Ohio Adm.Code 5160:1 | Ohio Administrative Code 5160:1 — Ohio Department of Medicaid | Eligibility

Chapter 5160:1-1 Medicaid General Principles

Ohio Adm.Code 5160:1-1-01 Medicaid: definitions.

(A) This rule contains definitions generally used in determining eligibility for medical assistance.

(B) Definitions.

(1) "Abuse" means any action by an individual or entity that results in unnecessary costs to the medical assistance program in accordance with 42 C.F.R 455.2 (as in effect October 1, 2022).

(2) "Administrative agency" means the Ohio department of medicaid (ODM) and/or an agent of ODM authorized to determine eligibility for a medical assistance program.

(3) "Advance notice of adverse action" means a written notice of the administrative agency's intent to discontinue or suspend medical assistance, reduce the level of benefits or covered services, or increase the amount of an individual's premium or patient liability, sent no less than fifteen calendar days prior to the date of the proposed action in accordance with rules 5101:6-2-04 and 5101:6-2-05 of the Administrative Code.

(4) "Applicant" means an individual who is seeking an eligibility determination for himself or herself through an application submission or a transfer from another agency or insurance affordability program in accordance with 42 C.F.R. 435.4 (as in effect October 1, 2022).

(5) "Approve" or "approval" means a determination by the administrative agency that an individual is eligible for one or more categories of medical assistance applied for by the individual or on behalf of the individual by his or her authorized representative.

(6) "Assets" means all income and resources of the individual and of the individual's spouse. This includes any income or resources the individual or the individual's spouse is entitled to, but does not receive, because of an action taken to avoid receipt of the asset by:

(a) The individual or the individual's spouse; or

(b) A person, including a court or administrative body, with legal authority to act in place of, or on behalf of, the individual or the individual's spouse; or

(c) Any person, including any court or administrative body, acting at the direction, or upon the request, of the individual or the individual's spouse.

(7) "Assignment" means an individual eligible for medical assistance has transferred his or her right, or the rights of any other individual for whom he or she can legally make an assignment, to collect and retain third-party and/or medical support payments to ODM up to the amount of medical services paid under the medicaid program.

(8) "Authorized representative" means a person, who is at least eighteen years of age, or a legal entity who stands in place of the individual. Actions or failures of an authorized representative will be accepted as the action or failure of the individual. When an individual has designated an authorized representative, all references to the individual's responsibilities include the authorized representative in accordance with rule 5160-1-33 of the Administrative Code.

(9) "Base eligibility" means the individual meets all of the eligibility requirements for at least one category of medical assistance described in Chapter 5160:1-3, 5160:1-4, or 5160:1-5 of the Administrative Code.

(10) "Caretaker relative" means a relative of a dependent child by blood, adoption, or marriage with whom the child is living, who assumes primary responsibility for the child's care (as may, but is not required to, be indicated by claiming the child as a tax dependent for federal income tax purposes), and who is one of the following:

(a) The child's father, mother, brother, sister, stepfather, stepmother, stepbrother, or stepsister; or

(b) The child's grandfather, grandmother, uncle, aunt, nephew, or niece, including such relatives with the prefix great, great-great, grand, or great-grand; or

(d) The spouse of such parent or relative, even after the marriage is terminated by death or divorce.

(11) "Case record" means electronic or paper documents and information used to determine, redetermine, or renew an individual's eligibility for medical assistance.

(12) "Creditable insurance" or "creditable coverage" means health insurance coverage as defined in 42 U.S.C. 300gg-3(c) (as in effect October 1, 2022).

(a) This includes:

(i) A group health plan; or

(ii) Health insurance coverage; or

(iii) Medicare part A, as set forth in 42 U.S.C. 1395c to 1395i-5 (as in effect October 1, 2022) or part B, as set forth in 42 U.S.C. 1395j to 1395w-6 (as in effect October 1, 2022); or

(iv) Coverage under medicaid, as set forth in Title XIX of the Social Security Act, other than coverage consisting solely of benefits under the pediatric vaccine program set forth in 42 U.S.C. 1396s (as in effect October 1, 2022); or

(v) Armed forces health insurance as set forth in 10 U.S.C. 1071 to 1110b (as in effect October 1, 2022); or

(vi) A medical care program of the Indian health service or of a tribal organization; or

(vii) A state health benefits risk pool; or

(viii) A federal employee health plan offered under 5 U.S.C. 8901 to 8992 (as in effect October 1, 2022); or

(ix) A public health plan; or

(x) A peace corps volunteer health benefit plan under section 22 U.S.C. 2504 (as in effect October 1, 2022).

(b) Creditable insurance does not include:

(i) Coverage only for accident or disability income insurance; or

(ii) Liability insurance, including general liability insurance and automobile liability insurance, or coverage issued as a supplement to liability insurance; or

(iii) Workers' compensation or similar insurance; or

(iv) Automobile medical payment insurance; or

(v) Credit insurance which pays off existing debts in the event of death, disability, or unemployment; or

(vi) Coverage for employment onsite medical clinics; or

(vii) Other similar insurance coverage under which benefits for medical care are secondary or incidental to other insurance benefits; or

(viii) Limited-scope dental or vision benefits; or

(ix) Benefits for long-term care, nursing facility care, home health care, or community-based care; or

(x) Coverage only for a specified disease or illness; or

(xi) Hospital indemnity or other fixed indemnity insurance, if purchased separately; or

(xii) Medicare supplemental health insurance as defined under 42 U.S.C. 1395ss (as in effect October 1, 2022), coverage supplemental to the coverage provided to military or former military personnel under 10 U.S.C. 1071 to 1110b (as in effect October 1, 2022), and similar supplemental coverage provided to coverage under a group health plan; or

(xiii) Coverage through a medical cost-sharing program, including a health care cost-sharing ministry.

(13) "Deduction" means a verifiable amount the individual pays for an expense. Garnishments or liens placed against earned or unearned income of an individual are not considered a deduction, regardless of the reason for the garnishment or lien.

(14) "Deny" or "denial" means a determination by the administrative agency that an individual is not eligible for one or more categories of medical assistance applied for by the individual or on behalf of the individual by his or her authorized representative.

(15) "Dependent child" means a person younger than age eighteen living with a parent or caretaker relative.

(16) "Discontinue" or "discontinuance" means a determination by the administrative agency that an individual is no longer eligible, or has failed to cooperate with verification of eligibility, for one or more categories of medical assistance currently being received by that individual, resulting in a written notice of the administrative agency's intention to end coverage under that category and providing notice of hearing rights in accordance with 42 C.F.R. 435.917 (as in effect October 1, 2022).

(17) "Disregard" means the amount subtracted from gross, non-excluded income in the medical assistance budget calculation.

(18) "Early and periodic screening, diagnostic and treatment" (EPSDT) means screening, vision, dental, and hearing services, and such other necessary health care, diagnostic services, treatment, and other measures described in 42 U.S.C. 1396d (as in effect October 1, 2022) to correct or ameliorate defects and physical and mental illnesses and conditions discovered by the screening services, whether or not such services are covered under the medicaid state plan. Healthchek is Ohio's EPSDT program.

(19) "Earned income" means income in cash or in-kind received as payment for services performed as an employee or as a self-employed individual. Earned income includes but is not limited to wages, salary, or commissions from which state or federal income taxes are paid or withheld.

(20) "Electronic equivalent" means an electronic version of an Ohio department of job family services (ODJFS) or ODM form or application which has not been modified in any way, other than format, prior to completion and submission of that form to the administrative agency. The administrative agency is not required to accept forms that are altered.

(21) "Electronic protected health information" (ePHI) means any protected health information (PHI) that is maintained or transmitted in electronic form, regardless of the format.

(22) "Electronic signature" means an electronic sound, symbol, or process attached to, or logically associated with, a record and executed or adopted by a person with the intent to sign the record as defined in section 1306.01 of the Revised Code.

(23) "Encumbrance" means a claim, lien, charge, or liability attached to and binding on an identified piece of real or personal property.

(24) "Equity value" means the fair market value of a resource minus any encumbrance.

(25) "Erroneous payment" means a medicaid reimbursement made for an individual who was ineligible at the time services were received, regardless of the presence of fraud or abuse.

(26) "Excluded income" means income that state or federal law prohibits from consideration in determining eligibility for medical assistance.

(27) "Fair market value" means, unless otherwise stated, the going price, at the time of the transfer or contract of sale, for which real or personal property can reasonably be expected to sell on the open market in the relevant geographic area. The appraised value of real property is determined by the county auditor and may be used to establish fair market value.

(28) "Family size" means the number of persons counted as members of an individual's medicaid household.

(29) "Federal adoption assistance" (AA) means the Title IV-E subsidy program as defined by the Adoption Assistance and Child Welfare Act of 1980 (Pub. L. No. 96-272).

(30) "Federal benefit rate" (FBR) means the supplemental security income (SSI) current payment standard published annually by the social security administration (SSA).

(31) "Federal foster care maintenance" (FCM) means the Title IV-E program, as described in rule 5101:2-47-01 of the Administrative Code.

(32) "Federal kinship guardianship assistance program" (KGAP) means the Title IV-E program to provide payments to relatives, as defined in section 5101.141 of the Revised Code, who have assumed legal custody or guardianship of eligible children whom they have cared for as foster parents for a minimum of six consecutive months and for whom there is a valid KGAP or KGAP C21 agreement.

(33) "Federal means-tested public benefit" means a benefit in which eligibility for the benefit or the amount of the benefit, or both, is determined on the basis of income or resources of the individual seeking the benefit. Medicaid, cash assistance, and food assistance are federal means-tested public benefits, but certain other benefits listed in 8 U.S.C. 1613(c) (as in effect October 1, 2022) are not considered means-tested.

(34) "Federal poverty level" (FPL) means a measure of income determined annually by the department of health and human services (HHS). The FPL is designed to provide a baseline for determining financial eligibility for federal programs and benefits.

(35) "Good cause" means circumstances that reasonably prevent an individual from cooperating with the administrative agency in the eligibility determination process. Factors relevant to good cause include, but are not limited to, natural disasters, riots or civil unrest, death or serious illness of the individual or a member of his/her immediate family, or the physical, mental, educational, or linguistic limitations of the individual.

(36) "Gross income" means income prior to any deductions or disregards, with the exception of self-employment gross countable income.

(37) "Health Insurance Portability and Accountability Act of 1996" (HIPAA) means a federal law to protect patient privacy, to protect security of electronic medical records, to prescribe methods and formats for exchange of electronic medical information, and to uniformly identify providers.

(38) "Immigrant" means a person who comes to the United States (U.S.) with plans to live in the country permanently. This term includes, but is not limited to, an individual who is a refugee, asylee, parolee, or other entrant regardless of whether he or she is residing in the U.S. legally.

(39) "Income" means cash, in-kind income as defined in paragraph (B)(43) of this rule, or something of value which is received, available, and attributable to an individual. Income includes the receipt of any item which can be applied, either directly or by sale or conversion, to meet the needs of an individual.

(40) "Income and eligibility verification system" (IEVS) means the electronic system that shares income and asset information among the social security administration (SSA), internal revenue service (IRS), state wage information collection agency (SWICA), agencies administering unemployment compensation (UC) benefits, and the administrative agency.

(41) "Individual" means a person applying for or receiving medical assistance.

(42) "Individually identifiable health information" means information that is a subset of health information that includes demographic information collected from an individual and:

(a) Is created or received by a health care provider, health plan, employer, or health care clearinghouse; and

(b) Relates to the past, present, or future physical condition or mental health condition of an individual, the provision of health care to an individual, or the past, present, or future payment for the provision of health care to an individual and either:

(i) Identifies the individual; or

(ii) There is a reasonable basis to believe the information can be used to identify the individual.

(43) "In-kind income" means any benefit received other than cash such as food, shelter, or something that can be used to get food or shelter.

(44) "Institution for mental diseases" (IMD) means a hospital, nursing facility, or other institution of more than sixteen beds which primarily provides diagnosis, treatment, or care of persons with mental diseases, including medical attention, nursing care, and related services.

(a) A facility is an IMD, whether or not it is licensed as such, if it is operated primarily for the care and treatment of individuals with mental diseases.

(b) An institution for persons with cognitive impairments or other developmental disabilities is not an IMD.

(45) "Lawfully residing" means a qualified non-citizen immigration status granted to an individual allowing him or her to live and/or work in the United States.

(46) "Legal custodian" means a person who has legal rights to have physical care and control of a child, as defined in section 2151.011 of the Revised Code.

(47) "Legal guardian" means any person, association, or corporation appointed by a probate court to exercise care and management of an individual, his or her estate, or both, as defined in section 2111.01 of the Revised Code.

(48) "Limited English proficiency" (LEP) means the inability of any person or group of persons to speak, read, write, or understand the English language at a level that allows them to meaningfully communicate with the administrative agency.

(49) "Liquid resource" means cash or property immediately convertible to cash.

(50) "Lump-sum" means a non-recurring payment received in a single amount, as opposed to smaller payments over time.

(51) "Managed care organization" (MCO) has the same meaning as in rule 5160-26-01 of the Administrative Code.

(52) "Medicaid buy-in for workers with disabilities" (MBIWD) as set forth in rule 5160:1-5-03 of the Administrative Code, is a category of medical assistance that enables workers with disabilities to earn income and have resources, not to exceed the limits established by the state, without the risk of losing health care coverage.

(53) "Medicaid eligibility fraud" means an intentional deception or misrepresentation made by a person with the knowledge that the deception could result in an unauthorized benefit to himself, herself, or some other person in accordance with 42 C.F.R. 455.2 (as in effect October 1, 2022). It includes any act that constitutes fraud under applicable federal or state law.

(54) "Medicaid household" means a group of individuals, defined in relationship to one specific medical assistance applicant or recipient, who impact the applicant's or recipient's family size, household income, or both.

(55) "Medical assistance" includes all programs administered by the state medicaid administrative agency.

(56) "Medical support" means an order by a court to provide medical coverage.

(57) "Medical verification of pregnancy" means a written statement signed by a licensed medical professional verifying pregnancy and includes the expected date of delivery and, if more than one, the expected number of fetuses.

(58) "Minor child" means a person younger than age eighteen.

(59) "Modified adjusted gross income" (MAGI or MAGI-based income) means the income methodology used for determining medical assistance eligibility for children through age eighteen, parents, caretaker relatives, pregnant women, and adults age nineteen through sixty-four.

(60) "Non-applicant" means a person who is not seeking an eligibility determination for himself or herself but is included in an applicant's or recipient's medicaid household to determine eligibility for such applicant or recipient.

(61) "Non-citizen emergency medical assistance" (NCEMA) as established in rule 5160:1-5-06 of the Administrative Code, means time-limited coverage of an emergency medical condition for certain individuals who do not meet the citizenship or satisfactory immigration status requirements.

(62) "Non-cooperation" or "failure to cooperate" means failure by an individual to present required verification, or to explain why it is not possible to present the verification, after being notified the verification was required for eligibility determination.

(63) "Non-excluded income" means income (earned or unearned) that is used in the eligibility determination for medical assistance.

(64) "Outstationing" means the federal requirement as described in 42 C.F.R. 435.904 (as in effect October 1, 2022) that administrative agencies provide opportunities for low-income pregnant women and children to apply for medical assistance at locations other than the local county department of job and family services.

(65) "Parent" means a natural, adoptive, or step-parent.

(66) "Personal property" means any property that is not real property, as defined in paragraph (B)(75) of this rule. Personal property includes, but is not limited to, such things as cash, jewelry, household goods, tools, life insurance policies, automobiles, and promissory notes.

(67) "Postpartum period" means the maximum permitted period of coverage as described in 42 U.S.C. 1396a(e) (as in effect October 1, 2022).

(68) "Pre-termination review" (PTR) means a review of eligibility criteria completed prior to each discontinuance of medical assistance, to determine whether an individual is eligible for any other category of medical assistance in accordance with 42 C.F.R. 435.916(f)(1) (as in effect October 1, 2022). Home and community-based services (HCBS), as defined in rule 5160:1-6-01.1 of the Administrative Code, the specialized recovery services (SRS) program described in rule 5160:1-5-07 of the Administrative Code, or both will be explored as part of the PTR process when:

(a) The individual or his or her authorized representative has requested HCBS or SRS; or

(b) The individual's case record contains information indicating that he or she may be eligible for or in need of HCBS or SRS. Receipt of SSI, social security disability insurance (SSDI), or any other income type resulting from an individual's disability is not sufficient, by itself, to demonstrate potential eligibility for or need of HCBS or SRS. There must be additional factors in the case record that indicate the individual's potential eligibility for or need of HCBS or SRS.

(69) "Private child placing agency" (PCPA) means any association that is certified to accept temporary, permanent, or legal custody of children and place the children for foster care or adoption, as defined in rule 5101:2-1-01 of the Administrative Code.

(70) "Protected health information" (PHI) means individually identifiable health information that is transmitted by electronic media, maintained in electronic media, or transmitted or maintained in any other form or medium.

(71) "Public children services agency" (PCSA) means an entity that has assumed the powers and duties of the children services function for a county, as defined in rule 5101:2-1-01 of the Administrative Code.

(72) "Public institution" means an institution, as defined in 42 C.F.R. 435.1010 (as in effect October 1, 2022), that is the responsibility of a governmental unit or over which a governmental unit exercises administrative control, such as a state or federal prison, local jail, detention facility, or other penal setting. Public institution does not include a medical institution, an intermediate care facility, a publicly operated community residence that serves no more than sixteen residents, or a child care institution.

(73) "Qualified entity" means the source of eligibility determinations for the presumptive eligibility program and is limited to the following:

(a) A county department of job and family services (CDJFS); or

(b) A hospital, the Ohio department of rehabilitation and correction (DRC), or the Ohio department of youth services (DYS); or

(c) A federally qualified health center (FQHC) or an FQHC look-alike that meets the requirements described in Chapter 5160-28 of the Administrative Code; or

(d) A local health department, a special supplemental nutrition program for women, infants, and children (WIC) clinic, or other entity as designated by the director.

(74) "Recipient" means an individual who has been determined eligible and is currently receiving medical assistance in accordance with 42 C.F.R. 435 (as in effect October 1, 2022).

(75) "Real property" means land, including buildings or immovable objects attached permanently to the land.

(76) "Refugee" means a person who flees his or her country due to persecution or a well-founded fear of persecution because of race, religion, nationality, political opinion, or membership in a social group and is admitted to the United States under Section 207 of the Immigration and Nationality Act (INA), 8 U.S.C. 1157 (as in effect October 1, 2022).

(77) "Redetermination" means acting upon new or changed information received after an individual's eligibility has been determined but prior to the regularly scheduled annual renewal.

