated payments can be used to meet food or shelter needs, the payments are income in the month received and a resource if retained into the following month and not otherwise excludable. (6) The receipt of an accelerated payment is not treated as a conversion of a resource for medicaid purposes. This is because, under an accelerated arrangement, an individual receives proceeds from the policy, not the policy's resource value, which is its CSV.
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Rule 5160:1-3-05.13 | Medicaid: treatment of the home.
(A) This rule describes the treatment of
an individual's home for purposes of determining eligibility for medical
assistance. (B) Definitions. (1) "Home," for the purpose of
this rule, means any property in which an individual has an ownership interest
and which serves as the individual's principal place of residence. Home
includes the structures and land appertaining to the home property.
Appertaining land must adjoin the land on which the home property is located
and must not be separated by intervening land property owned by
others. (2) "Principal place of
residence" means the dwelling considered to be the individual's
established or principal home and to which, when absent, the individual intends
to return. Principal place of residence can be real or personal property, fixed
or mobile, and located on land or water. (a) Only one dwelling may be established as the principal place
of residence. (b) The administrative agency must obtain a signed statement,
declaring the principal place of residence, when there is an indication the
individual resides in or has ownership of more than one place. (C) The home lived in, owned by, and
considered the principal place of residence by the individual, the couple, or
the parents with whom the eligible child is living is an excluded resource,
regardless of value. (1) For the value of the home to be
excluded: (a) The home must be the principal place of residence of the
individual, the individual's spouse, or a parent with whom the eligible
child is living; and (b) The deed to the home must be in the name of the individual,
the individual's spouse, or the name of the eligible child's parent;
or (c) The home must be deeded to a revocable trust so long as the
principal of the trust remains a resource of the individual or the
individual's spouse. (2) The home is no longer considered to
be the principal place of residence and shall be treated as a countable
resource when the individual does not intend to return to the
home. (3) A temporary absence
from the home does not affect the principal place of residence exclusion so
long as the individual provides a signed statement of intent to return to the
home and has not established permanent residence elsewhere. (4) When the individual leaves the home
with no intent of returning, the home remains an excluded resource for as long
as: (a) A spouse or dependent relative of the individual continues to
live in the home while the individual is receiving long-term care services, in
accordance with Chapter 5160:1-6 of the Administrative Code. (i) Dependency may be of
any kind (e.g., financial, medical, etc.). (ii) Relative
means: (a) Child, stepchild, or grandchild; (b) Parent, stepparent, or grandparent; (c) Aunt, uncle, niece, or nephew; (d) Brother, sister, stepbrother or stepsister, half brother or
half sister; (e) Cousin; or (f) In-law. (b) The sale of the home would cause undue hardship, due to loss
of housing for the co-owner of the property and the co-owner provides a signed
statement that the co-owner: (i) Uses the property as
the co-owner's principal place of residence; and (ii) Would have to move
when the property was sold; and (iii) Has no other
readily available housing. (c) The individual leaves the home due to domestic abuse and has
not established a new principal place of residence, or has not taken action to
render the home no longer excludable. (d) The property satisfies the provisions governing the treatment
of property essential for self-support described in rule 5160:1-3-05.19 of the
Administrative Code.
Last updated March 1, 2024 at 8:12 AM
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Rule 5160:1-3-05.14 | Medicaid: resource exclusions.
(A) This rule describes excluded
resources for the purpose of determining medical assistance eligibility for the
aged, blind, or disabled. (B) Resource exclusions. (1) Resources excluded by
federal laws other than the Social Security Act, in accordance with 20 C.F.R.
416.1236 (as in effect October 1, 2020), unless otherwise noted. This list
contains unspent income from exempt sources: (a) Agent orange settlement payments received on or after
January 1, 1989, under the Agent Orange Compensation Exclusion Act (Pub. L. No.
101-201). (b) Restitution payments under the Civil Liberties Act of
1988, to U.S. citizens of Japanese ancestry and permanent resident Japanese
non-citizens who were interned during World War II, or their survivors, in
accordance with 50 U.S.C. 4215 (as in effect October 1, 2020). (c) Restitution payments under the Aleutian and Pribilof
Island Restitution Act in accordance with 50 U.S.C. 4236 (as in effect October
1, 2020). (d) Payments to victims of Nazi persecution. (e) Payments received under the Radiation Exposure
Compensation Act of 1990 (Pub. L. No. 101-426). (f) Austrian social insurance payments, based in whole or
in part, on wage credits paid under paragraphs 500 to 506 of the Austrian
General Social Insurance Act (as in effect October 1, 2020). (g) Payments received from the Dutch government as a result
of the Netherlands' Benefit Act for victims of persecution from 1940-1945
(Dutch acronym, WUV) (Pub. L. No. 103-286). (h) Payments made to Native Americans as listed in section
IV of 20 C.F.R 416 subpart K appendix (as in effect October 1,
2020). (i) Payments from the Ricky Ray Hemophilia Relief Fund Act
of 1998 (Pub. L. No. 105-369) or payments made from any fund established
pursuant to a class settlement in the case of Susan Walker v. Bayer
corporation, 96-C-5024 (N.D. Ill). (j) The first two thousand dollars per calendar year
received as compensation for participation in clinical trials that meet the
criteria detailed in section 1612(b)(26) of the Social Security Act (as in
effect October 1, 2020). (k) Payments made for supporting services or reimbursement
of out-of-pocket expenses to volunteers participating in corporation for
national and community service (CNCS, formerly ACTION) programs in accordance
with 42 U.S.C. 1382a (as in effect October 1, 2020): (i) AmeriCorps VISTA
program; and (ii) Special and
demonstration volunteer program; and (iii) Retired senior
volunteer program (RSVP); and (iv) Foster grandparents
program; and (v) Senior companion
program. (l) Payments received under the Energy Employees
Occupational Illness Compensation Program Act of 2000 (Pub. L. No. 106-398).
