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This website publishes administrative rules on their effective dates, as designated by the adopting state agencies, colleges, and universities.

Chapter 5160:1-3 | Medicaid for the Aged Blind and Disabled

 
 
 
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 as set forth in section 1902 of the Social Security Act (as in effect on February 1, 2016). 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 disability 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 of the Administrative Code set forth income eligibility requirements.

(3) Rules under principal rule 5160:1-3-05 of the Administrative Code set forth resource eligibility requirements.

Supplemental Information

Authorized By: 5160.02, 5163.02
Amplifies: 5160.02, 5163.02
Five Year Review Date: 8/1/2021
Rule 5160:1-3-02 | Medicaid: criteria for age, blindness, or disability.
 

(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.

Supplemental Information

Authorized By: 5160.02, 5163.02
Amplifies: 5160.02, 5163.02
Five Year Review Date: 9/1/2022
Prior Effective Dates: 8/1/1985, 8/3/1987, 3/28/1988, 12/1/1991, 12/2/1991, 12/20/1991, 1/1/1992 (Emer.), 12/22/1992 (Emer.), 2/11/1993, 3/20/1993, 10/1/2002, 8/1/2016
Rule 5160:1-3-02.1 | Medicare premium assistance programs (MPAP).
 

(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 individuals (QI-1), and qualified disabled and working individuals (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) If 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, 2019), 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 individuals program established by section 1905(s) of the Social Security Act (as in effect October 1, 2019). 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, 2019).

(11) "QMB" means the qualified medicare beneficiary group described in section 1905(p)(1) of the Social Security Act (as in effect October 1, 2019).

(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, 2019).

(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, 2019). 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, 2019) 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) If 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 (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, if 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 the individual was eligible for benefits under QI-1 or QDWI 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.

Supplemental Information

Authorized By: 5162.03, 5163.02
Amplifies: 5162.03, 5163.02 , 5163.45
Five Year Review Date: 12/14/2025
Prior Effective Dates: 4/1/1989, 1/1/1990 (Emer.), 4/1/1990, 1/1/1992 (Emer.), 3/18/1993, 3/1/1994 (Emer.), 11/1/1998, 1/1/2010, 7/8/2020 (Emer.)
Rule 5160:1-3-02.2 | Medicare buy-in.
 

(A) This rule sets forth:

(1) The eligibility criteria for benefits under the medicare part B buy-in agreement between the social security administration (SSA) and the Ohio department of medicaid (ODM), which allows ODM to pay medicare part B (supplemental medical insurance) premiums for certain medicaid-eligible individuals even if those individuals are not eligible for a medicare premium assistance program (MPAP) set out in rule 5160:1-3-02.1 of the Administrative Code; and

(2) The beginning date of payment of medicare part B (part B) benefits under this rule; and

(3) The date and effect of termination of benefits under medicare 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 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 medicaid other than:

(a) Breast and cervical cancer project medicaid as set forth in rules 5160:1-5-02 to 5160:1-5-02.4 of the Adminstrative Code; or

(b) Presumptive medicaid 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 kinds 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) Grandfathered medicaid as 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) Medicaid as a result of section 1619(b) of the Social Security Act (as in effect October 1, 2019) as set forth in rule 5160:1-3-02.8 of the Administrative Code.

(g) Deemed OWF as described in 42 C.F.R 435.115 (as in effect October 1, 2019).

(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 (HCB) services, 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. If an individual is eligible for benefits under this rule or would be eligible if the individual were enrolled in part A or part B, the county department of job and family services (CDJFS) shall coordinate the individual's receipt of benefits. If 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 the Ohio department of medicaid (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. If 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 medicaid, if 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 last day of the month in which the individual dies.

Supplemental Information

Authorized By: 5160.02, 5163.02
Amplifies: 5160.02, 5163.02
Five Year Review Date: 12/14/2025
Prior Effective Dates: 1/1/2010
Rule 5160:1-3-02.3 | Medicaid: coverage for individuals receiving supplemental security income (SSI) benefits.
 

(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 on October 1, 2017). Eligibility for this category shall be determined for applications for medical assistance filed on or after August 1, 2016.

(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 on October 1, 2017); 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; and

(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, but coverage under this rule shall not begin prior to August 1, 2016, and shall not provide reimbursement of services rendered prior to August 1, 2016.

