Ohio Admin. Code 5160:1-6-01.1 - Medicaid: definitions relating to eligibility for long-term care (LTC) services
(A) For purposes of this chapter the
following definitions apply unless otherwise stated.
(10)(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.
(12)(11) "Home and
community-based services" (HCB services or
HCBS) means services provided under a waiver authorized in accordance with
42 U.S.C.
1396n(c) (as in effect
October 1, 2016
2023 ).
(13)(12) "Improper
transfer" means a transfer or disposal of an asset any time after the look-back
date for less than fair market value.
(14)(13) "Income" is
defined in rules
5160:1-3-03.1 and
5160:1-4-01
rule
5160:1-1-01 of the
Administrative Code.
(15)(14) "Individual"
means the person requesting or receiving LTC services.
(16)(15)
"Institutionalized individual" means an individual who is:
(17)(16)
"Institutionalized spouse" (IS) means an individual who is:
(18)(17) "Look-back date"
means the date that is sixty months before the individual's baseline
date.
(19)(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 whom
which payment is made based on a level-of-care
provided in a nursing facility.
(20)(19) "Long-term care
(LTC) services" means care provided to medicaid eligible individuals in a
medical institution as defined in paragraph (A)(21
20 ) of this rule,
through an HCBS waiver, or through PACE.
(21)(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,
2016
2023 ).
(23)(24) "Monthly income
allowance" (MIA) means a required deduction in the computation of patient
liability to provide for the needs of the community spouse.
(24)(25)
"Personal needs allowance" (PNA) means a required deduction in the computation
of patient liability for needs of the individual.
(25)(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.
(26)(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.
(27)(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).
(28)(29) "Standard utility
allowance" (SUA) is the amount used in lieu of the actual amount of utility
costs.
(29)(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.
(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 do
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 natural, adoptive, or
step-child
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 standard" (ESA
standard) 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) "Family maintenance needs
allowance standard" means the current Ohio works first payment standard for the
same number of applicable dependent family members.
(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.
(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.
(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).
(30) "Uncompensated value" means the
difference between the fair market value at the time of the transfer (less any
outstanding loans, mortgages, or other encumbrances on the asset at issue) and
the amount received for the resource.
(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.
Notes
Promulgated Under: 111.15
Statutory Authority: 5160.02, 5163.02
Rule Amplifies: 5160.02, 5163.02
Prior Effective Dates: 09/01/2017
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