Sec. 5160:1-6-01.1 - Medicaid: definitions relating to eligibility for long-term care services

ยง 5160:1-6-01.1. Medicaid: definitions relating to eligibility for long-term care services

(A) For purposes of this chapter the following definitions apply unless otherwise stated.

(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 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;

(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, 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.

(9) "Family maintenance needs allowance standard" means the current Ohio works first payment standard for the same number of applicable dependent family members.

(10) "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.

(11) "Home" is defined in rule 5160:1-3-05.13 of the Administrative Code.

(12) "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).

(13) "Improper transfer" means a transfer or disposal of an asset any time after the look-back date for less than fair market value.

(14) "Income" is defined in rules 5160:1-3-03.1 and 5160:1-4-01 of the Administrative Code.

(15) "Individual" means the person requesting or receiving LTC services.

(16) "Institutionalized individual" means an individual who is:

(a) An inpatient in a long-term care facility (LTCF); or

(b) Eligible for enrollment in an HCBS waiver by using the special income level (SIL) described in rule 5160:1-6-03.1 of the Administrative Code.

(17) "Institutionalized spouse" (IS) means an individual who is:

(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.

(18) "Look-back date" means the date that is sixty months before the individual's baseline date.

(19) "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 payment is made based on a level-of-care provided in a nursing facility.

(20) "Long-term care (LTC) services" means care provided to medicaid eligible individuals in a medical institution as defined in paragraph (A)(21) of this rule, through an HCBS waiver, or through PACE.

(21) "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).

(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) "Monthly income allowance" (MIA) means a required deduction in the computation of patient liability to provide for the needs of the community spouse.

(24) "Personal needs allowance" (PNA) means a required deduction in the computation of patient liability for needs of the individual.

(25) "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) "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) "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) "Standard utility allowance" (SUA) is the amount used in lieu of the actual amount of utility costs.

(29) "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.

(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.

(Effective: 9/1/2017 Five Year Review (FYR) Dates: 09/01/2022 Promulgated Under: 111.15 Statutory Authority: 5163.02, 5160.02 Rule Amplifies: 5160.02, 5163.02)

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