Interest received on any unspent payment is a countable resource. (m) Student financial assistance received under the Higher
Education Act of 1965 (as in effect October 1, 2020) or bureau of Indian
affairs is excluded from income and resources, regardless of use: (i) Pell grants;
and (ii) Student services
incentives; and (iii) Academic
achievement incentive scholarships; and (iv) Federal supplemental
education opportunity grants; and (v) Federal educational
loans (Stafford loans, William D. Ford federal direct and direct PLUS loans,
etc.); and (vi) Upward bound;
and (vii) Gear up (gaining
early awareness and readiness for undergraduate programs); and (viii) State educational
assistance programs funded by the leveraging educational assistance program;
and (ix) Work-study
programs. (n) Home energy assistance payments or allowances in
accordance with 20 C.F.R. 416.1157 (as in effect October 1, 2020). (o) Contributions, matching funds, or interest in
individual development accounts (IDAs), either demonstration project or
TANF-funded, in accordance with 42 U.S.C. 604 (as in effect October 1,
2020). (p) Veterans affairs payments made to or on behalf
of: (i) Certain Vietnam
veterans' natural children, regardless of age or marital status, for any
disability resulting from spina bifida suffered by such children;
and (ii) Certain Korea
service veterans' natural children, regardless of age or marital status,
for any disability resulting from spina bifida suffered by such children;
and (iii) The natural
children, regardless of age or marital status, with certain birth defects born
to a woman who served in Vietnam. (q) Funds and interest held in an account under the Stephen
Beck, Jr., Achieving a Better Life Experience (ABLE) Act of 2014 (Pub. L. No.
113-295): (i) A contribution to an
ABLE account by another individual or by a third party is neither income nor a
resource to the ABLE account holder. If the individual who made the
contribution later requests medical assistance for long-term care services, the
contribution will be evaluated in accordance with rule 5160:1-6-06 of the
Administrative Code. (ii) A distribution from
an ABLE account may be used to pay for a qualified disability expense (QDE). A
QDE is any expense related to the blindness or disability of the individual and
made for the benefit of the individual. QDEs include but are not limited
to: (a) Education; and (b) Housing; and (c) Transportation; and (d) Employment training and support; and (e) Assistive technology; and (f) Health; and (g) Prevention and wellness; and (h) Financial management and administrative services;
and (i) Legal fees; and (j) Expenses for ABLE account oversight and monitoring;
and (k) Funeral and burial; and (l) Basic living expenses. (iii) A distribution from
an ABLE account with the intent of paying for a QDE, except for housing, is
excluded as income and will be excluded as a resource while: (a) The individual continues to maintain the ABLE account;
and (b) The distribution is unspent; and (c) The distribution is identifiable even if commingled
with non-excluded funds; and (d) The individual's intent to use the distribution
for a QDE, other than housing, has not changed. (i) If the intent has
changed and the individual spent the distribution for a non-QDE or for housing,
the distribution is counted as a resource for the month in which the
distribution was spent. (ii) If the intent has
changed and the individual has decided to use the distribution for a non-QDE or
for housing, but has not yet spent the distribution, the retained portion of
the distribution is a countable resource the first day of the month following
the month in which the intent changed. (iv) A distribution from
an ABLE account with the intent of paying for a non-QDE or for a housing
expense is: (a) Not countable income. (b) A countable resource if retained into the following
month. (2) Resources excluded by
the Social Security Act, in accordance with 20 C.F.R. 416.1210 (as in effect
October 1, 2020), unless otherwise noted: (a) Household goods and personal effects of a reasonable
value as described in rule 5160:1-3-05.10 of the Administrative
Code. (b) One automobile or other mode of transportation as
described in rule 5160:1-3-05.11 of the Administrative Code. (c) Life insurance policies as described in rule
5160:1-3-05.12 of the Administrative Code. (d) The home considered the principal place of residence as
described in rule 5160:1-3-05.13 of the Administrative Code. (e) Real or personal property considered essential to the
means of self-support as described in rule 5160:1-3-05.19 of the Administrative
Code. (f) Certain burial funds and contracts as described in rule
5160:1-3-05.6 of the Administrative Code. (g) Value of a burial space as described in rule
5160:1-3-05.7 of the Administrative Code. (h) Cash or in-kind replacement received from any source
for purposes of replacing or repairing an excluded resource which is lost,
damaged, or stolen. Any interest earned on such cash payments is not income.
The total amount of cash (including interest earned) or the value of the
in-kind replacement is excluded as a resource for a period of nine months from
the date of receipt. (i) If the exclusion time
expires and the individual has not used all of the cash, any remaining cash (as
well as interest earned on such cash) is a countable resource effective the
first day of the month following the month in which the time period
expires. (ii) The exclusion time
may be extended for good cause for a reasonable period not to exceed an
additional nine months (a total of eighteen months from the date the cash is
received). (iii) Good cause may be
found if circumstances beyond the individual's control: (a) Prevent repair or replacement of the lost, damaged, or
stolen property; or (b) Keep the individual from contracting for such repair or
replacement. (iv) Any cash and
interest retained become a resource the first day of the month following the
month in which the eighteen-month period ends. (v) Temporary housing
received by an individual whose home was destroyed or damaged is also excluded
for a period of nine months beginning with the month the temporary housing is
first provided. For purposes of this rule, temporary housing includes the value
of support and maintenance. When a home is damaged or destroyed and temporary
housing is furnished to an individual who owned the home, any form of in-kind
support and maintenance is not counted as income. (i) Funds held in a plan to achieve self-support (PASS)
account in accordance with section 1613(a)(4) of the Social Security Act (as in
effect October 1, 2020). (j) Federal tax refunds and advance tax payments with
respect to refundable credits received on or after January 1, 2010, are
excluded for twelve months beginning the month following the month of receipt
under the American Taxpayer Relief Act of 2012 (Pub. L. No.
