(A) This rule describes the process for
calculating an individual's post-eligibility treatment of income (PETI),
commonly referred to as patient liability or share of cost, when the individual
is not living in a medical institution. This rule only applies to an individual
who is both eligible for medical assistance under the special income level
(SIL) as described in rule 5160:1-6-03.1 of the Administrative Code and who is
receiving HCBS waiver or PACE services.
(B) The administrative agency will reduce
its payment to the HCBS waiver or PACE providers for services provided to the
individual by the amount of the individual's patient liability calculated
in accordance with this rule.
(C) The individual must pay the patient
liability amount to his or her providers identified by the HCBS waiver or PACE
administrative agency.
(D) Providers are to collect the full
patient liability amount or up to the cost of care, whichever is
less.
(E) Patient liability must be recalculated when there is a
change in circumstances that affects the patient liability amount.
(F) A patient liability calculated for a
child younger than age nineteen shall not increase during the child's
continuous eligibility period as described in rule 5160:1-2-14 of the
Administrative Code. Any decrease in a child's patient liability results
in a new maximum amount, which will not increase for the remainder of the
child's continuous eligibility period.
(G) Providers are required to refund to the individual any
overpayments of patient liability paid by the individual, such as when
retroactive patient liability adjustments are made.
(H) For purposes of this rule, the following definitions
apply:
(1) "Assisted living
waiver maintenance needs allowance (ALMNA)" is an amount equal to the
current supplemental security income (SSI) federal benefit rate
(FBR).
(2) "Special individual maintenance
needs allowance (SIMNA)" is sixty-five per cent of the special income
level.
(I) For purposes of this rule, patient liability is
calculated in the following order:
(1) Total the
individual's gross monthly earned and unearned income, including SSI
payments. In the case of an institutionalized spouse, include any income
attributed to the institutionalized spouse in accordance with rule 5160:1-6-04
of the Administrative Code.
(2) Exclude the following
payments from the individual's gross monthly income:
(a) Payments to victims of Nazi persecution.
(b) 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 through 506 (as in effect October 1,
2022). These payments need to be documented and identifiable separate from
countable insurance.
(c) 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).
(d) 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, 2022).
(e) Restitution payments under the Aleutian and Pribilof
Island Restitution Act, in accordance with 50 U.S.C. 4236 (as in effect October
1, 2022).
(f) 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).
(g) 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).
(h) Radiation exposure compensation trust fund payments, in
accordance with the Radiation Exposure Compensation Act of 1990 (Pub. L. No.
101-426).
(i) 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.
(j) Veterans administration pensions, including payments
for aid and attendance, up to the amount of ninety dollars per month, paid to
veterans or their surviving spouse, if any, who are residing in a nursing
facility or are receiving HCBS waiver services. This exclusion applies
to:
(i) A veteran without a
spouse or dependent minor or disabled child; and
(ii) A veteran's
surviving spouse without a dependent minor or disabled child.
(k) Payments made to Native Americans as listed in section
IV of 20 C.F.R. 416 Subpart K Appendix (as in effect October 1,
2022).
(l) SSI benefits received under authority of sections
1611(e)(1)(E) and (G) of the Social Security Act (SSA) (as in effect October 1,
2022) for institutionalized individuals during the first three full months of
institutionalization. The administrative agency must not retroactively
redetermine patient liability determinations, made under the continued benefit
provision, if the individual's actual stay exceeds the expected stay of
ninety days or less.
(m) Residential state supplement (RSS) payments to
institutionalized individuals, in accordance with rule 5160:1-5-01 of the
Administrative Code.
(n) Payments from a state fund for victims of
crime.
(o) Payments made from any fund established pursuant to a
class action settlement in the case of "Factor VIII or IX concentrate
blood products litigation," MDL986, no. 93-C-7452 (N.D. Ill), per section
4735 of the Balanced Budget Act of 1997 (Pub. L. No. 105-33).
(p) Payments from the Ricky Ray Hemophilia 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. III).
(q) Payments made to individuals under the Energy Employees
Occupational Illness Compensation Program Act of 2000 (Pub. L. No.
106-398).
(r) Assistance (other than wages or salaries) under the
Older Americans Act of 1965 under 92 Stat. 1515, 42 U.S.C. 3020a Pub. L. No.
89-73).