(a) The administrative agency shall only redetermine eligibility using the new or changed information. All other factors of eligibility not affected by the new or changed information are presumed unchanged.

(b) The original renewal date is not changed when eligibility has been redetermined, unless the administrative agency has sufficient information regarding all eligibility factors to renew eligibility without requesting additional information from the individual.

(78) "Renew" or "renewal" means a review of eligibility factors to determine whether the individual continues to meet all of the criteria of a medical assistance category. A renewal is performed annually.

(79) "Reporting" means notifying the administrative agency of any changes that may affect an individual's eligibility for medical assistance. Reporting changes and providing verifications is the responsibility of any individual, person, or entity who has a legal or financial responsibility for, or who stands in the place of, an individual, including:

(a) The individual; and

(b) The individual's spouse, including a community spouse; and

(d) The individual's authorized representative.

(80) "Residence" means the place the individual considers his or her established or principal home and to which, if absent, he or she intends to return.

(81) "Residential care facility" (RCF) means a home that provides either of the following as described in section 3721.01 of the Revised Code:

(a) Accommodations for seventeen or more unrelated individuals and supervision and personal care services for three or more of those individuals who are dependent on the services of others by reason of age or physical or mental impairment; or

(b) Accommodations for three or more unrelated individuals, supervision and personal care services for at least three of those individuals who are dependent on the services of others by reason of age or physical or mental impairment, and, to at least one of those individuals, any of the skilled nursing care authorized by section 3721.011 of the Revised Code.

(82) "Resources" means cash, funds held within a financial institution, investments, personal property, and real property an individual and/or the individual's spouse has an ownership interest in, has the legal ability to access in order to convert to cash, and is not legally prohibited from using for support and maintenance.

(83) "Safeguarding" means security measures taken to ensure that the information of individuals applying for or receiving medical assistance is protected against unauthorized inspection, disclosure, or use. Safeguarding also refers to the restriction on the use, or disclosure, of individual information including federal tax information (FTI), any protected health information (PHI), or other confidential information used in the administration of the medicaid program in accordance with rule 5160-1-32 of the Administrative Code.

(84) "Self-attestation" or "self-declaration" means a statement of factual information made by an individual.

(85) "Self-Employment gross countable income" means the income from a business minus the expenses directly related to producing the goods or services, and without which the goods or services could not be produced.

(a) When the individual has filed taxes for the previous year, use all tax forms that were filed with the internal revenue service (IRS) to determine his or her self-employment gross countable income.

(b) When the individual has not filed taxes for the previous year, the following may be used to determine his or her self-employment gross countable income:

(i) Business records including receipts for the costs of doing business; or

(ii) Estimate of anticipated income and expenses.

(86) "Spouse" means a person who is legally married to another under Ohio law.

(87) "State adoption assistance" means the state-only adoption subsidy program as described in rule 5101:2-44-03 of the Administrative Code.

(88) "State foster care maintenance" means an entitlement for financial assistance for state-only foster care services as described in Chapter 5101:2-7 of the Administrative Code.

(89) "Support Services" means non-medical services offered or provided by the administrative agency to assist the individual and may include arranging or providing transportation, making medical appointments, accompanying the individual to medical appointments, and making referrals to community and other social services to be coordinated with the individual's medicaid-contracted managed care organization (MCO), where applicable.

(90) "Suspend" or "suspended" means the temporary discontinuance of eligibility.

(91) "Temporary absence" means that an individual is considered not to have changed residence and intends to return.

(a) An individual is considered to be temporarily absent with no time limit when all of the following conditions are met:

(i) The location of the absent individual is known; and

(ii) There is a definite plan for the return of the absent individual to the residence; and

(iii) The absent individual lived in the residence immediately prior to the absence, except for individuals described in paragraph (C)(1)(h) of rule 5160:1-4-02 of the Administrative Code.

(b) Child(ren) removed by the PCSA are considered temporarily absent as long as the reunification requirements specified in the reunification plan are met.

(92) "Terminate" or "terminated" has the same meaning as "discontinue" or "discontinuance" as defined in paragraph (B)(16) of this rule.

(93) "Unearned income" means all income that is not earned income as defined in paragraph (B)(19) of this rule.

(94) "United States (U.S.)" and "state(s)" mean all fifty U.S. states, the District of Columbia, and the U.S. territories of American Samoa, Guam, the Northern Mariana Islands, Puerto Rico, Swain's Island, and the U.S. Virgin Islands.

(95) "United States citizen or national" means any individual who is:

(a) A citizen or national through birth or collective naturalization as set forth in 8 U.S.C. Chapter 12, Subchapter III, Part I (as in effect October 1, 2022); or

(b) A naturalized citizen or national as set forth in 8 U.S.C. Chapter 12, Subchapter III, Part II (as in effect October 1, 2022).

(96) "Verification" means a document, statement, electronic validation, or other type of information provided by an individual or by a third party to confirm statements made by the individual regarding any requirement for eligibility for medical assistance. A verification document or written statement may be an original, photocopy, facsimile (fax), or electronic version of the original, unless otherwise stated.

Last updated June 27, 2025 at 12:22 AM

History

Effective: January 1, 2023
Promulgated Under: 111.15

Ohio Adm.Code 5160:1-1-03 Medicaid: restrictions on payment for services.

(A) Medicaid will not pay for services provided under the conditions set out in paragraph (C) of this rule, even when an individual has been found eligible for a medical assistance category and is enrolled in medicaid.

(B) Definitions. For the purposes of this rule:

(1) "Eligible juvenile" means:

(a) An individual under the age of twenty-one; or

(b) A former foster care child up to the age of twenty-six as described in 42 C.F.R. 435.150(b) (as in effect October 1, 2024).

(2) "Inmate" means an individual who is serving time for a criminal offense or who is confined in a state or federal prison, jail, detention facility, or other penal facility.

(3) "Inmate of a public institution" means an individual who is living in a public institution as defined in rule 5160:1-1-01 of the Administrative Code.

(a) An individual who is residing in a public institution awaiting criminal proceedings, penal dispositions, or other detainment determinations is considered an inmate. The duration of time that an individual is residing in the public institution awaiting these arrangements does not determine inmate status.

(b) An individual is not considered an inmate when:

(i) Residing in a public educational or vocational training institution for purposes of securing education or vocational training;

(ii) Residing in a public institution for a temporary period pending other living arrangements appropriate to his or her needs;

(iii) Residing in a detention center, jail, or county penal facility after his or her case has been adjudicated and other living arrangements are being decided;

(iv) On parole or probation and living in the community; or

(v) Serving the remainder of the criminal sentence in a halfway house licensed as such by the Ohio department of rehabilitation and correction (DRC), in accordance with section 2967.14 of the Revised Code, which allows for freedom of movement and association as determined by the Ohio department of medicaid (ODM) or its designee.

(4) "Inpatient" means a patient who has been admitted to a medical institution as an inpatient on recommendation of a physician or dentist and who:

(a) Receives room, board, and medical services in the institution for a twenty-four hour period or longer; or

(b) Is expected by the institution to receive room, board, and medical services in the institution for a twenty-four-hour period or longer even though it later develops that the patient dies, is discharged, or is transferred to another facility and does not actually stay in the institution for twenty-four hours.

(5) "Intermediate care facility for individuals with intellectual disabilities" (ICF-IID) is defined in Chapter 5160-3 of the Administrative Code.

(6) "Medical institution" means an institution that:

(a) Is organized to provide medical care, including nursing and convalescent care;

(b) Has the necessary professional personnel, equipment, and facilities to manage the medical, nursing, and other health needs of patients on a continuing basis in accordance with accepted standards;

(d) Is staffed by professional personnel who are responsible to the institution for professional medical and nursing services. The services must include:

(i) Adequate and continual medical care and supervision by a physician;

(ii) Registered nurse or licensed practical nurse supervision and services and nurses' aid services, sufficient to meet nursing care needs; and

(iii) A physician's guidance regarding the professional aspects of operating the institution.

(7) "Outpatient" means a patient of an organized medical facility or distinct part of that facility who is expected by the facility to receive, and who does receive, professional services for less than a twenty-four-hour period regardless of the hour of admission, whether or not a bed is used, and whether or not the patient remains in the facility past midnight.

(8) "Patient" means an individual who is receiving needed professional services that are directed by a licensed practitioner of the healing arts toward maintenance, improvement, or protection of health, or lessening of illness, disability, or pain.

(1) An individual who is an inmate of a public institution, except as outlined in paragraph (D) of this rule; or

(2) An individual who is a patient in an institution for mental diseases (IMD), as defined in rule 5160:1-1-01 of the Administrative Code, who is age twenty-two or older, but under age sixty-five, except:

(a) As permitted in 42 C.F.R. 438.6(e) (as in effect October 1, 2024); or

(b) As permitted under a demonstration waiver approved by the centers for medicare and medicaid services (CMS) under section 1115 of the Social Security Act (as in effect October 1, 2024).

(D) An exception to the prohibition against medicaid payment for services is permitted during the part of the month in which an individual is not an inmate of a public institution.

(1) An individual is not an inmate of a public institution during such time as the individual is admitted as an inpatient in a hospital, nursing facility, juvenile psychiatric facility, or ICF-IID.

(2) There is no time limit on medicaid payment for services as long as the individual continues to be eligible for medical assistance and is receiving services as an inpatient in the medical facility.

(3) An inmate is not considered a patient in a medical institution when:

(a) Services are provided on an outpatient basis at a hospital, nursing facility, juvenile psychiatric facility, ICF-IID, clinic, or physician office; or

(b) Medical care is provided to an inmate in a prison hospital or dispensary.

(E) An individual on conditional release or convalescent leave from an IMD is not considered to be a patient in that institution.

(1) An individual on conditional release is an individual who is on definite leave from the institution, but who is not discharged.

(2) An individual who is released from the institution on the condition that the individual receives outpatient treatment or on other comparable conditions is on conditional release.

(3) An individual who is sent home or to another setting for a trial visit is on convalescent leave.

(F) In accordance with the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act (Pub. L. No. 115-271), medical assistance for an eligible juvenile, as described in paragraph (B)(1) of this rule, will be suspended, not discontinued, when the individual becomes an inmate of a public institution on or after October 24, 2019. Prior to the individual's release from the public institution a redetermination of eligibility will be processed without a new application from the individual.

(G) In accordance with section 5121 of the Consolidated Appropriations Act, 2023 (Pub. L. No. 117-328), in the thirty days prior to release, any state plan screening and diagnostic services which meet reasonable standards of medical and dental practice, or otherwise indicated as medically necessary, and targeted case management services are available to an eligible juvenile, as described in paragraph (B)(1) of this rule.

Last updated July 1, 2025 at 7:57 AM

History

Effective: July 1, 2025
Promulgated Under: 111.15

Ohio Adm.Code 5160:1-1-04 Medicaid: income and eligibility verification system (IEVS).

(A) This rule describes the requirements in section 1137 of the Social Security Act (as in effect October 1, 2025) and in section 42 C.F.R. 435.945 (as in effect October 1, 2025), requiring state agencies administering certain federally funded public assistance programs to establish procedures for obtaining, using, and verifying information relevant to determinations of eligibility. The Ohio department of medicaid (ODM) shall obtain and share income and benefit information with the following sources:

(1) The social security administration (SSA).

(2) The internal revenue service (IRS).

(3) The state wage information collection agency (SWICA).

(4) Agencies administering unemployment compensation (UC) benefits.

(B) Definition. "Income and eligibility verification system" (IEVS) is defined in rule 5160:1-1-01 of the Administrative Code.

(C) Administrative agency responsibilities. Within forty-five days of receipt of the information, the administrative agency shall initiate, pursue, and complete the actions specified in this paragraph:

(1) Provide adequate safeguards in accordance with rule 5160-1-32 of the Administrative Code.

(2) Inform all individuals in writing at the time of application and renewal that the agency will obtain and use information available from IEVS data matches to verify initial or ongoing eligibility for medicaid.

(3) Review and compare against the case record all information received from the IEVS data matches to determine whether the information affects the individual's eligibility, in accordance with 42 C.F.R. 435.948 (as in effect October 1, 2025).

(4) Obtain additional information or documentation from the individual, if needed, to determine eligibility and initiate appropriate action in accordance with 42 C.F.R. 435.952(c) (as in effect October 1, 2025).

(5) Continue benefits while the steps listed in this rule are being taken to verify the matched data in accordance with 42 C.F.R. 435.952(d) (as in effect October 1, 2025). The administrative agency shall verify information relating to:

(a) The amount of the income and resource involved;

(b) Whether the individual actually has or had access and use of the resource, income, or both; and

(6) Update case information and redetermine eligibility when the verification received is discrepant from the information currently listed in the electronic eligibility system. The discrepancy threshold is determined by ODM.

Last updated July 10, 2026 at 7:48 AM

History

Effective: July 10, 2026
Promulgated Under: 111.15

Ohio Adm.Code 5160:1-1-05 Medicaid: asset verification system (AVS).

(A) This rule describes the asset verification program outlined in section 1940 of the Social Security Act (as in effect October 1, 2023), requiring state agencies that administer medical assistance to implement a system by which the agency will obtain financial records from financial institutions with respect to an individual, his or her spouse, or any other such person, as applicable, whose assets are required to be evaluated whenever the administrative agency determines the record is needed in connection with a determination of eligibility for, or the amount or extent of, medical assistance on the basis of age, blindness, or disability, including a determination regarding medical assistance for long-term care services. This rule applies to a determination of eligibility for medical assistance for any covered group subject to:

(1) A resource limit; and/or

(2) Provisions related to the transfer of assets.

(B) Definitions.

(1) "Financial institution" means any office of an institution engaged in the business of dealing with monetary transactions including, but not limited to, a bank, savings bank, trust company, savings association, cooperative bank, credit union, or consumer finance institution, as defined in 12 U.S.C. 3401 (as in effect October 1, 2023).

(2) "Financial record" means any record held by a financial institution pertaining to a customer's relationship with the financial institution, as defined in 12 U.S.C. 3401 (as in effect October 1, 2023).

(1) Use the authorization provided under paragraph (D) of this rule to electronically verify the assets of an individual, his or her spouse, or any other such person, as applicable, in order to determine or redetermine the individual's eligibility for medical assistance.

(2) Inform all individuals in writing at the time of application and renewal that the agency will obtain and use information available through AVS to determine eligibility for medical assistance.

(3) Determine an individual ineligible for medical assistance when he or she refuses to provide, or revokes, authorization under paragraph (D) of this rule.

(D) Individual responsibility. An individual must provide authorization for the administrative agency to obtain from any financial institution any financial record held by the institution with respect to the individual, the individual's spouse, or any other such person, as applicable, whenever the administrative agency determines the record is needed in connection with a determination of eligibility for, or the amount or extent of, medical assistance on the basis of age, blindness, or disability, including a determination regarding medical assistance for long-term care services. This authorization will remain in effect until the earliest of the following:

(1) The individual's application for medical assistance is denied; or

(2) The individual's eligibility for medical assistance is discontinued; or

(3) The individual expressly revokes authorization in a written notification to the administrative agency.

Last updated June 25, 2025 at 6:32 PM

History

Effective: February 1, 2024
Promulgated Under: 111.15

Ohio Adm.Code 5160:1-1-06 Medicaid: public assistance reporting information system (PARIS).

(A) This rule describes section 1903(r)(3) of the Social Security Act (as in effect October 1, 2024) and paragraph (d) of 42 C.F.R 435.945 (as in effect October 1, 2024), that each medicaid state agency have an eligibility determination system which provides for data matching through the public assistance reporting information system (PARIS).

(B) Definition. "PARIS" is a system for matching data with select federal and state agencies for the purpose of determining medicaid or other public assistance eligibility. PARIS provides information regarding federal wages, veterans administration benefits, and duplicate benefits received in two or more states.

(1) Review and compare against the case record all information received to determine whether it affects the individual's eligibility.

(2) Verify the information received, in accordance with 42 C.F.R. 435.948 (as in effect October 1, 2024) and 42 C.F.R. 435.949 (as in effect October 1, 2024).

(3) Request additional verification from the individual, if appropriate, to determine ongoing eligibility and initiate appropriate action in accordance with 42 C.F.R. 435.952(c) (as in effect October 1, 2024).

(4) Continue benefits while appropriate steps are being taken to verify the matched data in accordance with 42 C.F.R. 435.952(d) (as in effect October 1, 2024).

Last updated June 25, 2025 at 5:58 PM

History

Effective: January 1, 2025
Promulgated Under: 111.15

Chapter 5160:1-2 Medicaid Application Procedures

Ohio Adm.Code 5160:1-2-01 Medicaid: administrative agency responsibilities.

(A) This rule describes the responsibilities of the administrative agency.

(B) Calculation of time periods for eligibility determinations. All calculations of time periods used in the determination of eligibility, including an annual renewal or a redetermination as a result of a reported change, shall be computed as follows:

(1) When counting the number of days in a specified time period, the initial day is excluded from the computation and the last day is included.

(2) When the last day of the time period falls on a Saturday, Sunday, or legal holiday, the time period shall end on the next business day.

(C) Effective date of applications, reported information, or requests for applications or assistance. Applications, documents, or information submitted or provided to the administrative agency, or requests made to the administrative agency, are considered received by the administrative agency:

(1) That day, when received by the administrative agency or the electronic eligibility system during the administrative agency's business hours.

(2) On the next business day, when received by the administrative agency or the electronic eligibility system after the administrative agency's business hours or on a non-business day when the administrative agency is closed.

(D) Request for application. When an individual requests an application, the administrative agency shall:

(1) Not deny an individual's right to apply or discourage an individual from applying.

(2) Inform the individual of the following:

(a) An online application portal is available to complete an application for medical assistance and application assistance is available through the portal.

(b) The beginning date of benefits depends on the date the signed application is received by the administrative agency.

(d) Individuals shall cooperate with eligibility determinations, renewals, redeterminations, audits, and quality control processes as defined in this chapter of the Administrative Code.

(e) The meaning of and penalties for medicaid eligibility fraud as set forth in section 2913.401 of the Revised Code.

(f) The Ohio attorney general (AGO) shall seek recovery or adjustment on behalf of the administrative agency from the estate of the following individuals, as set forth in rule 5160:1-2-07 of the Administrative Code:

(i) A permanently institutionalized individual of any age; or

(ii) An individual fifty-five years of age or older who is not permanently institutionalized.

(3) Fulfill a request for an application within one business day.

(a) Fulfillment occurs when the administrative agency sends an electronic copy of the application or a link to an electronic copy of the application to the text or email address provided by the individual; hands the application to the individual; or places the application in the U.S. mail. When the application is provided in person or via U.S. mail, the administrative agency shall enclose a preaddressed, postage-paid envelope for return of the application.