112-240). (k) Funds or interest held in a dedicated account in a
financial institution for an individual under the age of eighteen, that is
maintained by a representative payee, from past-due supplemental security
income (SSI) benefits that exceed six times the monthly SSI payment which are
allowed to be deposited into such an account, and the use of which is
restricted by section 1631(a)(2)(F) of the Social Security Act (as in effect
October 1, 2020), are excluded as income and resources as defined in rule
5160:1-3-05.4 of the Administrative Code. (l) Payments received from a fund established by a state to
aid victims of crime are excluded for nine months beginning the month following
the month of receipt in accordance with section 1613(a)(9) of the Social
Security Act (as in effect October 1, 2020). Interest earned on any unspent
payment is a countable resource. (m) Relocation assistance in accordance with section
1613(a)(10) of the Social Security Act (as in effect October 1,
2020). (i) Payments under Title
II of the Uniform Relocation Assistance and Real Property Acquisitions Policies
Act of 1970 (Pub. L. No. 91-646) provided to individuals displaced by projects
in the acquisition of real property are excluded with no time
limits. (ii) Relocation
assistance payments from a state or local government are excluded for nine
months. (iii) Interest earned on
unspent relocation assistance is a countable resource. (n) Grants, scholarships, fellowships, and gifts used or
intended to be used to pay the cost of tuition, fees, or other necessary
educational expenses, in accordance with section 1613(A)(15) of the Social
Security Act (as in effect October 1, 2020) are excluded for nine
months. (o) Filipino veteran equity compensation fund payments in
accordance with section 1002 of the American Recovery and Reinvestment Act of
2009 (Pub. L. No. 111-5). Interest earned on the payment is a countable
resource. (p) Value of food or assistance provided under federal food
and nutrition programs. (q) Unspent portion of retroactive SSI and retirement,
survivors, and disability insurance (RSDI) payments are excluded for nine
months following the month of receipt in accordance with section 1613(a)(7) of
the Social Security Act (as in effect October 1, 2020). (r) Payments provided for flood mitigation activities under
section 1324 of the National Flood Insurance Act of 1968 (Pub. L. No.
109-64). (s) Payments received under the Robert T. Stafford Disaster
Relief and Emergency Assistance Act (Pub. L. No. 100-707) and assistance
provided under any federal statute because of a presidentially-declared
disaster in accordance with section 1613(a)(6) of the Social Security Act (as
in effect October 1, 2020). (t) The value of federal housing assistance in accordance
with section 1613(a)(8) of the Social Security Act (as in effect October 1,
2020) provided by: (i) The office of housing
and urban development (HUD); or (ii) The U.S. department
of agriculture's rural housing service (RHS), formally known as the
farmers home administration (FHA). (u) Gifts to children with life-threatening conditions in
accordance with section 1613(a)(13) of the Social Security Act (as in effect
October 1, 2020) from an organization described in section 501(c)(3) of the
Internal Revenue Code of 1986, within the following limitations: (i) In-kind gifts not
converted to cash. (ii) The first two
thousand dollars of any cash gifts within a calendar year. (iii) Interest or
dividends earned on any gift is a countable resource. (v) Restitution payments for misused benefits for
beneficiaries of RSDI, special benefits for certain world war II veterans, and
SSI are excluded for nine months following the month of receipt in accordance
with section 1613(a)(14) of the Social Security Act (as in effect October 1,
2020). Payments are made to the beneficiary or the beneficiary's
representative payee in the amount equal to the benefits misused in the
following situations: (i) The misuse resulted
from the negligent failure of the social security administration (SSA) to
investigate or monitor a representative payee; or (ii) An organization or
individual payee misused the benefits, without regard to whether SSA was
negligent. (w) A state annuity paid by a state, to an individual
and/or the individual's spouse, on the basis of the state's
determination that the individual is a veteran and is blind, disabled, or aged
in accordance with section 1613(a)(16) of the Social Security Act (as in effect
October 1, 2020). (C) Payments or benefits listed in this rule that have been
commingled with countable resources need to be identifiable in order to be
excluded as a resource. (D) Administrative agency responsibilities. (1) Evaluate interest
received on excluded resources in accordance with rule 5160:1-3-05.9 of the
Administrative Code. (2) Consider any resource
purchased with funds listed in this rule as not automatically excluded and
subject to medicaid resource requirements.
Last updated July 1, 2021 at 9:51 AM
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Rule 5160:1-3-05.16 | Medicaid: home replacement exclusion.
