Ohio Administrative Code › Title 5160:1 - Eligibility › Chapter 5160:1-6 - Long-Term Care › Section 5160:1-6-01.1 - Medicaid: definitions relating to eligibility for long-term care (LTC) services

Current through all regulations passed and filed through July 1, 2024
(A) For purposes of this chapter the
			 following definitions apply unless otherwise stated.
(1) "Baseline date" means the first date the
			 individual both is an institutionalized individual and has applied for medical
			 assistance. An individual only has one baseline date.
(2) "Community spouse" (CS) means an
			 individual who is not receiving medicaid payment for long-term care (LTC)
			 services and is married to an institutionalized spouse.
(3) "Community spouse resource allowance"
			 (CSRA) means the amount of a couple's combined countable resources that the
			 community spouse can keep and 
									that does not have to be made available for the
			 care of the institutionalized spouse.
(4) "Continuous period of
			 institutionalization" means:
(a) Thirty
			 consecutive days of being an inpatient in a medical institution;
			 or
(b) Thirty consecutive days of being in
			 receipt of home and community-based (HCBS) waiver or program of all-inclusive
			 care for the elderly (PACE) services; or
(c) Determined eligible for and in need of
			 HCBS waiver or PACE services for at least thirty consecutive days.
(5) "Dependent family member"
			 means a child (natural, adoptive, or
			 step), parent, or sibling of the institutionalized individual who is or
			 could be claimed as a dependent for the most recent federal tax year by the
			 institutionalized individual, the institutionalized individual's spouse, or the
			 couple.
(6) "Excess shelter
			 allowance " (ESA
			 ) is thirty per cent of the current
			 minimum monthly maintenance needs allowance (MMMNA) standard.
(7) "Family allowance" (FA) means a required
			 deduction in the computation of patient liability to provide for the needs of
			 dependent family members who reside with the community spouse.
(8) "Family maintenance needs allowance"
			 (FMNA) means a required deduction in the computation of patient liability to
			 provide for the needs of dependent family members residing in the community
			 when there is no community spouse. The FMNA is equal to
			 the current Ohio works first payment standard for the same number of applicable
			 dependent family members.
(9)
			 "First continuous period of institutionalization" means the first day of the
			 first month, that began on or after September 30, 1989, in which the individual
			 had a continuous period of institutionalization as defined in paragraph (A)(4)
			 of this rule. This is also called the snapshot date.
(10) "Home" is defined
			 in rule
			 5160:1-3-05.13 of the
			 Administrative Code.
(11) "Home and
			 community-based services" (
			 HCBS) means services provided under a waiver authorized in accordance with
			 42 U.S.C.
			 1396n(c) (as in effect
			 October 1, 2023).
(12) "Improper
			 transfer" means a transfer or disposal of an asset any time after the look-back
			 date for less than fair market value.
(13) "Income" is
			 defined in rule
			 5160:1-1-01 of the
			 Administrative Code.
(14) "Individual"
			 means the person requesting or receiving LTC services.
(15)
			 "Institutionalized individual" means an individual who is:
(a) An inpatient in a long-term care facility
			 (LTCF); or
(b) Eligible for
			 enrollment in an HCBS waiver or PACE services by
			 using the special income level (SIL) described in rule
			 5160:1-6-03.1 of the
			 Administrative Code.
(16)
			 "Institutionalized spouse" (IS) means an individual who is:
(a) In a medical institution and expected to
			 be there for at least thirty consecutive days; or
(b) Eligible for an HCBS waiver or PACE and
			 expected to be in need of such services for at least thirty consecutive days;
			 and
(c) Married to someone who is
			 not in a medical institution, or eligible for enrollment in an HCBS waiver, or
			 receiving PACE services.
(17) "Look-back date"
			 means the date that is sixty months before the individual's baseline
			 date.
(18) "Long-term care
			 facility" (LTCF) means a nursing facility, intermediate care facility for
			 individuals with intellectual disabilities (ICF-IID), or medical institution
			 with respect to 
									which payment is made based on a level-of-care
			 provided in a nursing facility.
(19) "Long-term care
			 (LTC) services" means care provided to medicaid eligible individuals in a
			 medical institution as defined in paragraph (A)(20) of this rule,
			 through an HCBS waiver, or through PACE.
(20)
			 "Medical institution" means a hospital or LTCF that provides medical care,
			 including nursing and convalescent care, as defined in
			 42 C.F.R.
			 435.1010 (as in effect October 1,
			 2023).
(21)
									"Minimum monthly
			 maintenance needs allowance" (MMMNA) means a calculation to determine the
			 amount of income needed from the IS to provide the monthly income allowance
			 (MIA) to the CS. The MMMNA standard and the MMMNA maximum are used to calculate
			 the MMMNA amount.
(22)
			 "Minimum monthly maintenance needs allowance standard" (MMMNA standard) is one
			 hundred fifty per cent of the federal poverty level (FPL) for a family unit
			 size of two members. The MMMNA standard is updated annually in accordance with
			 42 U.S.C
			 1396r-5(d).
(23)
									"Minimum monthly
			 maintenance needs allowance maximum or cap" (MMMNA maximum or cap) is
			 calculated annually based on the social security administration (SSA)
			 cost-of-living adjustment (COLA).
(24) "Monthly income
			 allowance" (MIA) means a required deduction in the computation of patient
			 liability to provide for the needs of the community spouse.
(25)
			 "Personal needs allowance" (PNA) means a required deduction in the computation
			 of patient liability for needs of the individual.
(26) "Program of
			 all-inclusive care for the elderly" (PACE) means the program administered by
			 the department of aging in accordance with Chapter 173-50 of the Administrative
			 Code.
(27) "Restricted
			 medicaid coverage period" (RMCP) means the period of time an institutionalized
			 individual is ineligible for medicaid payment of LTC services because of an
			 improper transfer.
(28) "Special income
			 level" (SIL) means three hundred per cent of the current supplemental security
			 income (SSI) payment standard. The SSI payment standard is also referred to as
			 the federal benefit rate (FBR).
(29) "Standard utility
			 allowance" (SUA) is the amount used in lieu of the actual amount of utility
			 costs.
(30) "Transfer" means
			 any action or failure to act which has the effect of changing an ownership
			 interest in an asset from one person to another person or entity, or of
			 preventing an ownership interest that the person would otherwise have enjoyed.
			 This includes any direct or indirect method of disposing of an interest in
			 property.
(31) "Valuable consideration" means that an
			 individual receives in exchange for his or her right or interest in an asset,
			 some act, object, service, or other benefit which has tangible and/or intrinsic
			 value to the individual that is roughly equivalent to or greater than the value
			 of the transferred asset.