(b) The application shall be accompanied by:

(i) The JFS 07217 "Voter Registration Notice of Rights and Declination" (rev. 5/2022) or a notice meeting the requirements of section 3503.10 of the Revised Code, and a voter registration form as required by section 329.051 of the Revised Code;

(ii) The ODM 07400 "Ohio Medicaid Estate Recovery" (rev. 5/2023); and

(iii) The JFS 07501 "Program Enrollment and Benefit Information" (rev. 4/2022).

(E) Upon receipt of a request for assistance or receipt of an application, the administrative agency shall:

(1) Make program information available and accessible to an individual upon request, consistent with 42 C.F.R. 435.905 (as in effect October 1, 2022):

(a) Provide language services at no cost to an individual with limited English proficiency, including oral interpretation and written translations; and

(b) Provide auxiliary aids and services at no cost to an individual living with a disability in accordance with the Americans with Disabilities Act of 1990 (ADA) (Pub. L. No. 101-336) and section 504 of the Rehabilitation Act of 1973 (Pub. L. No. 93-112).

(2) Distribute voter information and registration materials as required by 42 C.F.R. 431.307 (as in effect October 1, 2022).

(3) Coordinate with the special supplemental nutrition program for women, infants and children (WIC) as required by 42 C.F.R. 431.635 (as in effect October 1, 2022) to ensure written notice of the availability of the WIC program is provided to an individual determined eligible for medical assistance, including an individual who is presumptively eligible and is also a potential WIC recipient.

(a) The administrative agency shall advise a potential WIC recipient of the WIC program and refer the individual to the WIC agency by forwarding a copy of the individual's medical assistance application and any supplemental application, unless the individual is already receiving WIC assistance.

(b) For an individual already in receipt of medical assistance who is a potential WIC recipient, the administrative agency shall advise the individual of the WIC program at least annually.

(i) A woman who is:

(a) Pregnant;

(b) Within a six-month period after giving birth; or

(ii) A child younger than five years old.

(F) Assistance.

(1) The administrative agency shall allow a person or persons of the individual's choice to accompany, assist with, and represent the individual in the application, redetermination, or annual renewal process.

(a) A person may accompany and assist an individual without being an individual's authorized representative.

(b) The administrative agency shall not reveal confidential information, as described in rule 5160-1-32 of the Administrative Code, or send notices or correspondence to the person assisting the individual, unless the person has been designated in writing as an authorized representative.

(c) A person who is assisting an individual shall provide accurate information, to the best of his or her knowledge, regardless of whether the person is an authorized representative.

(2) When an individual has designated in writing an authorized representative, the administrative agency shall:

(a) Issue all notices and correspondence to both the authorized representative and the individual.

(b) Contact the individual to clarify or verify information provided by an authorized representative when the information provided on the application seems contradictory, unclear, or unrealistic.

(c) Remove the authorized representative from any correspondence or access to safeguarded information upon receipt of notice that:

(i) The authorized representative is declining or ending representation of the individual; or

(ii) The individual has withdrawn the authorized representative's authority.

(3) The administrative agency shall help complete the application when assistance is needed, including assistance through agents of the administrative agency, such as eligibility workers.

(a) At the individual's request, an eligibility worker shall assist with completing the application by asking the individual for answers needed to complete the application, then recording the individual's answers on the application form or in the electronic eligibility system. The eligibility worker shall not alter any answers given by the individual.

(b) When an eligibility worker assists with or helps complete an application, the worker shall sign the application form and include the worker's title as a person who assisted with completing the application.

(c) The process of inputting data into the electronic eligibility system or determining an individual's eligibility shall not be construed as providing assistance.

(4) Upon request, the administrative agency shall provide assistance to individuals having difficulty gathering verifications.

(5) When determining eligibility for an individual with a physical or mental impairment that substantially limits the individual's ability to access verifications, and who has not granted any person durable power of attorney, or who does not have a court-appointed guardian or a person with other legal authority and obligation to act on behalf of the individual, the administrative agency shall:

(a) Explore whether another person is available to assist the individual with obtaining verifications or accessing the individual's means of self-support. For an individual who resides in a nursing facility (NF), explore whether the person who signed the NF admission contract is able to assist the individual.

(i) When a person is available to assist the individual, request the person assist with obtaining the verifications or accessing the individual's means of self-support.

(ii) When verifications are provided, or when means of self-support are able to be accessed by the individual or on the individual's behalf by another person, the administrative agency shall consider the verified criteria or means of self-support in the eligibility determination process.

(b) When no person with the ability to access the individual's means of self-support is available to assist the individual:

(i) Refer the individual's case to the administrative agency's legal counsel and request counsel evaluate whether the matter should be referred to the probate court, adult protective services, or another entity deemed by the administrative agency's legal counsel to be appropriate. For cases referred to counsel for such evaluation, the administrative agency shall also:

(a) Note in the individual's case record that verifications or means of self-support are not available and shall not be considered a disqualifying factor until a means of access to those items is obtained or established; and

(b) Inform the administrative agency's legal counsel of any eligibility approval or denial.

(ii) Determine eligibility in accordance with Chapter 5160:1-2 of the Administrative Code, but without considering eligibility factors for which verification cannot be obtained or means of self-support cannot be accessed because of the individual's physical or mental impairment. Use the most reliable information available without delaying the determination of eligibility.

(iii) Redetermine eligibility once a means of access to verifications or means of self-support is obtained or established. When such access has not been obtained prior to the individual's annual renewal, determine continuing eligibility using the most reliable information available.

(G) Receipt of application. Upon receipt of a signed application for medical assistance or for specific medical assistance services or programs, the administrative agency shall:

(1) Give or send a receipt to the individual showing the date of application.

(2) Accept and register the application within one business day of the time the signed application is received. Only an application signed under penalty of perjury in accordance with 42 C.F.R. 435.907 (as in effect October 1, 2022) is considered valid.

(a) Acceptable signatures for an application include:

(i) An original handwritten signature; and

(ii) An "electronic signature" or "e-signature," that includes electronic sounds, symbols, or processes attached to or logically associated with records and executed or adopted by individuals with the intent to sign a record. An electronic signature satisfies legal requirements in accordance with section 1306.06 of the Revised Code and includes:

(a) An audio or "telephonically recorded" signature obtained in accordance with procedures approved by the Ohio department of job and family services (ODJFS) that is retrievable and complies with federal record retention requirements in accordance with 7 C.F.R. 272.1(f) (as in effect October 1, 2022); and

(b) A signature submitted electronically as part of the online medical assistance application process; and

(d) A rubber stamp that replaces a signature for an individual who has an inability to sign in accordance with the Rehabilitation Act of 1973 (Pub. L. No. 93-112); and

(e) When the signatory cannot sign with a name, an "X" is a valid signature; and

(f) An electronically signed application received from the federally facilitated marketplace (FFM); and

(g) An electronically signed application received from the social security administration (SSA) for the low-income subsidy (LIS) program.

(b) An individual who applies for health coverage through the FFM will be assessed for medicaid eligibility with the signature provided to the FFM.

(3) When an application is received from a local WIC clinic, maternal, child and family health (MCFH) clinic, or the children with medical handicaps program (CMH) office within five business days of the signature date, the application shall be registered using the signature date. When the application is not received within five business days of the signature date, the application shall be registered using the date the application was received by the administrative agency.

(4) When an application taken by an outstationed worker assigned to a federally qualified health center (FQHC) or a disproportionate share hospital (DSH) is not directly entered into the electronic eligibility system, the application shall immediately be submitted to the appropriate administrative agency, which shall register the application using the signature date.

(5) The administrative agency shall not delay the registration or processing of an application due to the lack of a signed acknowledgment of an individual's rights and responsibilities.

(6) As required by section 329.051 of the Revised Code, the administrative agency shall:

(a) Give or send a notice meeting the requirements of section 3503.10 of the Revised Code or the JFS 07217 "Voter Registration Notice of Rights and Declination" (rev. 5/2022); and

(b) Give or send the "Voter Registration Information and Update Form" (undated) as prescribed by the secretary of state.

(H) Verifications. Where manual verifications are required under rule 5160:1-2-10 of the Administrative Code, the administrative agency shall:

(1) Follow the safeguarding guidelines set forth in rule 5160-1-32 of the Administrative Code when providing or gathering information by telephone, in person, or in electronic or written form.

(2) Not require that an individual provide verification of unchanged information unless the information is incomplete, inaccurate, inconsistent, outdated, or missing from the case record due to record retention limitations.

(3) Not request that an individual provide duplicate copies of previously submitted verifications.

(4) To the extent possible, verify relevant eligibility criteria using electronic records available through the electronic eligibility system and other electronic data sources. Where electronic verification is not available, or electronic verification data conflicts with the individual's attestation, request verifications as set out in rule 5160:1-2-10 of the Administrative Code.

(5) When the administrative agency is unable to verify eligibility criteria through electronic sources, the administrative agency shall contact the individual to collect information needed to process the application, redetermination, or annual renewal. When the individual declares the verifications cannot be accessed or submitted, the individual's statement shall be accepted. When the administrative agency is unable to make contact with the individual, a written (electronic or on paper) request for the necessary information or verification documents shall be sent.

(a) The written request shall:

(i) Include the date by which the information must be provided to the administrative agency; and

(ii) Inform the individual that any delay in providing requested information or documents will delay the determination of an individual's eligibility; and

(iii) Provide information regarding how an individual can request assistance from the administrative agency with gathering the requested documents.

(b) When the information or verification required to establish the individual's eligibility for assistance is not received by the administrative agency by the stated date, the administrative agency shall contact the individual in writing no more than twenty calendar days following the date of the application, redetermination, or annual renewal.

(i) The follow-up request for information or verification documents:

(a) Shall be sent electronically, via postal mail, or personally delivered to the individual. When sent via postal mail or personally delivered, the administrative agency shall enclose a preaddressed, postage-paid envelope for return of the verification(s);

(b) Shall state that the required information or verification has not been received and that when the information or verification is not received within ten calendar days the administrative agency shall deny or discontinue the application, redetermination, or annual renewal for medical assistance;

(c) Shall include a clear statement that the administrative agency will assist with obtaining the required information or verification when the request for assistance is received on or prior to the given deadline; and

(d) Does not serve as a notice of denial of the application or discontinuance of benefits.

(ii) When the requested information or verification is not received by the stated deadline, the administrative agency shall propose a denial or discontinuance of benefits.

(c) The administrative agency shall deny the individual's application when the individual fails to provide the necessary information or verifications, or request assistance and cooperate with obtaining verifications, within the time specified in the second verification request. When this happens:

(i) An individual may reapply at any time.

(ii) An individual shall not be asked to re-verify information previously verified by the administrative agency without reason to believe the information may have changed.

(6) Give or send a dated itemized receipt that lists each verification document received from an individual.

(7) Record receipt of all verification documents, photocopy or scan the documents, and retain copies or images of the documents in the case record.

(8) When information is verified through a telephone contact, record the following details:

(a) The name and telephone number of the person providing the information;

(b) The name of the agency or business contacted, when applicable;

(d) An accurate summary of the information provided.

(I) Determination, redetermination, and renewal of eligibility. The administrative agency shall:

(1) Not schedule an interview except at the request of the individual.

(2) Inform all individuals at the time of application and renewal that the agency will obtain and use information available from the income and eligibility verification system (IEVS) to assist with the determination of eligibility, as required by section 1137 of the Social Security Act (as in effect October 1, 2022).

(3) Require a signature for all renewals of medical assistance where eligibility was not passively renewed using the electronic eligibility system.

(4) Using the electronic eligibility system, the administrative agency shall:

(a) Determine eligibility or renewal of an individual's eligibility for medical assistance within the application processing time limits set forth in this rule.

(i) The administrative agency shall not approve medical assistance to an individual merely because of an agency error or delay in determining eligibility. All eligibility factors shall be met.

(ii) The administrative agency shall not delay the approval of medical assistance due to the lack of information or verifications necessary to determine eligibility for other public assistance programs.

(b) Document and record determinations of eligibility. The administrative agency shall:

(i) Record, in physical or electronic case records, any information, action, decision, or delay in the application, eligibility determination, or discontinuance processes, as well as the reasons for any action, decision, or delay.

(ii) Make the case records, physical or electronic, available for compliance audits.

(i) Has signed an application under penalty of perjury; and

(ii) Has provided all necessary verifications as set forth in rule 5160:1-2-10 of the Administrative Code; and

(iii) Meets all conditions of eligibility for a medical assistance category set forth in Chapter 5160:1-2, 5160:1-3, 5160:1-4, 5160:1-5, or 5160:1-6 of the Administrative Code. When an individual who attests to U.S. citizenship or qualified non-citizen status meets all conditions of eligibility for a medical assistance category except for verification of the individual's citizenship or qualified non-citizen status, the administrative agency shall approve time-limited coverage during a reasonable opportunity period (ROP) as required in rule 5160:1-2-11 or 5160:1-2-12 of the Administrative Code.

(d) Deny an application for medical assistance for an individual who:

(i) Has not signed an application under penalty of perjury;

(ii) Withdraws the application;

(iii) Fails to cooperate with the application or determination process or fails to provide all necessary verifications set forth in rule 5160:1-2-10 of the Administrative Code; or

(iv) Does not meet all conditions of eligibility for any medical assistance category set forth in Chapter 5160:1-2, 5160:1-3, 5160:1-4, 5160:1-5, or 5160:1-6 of the Administrative Code.

(e) Suspend medical assistance upon notification that an individual meets any of the criteria for ineligibility for payment of services set forth in rule 5160:1-1-03 of the Administrative Code.

(f) Discontinue medical assistance for an individual who:

(i) Requests that assistance be discontinued;

(ii) Is no longer an Ohio resident;

(iii) Is deceased;

(iv) Fails to cooperate with the renewal process;

(v) Fails to cooperate with the quality control process;

(vi) Fails to provide all necessary verifications;

(vii) Is eligible as a result of an administrative agency error;

(viii) Provided fraudulent information or verifications;

(ix) Fails or refuses to comply with individual responsibilities as described in this chapter of the Administrative Code; or

(x) No longer meets the conditions of eligibility outlined in rule 5160:1-2-10 of the Administrative Code for any medical assistance category set forth in Chapter 5160:1-2, 5160:1-3, 5160:1-4, 5160:1-5, or 5160:1-6 of the Administrative Code. Before discontinuing coverage on this basis, the administrative agency shall conduct a pre-termination review (PTR) as defined in rule 5160:1-1-01 of the Administrative Code to determine that the individual is no longer eligible for coverage under any eligibility category.

(g) Administratively close an invalid application. An application form received without an acceptable signature is considered invalid and shall be administratively closed and not receive a notice of action (NOA) or hearing rights.

(J) Reinstatement of medical assistance.

(1) When an individual cooperates with the renewal process, the administrative agency shall:

(a) Reinstate medical assistance, discontinued for failure to cooperate with the renewal process or verification of a reported change, within ninety calendar days of the discontinuance date without requiring a new application in accordance with 42 C.F.R. 435.916(a)(3)(C)(iii) (as in effect October 1, 2022).

(b) Accept the renewal form and/or verifications that caused the discontinuance of medical assistance.

(d) Reinstated medical assistance coverage shall begin on the first day of the calendar month following the month medical assistance was discontinued.

(2) When a hearing request is filed timely by an individual as outlined in division 5101:6 of the Administrative Code, the administrative agency shall reinstate medical assistance benefits at the same benefit level until a hearing decision is rendered in accordance with 42 C.F.R. 431.230 (as in effect October 1, 2022).

(K) Timely determinations and renewals. The administrative agency shall make a timely determination of an individual's eligibility for medical assistance under this chapter of the Administrative Code. The administrative agency shall determine initial eligibility or a renewal of eligibility, including obtaining verifications when required, within:

(1) Ten calendar days of receiving a report of a change that could affect an individual's ongoing eligibility for medical assistance;

(2) Forty-five calendar days from the date of application or scheduled renewal, unless:

(a) An individual who otherwise meets the conditions of eligibility described in this chapter of the Administrative Code alleges blindness or disability. The administrative agency shall determine eligibility within ninety calendar days from the date of application unless the examining physician delays or fails to take a required action; or

(b) There is an administrative or other emergency beyond the administrative agency's control.

(3) Forty-five calendar days of receipt of new or changed information from IEVS. The administrative agency shall not deny or discontinue benefits until appropriate steps have been taken to verify the relevant information in accordance with 42 C.F.R. 435.952(d) (as in effect October 1, 2022).

(L) Effective dates of eligibility.

(1) Medical assistance coverage begins on the first day of the calendar month in which the application which resulted in eligibility was submitted to the administrative agency, except that:

(a) An individual's coverage cannot begin before the date on which the individual:

(i) Became a resident of Ohio; or

(ii) Was born.

(b) The administrative agency shall approve retroactive eligibility for medical assistance effective no later than the first day of the third month before the month of application when the individual:

(i) Reports he or she received medical services of a type covered by medical assistance within the three months prior to the application month;

(ii) Requests retroactive eligibility be determined; and

(iii) Would have been eligible for medical assistance at the time the services were provided if an application had been made at that time, regardless of whether the individual was alive when the application actually was made. Actual income received in each retroactive month shall be used to determine eligibility for that month;

(iv) Is eligible for a category of medical assistance other than:

(a) Transitional medical assistance as described in rule 5160:1-4-05 of the Administrative Code;

(b) Medicare premium assistance as described in rule 5160:1-3-02.1 of the Administrative Code; or

(2) Medical assistance coverage discontinues on the last day of a calendar month, except that coverage discontinues on the date an individual:

(a) Becomes a resident of another state;

(b) Dies; or

(M) Duration of eligibility span. The administrative agency shall:

(1) Discontinue coverage under a time-limited medical assistance category as described in the Administrative Code rule for the appropriate medical assistance category. These time-limited eligibility categories include:

(a) Any presumptive eligibility category, as described in rule 5160:1-2-13 of the Administrative Code,

(b) Non-citizen emergency medical assistance (NCEMA), as described in rule 5160:1-5-06 of the Administrative Code, and

(2) Schedule an individual's renewal of eligibility for medical assistance twelve months after the most recent eligibility determination.

(3) Redetermine medical assistance upon receiving a report of, or identifying, a change in circumstances that could affect an individual's eligibility for medical assistance.

(N) Third party liability (TPL). For individuals found eligible for or in receipt of medical assistance, the administrative agency shall report to the Ohio department of medicaid (ODM) any available information about a third party liable for an individual's health care costs.

(1) When determining an individual's eligibility for medical assistance coverage, the agency shall use the form (or an electronic equivalent) designated by the administrative agency to report:

(a) Possible health insurance coverage of an individual. A separate report shall be made for each possible health insurance policy.

(b) Potential TPL due to an injury, disability, or court order.