Effective:
December 14, 2020
(A) This rule describes the application
of the home replacement exclusion for purposes of determining eligibility for
medical assistance. When the home is being replaced due to loss or damage
resulting from a disaster, refer to rule 5160:1-3-05.14 of the Administrative
Code. (B) Definitions. (1) "Proceeds"
mean the net payments received by the seller after satisfaction of all
encumbrances and sale expenses. (2) "Sale
expenses" mean all expenses that must be paid by the seller in connection
with the sale of the home, including but not limited to broker fees,
commissions, legal fees, mortgage-related fees such as points paid by the
seller, inspection and settlement fees, and transfer and other accrued taxes
paid by the seller. (C) The home replacement exclusion allows an individual to
sell an excluded home that was the individual's principal place of
residence without having the proceeds of the sale count as a resource if used
for the purchase of, and costs incidental to occupying, another excluded
home. (1) This exclusion from
resources applies to the proceeds of the sale of the excluded home when they
are used or obligated to purchase and occupy another excluded home by the last
day of the third full month following the month of receipt. (2) When the home is not
replaced within this period, the proceeds are to be counted as a resource
beginning with the month following the month they were received by the
individual. (3) The exclusion does
not apply to interest earned on the proceeds of the sale. (4) The administrative
agency shall not implement the exclusion until the statement described in
paragraph (E) of this rule is obtained. (D) The home replacement period begins on the date the
proceeds of the sale are received by the individual. The home replacement
period ends on the last day of the third full month following the month the
proceeds are received. (E) When the individual states that the
home is being replaced, the administrative agency shall obtain a signed
statement from the individual containing the following required
information: (1) Date and amount of
proceeds received from the sale of the home; and (2) The individual's
intent to replace the home with another home by a specific date that is on or
before the last day of the third full month following the month of receipt of
the proceeds; and (3) An acknowledgement
that any proceeds of the sale not used for another excluded home by the date
identified in paragraph (E)(2) of this rule are to count in determining
eligibility for medical assistance beginning on a specific date that is the
first day of the first month following receipt of the proceeds. (4) The administrative
agency will contact the individual to collect the information needed. If the
individual declares the verifications cannot be accessed or submitted, the
individual's statement is to be accepted. (5) If the administrative
agency is unable to make contact with the individual, a written (electronic or
paper) request for the necessary information or verification documents is to be
sent as set forth in rule 5160:1-2-01 of the Administrative Code. (F) The administrative agency shall
verify the amount of the proceeds and the date they were received by obtaining
a copy of the settlement sheet or other documents prepared at settlement and
received by the individual from the sale. (G) By the last day of the month in which
the home replacement period expires, the administrative agency shall contact
the individual to verify the date and amount of any allowable costs or
deductions for the replacement home by obtaining written evidence (e.g.,
contracts, bills, receipts, settlement sheets) regarding the substitute
home. (1) The administrative
agency shall charge any retained proceeds not used or contracted to be used
toward the replacement home before expiration of the replacement period as a
resource beginning with the month following the month of receipt. (2) When the individual
has not replaced the home as intended, all of the proceeds will count as a
resource beginning with the month following the month of receipt.
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Rule 5160:1-3-05.17 | Medicaid: life estates.
Effective:
February 1, 2024
(A) This rule describes the treatment of life estates for the purposes of determining eligibility for medical assistance. (B) Definitions. (1) "Date of signature" is the date on which an individual with authority to transfer the physical property actually signed the life estate instrument. (2) "Individual," for the purpose of this rule, has the same meaning as in rule 5160:1-1-01 of the Administrative Code. (3) "Life estate" means an ownership interest in physical property wherein one person holds the right to possess, use, and obtain profits from the physical property for the extent of the person's lifetime, while another person holds the actual ownership interest in the physical property. (a) A life estate is a form of legal ownership. (b) A life estate is usually created through an instrument, such as a deed, a will, or by operation of law. (c) A life estate instrument often identifies remaindermen who will take possession of the physical property upon the expiration of the life estate. (d) A life estate owner, also known as a life tenant, owns a life estate property only for the duration of time specified in the life estate instrument. Only the individual who owns the life estate can sell interest in the life estate. The life estate owner cannot take any action concerning the interest of the remainderman. (4) "Recording date" means the date that the life estate deed is recorded with the county auditor, county recorder, or other appropriate government agency charged with the responsibility for recording real estate transfers and titles. (5) A "remainderman" is a person who inherits or is entitled to inherit physical property in a life estate. A remainderman has an ownership interest in the physical property but normally does not have the right to possess and use the property until the expiration of the life estate. (C) Unless specifically prohibited by the instrument establishing the life estate or remainder interest: (1) The life estate owner has the right to possess, use, and obtain profits from the physical property and to sell his or her life estate interest. (2) The remainderman has the right to sell his or her interest in the physical property even before the life estate interest expires, but the life estate owner still retains rights to use the physical property until the expiration of the life estate. (D) Categories of life estates. (1) Life estates established with the individual's property. (a) A life estate held by an individual falls within this category when the life estate is established with property in which the individual held an ownership interest. (b) When the individual has the right to transfer or sell the life estate, the life estate's fair market value is considered a countable resource unless it qualifies as an excluded resource as described in rule 5160:1-3-05.14 of the