(s) Student financial assistance received under the Higher
Education Act (HEA) of 1965 (as in effect October 1, 2022) or bureau of Indian
affairs is excluded from income, regardless of use:
(i) Pell
grants;
(ii) Student services
incentives;
(iii) Academic
achievement incentive scholarships;
(iv) Federal supplemental
education opportunity grants;
(v) Federal educational
loans (Stafford loans, William D. Ford federal direct and direct PLUS loans,
etc.);
(vi) Upward
bound;
(vii) Gear up (gaining
early awareness and readiness for undergraduate programs);
(viii) State educational
assistance programs funded by the leveraging educational assistance programs;
and
(ix) Work-study
programs.
(t) 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, 2022).
(u) 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.
(v) Federal and state foster care payments received under
title IV-B or title IV-E for a child currently living in the
household.
(w) Federal or state
adoption assistance payments received under title IV-B or title
IV-E.
(x) Payments received under the kinship guardianship
assistance program (KGAP), state KGAP, or kinship guardianship assistance
program connections to twenty-one (KGAP C21).
(y) Child care assistance under the Child Care and
Development Block Grant Act of 1990 (Pub. L. No. 113-186).
(z) Assistance or services received through the domestic
volunteer service under 42 U.S.C. 66 per 42 U.S.C. 5044(f) (as in effect
October 1, 2022).
(aa) 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,
2022):
(i) AmeriCorps VISTA
program;
(ii) Special and
demonstration volunteer program;
(iii) Retired senior
volunteer program (RSVP);
(iv) Foster grandparents
program; and
(v) Senior companion
program.
(bb) Assistance or services received through federal food
and nutrition programs:
(i) Supplemental
nutrition assistance program (SNAP);
(ii) The value of foods
donated by the U.S. department of agriculture commodity supplemental food
program;
(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);
(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).
(cc) 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.
(dd) Assistance, with respect to the dwelling unit occupied
by such individual (or such individual and spouse), under the United States
Housing Act of 1937 (Pub. L. No. 75-412), the National Housing Act (Pub. L. No.
73-479), section 101 of the Housing and Urban Development Act of 1965 (Pub. L.
No. 89-117), title V of the Housing Act of 1949 (Pub. L. No. 81-171), or
section 202(h) of the Housing Act of 1959 (Pub. L. No. 86-372).
(ee) Home energy
assistance provided on the basis of need, in accordance with 20 C.F.R. 416.1157
(as in effect October 1, 2022).
(ff) 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.
(gg) 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, 2022).
(3) Subtract the
applicable personal needs allowance (PNA) as follows:
(a) For individuals receiving services under an HCBS waiver,
other than the assisted living waiver, the PNA is the SIMNA. When the
individual has earned income, subtract up to an additional sixty-five dollars
from the earned income.
(b) For individuals receiving services under the assisted living
waiver or in an assisted living facility receiving services under the mycare
waiver, the PNA is the ALMNA. When the individual has earned income, subtract
up to an additional sixty-five dollars from the earned income.
(c) For individuals receiving PACE services and residing in the
community, the PNA is the SIMNA.
(d) For individuals receiving PACE services and residing in an
assisted living facility, the PNA is the ALMNA.
(4) When the individual
has a community spouse, subtract the monthly income allowance (MIA) for the
community spouse.
(a) The MIA of the community spouse is calculated as
follows:
(i) Determine the excess
shelter allowance (ESA):
(a) Total and round down
to the nearest dollar the community spouse's expenses for the principal
place of residence, as defined in rule 5160:1-3-05.13 of the Administrative
Code, including any rent or mortgage payment (including principal and
interest), current property taxes, insurance, and any required maintenance
charge for a condominium or cooperative; then
(b) When the community
spouse is responsible for payment towards the cost of gas, electric, coal,
wood, oil, water, sewage, or telephone service for the residence, add in the
standard utility allowance; then
(c) Subtract the ESA standard.
(d) The remainder is the ESA.
(ii) Add the calculated ESA to the minimum monthly maintenance
needs allowance (MMMNA) standard to determine the MMMNA. Except in accordance
with a hearing decision under rule 5101:6-7-02 of the Administrative Code, the
MMMNA must not exceed the MMMNA cap which is updated annually.
(iii) Subtract the
community spouse's gross monthly income from the lesser of the MMMNA,
calculated in paragraph (I)(4)(a)(ii) of this rule, or the MMMNA cap. When a
hearing decision under rule 5101:6-7-02 of the Administrative Code results in a
MMMNA that is greater than the MMMNA cap, use the amount established in the
hearing decision. The remainder, rounded down to the nearest dollar, is the
MIA.