(2) At renewal, or upon any reported or identified change, the administrative agency shall compare the individual's current information to the information on the most recent ODM 06612 "Health Insurance Information Sheet" (rev. 11/2020) or ODM 06613 "Accident/Injury Insurance Information" (rev. 7/2020). When any information has changed, the administrative agency shall report the changes to ODM by submitting a new ODM 06612 or ODM 06613, or an electronic equivalent.

(3) Upon a request by ODM, the administrative agency shall contact the individual to obtain information regarding potential TPL. When the individual fails to cooperate, the agency shall propose to deny or discontinue the individual's medical assistance for failure to cooperate, as set forth in paragraph (I)(4) of this rule.

(O) Upon a report (verbal or written) of a change of address within the state of Ohio, the administrative agency shall:

(1) Give or mail to the individual a notice meeting the voter registration requirements of section 3503.10 of the Revised Code and advise the individual that, upon request, the administrative agency will help the individual register to vote or update voter registration as outlined in rule 5101:1-2-15 of the Administrative Code.

(2) Process an intercounty transfer (ICT) when the individual has changed residence from one county to another. Both the county of original residence and the county of new residence have responsibilities in the ICT process. The ICT process shall be followed whether the individual reporting a change of residence is an individual or is currently in receipt of medical assistance benefits.

(a) The county department of job and family services (CDJFS) receiving report of a move shall determine whether the move is a change of residence or a temporary absence from the home. When the move is a temporary absence from the home, the county in which the individual is physically located shall provide necessary medical and transportation services.

(b) The CDJFS receiving report of a change of residence shall:

(i) Update the address in the electronic eligibility system. When the individual does not have an address in the new county, use the address of the administrative agency in the new county.

(ii) When the report is made to the administrative agency in the county of new residence, inform the county of original residence.

(i) The CDJFS in the individual's original county of residence shall take the following actions for the identified type of case record:

(a) Electronic records. When the individual moves to another county within the state, the electronic document management system shall be updated with the most recent eligibility determination documentation no later than the end of the business day following the date the CDJFS becomes aware of the address change.

(b) Online records. Prior to the online record being transferred, the CDJFS in the individual's original county of residence shall ensure the electronic eligibility system is updated no later than the end of the business day following the date the CDJFS becomes aware of the address change.

(c) Hard copy records. Hard copy records used in the most recent eligibility determination shall be converted into digital format in the electronic document management system no later than the end of the business day following the date the CDJFS becomes aware of the address change. The remaining hard copy records shall be transferred no later than five calendar days following the date the CDJFS becomes aware of the address change. The CDJFS in the individual's original county of residence shall notify the CDJFS in the individual's county of new residence when a hard copy record is being transferred.

(ii) The case record to be transferred shall contain the following documents:

(a) The most recently signed application for medical assistance; and

(b) Other pertinent documents, such as citizenship, qualified non-citizen status, income, and resource verifications.

(d) The CDJFS in the individual's county of new residence shall:

(i) Not require the individual to reapply or cooperate with a renewal of eligibility for medical assistance merely due to the change in county of residence.

(ii) Verify potential changes in income, expenses, employment, or household composition resulting from the change in residence when the CDJFS that received the reported change did not complete the verification prior to the intercounty transfer.

(iii) Provide the medical assistance benefits for which the individual is eligible.

(e) When the case being transferred is subject to a claim for overpayment as set out in rule 5160:1-2-04 of the Administrative Code:

(i) An existing claim shall not be transferred. The records transferred to the CDJFS in the county of new residence shall include copies of the documentation of the claim. The CDJFS that established the claim remains responsible for any necessary action on the claim.

(ii) When no claim has been established and the CDJFS in each county agrees the CDJFS in the county of new residence shall establish the claim, then a potential claim may be transferred to the CDJFS in the county of new residence to be established by the CDJFS in that county.

(P) When mail is returned indicating whereabouts unknown, the individual shall still be considered a resident of the state and medical assistance will not be discontinued.

(Q) Distribution of informational materials. The administrative agency:

(1) Shall distribute the internal revenue service (IRS) form 1095-B "Health Coverage" to individuals in January of each calendar year and upon an individual's request in accordance with the Patient Protection and Affordable Care Act (ACA) (Pub. L. No. 111-148).

(2) Shall distribute voter information and registration materials to individuals in accordance with 42 C.F.R. 431.307 (as in effect October 1, 2022).

(3) May distribute materials directly related to the health and welfare of individuals eligible for medical assistance, such as announcements of free medical examinations, availability of surplus food, and consumer protection information.

(R) The administrative agency shall provide timely and adequate written notice of any decision affecting an individual's eligibility, including an approval, denial, discontinuance, or suspension of eligibility, or a denial or change in benefits, consistent with 42 C.F.R. 435.917 (as in effect October 1, 2022) and division 5101:6 of the Administrative Code.

Last updated June 25, 2025 at 6:40 PM

History

Effective: January 26, 2024
Promulgated Under: 111.15

Ohio Adm.Code 5160:1-2-02 Medicaid: income guidelines, calculations, and exclusions.

(A) This rule sets forth general income guidelines, calculations, and exclusions used in determining eligibility for medical assistance. Income guidelines, calculations, or exclusions that apply to a specific covered group will be addressed in the eligibility rules for that group. Unless otherwise stated:

(1) If living in the same household, income and resources of a spouse are considered available to the other spouse, and income and resources of a parent are considered available to children under age twenty-one.

(2) The income of a minor's parent, living in the same home as the minor and the minor's dependent child, shall be counted as income to the covered group.

(B) Gross monthly income shall be calculated as follows:

(1) The amount of gross monthly non-excluded income shall first be established. Disregards and deductions, as defined in rule 5160:1-1-01 of the Administrative Code, shall then be subtracted when applicable.

(2) In calculating gross income, both earned and unearned, the monthly amounts shall be rounded down to the nearest whole dollar by dropping the cents.

(3) To correctly calculate gross income that is not received on a monthly basis, use the following conversion factors. All cents in gross weekly, bi-weekly, or semi-monthly income shall be dropped before and after multiplying.

(a) Income received weekly shall be multiplied by 4.3.

(b) Income received bi-weekly (every two weeks) shall be multiplied by 2.15.

(d) Gross annual income received shall be divided by 12.0.

(e) For contract employees, divide the gross payment amount by the number of calendar months the contract covers. This also applies when a one-time payment is made for work that is done over a period.

(4) Hourly rates that contain cents are not rounded when determining a weekly, bi-weekly, or semi-monthly amount.

(1) Grants, scholarships, fellowships, or gifts used to pay for educational expenses such as tuition, fees, or other necessary expenses that are required to attend an educational institution.

(2) Home produce, including farm and garden produce, grown by the individual or family, and utilized for household consumption, in accordance with 20 C.F.R. 416.1124 (as in effect October 1, 2022).

(3) Income tax refunds.

(4) Residential state supplement (RSS) payments.

(5) Federal, state, and local foster care payments received under title IV-E, for a child currently living in the household.

(6) Federal, state, and local adoption assistance payments received under title IV-E.

(7) Federal and state kinship guardianship assistance program (KGAP) payments received under title IV-E or state KGAP, including kinship guardianship assistance program connections to twenty-one (KGAP C21) payments.

(8) The value of foods donated by the U.S. department of agriculture commodity supplemental food program.

(9) Any relocation assistance paid by a public agency to a public assistance recipient, who has been relocated as a result of redevelopment, urban renewal, freeway construction, or any other public development involving condemnation or demolition of the existing residence.

(10) Payments to volunteers participating in the retired senior volunteer program (RSVP), foster grandparent program, senior companion program, service corps of retired executives (SCORE), active corps of executives (ACE), volunteers in service to america (VISTA), or any other programs under 42 U.S.C. 5044 (as in effect October 1, 2022).

(11) The value of supplemental food assistance received under the Child Nutrition Act of 1966 (Pub. L. No. 89-642) described in 42 U.S.C. 1771 (as in effect October 1, 2022) and the special food service program for children under the National School Lunch Act (Pub. L. No. 79-396) described in 42 U.S.C. 1751 (as in effect October 1, 2022).

(12) Payments made to Native Americans as listed in section IV of 20 C.F.R. 416 Subpart K Appendix (as in effect October 1, 2022).

(13) Benefits paid to eligible households under the Low-Income Home Energy Assistance Act of 1981 (Pub. L. No. 97-35), in accordance with 42 U.S.C. 8624 (as in effect October 1, 2022).

(14) Payments received on or after January 1, 1989, as a result of the Agent Orange Compensation Exclusion Act (Pub. L. No. 101-201).

(15) Restitution payments under the Civil Liberties Act of 1988 (Pub. L. No. 100-383) 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).

(16) Restitution payments for Aleutian and Pribilof Island Restitution Act (Pub. L. No. 100-383) in accordance with 50 U.S.C. 4236 (as in effect October 1, 2022).

(17) Payments under the Radiation Exposure Compensation Act, 42 U.S.C. 2210 (as in effect October 1, 2022).

(18) Earned income tax credit payments in the form of a refund of federal income tax.

(19) 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).

(20) Payments to victims of Nazi persecution.

(21) Principal of a bona-fide loan.

(22) Any federal major disaster and emergency assistance described in 42 U.S.C. 5170 (as in effect October 1, 2022), including comparable disaster assistance provided by states, local governments, and disaster assistance organizations.

(23) Nutrition program benefits provided for the elderly under Title VII of the Older Americans Act of 1965 (Pub. L. No. 89-73), as amended.

(24) Federal housing assistance provided by the office of housing and urban development (HUD) or the U.S. department of agriculture's rural housing service (RHS), formally known as the farmers home administration (FHA).

(25) Retroactive payments paid to the individual as the result of a state hearing.

(26) Payments to crime victims from a federal or federally funded state or local program including Washington state crime victims compensation program under title XXIII of the Violent Crime Control and Law Enforcement Act of 1994 (Pub. L. No. 103-322).

Last updated January 3, 2023 at 8:51 AM

History

Effective: January 1, 2023
Promulgated Under: 111.15

Ohio Adm.Code 5160:1-2-03 Medicaid: request for home and community-based services (HCBS) waiver.

(A) This rule sets forth the process for determining whether an individual is eligible for medical assistance payments for services under a home and community-based services (HCBS) waiver, as described in rules 5123-9-01, 5160-31-03, 5160-33-03, 5160-40-01, 5160-41-17, 5160-42-01, 5160-46-02, 5160-58-02.2, and 5160-59-04 of the Administrative Code.

(B) Eligibility for an HCBS waiver. To receive services under an HCBS waiver, the individual shall:

(1) Be eligible for medical assistance, as described in Chapters 5160:1-1 to 5160:1-6 of the Administrative Code;

(2) Be in need of HCBS under a waiver described in agency 5123 or 5160 of the Administrative Code;

(3) Be enrolled in an HCBS waiver described in agency 5123 or 5160 of the Administrative Code; and

(4) Not be simultaneously enrolled in another HCBS waiver, the residential state supplement (RSS) program described in rule 5160:1-5-01 of the Administrative Code, or the program of all-inclusive care for the elderly (PACE).

(1) An individual may request an HCBS waiver by:

(a) Indicating the request on an application for medical assistance;

(b) Submitting an ODM 02399 "Request for Medicaid Home and Community-Based Services (HCBS) Waiver" to the administrative agency;

(d) Indicating the request verbally or in writing to an Ohio department of medicaid (ODM) approved long-term services and supports agency.

(2) The effective date of an HCBS waiver request is determined in accordance with rule 5160:1-2-01 of the Administrative Code.

(D) Processing a request for an HCBS waiver.

(1) Upon receipt of an HCBS waiver request when the individual is currently in receipt of medical assistance, the administrative agency shall:

(a) Submit the request within two business days using the Ohio department of medicaid (ODM) approved submission process; and

(b) Document the following in the electronic eligibility system case record:

(i) The date the administrative agency received the request for HCBS; and

(ii) The date the administrative agency submitted the request using the ODM approved submission process.

(2) Upon receipt of an HCBS waiver request when the individual is not currently in receipt of medical assistance, the administrative agency shall:

(a) Begin the application process for medical assistance, as described in rule 5160:1-2-01 of the Administrative Code;

(b) Submit the request within two business days using the ODM approved submission process; and

(i) The date the administrative agency received the request for HCBS; and

(ii) The date the administrative agency submitted the request using the ODM approved submission process.

(E) Determination of eligibility for an HCBS waiver. The administrative agency shall approve an HCBS waiver for an individual eligible for medical assistance only upon:

(1) Approval by the HCBS waiver operational agency; and

(2) Notification that the individual may be enrolled in the waiver from ODM, its designee, or an HCBS waiver operational agency, when services under the waiver are available only to a specific number of individuals.

(F) Coverage period. The HCBS waiver coverage period can have a different beginning date or ending date from the medical assistance eligibility period.

(1) HCBS cannot:

(a) Begin before an individual's medical assistance eligibility period or before an individual's retroactive medical assistance eligibility period.

(b) Extend beyond the discontinuance date of an individual's medical assistance coverage.

(2) Medical assistance coverage of HCBS begins on the latest of the following dates:

(a) The date the administrative agency receives a request for an HCBS waiver from an individual;

(b) The date the individual meets all criteria for coverage of an HCBS waiver described in agency 5123 or 5160 of the Administrative Code; or

(c) The date the individual is authorized by the HCBS waiver operational agency to receive services under an HCBS waiver.

(3) Medical assistance coverage of HCBS ends when either:

(a) The administrative agency determines the individual no longer meets the conditions of eligibility, as described in rule 5160:1-2-10 of the Administrative Code, or the criteria for coverage of HCBS; or

(b) The HCBS waiver operational agency notifies the administrative agency that it no longer authorizes the individual to receive HCBS.

(G) HCBS waiver operational agency responsibilities.

(1) Determine, in accordance with this rule and agencies 5123 and 5160 of the Administrative Code, whether the individual requesting an HCBS waiver meets the requirements of the applicable HCBS waiver program.

(2) Provide written notification to the individual of the HCBS programmatic determination.

(3) Notify the administrative agency of determinations and subsequent changes regarding approval of HCBS.

(H) Administrative agency responsibilities.

(1) Determine an individual's eligibility for an HCBS waiver in accordance with this rule. When the administrative agency determines that an individual who requests an HCBS waiver is not eligible for any category of medical assistance, the administrative agency shall deny both the medical assistance application and HCBS waiver request for that individual.

(2) Notify the applicable HCBS waiver operational agency of changes in the individual's eligibility for medical assistance coverage of services under an HCBS waiver.

Last updated November 5, 2025 at 9:07 AM

History

Effective: November 1, 2025
Promulgated Under: 111.15

Ohio Adm.Code 5160:1-2-04 Medicaid: consumer fraud and recoupments.

(A) This rule sets out requirements for the administrative agency with regard to identifying and referring consumer fraud and recouping medicaid payments from an individual.

(B) Investigation of complaints. Upon notification of a complaint of medicaid fraud, abuse, or questionable practices, the administrative agency must conduct a preliminary investigation in accordance with 42 C.F.R. 455.14 (as in effect October 1, 2023) to determine whether there is sufficient basis to warrant a full investigation.

(1) When the preliminary investigation finds that a full investigation is warranted in accordance with 42 C.F.R. 455.15 (as in effect October 1, 2023):

(a) And there is reason to believe that a beneficiary has defrauded the medicaid program as described in section 2913.401 of the Revised Code, then the administrative agency must refer the case to the county prosecutor.

(b) And there is reason to believe that a beneficiary has abused the medicaid program, then the agency must conduct a full investigation of the abuse.

(2) The investigation must continue until the investigation is resolved in accordance with 42 C.F.R. 455.16 (as in effect October 1, 2023).

(C) The administrative agency cannot recover or recoup the cost of services from an individual, except under the following circumstances:

(1) When a court judgment finds that medicaid benefits were improperly paid, under section 1917(a)(1)(A) of the Social Security Act (as in effect October 1, 2023) and 42 C.F.R. 433.36(g)(1) (as in effect October 1, 2023);

(2) When an individual who is an inpatient in a medical institution, as defined in rule 5160:1-6-01.1 of the Administrative Code, who is receiving medicaid payment for long-term care services in accordance with Chapter 5160:1-6 of the Administrative Code, and who has been determined to not reasonably be expected to be discharged from the medical institution to return home;

(a) No lien may be imposed under paragraph (C)(2) of this rule on such individual's home when the following individuals lawfully reside in the home:

(i) The individual's spouse; or

(ii) The individual's child who is under the age of twenty-one, or is blind or disabled in accordance with section 1614 of the Social Security Act (as in effect October 1, 2023); or

(iii) The individual's sibling who has an equity interest in the home and who was residing in the individual's home for a period of at least one year before the date the individual was admitted into the medical institution.

(b) A lien imposed under paragraph (C)(2) of this rule shall dissolve upon that individual's discharge from the medical institution and return home.

(3) Estate recovery proceedings as described in rule 5160:1-2-07 of the Administrative Code.

Last updated March 1, 2024 at 8:11 AM

History

Effective: March 1, 2024
Promulgated Under: 111.15

Ohio Adm.Code 5160:1-2-05 Medicaid: notice of privacy practices.

(A) The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a federal law requiring the administrative agency to issue a notice of privacy practices.

(B) The administrative agency shall:

(1) Ensure appropriate safeguards are taken in accordance with rule 5160-1-32 of the Administrative Code.

(2) Issue a notice of privacy practices to all individuals eligible for medical assistance, as described in 45 C.F.R. 164.520 (as in effect October 1, 2023), outlining all of the following descriptions of uses, disclosures, and procedures:

(a) A description of the types of uses and disclosures of protected health information (PHI) the administrative agency is permitted with examples for each of the following purposes:

(i) Payment; and

(ii) Treatment; and

(iii) Healthcare operations.

(b) A description of the uses and disclosures permitted without the individual's written consent or authorization.

(d) Complaint procedure.

(e) Request for restriction procedure.

(f) Request for amendment procedure.

(g) Request for accounting procedure.

(h) A name, or title, and telephone number of a person or office to contact for further information.

Last updated January 2, 2024 at 9:33 AM

History

Effective: January 1, 2024
Promulgated Under: 111.15

Ohio Adm.Code 5160:1-2-06 Medicaid: outstationing workers at disproportionate share hospitals and federally qualified health centers.

(A) This rule describes the administrative agency's role in facilitating outreach services for low-income children and pregnant women through the process of outstationing workers at disproportionate share hospitals, federally qualified health centers, and other designated locations where potentially eligible children and pregnant women receive services.

(B) Definitions.

(1) "Administrative agency," for the purpose of this rule, means the Ohio department of medicaid (ODM) and/or an agent of ODM authorized to determine eligibility for a medical assistance program.