Supplemental Information

Authorized By: 5160.02, 5163.02
Amplifies: 5160.02, 5163.02
Five Year Review Date: 4/1/2023
Prior Effective Dates: 8/1/2016
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 on February 1, 2016) but 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 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;

(2) Determinations of blindness and disability must be in accordance with SSA policy;

(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;

(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;

(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 effective date of this rule and shall not provide reimbursement of services rendered prior to the effective date of this rule.

Supplemental Information

Authorized By: 5160.02, 5163.02
Amplifies: 5160.02, 5163.02
Five Year Review Date: 8/1/2021
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 an individual receving SSI benefits under section 1619 of the Social Security Act for continued medical assistance coverage.

(B) Section 1619 of the Social Security Act (as in effect January 10, 2016) 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 requirements and remain eligible for regular medicaid under the 1619 provisions.

(3) If the individual's 1619 status ends, the individual's medicaid protection is lost.

Supplemental Information

Authorized By: 5160.02, 5163.02
Amplifies: 5160.02, 5163.02
Five Year Review Date: 8/1/2021
Prior Effective Dates: 1/1/1988, 4/1/1989 (Emer.), 1/22/2015
Rule 5160:1-3-02.6 | Medicaid: grandfathering provisions and deemed eligibility.
 

(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.

Supplemental Information

Authorized By: 5160.02, 5163.02
Amplifies: 5160.02, 5163.02
Five Year Review Date: 12/14/2025
Prior Effective Dates: 10/26/1978, 9/21/1979, 6/30/1989, 10/15/1998
Rule 5160:1-3-02.9 | Medicaid: disability determination process.
 

(A) This rule addresses the process of determining blindness or disability for medical assistance eligibility purposes.

(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 a 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 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 on October 1, 2017), by the social security administration (SSA).

(C) Administrative agency responsibilities. The administrative agency shall:

(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 the limiting physical factor is met and shall 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 the limiting physical factor is not met and shall submit a disability packet to the DDA for a disability determination when the individual is potentially eligible for one of the following:

(a) Alien emergency medical assistance (AEMA) in accordance with rule 5160:1-5-06 of the Administrative Code; or

(b) Medicaid buy-in for workers with disabilities (MBIWD) in accordance with rule 5160:1-5-03 of the Administrative Code when an individual has not yet 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) An individual has an initial application for SSA disability pending with the SSA for ninety days or more.

(4) Presume the limiting physical factor is met and shall 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.

(5) Upon request, assist the individual with obtaining medical documentation to support the blindness or disability claim, including, if 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.

(6) Obtain and/or assist the individual in 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 it in 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.

(7) 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. 5/2018); and

(b) ODM 07308 "Mental Functional Capacity Assessment" (rev. 5/2018) when the individual has or appears to have a mental impairment; and

(c) JFS 03606 "Medication Dependencies" (rev. 5/2006) when applicable.

(8) Complete the ODM 07004 "Social Summary Report for Disability Determination" (rev. 5/2018).

(9) Obtain signed copies of form ODM 03397 "Authorization for the Release or Use of Protected Health Information (PHI)" (rev. 2/2016) from the individual for all providers who have or may have current medical information.

(10) Complete the JFS 03605 "CDJFS Referral to DDU" (rev. 6/2006) using current medical information.

(11) Submit the disability packet to the DDA for a blindness or disability determination.

(12) When the DDA has deferred a disability determination, and the administrative agency is unable to obtain all of the requested additional medical information, resubmit the initial disability packet and any additional information to the DDA for a final decision.

(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) Disability determination area (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)(12) 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) Eligibility for medical assistance during initial disability determination.

(1) If the individual meets all other medical assistance eligibility criteria and also meets the limiting physical factor in accordance with paragraph (C)(2) of this rule, the administrative agency shall approve eligibility for medical assistance, and shall not submit a disability packet to the DDA.

(2) If the individual meets all other medical assistance eligibility criteria, but has not yet been determined to meet the limiting physical factor, the administrative agency shall not approve eligibility for medical assistance and shall submit a disability packet to the DDA for a disability determination in accordance with paragraph (C)(3) of this rule.

(3) When the individual's SSA disability application is pending for ninety days or more, the administrative agency shall submit a disability packet to the DDA for a disability determination.

(a) If the DDA approves the blindness or disability, the limiting physical factor is met, and the individual meets all other medical assistance eligibility criteria, the administrative agency shall approve eligibility for medical assistance until the date the SSA makes a decision on the SSA application.

