Ohio Admin. Code 5160:1-6-07 - Medicaid: post-eligibility treatment of income for individuals in medical institutions
(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)
Patient liability can be established for retroactive
eligibility as described in paragraph (L) of rule
5160:1-2-01 of the
Administrative Code and will follow the same process as described in paragraph
(I) of this rule.
(F)
Once eligibility has been established, patient
liability cannot be increased for past months.
(E)(G) 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)(H) 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)(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 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, 20222024). 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, 20222024).
(e)
Restitution payments under the Aleutian and Pribilof Island Restitution Act, in
accordance with 50 U.S.C.
4236 (as in effect October 1, 20222024).
(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, 20222024).
(l) SSI benefits received under authority of
sections 1611(e)(1)(E) and (G) of the Social Security Act (as in effect October
1, 20222024) 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 1,2024) 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 1,2024).
(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, 20222024).
(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, 20222024):
(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, 20222024).
(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, 20222024).
(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)(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. These unpaid
pastThe 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.
(v)
Unpaid medical
expenses that were incurred in the past may be subtracted from the patient
liability as long as the services meet the criteria described in paragraph
(I)(6)(b) of this rule.
(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.
(H)(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.
(I)(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.
Notes
Promulgated Under: 111.15
Statutory Authority: 5160.02, 5163.02
Rule Amplifies: 5163.33
Prior Effective Dates: 06/01/1988 (Emer.), 08/01/1988 (Emer.), 10/30/1988, 01/01/1990 (Emer.), 03/01/1990 (Emer.), 03/30/1990 (Emer.), 04/01/1990, 06/29/1990, 07/01/1990, 10/01/1990, 01/01/1991 (Emer.), 04/01/1991, 01/01/1992 (Emer.), 03/20/1992, 05/01/1992 (Emer.), 07/01/1992, 08/14/1992 (Emer.), 11/01/1992, 05/01/1993, 09/01/1993, 07/01/1994, 01/01/1995 (Emer.), 03/20/1995, 10/01/1995, 04/01/1996, 01/01/1997 (Emer.), 02/09/1997, 12/31/1997 (Emer.), 02/01/1998, 04/01/1999, 01/01/2000, 01/01/2001, 05/12/2002, 07/01/2005, 12/01/2006, 11/01/2013, 01/01/2016, 09/01/2017, 01/01/2023
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
(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.
(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 : (c)(f) Agent Orange settlement fund payments under the provisions of received on or after January 1, 1989, as a result of the Agent Orange Compensation Exclusion Act, (Pub. L. No. 101-201 ) (as in effect October 1, 2016), received on or after January 1, 1989. (d)(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 (as in effect on October 1, 2016) (Pub. L. No. 105-78 ). (e)(h) Radiation exposure compensation trust fund payments, under the provisions of in accordance with the Radiation Exposure Compensation Act, of 1990 (Pub. L. No. 101-426 ) (as in effect October 1, 2016). (f)(i) Veterans affairs payments made to or on behalf of: (g)(j) Veterans administration pensions, including payments for aid and attendance, benefits, 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: (h)(k) Payments made to Native Americans as listed in section IV of 20 C.F.R. 416 Subpart K Appendix (as in effect on October 1, 2016 2022). (i)(l) SSI benefits received under authority of sections 1611 (e)(1)(E) and (G) of the Social Security Act ( SSA), Omnibus Budget Reconciliation Act of 1987, Pub. L. No. 100-203 (as in effect October 1, 201 2022), for institutionalized individual s, 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 recipient's individual 's actual stay exceeds the expected stay of ninety days or less. (j)(m) Residential state supplement (RSS) benefits payments to institutionalized individuals, in accordance with rule 5160:1-5-01 of the Administrative Code. (k)(n) Payments received under the provisions of a state "Victims of Crime Program", per 42 U.S.C 10602(c) (as in effect October 1, 2016) from a state compensation fund for victims of crime. (m)(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 ) (as in effect October 1, 2016). (n)(r) Assistance (other than wages or salaries) under the Older Americans Act of 1965 under 92 Stat. 1515, 42 U.S.C. 3020a (as in effect October 1, 2016 (Pub. L. No. 89-73). (o)(s) Student financial assistance from a program funded received under Title IV of the Higher Education Act (HEA) of 1965 (as in effect October 1, 2022) or bureau of Indian affairs is excluded from income , (BIA) per the Higher Education Technical Amendments Act of 1987 ( 20 U.S.C. 1087uu ; as in effect October 1, 2016). regardless of use: (q)(v) Foster Federal and state foster care subsidies under title IV-B or title-XX and adoption assistance subsidies under title IV-E per 42 U.S.C. 673(b) payments received under title IV-B or title IV-E for a child currently living in the household. (r)(y) Assistance Child care assistance under the Child Care and Development Block Grant Act of 1990 ( 20 USC 9858q ; as in effect October 1, 2016 Pub. L. No. 113-186 ). (s)(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, 2016 2022). (t)(bb) Assistance or services received through the Supplemental Nutrition Act Program per 7 U.S.C. 2017(b); the school lunch program per 42 U.S.C. 1760(e); the Child Nutrition Act per 42 U.S.C. 1780(b); and the nutrition program for elderly (Title VII) per 42 U.S.C. 3020a(a) (as in effect October 1, 2016). federal food and nutrition programs: (u)(cc) Payments made Assistance received under the Robert T. Stafford Disaster Relief and Emergency Assistance Act per 42 U.S.C. 5155(d) (as in effect October 1, 201) (Pub. L. No. 100-707) and assistance provided under any federal statute because of a presidentially-declared disaster. (v)(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) per 42 U.S.C. 1382a (as in effect October 1, 2016). (w)(ff) Relocation assistance provided under title II of the Uniform Relocation Assistance and Real Property Acquisitions Policies Act of 1970 in accordance with 42 U.S.C. 4636 (as in effect on October 1, 2016) (Pub. L. No. 91-646) provided to individuals displaced by or through any federal, or federally-assisted, project or state, or local government or through a state-assisted, local, or locally-assisted government project in the acquisition of real property. (x)(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 (Pub. L. 107-110 ) (as in effect October 1, 2016 2022).