(2) "Individual," for the purpose of this rule, means a person who is applying for medical assistance benefits at a disproportionate share hospital, federally qualified health center, or another designated outstation location.

(3) "Outstationing" refers to the federal requirement that administrative agencies must provide opportunities for low-income children and pregnant women to apply for medical assistance at locations other than the local county department of job and family services (CDJFS) office.

(1) Locations. The administrative agency:

(a) Must establish and staff outstation locations at each disproportionate share hospital and each federally qualified health center that participates in the medicaid program and provides services to children and pregnant women who are eligible for medical assistance.

(b) May establish additional outstation locations at other sites where potentially eligible children or pregnant women receive services. These additional locations may include sites independent from the main outstation locations of federally qualified health centers or disproportionate share hospitals.

(2) Hours.

(a) Workers must be available at each outstation location during the administrative agency's regular office operating hours to accept applications and to assist individuals with the application process.

(b) When the administrative agency determines that an outstation site is infrequently used and does not require a full-time outstationed worker, the following must occur:

(i) A notice must be displayed containing the following information:

(a) The hours when an outstationed worker will be available; and

(b) The telephone number of the administrative agency that individuals may call for assistance.

(ii) Adequate notice must be provided to individuals with visual or hearing impairments or who are unable to read or understand the English language.

(3) Workers and assistance.

(a) The administrative agency may use county employees, provider or contractor employees, or volunteers who have been properly trained to staff outstation locations under the following conditions:

(i) County outstation intake workers may perform all eligibility processing functions, including the eligibility determination, when the worker is authorized to determine medical assistance eligibility at a regular intake office.

(ii) Provider or contractor employees and volunteers may perform only initial processing functions. Provider and contractor employees and volunteers are subject to:

(a) The confidentiality of information rules specified in 42 C.F.R. Part 2 (as in effect October 1, 2023) and 42 C.F.R. part 431, subpart F (as in effect October 1, 2023); and

(b) The requirements of 42 C.F.R. section 447.10 (as in effect October 1, 2023), which prohibit medicaid payments to anyone other than a provider or recipient except under specific circumstances; and

(b) The outstationed worker must:

(i) Provide for the receipt and initial processing of medical assistance applications at each outstation location.

(a) When authorized by the administrative agency, the outstationed worker may evaluate an application for medical assistance and make a determination of eligibility.

(b) When the outstationed worker is only performing initial processing duties, the outstationed worker must forward the application to the administrative agency in accordance with Chapters 5160:1-1 and 5160:1-2 of the Administrative Code.

(ii) Accept and refer applications for other public assistance programs to the administrative agency or appropriate program office for processing. Assist individuals with connecting to appropriate agencies, organizations, providers and other community supports as requested.

Last updated June 25, 2025 at 5:50 PM

History

Effective: January 1, 2024
Promulgated Under: 111.15

Ohio Adm.Code 5160:1-2-07 Medicaid: estate recovery.

(A) This rule describes Ohio's medicaid estate recovery program and the undue hardship waiver request process.

(B) Definitions.

(1) "Estate" includes both of the following:

(a) All real and personal property and other assets to be administered under Title XXI of the Revised Code and property that would be administered under that title if not for section 2113.03 or 2113.031 of the Revised Code; and

(b) Any other real and personal property and other assets in which an individual had any legal title or interest at the time of death (to the extent of the interest), including assets conveyed to a survivor, heir, or assign of the individual through joint tenancy, tenancy in common, survivorship, life estate, living trust, or other arrangement.

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

(3) "Individual," for the purpose of this rule, means someone with past or current medicaid eligibility.

(4) "Permanently institutionalized individual" as defined in section 5162.21 of the Revised Code.

(5) "Person responsible for the estate" as defined in section 2117.061 of the Revised Code.

(6) "Qualified long- term care partnership (QLTCP)" as defined in rule 5160:1-6-02.2 of the Administrative Code.

(7) "Time of death" as defined in section 5162.21 of the Revised Code.

(C) The Ohio attorney general (AGO) will seek recovery or adjustment, on behalf of the Ohio department of medicaid (ODM), from the estates of the following individuals:

(1) A permanently institutionalized individual of any age, in the amount of all medicaid benefits correctly paid including managed care capitation payments; or

(2) An individual fifty-five years of age or older who is not permanently institutionalized, in the amount of all medicaid benefits correctly paid including managed care capitation payments (other than benefits paid on or after January 1, 2010, under the medicare premium assistance programs set forth in rule 5160:1-3-02.1 of the Administrative Code) after the individual attained such age.

(D) Any adjustment or recovery under paragraph (C) of this rule may be sought only:

(1) After the death of the individual's surviving spouse, if any; and

(2) When the individual has no surviving child who either is under age twenty-one or is blind or permanently and totally disabled as defined in Chapter 5160:1-3 of the Administrative Code; and

(3) When recovery is sought against a permanently institutionalized individual under paragraph (C)(1) of this rule, no recovery may be made against the individual's home while either of the following lawfully resides in the home:

(a) The permanently institutionalized individual's sibling who:

(i) Resided in the home for at least one year immediately before the date of the individual's admission to the institution, and

(ii) Has resided in the home on a continuous basis since that time.

(b) The permanently institutionalized individual's son or daughter who:

(i) Provided care to the permanently institutionalized individual that delayed the individual's institutionalization, and

(ii) Resided in the home for at least two years immediately before the date of the individual's admission to the institution, and

(iii) Has resided in the home on a continuous basis since that time, and

(iv) Documents that he or she has fulfilled these requirements by submitting the following:

(a) A written statement of the date that he or she moved into the home;

(b) A level of care assessment showing that the individual would have become institutionalized earlier without care provided by the adult son or daughter;

(c) A written statement from the individual's attending physician, stating the kind and duration of care that was required to delay the individual's institutionalization; and

(d) All relevant documentation of the care that delayed institutionalization and the role the adult son or daughter played in that care. This documentation shall include (but is not limited to) one or more of the following:

(i) A written statement of the number of hours per day during which the adult son or daughter provided personal care, specifying the extent and type of care provided;

(ii) A written statement of any part-time or full-time jobs performed by the adult son or daughter, and any schools or other similar institutions attended by the adult son or daughter, while providing care; or

(iii) Written documentation from a service agency which provided care to the individual, the dates on which care was provided, and the extent and type of care provided.

(E) Notice requirements.

(1) When an individual was age fifty-five or older or was permanently institutionalized at the time of death, the person responsible for the estate shall give notice to the AGO, as required by section 2117.061 of the Revised Code.

(2) After the individual's death, whenever adjustment or recovery is sought by ODM or its designee, a claim for recovery shall be presented by the AGO.

(a) The claim shall include all information required by Chapter 2117. of the Revised Code and shall be served on the person responsible for the estate or, when there is no person responsible for the estate, any person who received or controls probate or non-probate assets inherited from the individual.

(b) The claim shall include the following:

(i) The definition of undue hardship as stated in paragraph (H) of this rule;

(ii) The process for requesting an undue hardship as set forth in paragraph (I) of this rule; and

(iii) The date by which the request for an undue hardship waiver is to be received by ODM.

(3) The person responsible for the estate shall notify any person who received or controls probate or non-probate assets, inherited from the individual, affected by the proposed recovery.

(F) When the person responsible for the estate from which recovery is sought requests to satisfy the claim without selling a non-liquid asset subject to recovery, the AGO may establish a payment schedule, promissory note, or lien.

(G) Qualified long-term care partnership disregard.

(1) The amount of resources disregarded at eligibility determination (as established in rule 5160:1-6-02.2 of the Administrative Code) will be disregarded during estate recovery.

(2) The following resources, which are not considered a resource at eligibility determination, will not be disregarded during estate recovery:

(a) Special needs trusts as established in rule 5160:1-3-05.2 of the Administrative Code;

(b) Pooled trusts as established in rule 5160:1-3-05.2 of the Administrative Code; and

(3) The QLTCP disregard at estate recovery is reduced to the extent that an individual made a transfer (that would otherwise have been considered an improper transfer under rule 5160:1-6-06 of the Administrative Code) without a restricted medicaid coverage period.

(H) The ODM director, or designee, may grant an undue hardship waiver on a case-by-case basis when there are compelling circumstances.

(1) ODM may, at the sole discretion of the ODM director or the director's designee, waive estate recovery when recovery would work an undue hardship on an individual's survivors. Undue hardship may be found in the following cases.

(a) The estate subject to recovery is the sole income-producing asset of the survivor, such as a family farm or other family business, which:

(i) Produces a limited amount of income, or

(ii) Is the sole asset of the survivor.

(b) Without receipt of the estate proceeds, the survivor would become eligible for public assistance.

(c) Recovery would deprive the survivor of necessary food, shelter or clothing. Deprivation does not include situations in which the survivor is merely inconvenienced but would not be at risk of serious harm.

(d) The survivor provides clear and convincing evidence of substantial personal financial contributions to the deceased individual, creating an equity interest in the property.

(e) The survivor is age sixty-five or older and financially dependent upon receipt of the estate proceeds.

(f) The estate proceeds are preserved for the benefit of a survivor who:

(i) Is totally and permanently disabled as defined in Chapter 5160:1-3 of the Administrative Code; and

(ii) Is financially dependent upon receipt of the estate proceeds.

(2) The following situations do not, without additional showing of hardship, show undue hardship:

(a) When recovery will prevent heirs from receiving an anticipated inheritance.

(b) When recovery results in the loss of a pre-existing standard of living, or prevents the establishment of a source of maintenance that did not exist prior to the individual's death.

(3) Regardless of actual hardship, an undue hardship waiver will not be granted in the following situations:

(a) When the individual created the hardship by using estate planning methods under which the individual divested, transferred, or otherwise encumbered assets in whole or in part to avoid estate recovery.

(b) When an undue hardship waiver will result in the payment of claims to other creditors with lower priority standing under Ohio's probate law.

(I) Request for undue hardship waiver.

(1) Within thirty calendar days after notice of the estate recovery claim was mailed by the AGO, an undue hardship waiver may be requested by an heir or potential heir who would suffer an undue hardship if a waiver is not granted, a person with an interest in assets of the estate, or a representative of such persons. An undue hardship waiver may not be requested by a creditor of the estate, unless such creditor is also a potential heir of the estate.

(2) Within sixty calendar days of receipt of the request for an undue hardship waiver, ODM shall notify the applicant whether the waiver request has been approved (in full, in part, or for a limited time) or denied. Failure to meet this sixty day deadline does not result in an automatic decision on the request.

(3) When the waiver request was not approved in full, or when the approval was time-limited, the applicant may, within thirty calendar days, request that the ODM director, or designee, review the undue hardship waiver decision.

(a) The ODM director, or designee, will review only those portions of the undue hardship waiver request that were denied or time-limited. The director will not deny or limit any portion of the undue hardship waiver request that has already been granted.

(b) The ODM director, or designee, shall review the undue hardship waiver request and notify the applicant within sixty calendar days whether (at the director's sole discretion) the director, or designee, has approved (in full, in part, or for a limited time) or denied the request for an undue hardship waiver. Failure to meet this sixty day deadline does not result in an automatic decision on the request.

(J) Within thirty days after notice of the estate recovery claim was mailed by the AGO, a person with an interest in assets of the estate (or a representative of any such person) may present a claim showing evidence that assets of the estate are exempt assets under one of the following categories.

(1) Government reparation payments to special populations are exempt from medicaid estate recovery.

(2) Certain American Indian and Alaska native income and resources, including:

(a) American Indian and Alaska native income and resources which are exempt from medicaid estate recovery by other laws and regulations;

(b) Ownership interest (when ownership would pass from an Indian to one or more relatives; to a tribe or tribal organization; and/or to one or more Indians) in trust or non-trust property, including real property and improvements:

(i) Located on a reservation (any federally recognized Indian tribe's reservation, pueblo, or colony, including former reservations in Oklahoma, Alaska native regions established by Alaska native claims settlement act and Indian allotments) or near a reservation as designated and approved by the bureau of Indian affairs of the U.S. department of the interior; or

(ii) For any federally-recognized tribe not described in paragraph (J)(2)(b)(i) of this rule, located within the most recent boundaries of a prior federal reservation; or

(c) Income left as a remainder in an estate derived from property protected in paragraph (J)(2)(b) of this rule, that was either collected by an Indian, or by a tribe or a tribal organization and distributed to an Indian, as long as the income clearly comes from protected sources;

(d) Ownership interests left as a remainder in an estate in rents, leases, royalties, or usage rights related to natural resources (including extraction of natural resources or harvesting of timber, other plants and plant products, animals, fish, and shellfish) resulting from the exercise of federally-protected rights, and income either collected by an Indian, or by a tribe or tribal organization and distributed to an Indian derived from these sources the income or ownership interest clearly comes from protected sources; and

(e) Ownership interests in or usage rights to items that have unique religious, spiritual, traditional, and/or cultural significance or rights that support subsistence or a traditional life style according to applicable tribal law or custom.

Last updated November 17, 2025 at 10:08 AM

History

Effective: January 1, 2018
Promulgated Under: 111.15

Ohio Adm.Code 5160:1-2-08 Medicaid: individual responsibilities.

(A) This rule describes the responsibilities of an individual, or someone acting on an individual's behalf, who is applying for or receiving medical assistance.

(B) Individual responsibilities.

(1) When applying for or receiving any medical assistance, an individual must:

(a) Sign, under penalty of perjury, and submit an application for medical assistance in accordance with rule 5160:1-2-01 of the Administrative Code.

(b) Cooperate with the administrative agency in any eligibility determination for initial or continuing coverage, audit, and quality control process set out in this chapter of the Administrative Code. The individual must:

(i) In completing an application or renewal for medical assistance, answer all required questions and provide documentation requested by the administrative agency necessary to verify the conditions of eligibility as described in rule 5160:1-2-10 of the Administrative Code and any other relevant eligibility criteria required under Chapter 5160:1-3, 5160:1-4, 5160:1-5, or 5160:1-6 of the Administrative Code.

(ii) Request assistance from the administrative agency when unable to obtain requested information. The individual must provide the information necessary to allow the administrative agency to assist the individual.

(c) Select a managed care organization (MCO) as required by rule 5160-26-02 of the Administrative Code, unless the individual meets one of the exceptions listed in that rule.

(d) Inform the administrative agency within ten calendar days of any change to the following circumstances for the individual or any person living with the individual:

(i) Contact information.

(a) Address; or

(b) Phone number; or

(ii) Marital status.

(iii) Income, including any:

(a) One-time gifts or payments; or

(b) Change in hourly wage or salary; or

(d) Gain or loss of employment.

(iv) An individual's pregnancy status, such as an individual becoming pregnant or a pregnancy ending.

(v) Third-party responsibility for the individual's health care costs, including:

(a) New coverage under a health insurance policy, regardless of who is paying for the coverage; or

(b) A change in health insurers; or

(d) A court order requiring a person or entity to pay some or all of the individual's medical expenses; or

(e) Any accident or injury for which another person or entity may be responsible, such as a work-related injury or an injury received in an automobile collision. In addition to reporting the injury or accident, an individual must also report any information received about any involved insurance company.

(e) Cooperate with any third party responsible for an individual's health care costs.

(f) Not commit medicaid eligibility fraud as described in section 2913.401 of the Revised Code.

(2) When applying for or receiving medical assistance on the basis of being blind, disabled, or at least age sixty-five, an individual must also inform the administrative agency of any:

(a) Improvement of the condition for which the benefit is received; or

(b) Change in the ownership or value of a resource owned by the individual or the individual's spouse, including any change in an annuity or an annuity's remainder beneficiary designation.

(1) An individual may designate an authorized representative, in writing, to stand in place of the individual and act with authority on behalf of the individual, as described in rule 5160-1-33 of the Administrative Code.

(2) When an individual is unable to identify an authorized representative because of incapacity or incompetence, the administrative agency will assist the individual with appointing an authorized representative, as described in rule 5160:1-2-01 of the Administrative Code.

Last updated November 1, 2023 at 8:27 AM

History

Effective: November 1, 2023
Promulgated Under: 111.15

Ohio Adm.Code 5160:1-2-10 Medicaid: conditions of eligibility and verifications.

(A) This rule describes eligibility criteria that apply to all medical assistance programs, how eligibility criteria will be verified by the administrative agency, and when an individual will be asked to provide manual verification. Eligibility conditions that are specific to a certain eligibility group are addressed in the eligibility rule for that group.

(B) To be determined eligible for medical assistance, an individual shall:

(1) Provide a social security number (SSN) in accordance with 42 C.F.R. 435.910 (as in effect October 1, 2024).

(a) The individual's self-declaration of SSN meets this condition unless contradictory information is provided to or maintained by the administrative agency.

(b) An individual is not required to provide an SSN when the individual:

(i) Is applying for or receiving non-citizen emergency medical assistance (NCEMA), as described in rule 5160:1-5-06 of the Administrative Code.

(ii) Refuses to obtain an SSN because of well-established religious objections. Well-established religious objections exist when the individual:

(a) Is a member of a recognized religious sect or division of the sect; and

(b) Adheres to the tenets or teachings of the sect or division of the sect and for that reason is conscientiously opposed to applying for or using a national identification number.

(c) If the individual has not been issued or cannot recall his or her SSN, the administrative agency shall assist the individual with obtaining or applying for the individual's SSN.

(2) Be a resident, as defined in 42 C.F.R. 435.403 (as in effect October 1, 2024), of the state of Ohio on the date of application or requested coverage begin date.

(a) The individual's self-declaration of residency meets this condition unless contradictory information is provided to or maintained by the administrative agency.

(b) An individual remains a resident despite a temporary absence from the state when the individual intends to return when the purpose of the absence has been accomplished, unless another state has determined the individual is a resident there for purposes of medicaid eligibility.

(c) The individual shall not be eligible for and receiving medical assistance in another state or U.S. territory. An individual who has recently become an Ohio resident is not ineligible for medical assistance merely due to processing delays in terminating medical assistance in the prior state of residence.

(i) When there are delays in discontinuing medical assistance in the prior state of residence and the individual is unable to provide all needed verifications, the administrative agency shall explore presumptive coverage, as described in rule 5160:1-2-13 of the Administrative Code.

(ii) When all verifications have been provided, the administrative agency shall explore eligibility for medical assistance in accordance with Chapter 5160:1-3, 5160:1-4, 5160:1-5, or 5160:1-6 of the Administrative Code, as applicable.

(3) Be a U.S. citizen or qualified non-citizen.

(a) An individual is not required to declare or verify citizenship or non-citizen status when the individual is applying for benefits only on behalf of another person.

(b) An individual's declaration of U.S. citizenship shall be verified as described in rule 5160:1-2-11 of the Administrative Code.