(b) If the DDA denies the blindness or disability, the limiting physical factor is not met and the administrative agency shall deny eligibility for medical assistance until the SSA makes a decision on the SSA application.

(i) If the SSA approves SSA disability, the limiting physical factor is met and the administrative agency shall determine eligibility for medical assistance based upon the initial application for medical assistance and continue eligibility for medical assistance until a renewal is required.

(ii) If the SSA denies SSA disability, the limiting physical factor is not met and the administrative agency shall deny eligibility for medical assistance programs where blindness or disability is an eligibility requirement.

(G) Renewal for medical assistance. When an individual is terminated 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) Beyond twelve months of 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 (F) of this rule.

(H) 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.

Supplemental Information

Authorized By: 5163.02, 5160.02
Amplifies: 5160.02, 5163.02
Five Year Review Date: 8/1/2021
Prior Effective Dates: 1/1/1981, 3/28/1988, 10/1/1988 (Emer.), 4/1/1990, 10/1/1991 (Emer.), 12/1/1991, 12/20/1991, 1/1/1992 (Emer.), 1/1/1993 (Emer.), 8/1/1995 (Emer.), 10/30/1995, 11/25/2002, 2/23/2015, 8/1/2016
Rule 5160:1-3-03.1 | Medicaid: income.
 

(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 aged, blind, or disabled individuals.

(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 in 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 paid even if all of the work which produced the wages is performed in a prior month.

(ii) When the time of receipt of the income is at the employee's discretion, the employee shall avail himself/herself of such wages.

(iii) When the payment of wages is deferred at the employee'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 employee, 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 in 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 his or her own 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 if 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) Potential income must be explored prior to approving medical assistance. An individual who does not avail himself/herself of potential income is presumed to fail to do so in order to make himself/herself eligible for medical assistance. Such non-utilization of income constitutes ineligibility unless good cause can be shown. Such income includes but is not limited to:

(1) Retirement, survivors, disability insurance (RSDI);

(2) Prouty benefits;

(3) Railroad retirement;

(4) Veterans benefits;

(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, 2019). 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. If 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 in 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/renewal, the individual and household member(s) whose income affects the individual, shall be verified electronically or documents shall be required to be submitted which verifies 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. If the individual declares the verifications cannot be accessed or submitted, the individual's statement is to be accepted.

(b) 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.

(2) An individual's report of income is subject to verification when a review is conducted by the ODM quality assurance review 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/renewal, the administrative agency shall review the application/renewal for inconsistencies requiring resolution. It is the individual's responsibility to support the claim of no income. However, when verification is not available and the individual has cooperated in trying to obtain it, the administrative agency may process the case based on the individual's statement as long as there is no evidence to cast doubt on the income allegations. Reference rule 5160:1-2-10 of the Administrative Code for additional information on 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.

Supplemental Information

Authorized By: 5160.02, 5163.02
Amplifies: 5160.02, 5163.02
Five Year Review Date: 1/1/2023
Prior Effective Dates: 9/3/1977, 12/7/1979, 12/1/1984 (Emer.), 8/1/1985, 7/1/2005, 7/8/2020 (Emer.)
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

Supplemental Information

Authorized By: 5160.02, 5163.02
Amplifies: 5160.02, 5163.02
Five Year Review Date: 7/1/2026
Prior Effective Dates: 9/3/1977, 12/31/1977, 12/20/1988, 10/1/1991, 8/13/1992, 11/1/1993, 10/7/1994, 1/1/1995, 7/1/1996 (Emer.), 9/10/1999, 1/25/2015
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.

Supplemental Information

Authorized By: 5160.02, 5163.02
Amplifies: 5160.02, 5163.02
Five Year Review Date: 4/1/2024
Prior Effective Dates: 12/31/1977, 1/3/1980, 6/10/1985, 11/1/1993, 12/15/1996, 10/1/2002, 1/25/2015
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.

Supplemental Information

Authorized By: 5160.02, 5163.02
Amplifies: 5160.02, 5163.02
Five Year Review Date: 7/1/2021
Prior Effective Dates: 12/31/1977, 12/7/1979, 7/1/1980, 7/1/1982, 9/24/1983, 5/1/1985 (Emer.), 7/31/1985, 1/1/1986 (Emer.), 3/20/1987, 1/1/1988 (Emer.), 1/1/1989 (Emer.), 1/1/1990 (Emer.), 4/2/1990 (Emer.), 3/18/1993, 6/11/1993, 9/1/1993, 6/11/1995, 1/1/1997 (Emer.), 1/1/2000 (Emer.), 1/25/2015
Rule 5160:1-3-03.6 | Medicaid: treatment of rental income.
 

