(A) Purpose
This rule establishes requirements and procedures regarding
personal needs allowance accounts of residents of an intermediate care facility
for individuals with intellectual disabilities (ICFIID).
(B) Definitions
For the purposes of this rule, the following definitions
shall apply:
(1) "Patient liability" means an individual's
financial obligation toward the medicaid cost of care.
(2) "Personal needs allowance" means a
required deduction in the computation of patient liability for needs of a
resident of an ICFIID.
(3)
"Personal needs allowance account" means an account or petty cash fund that
holds the
money
personal needs allowance funds of a resident of an
ICFIID and is managed for the resident by the ICFIID.
(C) Management of resident funds
(1) An ICFIID
shall
will allow
residents to manage their financial affairs and teach them to do so to the
extent of their capabilities in accordance with
42 C.F.R.
483.420, as in effect on the effective date
of this rule.
(2) An ICFIID
shall
will
hold, safeguard, manage, account for, and convey a resident's funds in
accordance with rule
5123:2-2-07
5123-2-07 of the Administrative Code.
(D) Personal needs allowance
account
(1) A medicaid-eligible resident of an
ICFIID may retain a personal needs allowance account in the amount set forth in
section 5163.33 of the Revised
Code.
(2) A personal needs
allowance account is the exclusive property of the resident, who may use the
funds as
he or she
the resident chooses in any lawful manner.
(3) An ICFIID shall not require a resident to
deposit
his or her personal needs allowance
funds with the ICFIID; a resident wishing to do so
shall
will submit a
request to the ICFIID in writing.
(4) An ICFIID shall explain both verbally and
in writing to a resident or the resident's representative, as applicable, that
personal needs allowance funds are for the resident to use as
he or she
the
resident chooses. If a resident's representative is the payee for the
resident's personal needs allowance account, the resident's representative
shall be
is
responsible for ensuring that the funds are used to meet the personal needs of
the resident.
(E)
Notification of certain balances and transactions that may affect medicaid
eligibility
(1) When the funds in a personal
needs allowance account of a medicaid-eligible resident reach two hundred
dollars less than the resource limit set forth in rule
5160:1-3-05.1 of the Administrative Code
or section
5163.092 of the Revised Code, as
applicable, the ICFIID shall:
(a) Give written
notice to the resident or the resident's representative, as applicable, that
the resident may lose medicaid eligibility if the amount in the personal needs
allowance account, in addition to the value of other nonexempt resources,
exceeds the resource limit and retain a copy of the written notice in the
resident's file; and
(b) Work with
the resident or the resident's representative, as applicable, and the county
department of job and family services to coordinate a spenddown plan.
(2) An ICFIID shall report to the
county department of job and family services any personal needs allowance
account balance in excess of the resource limit. The county department of job
and family services
shall
will apply the excess amount to the routine cost
of the resident's ICFIID services.
(3) If a resident is considering using
personal needs allowance funds to purchase life insurance, grave space, a
burial account, or other item that may be considered a countable resource, the
ICFIID shall refer the resident or the resident's representative, as
applicable, to the county department of job and family services for an
explanation of the effect the purchase may have on the resident's medicaid
eligibility.
(F)
Limitations on charges to the personal needs allowance account
(1) An ICFIID shall not charge a resident's
personal needs allowance account for items and services that the ICFIID is
required to furnish in order to participate in the medicaid program and that
are included in medicaid payments made to the ICFIID. An ICFIID shall provide
or arrange for, at no charge to a resident, any item or service that is ordered
by a physician, determined medically necessary by the resident's team, and does
not conflict with any state or federal regulations.
(2) Items and services that may not be
purchased with personal needs allowance account funds include, but are not
limited to:
(a) Nursing services;
(b) Dietary services;
(c) Activities programs;
(d) Room and board maintenance
services;
(e) Routine personal
hygiene items and services required to meet the needs of the resident,
including but not limited to, hair hygiene supplies, comb, brush, bath soap,
disinfecting soap or specialized cleansing agents when indicated to treat
special skin problems or to fight infection, razor, shaving cream, toothbrush,
toothpaste, denture adhesive, denture cleaner, dental floss, moisturizing
lotion, tissues, cotton balls, deodorant, incontinence care supplies, feminine
hygiene products, towels, washcloths, hospital gowns, over-the-counter
medication, hair and nail hygiene services, and basic personal
laundry;
(f) Medically related
social services;
(g) Medical
supplies such as irrigation trays, catheters, drainage bags, syringes, and
needles;
(h) Durable medical
equipment;
(i) Air conditioners or
charges to resident for the use of electricity;
(j) Therapy or podiatry services;
and
(k) Charges for telephone
consultation by physicians or other personnel.