Administrative Code. (2) Life estates not established by the individual. (a) A life estate held by an individual falls within this category when the life estate is established with physical property that the individual did not hold an ownership interest in at the time of the establishment of the life estate. (b) When the individual has the right to transfer or sell the life estate, the life estate's fair market value is considered a countable resource unless it qualifies as an excluded resource as described in rule 5160:1-3-05.14 of the Administrative Code. (E) When the life estate is the individual's principal place of residence, as described in rule 5160:1-3-05.13 of the Administrative Code, the fair market value of the life estate is excluded as a resource. (F) Effective date of the creation of a life estate. (1) For life estates that are recorded within six months after the date of signature, the date of signature is the date of transfer. (2) When a life estate is recorded more than six months after the date of signature, the individual must produce documentation from other sources verifying that the transfer occurred on the date of signature rather than the date of recording. (a) Such documentation may consist of financial records from lending institutions, tax records from governmental agencies, or records from other agencies or private or public institutions. (b) The individual may provide statements of persons holding a remainder interest, or other persons who participated in the creation of the life estate. (G) Calculating the fair market value of a life estate. (1) The administrative agency must first determine the fair market value of the physical property as established by the county auditor. When a valuation by a county auditor is unavailable, the value shall be based upon a valuation by the appropriate governmental agency charged with the responsibility for valuation of real property. (2) The administrative agency must deduct from the fair market value of the physical property all liens and encumbrances that have been placed against the property. (3) The administrative agency must deduct from the fair market value of the physical property all liens and encumbrances that have been placed against the life estate. (4) After deductions, the balance is the equity value of the physical property. (5) The administrative agency must multiply the equity value of the physical property by the product that corresponds to the life estate owner's age at the time of determination for medical assistance on the following life estate table: | AGE | LIFE ESTATE | REMAINDER | | 0 | .97188 | .02812 | | 1 | .98988 | .01012 | | 2 | .99017 | .00983 | | 3 | .99008 | .00992 | | 4 | .98981 | .01019 | | 5 | .98938 | .01062 | | 6 | .98884 | .01116 | | 7 | .98822 | .01178 | | 8 | .98748 | .01252 | | 9 | .98663 | .01337 | | 10 | .98565 | .01435 | | 11 | .98453 | .01547 | | 12 | .98329 | .01671 | | 13 | .98198 | .01802 | | 14 | .98066 | .01934 | | 15 | .97937 | .02063 | | 16 | .97815 | .02185 | | 17 | .97700 | .02300 | | 18 | .97590 | .02410 | | 19 | .97480 | .02520 | | 20 | .97365 | .02635 | | 21 | .97245 | .02755 | | 22 | .97120 | .02880 | | 23 | .96986 | .03014 | | 24 | .96841 | .03159 | | 25 | .96678 | .03322 | | 26 | .96495 | .03505 | | 27 | .96290 | .03710 | | 28 | .96062 | .03938 | | 29 | .95813 | .04187 | | 30 | .95543 | .04457 | | 31 | .95254 | .04746 | | 32 | .94942 | .05058 | | 33 | .94608 | .05392 | | 34 | .94250 | .05750 | | 35 | .93868 | .06132 | | 36 | .93460 | .06540 | | 37 | .93026 | .06974 | | 38 | .92567 | .07433 | | 39 | .92083 | .07917 | | 40 | .91571 | .08429 | | 41 | .91030 | .08970 | | 42 | .90457 | .09543 | | 43 | .89855 | .10145 | | 44 | .89221 | .10779 | | 45 | .88558 | .11442 | | 46 | .87863 | .12137 | | 47 | .87137 | .12863 | | 48 | .86374 | .13626 | | 49 | .85578 | .14422 | | 50 | .84743 | .15257 | | 51 | .83674 | .16126 | | 52 | .82969 | .17031 | | 53 | .82028 | .17972 | | 54 | .81054 | .18946 | | 55 | .80046 | .19954 | | 56 | .79006 | .20994 | | 57 | .77931 | .22069 | | 58 | .76822 | .23178 | | 59 | .75675 | .24325 | | 60 | .74491 | .25509 | | 61 | .73267 | .26733 | | 62 | .72002 | .27998 | | 63 | .70696 | .29304 | | 64 | .69352 | .30648 | | 65 | .67970 | .32030 | | 66 | .66551 | .33449 | | 67 | .65098 | .34902 | | 68 | .63610 | .36390 | | 69 | .62086 | .37914 | | 70 | .60522 | .39478 | | 71 | .58914 | .41086 | | 72 | .57261 | .42739 | | 73 | .55571 | .44429 | | 74 | .53862 | .46138 | | 75 | .52149 | .47851 | | 76 | .50441 | .49559 | | 77 | .48742 | .51258 | | 78 | .47049 | .52951 | | 79 | .45357 | .54643 | | 80 | .43659 | .56341 | | 81 | .41967 | .58033 | | 82 | .40295 | .59705 | | 83 | .38642 | .61358 | | 84 | .36998 | .63002 | | 85 | .35359 | .64641 | | 86 | .33764 | .66236 | | 87 | .32262 | .67738 | | 88 | .30859 | .69141 | | 89 | .29526 | .70474 | | 90 | .28221 | .71779 | | 91 | .26955 | .73045 | | 92 | .25771 | .74229 | | 93 | .24692 | .75308 | | 94 | .23728 | .76272 | | 95 | .22887 | .77113 | | 96 | .22181 | .77819 | | 97 | .21550 | .78450 | | 98 | .21000 | .79000 | | 99 | .20486 | .79514 | | 100 | .19975 | .80025 | | 101 | .19532 | .80468 | | 102 | .19054 | .80946 | | 103 | .18437 | .81563 | | 104 | .17856 | .82144 | | 105 | .16962 | .83038 | | 106 | .15488 | .84512 | | 107 | .13409 | .86591 | | 108 | .10068 | .89932 | | 109 | .04545 | .95455 |
(H) When the individual disagrees with the county auditor's determination of the fair market value of the physical property as described in paragraph (G)(1) of this rule, the individual may have a licensed real estate broker perform an appraisal of the property's value, which may be substituted as the fair market value of the physical property in paragraph (G)(1) of this rule. Such appraisal services may be provided through the use of administrative funds when the individual is unable to obtain an appraisal due to insufficient personal funds. (I) Administrative agency responsibilities. The administrative agency shall: (1) Determine the effective date of the creation of a life estate. (2) Accept the statements of persons holding a remainder interest, or other persons who participated in the creation of the life estate, only upon a finding that their statements are corroborated and credible. (3) Use the date of recording as the effective date of the creation of the life estate when the individual fails to produce documentation verifying that the transfer occurred on the date of signature. (4) When the life estate has not been recorded, the administrative agency shall request that the individual verify transfer by recording the life estate and, unless the life estate was created within the prior six months, provide documentation as required in paragraph (F)(2) of this rule. When the individual does not provide documentation that the life estate has been recorded, disregard the life estate and consider the entire property as an available resource to the individual.
Last updated February 1, 2024 at 8:20 AM
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Rule 5160:1-3-05.18 | Medicaid: stocks, mutual funds, and bonds.