(c) An individual's declaration of qualified non-citizen status shall be verified as described in rule 5160:1-2-12 of the Administrative Code.

(d) Verification of non-citizen status is not required when the individual is applying for NCEMA, as described in rule 5160:1-5-06 of the Administrative Code.

(4) In accordance with 42 C.F.R. 435.610 (as in effect October 1, 2024) and section 5160.38 of the Revised Code, the state of Ohio shall automatically be assigned any rights to medical support and payments for medical care from any third party for:

(a) The individual; and

(b) Any medicaid-eligible individual for whom the individual is legally able to make an assignment.

(5) Cooperate with the child support enforcement agency (CSEA) in establishing the paternity of any medicaid-eligible child and in obtaining medical support and payments as described in paragraph (B)(4) of this rule, in accordance with 42 C.F.R. 433.147 (as in effect October 1, 2024).

(a) As part of cooperation, the individual may be required to:

(i) Appear at a state or local office to provide information or evidence relevant to the case; and

(ii) Appear as a witness at a court or other proceeding; and

(iii) Provide information, or attest to lack of information, under penalty of perjury; and

(iv) Take any reasonable steps to assist with establishing paternity and securing medical support or payments.

(b) Cooperation is required unless the individual:

(i) Is not receiving medical assistance for himself or herself;

(ii) Is a pregnant woman, including a woman who is in her postpartum period;

(iii) Has been approved for a good cause waiver as determined by the local CSEA; or

(iv) Is receiving transitional medical assistance.

(6) Cooperate with the administrative agency in identifying and providing information to assist the state with pursuing any third party who may be liable to pay for care and services. To meet this condition, the individual shall provide the name of the insurance company, billing address, subscriber identification number, group number, name of policy holder, and a list of covered individuals. In addition, the individual shall cooperate with requests:

(a) From a third-party insurance company to provide additional information that is required to authorize coverage or obtain benefits through the third-party insurance company.

(b) From a medicaid provider, managed care plan, or a managed care plan's contracted provider to provide additional information that is required for the provider or plan to obtain payments from a third-party insurance company for medicaid covered services.

(c) From a third-party insurance company, medicaid provider, managed care plan, or a managed care plan's contracted provider to forward or return to the third-party insurance company, medicaid provider, managed care plan, or managed care plan's contracted provider any payments received from the third-party insurance company for medicaid covered services when:

(i) The provider has billed the third-party insurance company for medicaid covered services provided to the individual; and

(ii) The third-party insurance company has sent payment to the individual for medicaid covered services the individual received from the provider.

(7) Meet all eligibility requirements for an eligibility category set out in an approved state plan amendment, Chapter 5160:1-2, 5160:1-3, 5160:1-4, 5160:1-5, or 5160:1-6 of the Administrative Code, including:

(a) Income requirements for the eligibility category.

(i) When an individual's declared income exceeds the relevant federal poverty level (FPL) threshold, the individual's declared income will be accepted without further verification.

(ii) When an individual's declared income is reasonably compatible with data available through electronic data sources, the individual's declared income will be accepted without further verification. Income shall be considered reasonably compatible when:

(a) Both the declared income and the electronic data verification are above, at, or below the applicable income standard for the individual's family size for the eligibility category being determined; or

(b) The difference between the declared income and the electronic data verification is within an amount equal to the reasonable compatibility standard threshold for income specified in the state's MAGI-based eligibility verification plan.

(iii) When the administrative agency is unable to verify income through electronic data sources, acceptable verification documentation includes, but is not limited to:

(a) Information maintained as a regular part of business by a government entity;

(b) A current pay stub;

(d) IRS form 1099 or other tax documents;

(e) An employer statement including hourly or salary wage, hours worked per pay period, length of pay period, and any tax withholdings; or

(f) The individual's statement, if he or she declares the income verification cannot be accessed or submitted.

(b) Resource and asset requirements for the eligibility category.

(i) When an individual's declared resources are reasonably compatible with data available through electronic data sources, the individual's declared resources will be accepted without further verification. Resources shall be considered reasonably compatible when:

(a) Both the declared resources and the electronic data verification are above, at, or below the applicable resource standard for the eligibility category being determined; or

(b) The difference between the declared resources and the electronic data verification is within an amount equal to five per cent.

(ii) When the administrative agency is unable to verify the value of an individual's resources through electronic data sources, acceptable verification documentation includes, but is not limited to:

(a) Information maintained as a regular part of business by a government entity;

(b) A financial institution statement;

(d) The individual's statement, if he or she declares the resource verification cannot be accessed or submitted.

Last updated March 4, 2025 at 7:52 AM

History

Effective: March 1, 2025
Promulgated Under: 111.15

Ohio Adm.Code 5160:1-2-11 Medicaid: United States (U.S.) citizenship documentation.

(A) This rule sets forth acceptable documentary evidence of U.S. citizenship and the circumstances under which an individual who declares U.S. citizenship, under penalty of perjury, may be given a reasonable opportunity to verify U.S. citizenship.

(B) Definition."National of the U.S." for the purpose of this rule, means an individual who is not a U.S. citizen, but owes permanent allegiance to the U.S. as defined in 8 U.S.C 1101(a)(22) (as in effect October 1, 2025) and is treated the same as a U.S. citizen for medicaid eligibility purposes in accordance with 42 C.F.R 435.406 (as in effect October 1, 2025).

(C) Any individual applying for medical assistance and declaring to be a U.S. citizen or a national of the U.S.shall verify citizenship in accordance with 42 C.F.R. 435.407 (as in effect October 1, 2025).

(1) After a U.S. citizen or national of the U.S. is verified by the administrative agency, the administrative agency shall not require the individual to re-verify citizenship.

(2) The following individuals are not required to verify their U.S. citizenship:

(a) An individual applying for medical assistance only for other individuals.

(b) A child who received medical assistance as a deemed newborn on or after July 1, 2006.

(i) Enrolled in medicare;

(ii) Receiving supplemental security income (SSI);

(iii) Receiving social security disability insurance (SSDI);

(iv) Receiving adoption or foster care assistance under Title IV-E of the Social Security Act (as in effect October 1, 2025);

(v) In foster care and receiving child welfare services under Title IV-B of the Social Security Act (as in effect October 1, 2025); or

(vi) Receiving federal kinship guardianship assistance program (KGAP) payments under Title IV-E of the Social Security Act (as in effect October 1, 2025).

(d) Other individuals on such other basis as the secretary of the department of health and human services may specify, by regulation, that satisfactory documentary evidence of citizenship or nationality was previously presented.

(e) The administrative agency may rely, without further documentation of citizenship or identity, on a verification of citizenship made by a federal agency or another state agency, when such verification was done on or after July 1, 2006.

(D) When the administrative agency is unable to verify an individual's citizenship through the social security administration (SSA) or department of homeland security (DHS) electronic data exchange in the electronic eligibility system, the following documents must be accepted as satisfactory documentary evidence of citizenship:

(1) A U.S. passport, unless it was issued with a limitation; limited passports are issued through DHS using form I-131. A passport does not have to be currently valid unless it was issued to an individual born in Puerto Rico.

(2) A certificate of naturalization (DHS form N-550 or N-570).

(3) A certificate of U.S. citizenship (DHS form N-560 or N-561).

(4) A valid state-issued driver's license, when the state issuing the license requires proof of U.S. citizenship before issuance of such license or obtains a social security number (SSN) from the applicant and verifies before certification that such number is valid and assigned to the individual, who is a citizen.

(5) Native American tribal documents, including, but not limited to:

(a) A Seneca Indian tribal census record;

(b) The bureau of Indian affairs tribal census records of the Navajo Indians;

(d) A U.S. American Indian or Alaska native tribal document; or

(e) Other native American tribal documents.

(6) Such other documents as the secretary of the department of health and human services may specify, by regulation, provide proof of U.S. citizenship or nationality and that provide a reliable means of personal identity.

(E) In the case of an individual declaring citizenship who does not have an SSN at the time of declaration, the county department of job and family services (CDJFS) may assist the individual with obtaining an SSN and attempt to verify the individual's citizenship in accordance with paragraph (C) of this rule.

(F) When none of the documents from paragraph (D) of this rule are available, the administrative agency shall verify U.S. citizenship using a combination of one birth or nationality document from paragraph (F)(1) of this rule and one identity document from paragraph (F)(2) of this rule. Although some documents may be listed as both birth and nationality documents and identity documents, a particular document may only be used to satisfy either birth and nationality or identity, not both. A birth or nationality document or an identity document alone does not satisfy the citizenship documentation requirement.

(1) Birth or nationality shall be documented using an item from the following hierarchical list:

(a) A U.S. public birth record or birth document, showing birth in one of the fifty states, the District of Columbia, American Samoa, Guam (on or after April 10, 1899), the Northern Mariana Islands (NMI) (after November 4, 1986 NMI local time), Puerto Rico (on or after January 13, 1941), Swain's island, or the U.S. Virgin islands (on or after January 17, 1917) and for individuals whose U.S. citizenship may be established for collectively naturalized individuals as designated, by regulation, from the secretary of the department of health and human services. A birth certificate issued by Puerto Rico is valid only when it was issued on or after July 1, 2010.

(b) Birth information obtained through the administrative agency's data exchanges, as authorized by federal regulation or guidance from the secretary of the department of health and human services.

(d) A certification of birth abroad (FS-545).

(e) A U.S. citizen identification card (I-197 or I-179).

(f) A report of birth abroad of a citizen of the U.S. (FS-240).

(g) A northern Mariana islands identification card (I-873), issued by the United States citizenship and immigration service (USCIS), to a collectively naturalized citizen of the U.S. who was born in the northern Mariana islands before November 3, 1986.

(h) A final adoption decree or a statement from a state-approved adoption agency showing the individual's name and U.S. place of birth. In situations in which the adoption is not finalized and the state will not release a birth certificate prior to a final adoption decree, a statement showing the individual's name and U.S. place of birth, and stating that the source of information regarding the place of birth is an original birth certificate.

(i) Evidence of civil service employment by the U.S. government prior to June 1, 1976.

(j) An official military record of service showing a U.S. place of birth.

(k) A data verification with the systematic alien verification for entitlements (SAVE) program for naturalized citizens, including but not limited to the provision of the individual's alien registration number.

(l) Evidence showing an individual meets the requirements of the Child Citizenship Act of 2000, (Pub. L. No. 106-395). The administrative agency must obtain documentary evidence verifying that at any time on or after February 27, 2001, the following conditions have been met:

(i) At least one parent of the child is a U.S. citizen by either birth or naturalization;

(ii) The child is under the age of eighteen years;

(iii) The child is residing in the U.S. in legal and physical custody of the U.S. citizen parent;

(iv) The child was admitted to the U.S. for lawful permanent residence, as verified under the requirements of 8 U.S.C. 1641 as in effect on July 13, 2007 pertaining to verification of qualified non-citizen status; and

(v) When adopted, the child satisfies the requirements of section 101(b)(1) of the Immigration and Nationality Act (Pub. L. No. 82-414) pertaining to international adoptions, as in effect on July 13, 2007 including:

(a) Admission for lawful permanent residence as a child adopted outside the U.S. (IR-3); or

(b) Admission for lawful permanent residence as a child coming to the U.S. to be adopted, with final adoption having subsequently occurred (IR-4).

(m) Medical records including, but not limited to, hospital, clinic, or doctor records or admission papers from a nursing facility, skilled care facility, or other institution that indicate a U.S. place of birth.

(n) A life insurance, health insurance, or other insurance record showing a U.S. place of birth.

(o) Official religious record recorded in the U.S. showing that the birth occurred in the U.S..

(p) School records, including pre-school, Head Start and daycare, showing the child's name and U.S. place of birth.

(q) A federal or state census record showing U.S. citizenship or a U.S. place of birth, including the individual's age.

(r) Affidavits made under penalty of perjury. The affidavits do not need to be notarized. Affidavits may be used only in rare circumstances when the administrative agency is unable to secure evidence of birth or nationality from another listing. When the documentation requirement needs to be met through affidavits, the affidavit must be signed by another individual under penalty of perjury who can reasonably attest to the applicant's citizenship, and contain the applicant's name, date of birth, and place of U.S. birth.

(s) Such other documents as the secretary of the department of health and human services may specify, by regulation, that provide proof an individual is a U.S. citizen or national of the U.S.

(2) One of the following identity documents shall be used in combination with a birth or nationality document listed in paragraph (F)(1) of this rule. A document used to verify birth or nationality may not also be used to verify identity, even when the document is listed in this paragraph.

(a) A driver's license or similar document issued for the purpose of identification by a state, when the license or document contains a photograph of the individual or such other personal identifying information relating to the individual such as name, date of birth, gender, height, eye color, and address.

(b) An identification card issued by a federal, state, or local government agency or entity, provided the card contains a photograph or other information such as name, date of birth, gender, height, eye color, and address:

(i) A U.S. military card or draft record;

(ii) A military dependent's identification card;

(iii) A U.S. coast guard merchant mariner card; or

(iv) A school identification card with a photograph.

(c) For children under age nineteen, a clinic, doctor, hospital, or school record, including preschool or day care records.

(d) Two documents containing consistent information that corroborates an applicant's identity. Such documents include, but are not limited to, employer identification cards, high school and college diplomas (including high school equivalency diplomas), marriage certificates, divorce decrees, and property deeds or titles.

(e) When the individual does not have any document specified in paragraphs (F)(2)(a) to (F)(2)(d) of this rule, the individual may submit an affidavit signed under penalty of perjury by another person who can reasonably attest to the individual's identity. Such affidavit must contain the individual's name and other identifying information establishing identity, such as date of birth, gender, height, eye color, and address. The affidavit does not have to be notarized.

(f) Such other documents of personal identity as the secretary of the department of health and human services finds, by regulation, provide reliable means of identification.

(G) Reasonable opportunity period.

(1) When the administrative agency is unable to verify U.S. citizenship through the SSA electronic state verification and exchange system (SVES), and the individual has not provided satisfactory documentation as described in paragraphs (D) and (F) of this rule, the administrative agency shall give the individual a reasonable opportunity to present satisfactory documentation of U.S. citizenship.

(2) The administrative agency shall approve time-limited medical assistance, provided the individual satisfies all other conditions of eligibility outlined in rule 5160:1-2-10 of the Administrative Code. The reasonable opportunity period:

(a) Begins on and extends up to ninety days from the date the notice of reasonable opportunity is received by the individual.

(i) The date on which the notice is received is considered to be five days after the date on the notice, unless the individual shows the notice was not received within the five-day period.

(ii) The reasonable opportunity period may end before the ninetieth day when the agency verifies the individual's U.S. citizenship status.

(iii) Medical assistance coverage for an individual on a reasonable opportunity period is effective the first day of the calendar month in which the Ohio department of medicaid (ODM) receives the application as defined in rule 5160:1-2-01 of the Administrative Code.

(b) May be extended. The administrative agency is to provide an extension of the reasonable opportunity period when the individual is making a good faith effort to resolve any inconsistencies or obtain necessary documentation or when the administrative agency is unable to complete the verification process within the ninety-day reasonable opportunity period.

(c) Is granted with each application needing verification of U.S. citizenship, provided the individual satisfies all other conditions of eligibility outlined in rule 5160:1-2-10 of the Administrative Code. When an individual who was previously provided a reasonable opportunity period was discontinued after ninety days for failing to provide verification, the individual is to be granted another ninety-day reasonable opportunity period with each subsequent new application.

(d) Ends on:

(i) The date the administrative agency verifies the individual's U.S. citizenship;

(ii) The last date of the month in which the ninetieth day falls as described in paragraph (G)(2)(a) of this rule; or

(iii) An administrative agency approved extension date beyond the ninety-day reasonable opportunity period when:

(a) The administrative agency has determined the individual is making a good faith effort to resolve any inconsistencies or obtain necessary documentation; or

(b) The administrative agency is unable to complete the verification process within the ninety-day reasonable opportunity period.

(3) Retroactive coverage.

(a) There is no provision for retroactive coverage for individuals on a reasonable opportunity period.

(b) When an individual provides evidence of satisfactory immigration status during the individual's ninety-day reasonable opportunity period, the individual may have eligibility explored for retroactive medical assistance in accordance with rule 5160:1-2-01 of the Administrative Code.

Last updated February 13, 2026 at 8:04 AM

History

Effective: February 13, 2026
Promulgated Under: 111.15

Ohio Adm.Code 5160:1-2-12 Medicaid: non-citizens.

(A) This rule sets forth:

(1) Medical assistance eligibility criteria for an individual who is not a United States (U.S.) citizen or a national of the U.S.;

(2) Acceptable documentary evidence of full medicaid eligible non-citizen status; and

(3) The circumstances under which an individual who declares full medicaid eligible non-citizen status, under penalty of perjury, may be given a reasonable opportunity to verify that status.

(B) Definitions. For the purposes of this rule:

(1) "A-number" means the alien registration number issued to a non-citizen by the United States citizenship and immigration service (USCIS) or, in limited circumstances, by the United States department of state.

(2) "Active duty" means full-time employment in the military service, and does not include reserve or guard duty. The service member shall serve a minimum of twenty-four months or the period for which the person was called to military service in order to be eligible for benefits that are based on the length of active duty service.

(3) "Amerasian" means a person born in Cambodia, Korea, Laos, Thailand, or Vietnam after December 31, 1950, and before October 22, 1982, who was fathered by a U.S. citizen as defined in Section 584 of the Foreign Operations, Export Financing, and Related Programs Appropriations Act of 1988 (Pub. L. No. 100-202).

(4) "Asylee" means a person who has been granted asylum under section 208 of the Immigration and Nationality Act (INA) (as in effect October 1, 2026).

(5) "Child" means an individual under the age of twenty-one.

(6) "Full medicaid eligible non-citizen" means:

(a) A lawful permanent resident (LPR);

(b) A Cuban or Haitian entrant as defined in section 501(e) of the Refugee Education Assistance Act of 1980; or

(c) A compact of free association (COFA) individual, including a citizen of the Federated States of Micronesia, the Republic of the Marshall Islands, or the Republic or Palau, pursuant to 8 U.S.C. 1641(b)(8) (as in effect October 1, 2026).

(7) "Indefinite detainee" means a non-citizen who has served time for a criminal conviction and has received a final order of removal, but remains indefinitely in the U.S. because neither the individual's home country nor any other country will accept the individual. Being an indefinite detainee does not confer eligibility for medical assistance upon an individual nor does it serve as an exemption to the five-year bar described in paragraph (C)(1) of this rule.

(8) "LPR" means a person who is legally authorized to live permanently within the U.S. as an immigrant.