(a) German reparation payments, Austrian social insurance payments, and Netherlands reparation payments, in accordance with the Nazi Persecution Victims Eligibility Act, Pub. L. No.
(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 ).
(b) Japanese and Aleutian restitution payments, under the provisions of section
(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).
(i) Certain Vietnam veterans' natural children regardless of or age or marital status, for any disability resulting from spina bifida suffered by such children under provision 421 of Pub. L. No. 104-204 ( 38 U.S.C. 1805(d); as in effect October 1, 2016);
(ii) Certain Korea service veterans' natural children, regardless of their age or marital status, for any disability resulting from spina bifida suffered by such children under provision 102 of the Veterans Benefits Act of 2003, P.L. 108-183 (as in effect October 1, 2016); and
(iii) Women Vietnam veterans' The natural children, regardless of their age or marital status, for with certain birth defects under provision 401 of Pub. L. No. 106-419 ( 38 U.S.C. 1833(c); as in effect October 1, 2016) born to a woman who served in Vietnam.
(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.
(l) 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. Ill), per section 4735 of the Balanced Budget Act of 1997, Pub. L. No.
(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 ).
(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.
(p) Monies in an
(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.
(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).
(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.
(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).
(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).
(3) Subtract a personal needs allowance (PNA) of fifty dollars. If When the individual has earned income , subtract up to an additional sixty-five dollars from the earned income amount.
(4) If 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) If 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, calculated in paragraph (a) above, 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 (F)(4)(a)(ii) (G)(4)(a)(ii) of this rule, or the MMMNA cap. If 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) If When there is court ordered support that is greater than the MIA calculated above, the court ordered amount is used as the MIA.
(c) If 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) If 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 if when there is a an FMNA.
(a) Subtract a an FA if 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 a an FMNA if 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 if when there is a spouse in the community. The FMNA is calculated as follows. (i)(ii) Subtract the combined monthly income of the dependent family members from the FMNA standard; then (ii)(iii) Round the result down to the nearest dollar. (iii)(iv) The remainder is the FMNA.
(i) The FMNA standard is the Ohio works first (OWF) payment standard for the same number of applicable dependent family members.
(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: (iii)(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.
(i) The service must have been was medically necessary as determined by the administrative agency.
(ii) Expenses for medical care shall not have been 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.
(7) Subtract the payment to a financial institution 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) If 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.
Notes
Promulgated Under: 111.15
Statutory Authority: 5160.02, 5163.02
Rule Amplifies: 5163.33
Prior Effective Dates: 06/01/1988 (Emer.), 08/01/1988 (Emer.), 10/30/1988, 01/01/1990 (Emer.), 03/01/1990 (Emer.), 03/30/1990 (Emer.), 04/01/1990, 06/29/1990, 07/01/1990, 10/01/1990, 01/01/1991 (Emer.), 04/01/1991, 01/01/1992 (Emer.), 03/20/1992, 05/01/1992 (Emer.), 07/01/1992, 08/14/1992 (Emer.), 11/01/1992, 05/01/1993, 09/01/1993, 07/01/1994, 01/01/1995 (Emer.), 03/20/1995, 10/01/1995, 04/01/1996, 01/01/1997 (Emer.), 02/09/1997, 12/31/1997 (Emer.), 02/01/1998, 04/01/1999, 01/01/2000, 01/01/2001, 05/12/2002, 07/01/2005, 12/01/2006, 11/01/2013, 01/01/2016, 09/01/2017