Ohio Administrative Code › Title 3701 - Department of Health - Administration and Director › Chapter 3701-43 - Program for Medically Handicapped Children › Section 3701-43-16 - Financial eligibility requirements for payment for treatment for children with medical handicaps

Current through all regulations passed and filed through July 1, 2024
(A) As used in this rule:
(1) "Income guidelines" means the guidelines,
			 as established by the director on April first of each year, for use in
			 determining financial eligibility for payment for treatment. The income
			 guidelines shall be equal to one hundred eighty-five per cent of the poverty
			 income for each size family, as reported in the "Federal Register" by the
			 United States department of health and human services, rounded up to the
			 nearest five hundred dollars.
(2)
			 A "family unit" means the group consisting of the following persons:
(a) The applicant or recipient;
(b) The applicant's or recipient's spouse;
(c) The applicant's or recipient's
			 parent(s) or custodian(s); and
(d)
			 Other persons who, for federal income tax purposes, are considered dependents
			 of the individual who claims the applicant or recipient as a dependent or who
			 are considered dependents of the applicant or recipient, except for a spouse
			 who is not the biological parent.
A family unit consists only of the applicant or recipient if
				the applicant or recipient is self-supporting and has no spouse or dependents,
				or if the applicant or recipient is in the custody of a government or private
				agency.
(3)
			 "Family income" means the current year's projected adjusted gross earnings
			 based on current gross earnings as reported on pay stubs and/or the sum of the
			 annual adjusted gross incomes, as reported to the United States internal
			 revenue service for federal income tax purposes for the previous year, of each
			 member of the family unit, except for the incomes of a custodian who is not the
			 applicant's or recipient's natural or adoptive parent and the custodian's
			 dependents. In the case of an applicant or recipient who is eighteen or more
			 years of age and self-supporting or twenty-one or more years of age, the family
			 income shall include only the adjusted gross income of the applicant or
			 recipient.
For the purposes of this rule, family income shall not include
				educational scholarships, loans, and grants; amounts spent by the family unit
				for child care expenses; amounts spent by the family unit for respite care
				(with appropriate verification from a qualified respite care provider); and
				lump-sum death benefits.
(4) "Maximum ability to pay for medical care"
			 means the difference between the amount a family unit spends, including payroll
			 deductions, for health-related insurance coverage and the sum of the following
			 amounts:
(a) Ten per cent of the first
			 fifteen thousand dollars by which the family income exceeds the applicable
			 income guideline, as defined in paragraph (A)(1) of this rule;
(b) Twenty-five per cent of the next
			 twenty-five thousand dollars by which the family income exceeds the applicable
			 income guideline, as defined in paragraph (A)(1) of this rule; and
(c) Thirty-seven and one half per cent of the
			 remaining amount by which the family income exceeds the applicable income
			 guideline, as defined in paragraph (A)(1) of this rule.
(5) "Service level credit" means a credit
			 against the maximum ability to pay for medical care as determined by the
			 director based upon the applicant's or recipient's need for treatment services.
			 The need for treatment services is determined by reference to the services
			 requested by the managing physician on the medical application, to the extent
			 that those services are eligible for authorization under paragraph (E) of rule
			 3701-43-18
			 of the Administrative Code. Service levels and service level credits are the
			 following:
(a) Service level one is based on
			 the applicant's or recipient's need for routine physician visits or routine
			 outpatient hospital care. The service level credit for this service level is
			 five hundred dollars.
(b) Service
			 level two is based on the applicant's or recipient's anticipated need for brief
			 hospitalizations, minor surgical procedures, medications, durable equipment, or
			 medical supplies. The service level credit for this service level is one
			 thousand dollars.
(c) Service
			 level three is based on the applicant's or recipient's documented need for
			 multiple hospitalizations, major surgical procedures, medications or supplies
			 costing more than five hundred dollars per month, or medical services for more
			 than one child with special health care needs. The service level credit for
			 this service level is two thousand dollars.