(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.

Supplemental Information

Authorized By: 5160.02, 5163.02
Amplifies: 5160.02, 5163.02
Five Year Review Date: 12/14/2025
Prior Effective Dates: 12/31/1977, 10/1/1979, 12/7/1979, 1/3/1980, 10/1/1988 (Emer.), 12/16/1989, 5/1/1991 (Emer.), 7/17/1991, 1/25/2015, 7/8/2020 (Emer.)
Rule 5160:1-3-03.7 | Medicaid: treatment of sick pay and sick leave.
 

(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.

Supplemental Information

Authorized By: 5160.02, 5163.02
Amplifies: 5160.02, 5163.02
Five Year Review Date: 1/25/2020
Rule 5160:1-3-03.8 | Medicaid: in-kind support and maintenance.
 

(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.

Supplemental Information

Authorized By: 5160.02, 5163.02
Amplifies: 5160.02, 5163.02
Five Year Review Date: 1/25/2020
Prior Effective Dates: 12/31/1977, 10/1/1979, 12/1/1984 (Emer.), 7/1/1987 (Emer.), 1/1/1999, 7/1/2005
Rule 5160:1-3-03.10 | Medicaid: retirement funds.
 

(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.

Supplemental Information

Authorized By: 5160.02, 5163.02
Amplifies: 5160.02, 5163.02
Five Year Review Date: 8/1/2021
Prior Effective Dates: 1/1/1993, 12/1/2004
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) "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.

(6) "Real property" means land, including buildings or immovable objects, attached permanently to the land.

(7) "Resources" is defined in rule 5160:1-1-01 of the Administrative Code.

(8) "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.

(9) "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.

(1) 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 if 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.

(a) Receipt and retention of cash or in-kind items.

(i) 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 possible source of countable income for the month of receipt under the rules governing income.

(ii) If 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 possible countable resource under the rules governing resources.

(iii) 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.

(b) If 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 under the rules governing the treatment of resources, even in the first calendar month.

(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, if the change may affect the individual's eligibility for medical assistance.

(b) The review may 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 as soon as possible.

(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, that confirms the individual's claim.

(c) If the administrative agency obtains both the signed statement and adequate supporting documentation from the individual, the administrative agency will 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) If either 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 may refer the case to the administrative agency's benefit recovery unit.

(4) Shared ownership.

(a) If 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 counted. Availability of the resource is reexamined at each eligibility review.

(b) If the co-owner is the individual's spouse, parent (if the individual is under age eighteen), or child under age eighteen, the ability to use or dispose of the resource is assumed to exist unless the individual can provide documentation of 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 that indicates that 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.

(D) Resources of family members, households, and aliens.

(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 limitation for an individual effective with 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 an alien and sponsor(s) are addressed in accordance with the sponsor-to-alien deeming requirements in Chapter 5101:1-2 of the Administrative Code.

(E) Resources determined 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) For purposes of determining or renewing eligibility for medical assistance on or after February 8, 2006, 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 5160:1-6-01.8 of the Administrative Code.

Supplemental Information

Authorized By: 5160.02, 5163.02
Amplifies: 5160.02, 5163.02
Five Year Review Date: 8/1/2021
Prior Effective Dates: 1/3/1980, 5/14/1985 (Emer.), 6/10/1985, 9/1/1992, 10/1/2006, 1/15/2015
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 purposes 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 purposes 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 if 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, if 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 if 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 if 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) If 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; and

(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 if 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; 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 if 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 under all of the following conditions.

(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 if 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) If 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 if 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 if 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 if 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) If 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) If 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) If 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) If 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) If 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) If 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) If 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) If 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) If 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 if 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) If 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.

Supplemental Information

Authorized By: 5160.02, 5163.02
Amplifies: 5160.02, 5163.02
Five Year Review Date: 9/1/2022
Prior Effective Dates: 2/1/1979, 5/3/1985 (Emer.), 8/1/1985, 11/25/1985, 12/16/1989, 2/1/1995 (Emer.), 4/27/1995, 10/1/2006, 8/1/2016
Rule 5160:1-3-05.3 | Medicaid: annuities.
 

