5160:1-3-04.4 Medicaid: income and patient liability determinations for individuals under the assisted living home and community based waiver.

 

 

 

5160:1-3-04.4              Medicaid: income and patient liability determinations for individuals under the assisted living home and community based waiver.

 

 

 

(A)For individuals enrolled in the assisted living waiver, this rule defines how the administrative agency will:

 

(1) Compute income to determine medicaid eligibility, and

 

(2) Determine patient liability.

 

(B)Definitions. All definitions found in rules 5160:1-3-04.2 and 5160:1-3-04.3 of the Administrative Code apply to the content of this rule, with the following additions:

 

(1)"Assisted living facility" means a facility certified by the Ohio department of aging in accordance with rule 173-39-02 of the Administrative Code.

 

(2)"Assisted living waiver" (ALW) means the home and community based services waiver, approved by the centers for medicare and medicaid services, that provides an alternative to nursing facility placement for persons aged twenty-one and over who require intermediate or skilled care.

 

(3)"Assisted living waiver maintenance needs allowance" (ALMNA) means the amount equal to the supplemental security income (SSI) federal benefit rate, which is a required deduction in the computation of patient liability for those enrolled in the ALW. This amount is to be used for the needs of an individual enrolled in the ALW. For these individuals, the ALMNA is used in lieu of the special individual maintenance needs allowance found in rule 5160:1-3-04.3 of the Administrative Code.

 

(4)"Personal needs allowance" for individuals enrolled in the ALW is a required deduction in the computation of patient liability. It is the total of the ALMNA plus up to sixty-five dollars for those individuals who receive earnings from employment.

 

(5)"SSI federal benefit rate" means the monthly amount issued by the social security administration to individuals receiving SSI cash payments. It is adjusted each year effective the first of January.

 

(C)The administrative agency must:

 

(1)Determine medicaid eligibility in accordance with the eligibility rules contained in Chapters 5160:1-1 through 5160:1-6 of the Administrative Code, including the individual's eligibility for medicaid buy-in and low-income medicare assistance programs, in accordance with rules 5160:1-3-02.6, 5160:1-3-02.1 and 5160:1-3-02.2 of the Administrative Code.

 

(2) Process requests for enrollment into the ALW in accordance with this rule, and

 

 

rules 5160:1-2-01.6 and 5160-33-04 of the Administrative Code.

(3) Determine if the individual meets the income criteria for medicaid eligibility for coverage of services under the ALW program, using the same methodology found in rule 5160:1-3-04.2 of the Administrative Code.

(4) Determine patient liability in accordance with the methodology found in rule 5160:1-3-04.3 of the Administrative Code, with the following exceptions:

(a) Calculate   the   personal   needs   allowance   by   using   the   following methodology:

(i) Determine the current SSI federal benefit rate.

(ii) For individuals who have no earned income, the SSI federal benefit rate amount is the ALMNA.

(iii) For individuals who have earned income as a result of employment, the ALMNA is the total of the following two amounts:

(A)        The SSI federal benefit rate, and

(B)         Up to a maximum of sixty-five dollars of the gross earnings received as a result of employment.

(iv) The ALMNA is used as the personal needs allowance for ALW eligible individuals in the calculation of patient liability.

(b) The remainder, after subtracting all other applicable exemptions and deductions listed in rule 5160:1-3-04.3 of the Administrative Code, is the individual's patient liability.

(D) The individual must pay the patient liability amount to the facility in accordance with rule 5160:1-3-04.3 of the Administrative Code.

(E) The administrative agency must issue proper notice and hearing rights as outlined in division 5101:6 of the Administrative Code.

Replaces:                                                              5163:1-3-24.1

Effective:                                                             01/01/2016

Five Year Review (FYR) Dates:                         01/01/2021

CERTIFIED ELECTRONICALLY
Certification
12/02/2015
Date
Promulgated Under:	111.15
Statutory Authority:	5160.02, 5163.02
Rule Amplifies: Prior Effective Dates:	5160.02, 5163.02 7/1/06 (Emer.), 9/15/06