Effective:
September 12, 2016
(A) This rule describes the treatment of
stocks, mutual funds, and bonds for purposes of determining eligibility for
medical assistance. (B) Stocks held by an individual,
including preferred stocks, warrants and rights, and stock option
purchases. (1) Stock shares
represent ownership in a business corporation. Their value shifts with demand
and may fluctuate widely. (2) The current market
value of publicly traded stock as of the first moment of a given month is its
closing price on the last business day of the preceding month. The stock
closing price, on a given day, can usually be found in the next day's
regulator or financial newspaper. The value of over-the-counter stocks are
shown on a "bid" and "asked" basis. The bid price is used
to determine the stock's value. (a) If the closing or bid price of a stock is not shown, a
local securities firm must determine its value. (b) The stock of some corporations not publicly traded is
held within close groups and traded very infrequently. The sale of such stock
is often handled privately and subject to restrictions. The burden of proof for
establishing the value of this kind of stock is on the individual. The
preferred evidence is a letter or other written statement from the firm's
accountants giving their best estimate of the stock's value and the basis
for the estimate, and can include the most recent sale, the most recent offer
from outsiders, the current market value of assets less debts on them,
cessation of activity and sale of assets, and bankruptcy. (3) The county prosecutor
or the administrative agency's legal staff shall be consulted for
assistance in determining the value of the stock when the verification of the
current value of the stock of a closely held corporation is questionable,
including when there are indications that the extent of an individual's
ownership is being manipulated to reduce the value of the stock as a countable
resource. (4) If the ownership of
the stock is shared (i.e., more than one name is on the face of the stock
certificate), each owner owns an equal share of the value of the
stock. (5) Shares of stock in an
Alaskan native regional or village corporation, as defined in 43 U.S.C. 1601 -
1624 (as in effect on February 1, 2016), are excluded from
resources. (C) A mutual fund is determined in the
same manner as the value of a stock. (D) The current market value of a
municipal, corporate, or government bond is counted as a resource. If the
ownership of a bond is shared, each owner owns an equal share of the current
market value of the bond. (E) The current redemption value of a
U.S. savings bond is a countable resource. If the ownership of the U.S. savings
bond is shared, each owner owns equal shares of the redemption value of the
bond.
Last updated February 21, 2024 at 4:44 PM
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Rule 5160:1-3-05.19 | Medicaid: real or personal property essential to self-support.
(A) This rule describes exclusions when
real or personal property is essential to an individual's means of
self-support. (B) Definition. (1) "Basic daily
living needs", for the purpose of this rule, means any food, basic
clothing, basic shelter, and any medical care that are not provided by
medicaid. Items for entertainment or leisure are not basic daily living
needs. (2) "Maximum
allowable equity" means an individual's equity in income-producing
property, up to a maximum of six thousand dollars. (C) Categories of property essential to
self-support. (1) Property used in a
trade or business, government permits that represent authority granted by a
government agency to engage in an income-producing activity, or property used
by an individual as an employee for work. (a) Is excluded as a resource regardless of value or rate of
return. (b) Government permits includes any permit, license, or similiar
instrument issued by a federal, state, or local government agency. (c) Personal property used by an employee for work includes farm
machinery, tools, safety equipment, uniforms, etc. (2) Nonbusiness real or
personal property used to produce goods or services essential to basic daily
living needs. (a) Up to six thousand dollars of the equity value is excluded,
regardless of rate of return. (b) Any portion of the property's equity value in excess of
six thousand dollars is a countable resource. (c) Nonbusiness property used to produce goods or services
includes growing produce or livestock solely for personal consumption in the
individual's household or performing activities essential to the
production of food solely for home consumption. (3) Nonbusiness
income-producing property. (a) Up to six thousand dollars of the equity value is excluded as
a resource if the property produces a net annual return equal to at least six
per cent of the excluded equity. (b) Any portion of the property's equity value in excess of
six thousand dollars is a countable resource. (c) If the property produces less than a six per cent return, the
exclusion can only apply if the lower return is for reasons beyond the
individual's control and there is a reasonable expectation that the
property will again produce a six per cent return. Otherwise, none of the
equity value is excluded under this section. (d) If the earnings decline was for reasons beyond the
individual's control, up to twenty-four months are to be allowed for the
property to resume producing a six per cent return. The twenty-four month
period begins with the first day of the tax year following the tax year in
which the return dropped to below six per cent. (e) If the tax return shows that the property has operated at a
loss for the two most recent years or longer, the property cannot be excluded
unless the individual submits current receipts and records to show that the
property currently is producing a six per cent return. (f) If an individual owns more than one piece of income-producing
property, the six per cent return requirement applies individually to each
property and the six thousand dollar equity value limit applies to the total
equity value of all the properties meeting the six per cent return
requirement. (g) If all properties meet the six per cent return requirement
but the total equity value exceeds six thousand dollars, that portion of the
total equity value in excess of six thousand dollars is a countable
resource. (D) For any of the exclusions to apply,
the property is to be in current use in the type of activity that qualifies it
as essential. (E) Property not in current use. If the property is not in
current use, it must be for reasons beyond the individual's control and
there must be a reasonable expectation that the use will resume within twelve
months of last use. (1) Property not in
current use is to be excluded for twelve months as essential for self-support
if the property has been in use and there is reasonable expectation that the
use will resume. The individual is to provide a signed statement of last date
of use, reason the property is not in use, and when the individual expects to
resume the self-support activity. (2) If an individual alleges that
self-support property is not in current use because of a disabling condition of
the individual, the individual is to provide a signed statement of the nature
of the condition, the date the individual ceased the self-support activity, and
