Ohio Administrative Code › Title 5160:1 - Eligibility › Chapter 5160:1-6 - Long-Term Care › Section 5160:1-6-07 - Medicaid: post-eligibility treatment of income for individuals in medical institutions

Current through all regulations passed and filed through July 1, 2024
(A) This rule describes how to calculate an
			 institutionalized individual's post-eligibility treatment of income (PETI),
			 commonly referred to as patient liability or share of cost. This rule only
			 applies to an individual residing in a medical institution who does not have a
			 base eligibility category which uses the modified
			 adjusted gross income (MAGI) budgeting methodology in accordance with Chapter
			 5160:1-4 of the Administrative Code.
(B) The administrative agency will reduce its
			 payment to a medical institution, for services provided to an institutionalized
			 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 the medical
			 institution.
(D) Patient liability
			 must be recalculated when there is a change in circumstances that affects the
			 patient liability amount.
(E)
								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.
(F) Medical
			 institutions are required to refund to the institutionalized individual any
			 overpayments of patient liability paid by the institutionalized individual,
			 such as when retroactive patient liability adjustments are made.
(G)
			 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 supplemental security income ( 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 on 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
			 ;
(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 compensation 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
			 
										(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 program; 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 on 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 a personal needs allowance (PNA)
			 of fifty dollars. 
									When the individual has earned income, subtract
			 up to an additional sixty-five dollars from the earned income amount.
(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 
											(G)(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. These 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 institutionalization.
(9)
									
									When the institutionalized individual is
			 institutionalized for less than a full month due to date of admission, death,
			 or discharge from the medical institution, the patient liability amount is
			 prorated for that month. Prorated patient liability amounts are calculated as
			 follows.
(a) Determine the per diem patient liability
			 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 amount, rounding down to the nearest
			 dollar. This is the institutionalized individual's prorated patient liability
			 amount.