(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.

Supplemental Information

Authorized By: 5163.02, 5160.02
Amplifies: 5160.02, 5163.02
Five Year Review Date: 9/1/2022
Prior Effective Dates: 10/28/2002
Rule 5160:1-3-05.4 | Medicaid: cash and checking and savings accounts and time deposits.
 

(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.

Supplemental Information

Authorized By: 5160.02, 5163.02
Amplifies: 5160.02, 5163.02
Five Year Review Date: 12/14/2025
Prior Effective Dates: 9/3/1977, 1/3/1980, 12/1/1984 (Emer.), 11/25/1985, 5/1/1998, 7/8/2020 (Emer.)
Rule 5160:1-3-05.5 | Medicaid: promissory notes, property agreements, and loans.
 

(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.

Supplemental Information

Authorized By: 5163.02, 5160.02
Amplifies: 5160.02, 5163.02
Five Year Review Date: 9/1/2022
Prior Effective Dates: 2/1/1979, 1/3/1980, 11/25/1985, 12/22/1986, 10/1/1991, 7/1/1994, 9/1/1994, 11/7/2002, 9/12/2016
Rule 5160:1-3-05.6 | Medicaid: burial funds and contracts.
 

(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.

Supplemental Information

Authorized By: 5160.02, 5163.02
Amplifies: 5160.02, 5163.02
Five Year Review Date: 8/1/2021
Prior Effective Dates: 2/1/1979, 12/20/1988
Rule 5160:1-3-05.7 | Medicaid: burial spaces.
 

(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.

Supplemental Information

Authorized By: 5160.02, 5163.02
Amplifies: 5160.02, 5163.02
Five Year Review Date: 8/1/2021
Prior Effective Dates: 9/3/1977, 12/1/1984 (Emer.)
Rule 5160:1-3-05.8 | Medicaid: lump-sum payments.
 

(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, 2020).

(G) 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 CDJFS compares the amount received to the amount of medicaid payments made on behalf of the individual. The individual has the choice of:

(1) 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

(2) Using some or all of the lump-sum payment to pay personal debts; or

(3) 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

(4) 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 if the individual agrees and if the repayment amount will continue to ensure the individual's resources remain within the allowable limits; or

(5) Requesting that his or her medicaid be discontinued.

Supplemental Information

Authorized By: 5160.02, 5163.02
Amplifies: 5160.02, 5163.02
Five Year Review Date: 9/1/2022
Prior Effective Dates: 2/10/1985, 8/1/1985, 9/1/1994, 9/1/2017
Rule 5160:1-3-05.9 | Medicaid: dividends and interest.
 

(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.

Supplemental Information

Authorized By: 5160.02, 5163.02
Amplifies: 5160.02, 5163.02
Five Year Review Date: 8/1/2021
Prior Effective Dates: 9/3/1977, 2/1/1979, 10/1/1979, 5/3/1985 (Emer.), 10/2/2014
Rule 5160:1-3-05.10 | Medicaid: household goods and personal effects as resources.
 

(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.

Supplemental Information

Authorized By: 5160.02, 5163.02
Amplifies: 5160.02, 5163.02
Five Year Review Date: 8/1/2021
Prior Effective Dates: 9/3/1977, 2/1/1979, 1/3/1980, 10/1/2002
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

Supplemental Information

Authorized By: 5160.02, 5163.02
Amplifies: 5160.02, 5163.02
Five Year Review Date: 6/1/2026
Prior Effective Dates: 4/1/1990
Rule 5160:1-3-05.12 | Medicaid: life insurance.
 

(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.

Supplemental Information

Authorized By: 5160.02, 5163.02
Amplifies: 5160.02, 5163.02
Five Year Review Date: 8/1/2021
Prior Effective Dates: 2/1/1979, 9/1/1992, 8/13/2002
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 in 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 the individual considers his or her established or principal home and to which, if absent, he or she 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 living place 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 individual's, the individual's spouse's, or the parents' with whom the eligible child is living principal place of residence; and

(b) The deed to the home must be in the individual's, individual's spouse's, or the eligible child's parents' name; 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 if 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 his or her intentions to return to the home and has not established permanent residence elsewhere.