when the individual intends to resume activity to receive up to an additional
twelve months. (3) If the individual does not intend to
resume the self-support activity, the property is a countable resource in the
month after the month of last use. (4) If, after property has been excluded
because an individual intends to resume self-support activity, the individual
decides not to resume such activity, the exclusion ceases to apply as of the
date of the change of intent. The property is a resource in the following
month. (F) Individual responsibilities. The
individual is to: (1) Provide a copy of the
tax return for the tax year prior to application or renewal if the property is
used in a trade or business in order for the administrative agency to determine
the net income earned by the individual. (2) Provide pertinent
documents and a signed statement if the individual alleges owning a government
license, permit, or other property that represents government authority to
engage in an income-producing activity, and has value as a resource. The
statement is to include: (a) The type of license, permit, or other property;
and (b) The name of the issuing agency, if appropriate;
and (c) Whether the law requires such license, permit, or property
for engaging in the income-producing activity at issue; and (d) How the license, permit, or other property is being used;
or (e) Why the license, permit, or other property is not being
used. (3) Provide a signed statement if the
individual alleges owning items used in his or her work as an employee. The
statement is to include: (a) The name, address, and telephone number of the employer;
and (b) A general description of the items; and (c) A general description of the individual's duties;
and (d) Whether the items are currently being used. (4) Provide a signed
statement if the individual alleges owning property used to produce goods or
services essential to basic daily living needs. The statement is to
include: (a) A description of the property; and (b) How the property is used; and (c) An estimate of the property's fair market value
and any encumbrances on the property. (G) Administrative agency
responsibilities. The administrative agency is to: (1) Determine whether the
property qualifies under one of the three categories identified in paragraph
(C) of this rule if the individual asserts his or her property is essential for
self-support. (2) Determine whether to
exclude equity in property that provides either a product or a service that
supplies basic daily living needs for the individual as described in paragraph
(C)(2) of this rule. (a) If the property does provide basic daily living needs
for the individual, then the individual's equity up to a maximum of six
thousand dollars is not to be counted as a resource. Any equity in excess of
six thousand dollars is to be counted as a resource. (b) If the property does not provide basic daily living
needs for the individual, then the entire equity is a countable
resource. (3) Determine whether to exclude equity
in nonbusiness income-producing property described in paragraph (C)(3) of this
rule as follows: (a) Determine the individual's maximum allowable equity in
the property. (b) Multiply the individual's maximum allowable equity by
six per cent. (c) Establish the net annual income the property produces for the
individual. (i) If the income to the
individual is equal to or greater than the six per cent calculated in paragraph
(G)(3)(b) of this rule, then the maximum allowable equity is not counted as a
resource. (ii) If the income to the
individual is less than the six per cent calculated in paragraph (G)(3)(b) of
this rule, then the individual's entire equity is counted as an available
resource. (d) If there is more than one potentially excluded property, the
six per cent return requirement applies individually to each property and the
six thousand dollars equity value limit applies to the total equity value of
all the properties meeting the six per cent return requirement. (4) Apply only the
provision that is most beneficial to the individual if the individual's
property falls under more than one of the categories in paragraph (C) of this
rule. (5) Request any other
documentation necessary to fully and adequately distinguish between the income
from the income-producing property, and income from other sources. (6) Consider the
individual's entire equity as a countable resource if the individual fails
to cooperate with providing the appropriate documentation.
Last updated June 1, 2021 at 10:12 AM
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Rule 5160:1-3-05.20 | Medicaid: deeming of resources.
(A) This rule describes the deeming of
resources from an ineligible spouse to an eligible spouse or from parent(s) to
an eligible child who are living in the same household when determining
eligibility for medical assistance. (B) Definitions. (1) "Child,"
for deeming purposes, means an individual under age eighteen who lives in the
household with one or both parents and is neither married nor head of
household. The deeming of parental resources applies through the month in which
the eligible child becomes eighteen years old. An eligible or ineligible
child's resources are never deemed to parent(s) or
sibling(s). (2) "Deemed
resources" means resources attributed to another person whether or not the
resource is actually available to the person to whom they are
deemed. (3) "Eligible
child" means a child in the household who has applied for medical
assistance for the blind or disabled, and who meets all the applicable
non-financial and income eligibility criteria for medical
assistance. (4) "Eligible
spouse" means the member of a married couple who has applied for medical
assistance for the aged, blind, or disabled, and who meets all the applicable
non-financial and income eligibility criteria for medical
assistance. (5) "Household"
means the eligible spouse, ineligible spouse, and any of the couple's
children or the children of either member of the couple; or the eligible child,
and the eligible child's parent(s), and other children of the
parent(s). (a) A household does not exist if an individual or a group
of individuals does not have a residence. In such a case, only the eligible
individual's resources are used to determine eligibility for medical
assistance. (b) If a child is born in an institution (e.g., hospital),
the child is a member of the household at the time of birth unless the parents
have completed the required paperwork to surrender the child for adoption or
the child has been placed in the temporary custody of a public children's
services agency (PCSA) or private child placing agency (PCPA). (c) An eligible individual or an ineligible spouse or
ineligible parent who is temporarily absent, as defined in rule 5160:1-1-01 of
the Administrative Code, is still considered to be a member of the household
for deeming purposes. (6) "Ineligible
child" means a child in the household who has not applied for medical
assistance for the blind or disabled. (7) "Ineligible
parent" means an eligible child's parent who has not applied for
medical assistance for the aged, blind, or disabled. (8) "Ineligible
spouse" means an eligible spouse's husband or wife who has not
applied for medical assistance for the aged, blind, or disabled. (9) "Parent" means a natural or
adoptive father or mother living in the same household as the eligible child.