(9) "National of the U.S." means an individual who is not a U.S. citizen, but owes permanent allegiance to the U.S. as defined in 8 U.S.C. 1101(a)(22) (as in effect October 1, 2026) and is treated the same as a U.S. citizen for medicaid eligibility purposes in accordance with 42 C.F.R. 435.406 (as in effect October 1, 2026).

(10) "Parolee" means a person who has been given permission by the United States department of justice or the United States department of homeland security (DHS) to enter the U.S. in an emergency or because it serves an overriding public interest. Parolees are granted temporary residence and are not on a predetermined path to permanent resident status.

(11) "Quarter of coverage" is the basic unit for determining whether a worker is insured under the social security program. The amount of wages and self-employment income which an individual shall have in order to be credited with a quarter of coverage is defined in 42 U.S.C. 413(d) (as in effect October 1, 2026), and is published annually in the Federal Register.

(12) "Veteran" means a person who served in the active U.S. military, naval, or air service, who fulfilled the minimum active duty service requirements and was released with a discharge characterized as honorable and not on account of alienage, including veterans who die while serving in active duty in the armed forces of the U.S. as defined in 38 U.S.C. 1101 (as in effect October 1, 2026). A veteran also includes individuals with certain military service before July 1, 1946 in the military forces (including certain organized guerrilla forces) of the government of the Commonwealth of the Philippines and certain service in the Philippine scouts as described in 38 U.S.C. 107 (as in effect October 1, 2026).

(13) "Victim of trafficking" refers to:

(a) A victim of trafficking and certain family members, as identified in the Trafficking Victims Protection Reauthorization Act of 2003 (TVPRA) (Pub. L. No. 108-193), who are eligible for federally funded or administered benefits to the same extent as refugees, per 22 U.S.C. 7105(b)(1)(A) (as in effect October 1, 2026).

(b) A victim of trafficking who is awarded a certification letter from the office of refugee resettlement (ORR). Certain family members of a victim of trafficking are awarded "Derivative T" visas.

(c) A victim of trafficking who is younger than eighteen years of age is issued a notarized letter from the ORR, which is similar to an adult certification letter, stating the child is a victim of trafficking.

(C) As of the effective date of this rule, an individual who is not a U.S. citizen or national of the U.S. must be a full medicaid eligible non-citizen to be eligible for medical assistance.

(1) An individual who is a full medicaid eligible non-citizen does not have a satisfactory immigration status for medical assistance for a period of five years beginning on the date the status was granted, unless the individual is one of the following:

(a) An individual who adjusted to LPR status from any of the following immigration statuses:

(i) A refugee admitted to the U.S. under section 207 of the INA (as in effect October 1, 2026);

(ii) An asylee who has been granted asylum under section 208 of the INA (as in effect October 1, 2026);

(iii) A person whose deportation is being withheld under section 243(h) of the INA (as in effect October 1, 2026) or whose removal has been withheld under section 241(b)(3) of the INA (as in effect October 1, 2026);

(iv) Amerasian immigrant;

(v) Victim of trafficking;

(vi) An Afghan or Iraqi non-citizen granted special immigrant visa (SIV) status under section 8120 of the December 19, 2009 Defense Appropriations Bill (Pub. L. No. 111-118) and section 101(a)(27) of the INA (as in effect October 1, 2026);

(vii) An American Indian born in Canada with at least fifty per cent American Indian blood, covered by the provisions of 289 of the INA (8 U.S.C. 1359) (as in effect October 1, 20252026); or

(viii) A member of an Indian tribe, as defined in 25 U.S.C. 450b(e) (as in effect October 1, 20252026) and the Indian Self-Determination and Education Assistance Act of 1975 (Pub. L. No. 93-638).

(b) A Cuban or Haitian entrant;

(c) A COFA individual, including a citizen of the Federated States of Micronesia, the Republic of the Marshall Islands, or the Republic of Palau.

(d) A child or pregnant woman, including a woman in her postpartum period as defined in rule 5160:1-1-01 of the Administrative Code;

(e) An LPR who has forty quarters of coverage under Title II of the Social Security Act (as in effect October 1, 2026) or can be credited with such quarters.

(i) In determining the number of quarters of coverage, an LPR shall be credited as follows:

(a) All qualifying quarters worked by the LPR;

(b) All of the qualifying quarters of coverage worked by a natural or adoptive parent of the LPR before the date the individual attains age eighteen can be credited;

(c) All of the qualifying quarters worked by a spouse of the LPR during their marriage shall be credited so long as the LPR remains married to such spouse or such spouse is deceased; and

(d) A parent or spouse whose quarters are credited to the LPR must be a U.S. citizen or an LPR.

(ii) A qualifying quarter does not include any quarter after December 31, 1996, in which the LPR also received a federal means-tested public benefit.

(f) An individual who:

(i) Is a military member on active duty (other than active duty for training) in the armed forces of the U.S.; or

(ii) Is a veteran who received an honorable discharge, not a discharge on account of alienage as described in 8 U.S.C. 1426 (as in effect October 1, 2026).

(g) A spouse or unmarried dependent child of a veteran or active duty service member as described in paragraph (C)(1)(f) of this rule.

(h) The surviving spouse of a deceased veteran or service member, provided the spouse has not remarried and the marriage fulfills the following requirements:

(i) Married for at least one year;

(ii) Married before the end of a fifteen-year time span following the end of the period of military service in which the injury or disease was incurred or aggravated; or

(iii) Married for any period when a child was born of or before the marriage.

(2) An individual who is not a U.S. citizen or national of the U.S. and not in a full medicaid eligible non-citizen status may be eligible for medical assistance when the individual is one of the following:

(a) A lawfully residing pregnant woman, including a woman in her postpartum period; or

(b) A lawfully residing child.

(D) An individual who is not a U.S. citizen or national of the U.S. and not in a status that meets the criteria established in paragraph (C) of this rule may be eligible for non-citizen emergency medical assistance (NCEMA) as described in rule 5160:1-5-06 of the Administrative Code, and is not required to verify non-citizenship status.

(E) Any individual applying for medical assistance and declaring a status that meets the criteria established in paragraph (C) of this rule shall bear the burden of proof of that status.

(F) The process for establishing a status that meets the criteria established in paragraph (C) of this rule shall include that:

(1) The administrative agency must attempt to verify an individual's immigration status through the electronic eligibility system.

(2) When the individual's immigration status cannot be verified through the electronic eligibility system, the individual must present documentary evidence of immigration status. The administrative agency is required to confirm the authenticity of the documentation provided by the individual through the automated systematic alien verification for entitlements (SAVE) system. Documentary evidence of immigration status refers to:

(a) I-94 (arrival/departure record).

(b) I-551 (permanent resident card).

(d) Other documentation as prescribed or allowed by federal law.

(G) When the administrative agency has been unable to verify a status that meets the criteria established in paragraph (C) of this rule through the electronic eligibility system, and the individual has not provided verification as described in paragraph (F)(2) of this rule, the administrative agency:

(1) Shall provide a reasonable opportunity period in accordance with paragraph (H) of this rule; and

(2) Shall not delay, deny, reduce, or discontinue benefits for an individual who is determined by the agency to be otherwise eligible for medical assistance during such reasonable opportunity period, in accordance with 42 C.F.R. 435.911(c) (as in effect October 1, 2026).

(3) Shall promptly provide the individual with information obtained from the electronic data source described in paragraph (F) of this rule so that the individual can attempt to resolve any inconsistencies with regard to immigration status.

(H) The reasonable opportunity period:

(1) Begins on and extends up to ninety days from the date the notice of reasonable opportunity is received by the individual.

(a) The date on which the notice is received is considered to be five days after the date on the notice, unless the individual shows the notice was not received within the five-day period.

(b) The reasonable opportunity period may end before the ninetieth day when the agency verifies the individual's status that meets the criteria established in paragraph (C) of this rule.

(c) Medical assistance coverage for an individual on a reasonable opportunity period is effective the first day of the calendar month in which the Ohio department of medicaid (ODM) receives the application as defined in rule 5160:1-2-01 of the Administrative Code.

(2) May be extended. The administrative agency is to provide an extension of the reasonable opportunity period when the individual is making a good faith effort to resolve any inconsistencies or obtain necessary documentation or when the administrative agency is unable to complete the verification process within the ninety-day reasonable opportunity period.

(3) Is granted with each application needing verification of a status that meets the criteria established in paragraph (C) of this rule, provided the individual satisfies all other conditions of eligibility outlined in rule 5160:1-2-10 of the Administrative Code. When an individual who was previously provided a reasonable opportunity period was discontinued after ninety days for failing to provide verification, the individual is to be granted another ninety-day reasonable opportunity period with each subsequent new application.

(4) Ends on:

(a) The date the administrative agency verifies the individual's status that meets the criteria established in paragraph (C) of this rule;

(b) The last day of the month in which the ninetieth day falls as described in paragraph (H)(1) of this rule; or

(i) The administrative agency has determined the individual is making a good faith effort to resolve any inconsistencies or obtain necessary documentation; or

(ii) The administrative agency is unable to complete the verification process within the ninety-day reasonable opportunity period.

(5) When an individual's immigration status changes during the reasonable opportunity period to one that no longer meets the criteria established in paragraph (C) of this rule, the medical assistance coverage established through paragraph (H)(1)(c) of this rule will transition to NCEMA coverage as described in paragraph (D) of this rule.

(6) Retroactive coverage.

(a) There is no provision for retroactive coverage for individuals on a reasonable opportunity period.

(b) When an individual provides evidence of a status that meets the criteria established in paragraph (C) of this rule during the individual's ninety-day reasonable opportunity period, the individual may have eligibility explored for retroactive medical assistance in accordance with rule 5160:1-2-01 of the Administrative Code.

Last updated October 1, 2026 at 9:10 AM

History

Effective: October 1, 2026
Promulgated Under: 111.15

Ohio Adm.Code 5160:1-2-12.1 Medicaid: sponsored non-citizens.

(A) This rule describes the requirement to deem income and resources from a sponsor to a non-citizen, exemptions from the sponsor deeming requirement, and the process for calculating the amount of income and resources to deem.

(1) In accordance with 8 U.S.C. 1182 (as in effect October 1, 2024), certain non-citizens seeking lawful permanent resident (LPR) status are required to provide an affidavit of support from a sponsor(s). A sponsor must agree to assume financial support for the non-citizen.

(2) When determining the non-citizen's eligibility for medical assistance, the income and resources of the sponsor and the sponsor's spouse, when the spouse also signed an affidavit of support, must be counted.

(3) Divorce does not end the sponsorship obligation.

(4) Deeming of income and resources applies regardless of whether the sponsor and the sponsored non-citizen live in the same household or whether the sponsor actually provides support to the sponsored non-citizen.

(B) Definitions. For the purposes of this rule:

(1) "Allocation" means an amount deducted from income subject to deeming, which is considered to be set aside for the support another individual.

(2) "Child" means an individual under age eighteen who lives in a household with one or both parents and who is neither married nor the head of household. The deeming of parental income applies through the month in which the child attains eighteen years of age. A child's income and resources are never deemed to parent(s) or sibling(s).

(3) "Deemed income" means income attributed to another person whether or not the income is actually available to the person to whom it is deemed.

(4) "Deemed resources" means resources attributed to another person whether or not the resource is actually available to the person to whom they are deemed.

(5) "Eligible child" means a child in the household who has applied for non-modified adjusted gross income (MAGI) medical assistance and meets all the applicable non-financial and income eligibility criteria.

(6) "Ineligible parent," for the purpose of non-MAGI determinations, means an eligible child's parent who has not applied for non-MAGI medical assistance.

(7) "Ineligible spouse," for the purpose of non-MAGI determinations, means the member of the married couple who has not applied for non-MAGI medical assistance.

(8) "Parent" means a natural, adoptive, or stepparent living in the same household as the eligible child. For the purpose of non-MAGI determinations, the income of a stepparent who lives with the eligible child is deemed to the child only when the natural or adoptive parent also lives in the household with the stepparent and the child. When the natural or adoptive parent divorces a stepparent and the child is living with the stepparent, the stepparent is not considered a parent or spouse for deeming purposes.

(9) "Sponsor" means an individual who signs an affidavit of support agreeing to assume financial support of a sponsored non-citizen as a condition of the non-citizen's admission for permanent residence in the United States. A sponsored non-citizen may have more than one sponsor. For deeming purposes, a sponsor does not include an organization such as the congregation of a church, a service club, or an employer who only guarantees employment for a non-citizen upon entry but does not sign an affidavit of support.

(10) "Sponsored non-citizen" means an individual lawfully admitted for permanent residence in the United States who is supported by a sponsor(s). Such an individual has applied for medical assistance and meets all the applicable non-financial eligibility criteria.

(11) "Spouse" means a person who is legally married to another under Ohio law.

(C) The following non-citizens, even when they have sponsors who signed an affidavit of support, are not subject to the sponsor deeming requirements:

(1) A non-citizen being determined for non-citizen emergency medical assistance (NCEMA) as described in rule 5160:1-5-06 of the Administrative Code.

(2) A lawfully residing pregnant woman or lawfully residing woman within the postpartum period as defined in rule 5160:1-1-01 of the Administrative Code.

(3) A lawfully residing child.

(4) A non-citizen who has forty qualifying work quarters or who can be credited with such quarters, as described in rule 5160:1-2-12 of the Administrative Code.

(D) The administrative agency has the responsibility to make determinations for the following two exemptions to the sponsor deeming requirements, in accordance with 8 U.S.C. 1631(e) and 1631(f) (as in effect October 1, 2024):

(1) A victim who has been battered or subjected to extreme cruelty.

(a) None of the sponsor's income or resources are counted when determining the non-citizen's eligibility when this exemption applies.

(b) The initial exemption is in effect for twelve months from the date the administrative agency makes the determination of abuse or cruelty. The exemption can be extended only when the battery or extreme cruelty is recognized by the department of justice, an administrative law judge, or the United States department of homeland security (DHS).

(2) An indigent non-citizen.

(a) A non-citizen is considered indigent when all of the following conditions are met:

(i) The non-citizen is not living with a sponsor;

(ii) The non-citizen's total income received is less than the current supplemental security income (SSI) federal benefit rate (FBR); and

(iii) The resources available to the non-citizen are under the applicable resource limit for an individual as described in rule 5160:1-3-05.1 of the Administrative Code.

(b) A non-citizen will not be granted an indigent exemption when living with a sponsor, as it is assumed the sponsor is providing food and shelter.

(c) When a non-citizen is determined to be indigent, beginning on the date the determination is made, only the actual amount of income and resources provided by the sponsor to the non-citizen is counted for twelve months.

(d) The administrative agency may extend this exemption for additional twelve-month periods but must make a new indigency determination for each period.

(e) When the administrative agency has determined a sponsored non-citizen to be indigent, the agency must provide written notice to DHS, including the name of the non-citizen and the sponsor.

(f) The administrative agency must notify the sponsored non-citizen that a finding of indigence will be reported to DHS so the non-citizen can decide whether or not to request consideration for the indigence exemption.

(E) Deeming of income.

(1) MAGI-based eligibility.

(a) When the non-citizen is not claimed as a tax dependent of the sponsor or when the sponsor claims the non-citizen as a tax dependent but is not the spouse or parent of the non-citizen, any cash contributions given to the non-citizen are considered countable unearned income.

(b) When the sponsor is the spouse or parent of the non-citizen, the household composition and income calculations as described in rule 5160:1-4-01 of the Administrative Code must be followed.

(2) Non-MAGI-based eligibility.

(a) When a non-citizen is sponsored by an ineligible spouse or ineligible parent(s), apply spouse-to-spouse or parent-to-child income deeming calculations as described in rule 5160:1-3-03.3 of the Administrative Code.

(b) When a non-citizen has a sponsor and has an ineligible spouse or ineligible parent(s) who is not the individual's sponsor, apply both sponsor-to-non-citizen income deeming as described in this rule and spouse-to-spouse or parent-to-child income deeming calculations as described in rule 5160:1-3-03.3 of the Administrative Code.

(c) When a non-citizen is sponsored by an individual who is not a spouse or parent, follow the sponsor-to-non-citizen income deeming process as follows:

(i) Items described in 20 C.F.R. 416.1161 (as in effect October 1, 2024) are not considered countable income for the deeming process.

(ii) Total all countable earned and unearned income of the sponsor.

(iii) Deduct the appropriate allocation as follows from the total countable income for each sponsor, each sponsor's spouse, and each child of each sponsor.

(a) The allocation amount for each sponsor is the current SSI FBR for an individual.

(b) The allocation amount for each sponsor's spouse and each child of each sponsor is one-half of the current SSI FBR for an individual.

(iv) The remaining amount of income is deemed to the sponsored non-citizen as unearned income.

(v) When there are multiple non-citizens who are sponsored by the same individual, the deemed amount is applied in full to each sponsored non-citizen.

(vi) Combine the sponsored non-citizen's unearned (including the deemed income) and earned income, applying all appropriate exclusions, such as the twenty dollar general income exclusion, listed in rule 5160:1-3-03.2 of the Administrative Code.

(vii) When the resulting countable income of the sponsored non-citizen is less than or equal to the current income standard for an individual for the specific non-MAGI category, the sponsored non-citizen is financially eligible for medical assistance.

(F) Deeming of resources.

(1) Resources will only be deemed from a sponsor when the non-citizen is seeking eligibility for a category of medical assistance where individuals are subject to a resource limit.

(2) When a non-citizen is sponsored by an ineligible spouse or ineligible parent(s), apply spouse-to-spouse or parent-to-child resource deeming calculations as described in rule 5160:1-3-05.20 of the Administrative Code.

(3) When a non-citizen has a sponsor and also has an ineligible spouse or ineligible parent(s) who is not the individual's sponsor, apply both sponsor-to-non-citizen resource deeming as described in this rule and spouse-to-spouse or parent-to-child resource deeming calculations as described in rule 5160:1-3-05.20 of the Administrative Code.

(4) When a non-citizen is sponsored by an individual who is not a spouse or parent, follow the sponsor-to-non-citizen resource deeming process as follows:

(a) Combine the resources of the sponsor (and sponsor's spouse, when applicable) and apply all appropriate exclusions described in rule 5160:1-3-05.14 of the Administrative Code.

(b) After the exclusions are applied, only the amount of the sponsor's countable resources that exceed the applicable resource limit are deemed to the non-citizen.

(i) When the sponsor does not live with a spouse, the resource limit is two thousand dollars.

(ii) When the sponsor lives with a spouse, the resource limit is three thousand dollars.

(iii) When the sponsor lives with a spouse and the spouse is also a sponsor of the non-citizen, the resource limit is four thousand dollars.

(c) A non-citizen is not eligible for non-MAGI medical assistance when his or her countable resources plus the value of the sponsor's resources deemed to the non-citizen exceed the resource limit for an individual described in rule 5160:1-3-05.1 of the Administrative Code.