(G) Resident requests for items and services
(1) A resident's personal needs allowance
account funds may be used to purchase only those items and services requested
by the resident.
(2) When a
resident requests an item or service for which a charge to the resident's
personal needs allowance account will be made, the ICFIID shall inform the
resident that there will be a charge and the amount of the charge.
(3) An ICFIID shall not require a resident to
request an item or service as a condition for admission to, or continued stay
in, the ICFIID.
(H)
Items and services that may be charged to the personal needs allowance account
(1) An ICFIID shall accept medicaid payment
as payment in full for items and services that are covered by the medicaid
program. If a resident clearly expresses a desire for a particular brand or
item not available from the ICFIID, the resident's personal needs allowance
funds may be used as long as a comparable item of reasonable quality is
available from the ICFIID at no charge.
(2) Items and services that may be charged to
a resident's personal needs allowance account include, but are not limited to:
(a) Telephone, television, or radio for the
resident's exclusive use;
(b)
Personal comfort items, including smoking materials, notions, novelties, and
confections;
(c) Cosmetics and
grooming items and services in excess of those for which payment is made under
the medicaid program;
(d) Personal
reading material;
(e) Stationary or
stamps;
(f) Personal clothing in
excess of that required by paragraph
(G)(1) of rule
5123:2-3-04
(H)(1) of rule
5123-3-04 of the
Administrative Code;
(g) Specialty
laundry services such as dry cleaning, mending, or hand-washing;
(h) Flowers or plants;
(i) Gifts
purchased on behalf of a resident
the resident purchases for others;
(j) Social events or entertainment offered
outside the scope of the ICFIID's activities program; and
(k) Burial plots.
(I) Monitoring
The county department of job and family services
shall
will
monitor personal needs allowance accounts in accordance with section
5163.33 of the Revised Code. At
least once a quarter, a designated employee of the county department of job and
family services shall
will determine if an ICFIID is following the
provisions of this rule, and
shall report any questions concerning
inappropriate use or inadequate record keeping of personal needs allowance
funds to the department and to the Ohio department of health for further
action. Inappropriate use of personal needs allowance funds by a payee or an
ICFIID does not, however, reduce the scope or duration of medicaid benefits for
a medicaid recipient.
(J)
Disposition of personal needs allowance account funds
in the event of a resident's death
(1)
A department-operated ICFIID that has possession of a
resident's personal needs allowance account funds at the time of the resident's
death will dispose of the funds in accordance with section
5123.28 of the Revised
Code.
(2)
An ICFIID other than a department-operated ICFIID that
has possession of a resident's personal needs allowance account funds at the
time of the resident's death will dispose of the funds in accordance with
paragraphs (J)(2)(a) to (J)(2)(c) of this rule, as applicable.
(a)
If funeral or
burial expenses for a deceased resident have not been paid and the only
resource left to pay those expenses is the resident's personal needs allowance
account funds, or all other resources of the resident are inadequate to pay the
full amount, the resident's personal needs allowance account funds will be used
to pay the expenses.
(b)
If, within sixty calendar days after the resident's
death, letters testamentary or letters of administration are issued, or an
application for release from administration is filed under section
2113.03 of the Revised Code
concerning the resident's estate, the ICFIID will transfer the resident's
personal needs allowance account funds and a final accounting of those funds to
the administrator, executor, commissioner, or person who filed the application
for release from administration.
(c)
If, within sixty
calendar days after the resident's death, letters testamentary or letters of
administration are not issued, or an application for release from
administration is not filed under section
2113.03 of the Revised Code
concerning the resident's estate, and if the resident was a recipient of
medicaid benefits, the ICFIID will transfer the resident's personal needs
allowance account funds to the Ohio department of medicaid no earlier than
sixty calendar days and no later than ninety calendar days after the resident's
death, with the exception of the amount used for funeral or burial expenses in
accordance with paragraph (J)(2)(a) of this rule. Personal needs allowance
account funds transferred to the Ohio department of medicaid will be
accompanied by a completed Ohio department of medicaid form 09405, "Personal
Needs Allowance Account Remittance Notice," in accordance with the instructions
on the form.
Notes
Ohio Admin. Code 5123-7-09
Effective:
4/27/2023
Five Year Review (FYR) Dates:
12/16/2024
Promulgated
Under: 119.03
Statutory
Authority: 5123.04,
5123.28,
5124.03
Rule
Amplifies: 5123.04,
5123.28,
5124.03,
5163.33
Prior
Effective Dates: 01/10/2013, 12/16/2019