The resources of a step-parent who lives with the eligible child are deemed to
the eligible child only when the natural or adoptive parent also lives in the
household with the step-parent and eligible child. If the natural or adoptive
parent divorces a step-parent and the eligible child is living with the
step-parent, the step-parent is not a parent for deeming purposes. (10) "Sponsor"
means an individual who signs an affidavit of support agreeing to support a
non-citizen as a condition of the non-citizen's admission for permanent
residence in the U.S. A sponsored non-citizen may have more than one sponsor.
For deeming purposes, a sponsor does not include an organization such as the
congregation of a church or a service club, or an employer that only guarantees
employment for a non-citizen upon entry but does not sign an affidavit of
support. (11) "Sponsored
non-citizen", for the purpose of this rule, means an individual lawfully
admitted for permanent residence in the U.S. who is supported by a sponsor(s).
Such an individual has applied for medical assistance for the aged, blind, or
disabled, and meets all the applicable non-financial eligibility criteria for
medical assistance. (12) "Spouse" means a person who
is legally married to another under Ohio law. (C) In deeming resources from an
ineligible spouse to an eligible spouse, only the resources of those two
individuals are considered. In deeming resources from a parent(s) to an
eligible child, only the resources of the parent(s) are
considered. (D) Retirement funds, described in rule
5160:1-3-03.10 of the Administrative Code, owned by an ineligble spouse,
parent(s), or sponsor are excluded from resources for deeming
purposes. (E) Spouse to spouse
deeming. (1) When an eligible
spouse and his or her ineligible spouse live together, all resources are
combined and the couple is permitted resources in the amount described in rule
5160:1-3-05.1 of the Administrative Code in addition to what is excluded as
described in rule 5160:1-3-05.14 of the Administrative Code. (2) The couple's
resource limitation is not affected by whether the spouse of the eligible
individual is eligible or ineligible for medical assistance. (3) If the couple's
countable resources are less than or equal to the resource limit for a couple
described in rule 5160:1-3-05.1 of the Administrative Code, the eligible spouse
is resource eligible for medical assistance. (4) When spouses are no
longer living together, each person is considered as an individual living alone
beginning the month after separation. The individual resource limit, as
described in rule 5160:1-3-05.1 of the Administrative Code, is then
applicable. (a) For the month of separation, the spouses are treated as
an eligible couple or as an eligible spouse and ineligible spouse living
together in the same household with a resource limit for a couple described in
rule 5160:1-3-05.1 of the Administrative Code. (b) In the month after the month of separation, resources
are computed separately because each person is considered to be an individual
without a spouse. (F) Parent to child deeming. (1) The resource limit for a child is
described in rule 5160:1-3-05.1 of the Administrative Code in addition to what
is excluded as described in rule 5160:1-3-05.14 of the Administrative
Code. (2) The resources of an eligible child
consist of whatever resources the eligible child has in his or her own right
plus whatever resources are deemed to the eligible child from his or her
parent(s). (3) In determining the amount of
resources to be deemed to an eligible child, the resources of the eligible
child and of the parent(s) are computed separately and both the eligible child
and the parent(s) are each allowed all of the resource exclusions they would
normally be eligible for in their own right. Only one home and one automobile
are excluded. (a) After the exclusions are applied, only the countable
resources over the resource limit of the parent(s) living in the household are
deemed to the eligible child when there is only one eligible
child. (i) If there is one
parent in the household the parental resource limit is two thousand
dollars. (ii) If both parents are
in the household the parental resource limit is three thousand
dollars. (iii) If both natural or
adoptive parents and a step-parent are in the household the parental resource
limit is two thousand dollars for one natural or adoptive parent plus three
thousand dollars for the other natural or adoptive parent with the
step-parent. (b) When there is more than one eligible child, the
resources available for deeming are shared equally among the eligible
child(ren). (c) None of the parents' resources are deemed to any
ineligible children. (4) An eligible child is not eligible for
medical assistance if his or her own countable resources plus the value of the
parent(s)'s resources deemed to the eligible child exceed the resource
limit for a child described in rule 5160:1-3-05.1 of the Administrative
Code. (G) Sponsor to non-citizen
deeming. (1) Sponsor to
non-citizen deeming is to apply: (a) Regardless of whether the sponsor and the sponsored
non-citizen live in the same household or whether the sponsor actually provides
the sponsored non-citizen any support; and (b) For a period of three years following a sponsored
non-citizen's lawful admission to the U.S. as a permanent resident or the
sponsored non-citizen's status is adjusted to permanent
resident. (2) If a sponsored
non-citizen is sponsored by his or her ineligible spouse or ineligible
parent(s), apply spouse to spouse and parent to child deeming
calculations. (3) If a sponsored
non-citizen has a sponsor and also has an ineligible spouse or ineligible
parent(s) who is not his or her sponsor, apply both sponsor to non-citizen and
spouse to spouse or parent to child deeming calculations. (4) In determining the
amount of resources to be deemed to a sponsored non-citizen, combine the
resources of the sponsor (and sponsor's spouse, if applicable) and apply
any appropriate exclusions described in rule 5160:1-3-05.14 of the
Administrative Code. (a) After the exclusions are applied, only the countable
resources over the resource limit of the sponsor are deemed to the sponsored
non-citizen. (i) If the sponsor does
not live with a spouse, the resource limit is two thousand
dollars. (ii) If the sponser lives
with a spouse and the spouse is not the non-citizen's sponsor, the
resource limit is three thousand dollars. (iii) If the sponser
lives with a spouse and the spouse is also a sponsor of the non-citizen, the
resource limit is four thousand dollars. (b) A sponsored non-citizen is not eligible for medical
assistance if his or her countable resources plus the value of the
sponsor's resources deemed to the sponsored non-citizen exceed the
resource limit for an individual described in rule 5160:1-3-05.1 of the
Administrative Code.
Last updated June 1, 2021 at 10:13 AM
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