(4) If the individual leaves the home with no intentions of returning, the home remains an excluded resource for as long as:

(a) A spouse or dependent relative of the individual continues to live there 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) Its sale would cause undue hardship, due to loss of housing for co-owner of the property and the co-owner provides a signed statement that he or she:

(i) Uses the property as his or her principal place of residence; and

(ii) Would have to move if the property were sold; and

(iii) Has no other living quarter readily available.

(c) The individual leaves his or her 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 satifies the provisions governing the treatment of property essential for self-support described in rule 5160:1-3-05.19 of the Administrative Code.

Supplemental Information

Authorized By: 5160.02, 5163.02
Amplifies: 5160.02, 5163.02
Five Year Review Date: 9/1/2022
Prior Effective Dates: 1/3/1980, 12/1/1984 (Emer.), 9/1/1996, 9/1/2007, 8/1/2016
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

Supplemental Information

Authorized By: 5160.02, 5163.02
Amplifies: 5160.02, 5163.02
Five Year Review Date: 7/1/2026
Prior Effective Dates: 9/3/1977, 4/1/1986, 12/22/1986, 11/1/1987, 7/1/1988 (Emer.), 9/1/1988, 6/1/1990 (Emer.), 8/31/1990, 10/1/1991, 8/13/1992, 10/1/2006
Rule 5160:1-3-05.16 | Medicaid: home replacement exclusion.
 

(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.

Supplemental Information

Authorized By: 5160.02, 5163.02
Amplifies: 5160.02, 5163.02
Five Year Review Date: 12/14/2025
Prior Effective Dates: 7/8/2020 (Emer.)
Rule 5160:1-3-05.17 | Medicaid: life estates.
 

(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 property actually signed.

(2) "Life estate" means an ownership interest in property wherein one person holds the right to possess, use, and obtain profits from the property as long as he or she lives, while another person holds the actual ownership interest in the property.

(a) A life estate is a form of legal ownership.

(b) It is usually created through an instrument such as deed or will or by operation of law.

(c) A life estate instrument often identifies remaindermen who will take possession of the property upon the expiration of the life estate.

(d) A life estate owner owns the property only for the duration of the life estate. The owner can sell only his or her interest in the life estate. The owner cannot take any action concerning the interest of the remainderman.

(3) "Recording date" means the date that the 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.

(4) A "remainderman" has an ownership interest in the physical property but normally does not have the right to possess and use the property until termination 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 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.

(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 if the life estate is established with property that the individual held an ownership interest.

(b) If 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 if the life estate is established with property that the individual did not hold an ownership interest in at the time of the establishment of the life estate.

(b) If 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) If 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) If 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 instititutions.

(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 property as established by the county auditor. If 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 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 property all liens and encumbrances that have been placed against the life estate.

(4) After the deductions, the balance is the equity value of the property.

(5) The administrative agency must multiply the equity value of the 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:

AGELIFE ESTATEREMAINDER
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) If the individual disagrees with the county auditor's determination of the fair market value of the 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 property in paragraph (G)(1) of this rule. Such appraisal services may be provided through the use of administrative funds if the individual is unable to obtain an appraisal due to insufficient funds of his or her own.

(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 if the individual fails to produce documentation verifying that the transfer occurred on the date of signature.

(4) If 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 paragarph (E)(2) of this rule. If 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.

Supplemental Information

Authorized By: 5163.02, 5160.02
Amplifies: 5160.02, 5163.02
Five Year Review Date: 9/1/2022
Prior Effective Dates: 9/3/1977, 9/1/1988, 1/1/1990 (Emer.), 6/17/1991, 9/1/1994, 11/1/2013
Rule 5160:1-3-05.18 | Medicaid: stocks, mutual funds, and bonds.
 

(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.

Supplemental Information

Authorized By: 5160.02, 5163.02
Amplifies: 5160.02, 5163.02
Five Year Review Date: 9/12/2021
Prior Effective Dates: 10/1/1979, 1/3/1980, 2/10/1985, 5/3/1985 (Emer.), 8/1/1985, 9/1/1985 (Emer.), 10/2/2014, 1/1/2016
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

Supplemental Information

Authorized By: 5160.02, 5163.02
Amplifies: 5160.02, 5163.02
Five Year Review Date: 6/1/2026
Prior Effective Dates: 2/1/1979
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

Supplemental Information

Authorized By: 5160.02, 5163.02
Amplifies: 5160.02, 5163.02
Five Year Review Date: 6/1/2026
Prior Effective Dates: 10/1/1996 (Emer.), 12/15/1996