3701-43-16.2. Financial eligibility requirements for payment for treatment for adults with cystic fibrosis

(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 an 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) 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.

(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. 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 guidelines, 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 of two thousand dollars.

(B) The director shall determine the applicant or recipient to be financially eligible for payment for treatment services if either of the following apply:

(1) Family income of the applicant's or recipient's family unit, as defined in paragraph (A)(3) of this rule, is less than or equal to the applicable income guideline, as defined in paragraph (A)(1) of this rule; or

(2) The service level credit for the applicant or recipient, as defined in paragraph (A)(5) of this rule, equals or exceeds his or her family unit's maximum ability to pay for medical care, as defined in paragraph (A)(4) of this rule.

(C) Notwithstanding paragraph (B) of this rule, in order to assure that services to a medically eligible applicant will not be interrupted, the director may determine that such an applicant is financially eligible for payment for treatment services if the applicant's family unit provides satisfactory evidence of both of the following:

(1) During the twelve-month period before the date of application, the family unit paid for unreimbursed medical, vision, therapy services and dental services that were provided to any member of the family unit, or the family unit has contracted in writing to pay for any such services during the twelve months after the date of application; and

(2) The total dollar amount that the family unit spent or is contracted to pay equals or exceeds the difference the maximum ability to pay for medical care, as defined in paragraph (A)(4) of this rule, and the applicable service level credit, as defined in paragraph (A)(5) of this rule.

(D) Applicants or recipients who are receiving services from the special supplemental food program for women, infants, and children (WIC), supplemental security income (SSI) benefits, or medicaid benefits, except for delayed medical spend-down cases as defined in rule 5101:1-39-10 of the Administrative Code, are financially eligible for payment for treatment by the program.

R.C. 119.032 review dates: 10/28/2013 and 10/28/2018
Promulgated Under: 119.03
Statutory Authority: 3701.021
Rule Amplifies: 3701.023
Prior Effective Dates: 10/1/2005

Prior History: (R.C. 119.032 review dates: 09/15/2010 and 09/01/2013
Promulgated Under: 119.03
Statutory Authority: 3701.021
Rule Amplifies: 3701.023
Prior Effective Dates: 10/01/2005 )