(b) When there is court ordered support that is greater than the
MIA calculated above, the court ordered amount is used as the MIA.
(c) When the community spouse's income is still below the
MMMNA after all of the institutionalized spouse's income is allocated to
the community spouse, the community spouse resource allowance can be increased
in accordance with rules 5160:1-6-04 and 5101:6-7-02 of the Administrative
Code, to generate additional income for the community spouse.
(5) When the individual
has dependent family members, subtract either the family allowance (FA) or the
family maintenance needs allowance (FMNA). The FA does not apply when there is
an FMNA.
(a) Subtract an FA when the institutionalized individual has
family members residing with his or her spouse in the community. The FA is
calculated as follows:
(i) For each family
member, multiply the MMMNA standard by one-third; then
(ii) Subtract that family
member's gross monthly income; then
(iii) Round the result
down to the nearest dollar.
(iv) The remainder is the
allowance amount for that family member.
(v) The allowances for
each family member are added together to determine the FA.
(b) Subtract an FMNA when the institutionalized individual has
dependent family members who resided with the institutionalized individual
immediately before the individual was admitted to a medical institution. The
FMNA does not apply when there is a spouse in the community. The FMNA is
calculated as follows:
(i) The FMNA standard is
the Ohio works first (OWF) payment standard for the same number of applicable
dependent family members.
(ii) Subtract the combined monthly income of the dependent
family members from the FMNA standard; then
(iii) Round the result down to the nearest
dollar.
(iv) The remainder is the FMNA.
(6) The following types
of health care costs shall be subtracted from the institutionalized
individual's patient liability. Any requests for subtraction of these
costs must include documentation that clearly shows the type of medical
expense, the amount the individual is responsible for paying, and the date the
service or item was provided to the individual.
(a) Health insurance premiums (including medicaid and medicare
premiums) and coinsurance, insurance deductibles and copayments, that are
incurred by:
(i) The institutionalized
individual;
(ii) The
institutionalized individual's spouse; or
(iii) The
institutionalized individual's minor or disabled child.
(b) The cost of any of the institutionalized individual's
incurred expenses for medical care, recognized under Ohio law, but not covered
by medicaid and not subject to third-party payment. The unpaid past medical
expenses, and any request to subtract such expenses from the patient liability,
must meet the following criteria:
(i) The service was
medically necessary as determined by the administrative agency.
(ii) Expenses for medical
care were not incurred while serving a restricted medicaid coverage period
(RMCP) per rule 5160:1-6-06.5 of the Administrative Code. Expenses that were
incurred while serving an RMCP shall not count as unpaid past expenses and
shall not be subtracted from the patient liability calculation.
(iii) Unpaid patient
liability shall not count as unpaid past medical expenses and shall not be
subtracted from the patient liability calculation.
(iv) The request for the subtraction of incurred expenses
for medical care can only be initiated by either the institutionalized
individual or person or entity who has the legal ability to act on the
individual's behalf, including the institutionalized individual's
authorized representative. A request for a deduction cannot be initiated by a
medical services provider or supplier, unless such provider or supplier is also
the institutionalized individual's authorized representative.
(7) Subtract the payment
in an amount up to fifteen dollars per month, or the amount approved by the
administrative agency, to administer a qualified income trust (QIT) account in
accordance with rule 5160:1-6-03.2 of the Administrative Code.
(8) The remainder,
rounded down to the nearest dollar, is the individual's monthly patient
liability, for a full month of HCBS or PACE services.
(9) The individual's
patient liability will be prorated when the individual is enrolled in an HCBS
waiver or PACE program for less than a full month. Prorated patient liability
amounts are calculated as follows:
(a) Determine the per diem patient liability amount by dividing
the patient liability for a full month of institutionalization by the number of
days in the month for which the prorated payment is to be
determined.
(b) Determine the actual number of days of institutionalization
in the month for which the prorated payment is to be determined, including the
first date of institutionalization in the month. The date of discharge or the
date of death is not included in this calculation.
(c) Multiply the actual number of days of institutionalization
by the per diem patient liability amount and round this number down to the
nearest dollar. This is the individual's prorated patient
liability.
(J) The individual will receive written notification of the
amount of patient liability for which he or she is responsible. Such notice
will explain how the individual can request a hearing if he or she disagrees
with the patient liability amount.
(K) When applicable, the individual will receive written
notification of the MIA, FA, or FMNA that were calculated in accordance with
this rule. Such notice will explain how the individual can request a hearing if
he or she disagrees with those amounts.