Last updated September 18, 2026 at 8:23 PM

History

Effective: February 15, 2026
Promulgated Under: 111.15

Ohio Adm.Code 5160:1-2-13 Medicaid: presumptive eligibility.

(A) This rule describes the conditions under which an individual may receive time-limited medical assistance as a result of an initial, simplified determination of eligibility based on the individual's self-declared statements.

(B) Eligibility criteria for presumptive coverage.

(1) Except as set forth in paragraph (B)(2) of this rule, an individual is eligible for presumptive coverage when the individual:

(a) Is a resident of the state of Ohio; and

(b) Is a U.S. citizen or has an immigration status as defined in rule 5160:1-2-12 of the Administrative Code that allows for medicaid eligibility; and

(c) Meets the non-financial eligibility criteria for a group set out in rule 5160:1-4-02, 5160:1-4-03, 5160:1-4-04, or 5160:1-4-05 of the Administrative Code, except that a simplified household composition will be determined, comprised of the individual and, if living in the home:

(i) The individual's spouse; and

(ii) The individual's children under age nineteen; and

(iii) When the individual is under age nineteen:

(a) The individual's parents; and

(b) The individual's siblings under the age of nineteen.

(d) Has gross family income, for the individual's family size, of no more than the eligibility limit set out for the relevant eligibility group in rule 5160:1-4-02, 5160:1-4-03, 5160:1-4-04, or 5160:1-4-05 of the Administrative Code.

(2) Limitations. An individual is ineligible for a subsequent presumptive coverage period for twelve months beginning on the date of a presumptive coverage determination, except that a woman may receive presumptive coverage based on pregnancy once during each pregnancy.

(1) Presumptive coverage begins on the date an individual is determined to be presumptively eligible. No retroactive coverage may be provided as a result of a presumptive eligibility determination.

(2) Presumptive coverage ends on the earlier of (and includes):

(a) The date the administrative agency determines the individual is eligible or ineligible for ongoing medical assistance pursuant to rule 5160:1-2-01 of the Administrative Code; or

(b) When an application for ongoing medical assistance for the individual has not been filed, the last day of the month following the month in which the individual was determined to be presumptively eligible.

(3) Services for individuals found presumptively eligible on the basis of pregnancy are restricted to ambulatory prenatal care.

(D) State agency responsibilities. The Ohio department of medicaid (ODM) is responsible for training and monitoring each qualified entity (QE) in accordance with rule 5160-1-17.12 of the Administrative Code.

(E) QE responsibilities.

(1) When the QE is a county department of job and family services (CDJFS) office:

(a) No later than twenty-four hours after receipt of a signed and dated full application for medical assistance on behalf of an individual, the CDJFS must determine, based on the individual's self-declared information, whether the individual is eligible for presumptive coverage under this rule.

(b) When an individual is eligible for presumptive coverage, the CDJFS must:

(i) Approve presumptive coverage for the individual; and

(ii) Provide a notice issued from the electronic eligibility system to inform the individual:

(a) That presumptive coverage was approved; and

(b) That failure to cooperate with the eligibility determination process set forth in rule 5160:1-2-01 of the Administrative Code will result in a denial of medical assistance, which will trigger the discontinuance of presumptive coverage.

(c) When an individual is not eligible for presumptive coverage, the CDJFS must inform the individual that eligibility for medical assistance will be determined within forty-five days.

(d) Whether or not an individual is eligible for presumptive coverage, the CDJFS must determine whether the individual is eligible for ongoing medical assistance pursuant to rule 5160:1-2-01 of the Administrative Code.

(2) When the QE is a hospital, the Ohio department of rehabilitation and correction (DRC), the Ohio department of youth services (DYS), a federally qualified health center (FQHC), an FQHC look-alike, a local health department, a special supplemental nutrition program for women, infants, and children (WIC) clinic, or other entity as designated by the director as defined in rule 5160:1-1-01 of the Administrative Code:

(a) Upon request, determine whether the individual is presumptively eligible under this rule. Such determination shall not be delegated to a third party, but shall be completed by the QE.

(b) Accept self-declaration of the presumptive eligibility criteria unless contradictory information is provided to or maintained by the QE.

(i) Approve presumptive coverage for the individual using the electronic eligibility system designated by ODM; and

(ii) Provide a notice issued from the electronic eligibility system to the individual at the time of determination which indicates that presumptive coverage was approved and which includes:

(a) The presumptive eligibility determination date; and

(b) The basis for presumptive eligibility; and

(d) The individual's medicaid billing number; and

(e) A reminder that the individual must apply for ongoing medical assistance no later than the last day of the month following the month of approval.

(iii) Upon request, assist the individual with completing an application for ongoing medical assistance.

(d) When the individual is not presumptively eligible, inform the individual that there may be other categories of medical assistance available and that he or she should apply for a full determination of eligibility for medical assistance.

(F) Denial of presumptive coverage is not grounds for a state hearing under division 5101:6 of the Administrative Code.

Last updated September 1, 2023 at 8:54 AM

History

Effective: September 1, 2023
Promulgated Under: 111.15

Ohio Adm.Code 5160:1-2-14 Medicaid: continuous eligibility for children younger than age nineteen.

(A) This rule describes the twelve-month period of continuous eligibility for a child younger than age nineteen, and the conditions under which the child's coverage ends during the twelve-month period, as described in section 1902(e)(12) of the Social Security Act (as in effect October 1, 2023).

(B) Eligibility criteria. A child remains eligible for coverage despite changes in the child's circumstances for a period of twelve months when the child was found to be eligible for a category of medical assistance other than:

(1) Presumptive eligibility as described in rule 5160:1-2-13 of the Administrative Code;

(2) Non-citizen emergency medical assistance as described in rule 5160:1-5-06 of the Administrative Code; or

(3) Refugee medical assistance as described in rule 5160:1-5-05 of the Administrative Code.

(1) A child's twelve-month period of continuous eligibility begins:

(a) On the date that medical assistance began as a result of an initial determination or annual renewal in accordance with rule 5160:1-2-01 of the Administrative Code.

(b) Any months of retroactive eligibility received by the child are not included in the twelve-month period of continuous eligibility.

(2) The child's coverage shall be terminated during the continuous eligibility period only:

(a) Upon oral or written request of the child (when the child is at least eighteen years old) or the child's representative; or

(b) When the child:

(i) No longer resides in the state of Ohio; or

(ii) Dies; or

(iii) Has not paid the premium amounts required for coverage, when the child is covered under the medicaid buy-in for workers with disabilities category described in rule 5160:1-5-03 of the Administrative Code; or

(iv) Reaches the age of nineteen.

(D) Patient liability, or premium. A patient liability or premium calculated for a child in accordance with Chapters 5160:1-3 to 5160:1-6 of the Administrative Code shall not increase during the child's continuous coverage period. Any decrease in a child's patient liability or premium results in a new maximum amount, which will not increase for the remainder of the child's continuous coverage period.

(E) Regardless of a child's status under this rule, payment for services shall not be made when payment is prohibited under rule 5160:1-1-03 of the Administrative Code.

Last updated May 5, 2025 at 11:24 AM

History

Effective: November 1, 2023
Promulgated Under: 111.15

Ohio Adm.Code 5160:1-2-15 Medicaid: healthchek (early and periodic screening, diagnostic and treatment services).

(A) This rule explains the requirements of healthchek, Ohio's early and periodic screening, diagnostic and treatment (EPSDT) benefit that is mandatory for an individual under twenty-one years of age who is enrolled in medicaid.

(1) The healthchek benefit provides comprehensive preventative, diagnostic, and treatment services for an eligible individual as specified in Section 1905(r) of the Social Security Act (as in effect October 1, 2024).

(2) There is no separate enrollment for healthchek. When an individual is eligible for medical assistance and is under twenty-one years of age, the individual automatically qualifies for healthchek services.

(3) Each county department of job and family services (CDJFS) is required to have a healthchek coordinator.

(4) The Ohio department of medicaid (ODM) will cover all medically necessary state plan services for a healthchek eligible individual when a need is identified during the course of an EPSDT exam, even when the service is not covered under ODM's state plan.

(B) Definitions. For the purposes of this rule, the following terms have the following meanings:

(1) "Administrative agency," for the purpose of this rule, means the CDJFS.

(2) "Healthchek" is Ohio's early and periodic screening, diagnostic and treatment benefit for all medicaid eligible individuals under twenty-one years of age.

(3) "Healthchek coordinator" is the CDJFS employee who is responsible for the implementation of healthchek services.

(4) "Healthchek services" are periodic screening services (including a comprehensive medical exam, vision, dental, and hearing screenings) and such other necessary health care, diagnostic services, treatment, and other measures described in 42 U.S.C. section 1396d(a) (as in effect October 1, 2024) to correct or ameliorate defects and physical and mental illnesses and conditions discovered by the screening services, whether or not such services are covered under the state plan. Healthchek services are identical to "EPSDT services" as defined at 42 U.S.C. section 1396d(r) (as in effect October 1, 2024).

(5) "Healthchek Services Implementation Plan" (HSIP), ODM 03517, means the document submitted by a CDJFS describing how it delivers healthchek services to individuals in its county and who in the agency is responsible for ensuring the delivery of healthchek services.

(6) "Individual," for the purpose of this rule, means an individual under twenty-one years of age who is eligible for medical assistance.

(a) An individual under twenty-one years of age who receives medical assistance via presumptive eligibility, as described in rule 5160:1-2-13 of the Administrative Code, is entitled to the healthchek benefit.

(b) An individual under twenty-one years of age who receives medical assistance for coverage of the treatment of an emergency medical condition, as described in rule 5160:1-5-06 of the Administrative Code, is not entitled to the healthchek benefit.

(7) "Medically necessary," otherwise known as "medical necessity," as used in this chapter, is the same as defined in paragraph (A) of rule 5160-1-01 of the Administrative Code.

(8) "Prior authorization" for a member of a medicaid managed care organization (MCO) is the process outlined in rule 5160-26-03.1 of the Administrative Code. For all other individuals, prior authorization is the process outlined in rule 5160-1-31 of the Administrative Code.

(9) "Support services" are non-medical services offered or provided by the administrative agency to assist the individual and may include arranging or providing transportation, making medical appointments, accompanying the individual to medical appointments, and making referrals to community agencies and other social services. Support services shall be coordinated with the individual's medicaid-contracting MCO, where applicable.

(1) Complete and sign the ODM 03528, "Healthchek and Pregnancy Related Services Information Sheet" to verify receipt and understanding of information about healthchek;

(2) Complete, sign, and return the ODM 03528 to identify service needs; and

(3) Request and attend scheduled appointments for healthchek services.

(D) CDJFS responsibilities. Each CDJFS shall:

(1) Inform. The CDJFS shall use a combination of written and oral methods (including telephone calls, office visits, or home visits) to inform the individual (or such individual's parent, guardian, or legal custodian, as applicable) in its county about healthchek.

(a) Inform in writing.

(i) Ensure each eligible individual (or such individual's parent, guardian, or legal custodian, as applicable) in its county receives the ODM 03528 within sixty days after the individual is determined eligible for medical assistance and at least once each year thereafter. For newborns, ensure the parent, guardian, or legal custodian receives the ODM 03528 as soon as the agency learns of the child's birth.

(ii) Document that each individual (or such individual's parent, guardian, or legal custodian, as applicable) in its county has received the ODM 03528.

(iii) When written healthchek information that is mailed to an individual (or such individual's parent, guardian, or legal custodian, as applicable) is returned as undeliverable, the CDJFS shall make a second attempt to contact the individual by alternate means. All attempts to contact an individual (or such individual's parent, guardian, or legal custodian, as applicable) shall be documented in the electronic information system.

(iv) Upon completion of the ODM 03528, ask the individual (or such individual's parent, guardian, or legal custodian, as applicable) to sign the ODM 03528 to acknowledge receipt of healthchek information and to verify understanding of the healthchek services available. When the individual (or such individual's parent, guardian, or legal custodian, as applicable) needs additional information in order to understand healthchek services, the CDJFS shall immediately provide the necessary information.

(v) Enter data regarding the individual into the electronic information system, as directed by ODM. Such information shall include information from the completed ODM 03528, record of contact with the individual and any requests and referrals made or services provided.

(vi) Prominently display a notice that complies with the methods of providing information about healthchek as established by section 5164.26 of the Revised Code. All entities that distribute or accept applications for medical assistance must display a notice about healthchek.

(vii) Distribute written materials as directed by ODM. ODM may develop additional written materials containing information about healthchek. Any written materials developed by a CDJFS to inform individuals about healthchek shall be submitted to ODM for review and approval.

(b) Inform orally. The CDJFS shall ensure that each individual (or such individual's parent, guardian, or legal custodian, as applicable), who has an in-person meeting or telephone call with CDJFS staff to apply for medical assistance, is orally informed about healthchek using clear and non-technical language about the following:

(i) The benefits of preventive health care, including:

(a) Increased well-being;

(b) Reduced risk to the individual's health;

(c) Identification and treatment of health problems early to reduce the possibility of an increase in severity and cost of treatment; and

(d) Education of the family to promote optimal health.

(ii) The services covered by healthchek.

(iii) Where and how to obtain healthchek services.

(iv) That services covered by healthchek are without cost to eligible individuals.

(v) The individual's ability to request and schedule dental, vision, and hearing services separately from the healthchek screening visit.

(vi) The availability of medically necessary diagnostic and follow-up treatment services, including referrals, for problems discovered during the healthchek screening service.

(vii) The prior authorization process, including:

(a) The process, whether fee-for-service or managed care, must be started by the individual's medical assistance provider;

(b) The prior authorization requirement for some services, products, or procedures applies even when the individual is under twenty-one years of age;

(c) The prior authorization process may enable an individual under twenty-one years of age to receive services not available to adults, including services that are limited in number for adults; and

(d) Certain services require prior authorization, which must be requested by a provider and approved by ODM before the service is provided.

(viii) Effectively describe to an individual the services that are available under the healthchek benefit, including an explanation that necessary transportation and scheduling assistance are available in accordance with Chapter 5160-15 of the Administrative Code, including the following:

(a) Transportation is provided to any medicaid reimbursable service;

(b) How to request transportation and the timeframes for requesting transportation;

(d) For an individual who is a member of an MCO, transportation is available through the individual's MCO.

(c) Use appropriate methods to inform an individual with a visual or hearing impairment or who cannot read or understand the English language (or such individual's parent, guardian, or legal custodian, as applicable) about the healthchek benefit. Information provided to individuals with visual or hearing impairments or who cannot read or understand the English language shall meet the requirements of paragraphs (D)(1) and (D)(2) of this rule.

(d) Informing a pregnant woman. Any time the administrative agency becomes aware of an individual's pregnancy, the ODM 03528 shall be utilized to document the informing of a pregnant woman about healthchek services. After an infant's birth, the ODM 03528 shall again be used to document the informing of the individual about healthchek.

(e) Use electronic means to track a pregnant woman and the birth of her infant to accomplish the following:

(i) Identify newborn and the infant's parent, guardian, or legal custodian, as applicable;

(ii) Ensure that any infant born to an individual eligible for medical assistance is added to the medicaid case, in accordance with rule 5160:1-4-02 of the Administrative Code;

(iii) Ensure the infant's parent, guardian, or legal custodian, as applicable, is informed about healthchek services within sixty days of the infant's birth;

(iv) Contact the infant's parent, guardian, or legal custodian, as applicable, to assist with securing an ongoing primary care provider for the newborn; and

(v) Coordinate the activity in paragraphs (C)(1) to (C)(3) of this rule with the individual's MCO, other agencies, and programs where applicable.

(2) Provide support services.

(a) Refer the individual (or the individual's parent, guardian, or legal custodian, as applicable) to entities listed on the ODM 03528 and/or other community supportive services as requested. The CDJFS will ensure:

(i) That referrals are made, as needed, for both medical and other services such as help me grow (HMG); the special supplemental nutrition program for women, infants, and children (WIC); maternal, child and family health (MCFH) clinics; local health departments; head start (HS); child care; clothing and/or other community social services, where applicable.

(ii) Coordination between the individual and the entity where the referral is made.

(iii) Coordination between the individual and the individual's MCO by forwarding a copy of the ODM 03528 to the individual's MCO, when applicable.

(iv) The individual enrolled in an MCO (or the individual's parent, guardian, or legal custodian, as applicable) is advised to contact the individual's MCO for medical care options and/or referrals.

(v) Assistance is provided with scheduling medical appointments as requested by the individual or the individual's parent, guardian, or legal custodian, as applicable.

(vi) Requests for support services available in the individual's county of residence received by the individual's MCO and forwarded to the CDJFS are acted upon and the requested service(s) provided.

(b) Provide the individual with necessary assistance in obtaining transportation to medicaid reimbursable services as requested by the individual or the individual's parent, guardian, or legal custodian, as applicable.

(c) Refer each individual in a household who requests or is in need of services not covered by medicaid, as indicated on the ODM 03528 or through other verbal or written communication, to community, medical, or other social services, as needed, including providers who have expressed a willingness to furnish non-medicaid covered services at little or no expense to the family. Community and medical service requests will be documented and forwarded to the appropriate community provider, medical provider, and/or MCO.

(d) When notified, provide services for an individual identified as having elevated blood lead levels, including the following:

(i) Referral of the individual to the Ohio department of health (ODH) for an environmental assessment.

(ii) Verification of the individual's medical assistance eligibility at the time the environmental assessment is conducted and the ODH agent is informed of such eligibility. Verification shall only be provided upon receipt of proper verification of the identity of the ODH agent who is requesting the information.

(iii) Education of the family about the purpose of the environmental assessment by:

(a) Informing the family of the need to remove the source of lead or removing the individual from the contaminated environment;

(b) Explaining the family's responsibility to inform the health department staff who conduct the environmental assessment of places the individual visits regularly; and

(c) Assisting the family with securing lead-free housing by making any necessary referrals when the source of lead cannot or will not be removed from the environment.

(iv) The CDJFS is responsible for maintaining records of environmental assessment recommendations made by ODH and any action taken as a result of those recommendations. When, as a result of CDJFS efforts, a family relocates, the CDJFS must inform ODH of the family's new address.

(v) In geographic areas with local arrangements for environmental assessments and follow-up, the requirements of those programs supersede this rule.

(3) The HSIP. The CDJFS is required to have a healthchek services implementation plan on file with ODM. The plan shall be signed by the agency director or the director's designee.

(a) The CDJFS shall complete and sign the HSIP to describe how EPSDT services are delivered to eligible individuals.

(b) The CDJFS shall provide a description in the HSIP of the electronic and/or hard-copy methods for ensuring permanent records and documentation are maintained in a case file for each individual. The case file shall contain the following information, when appropriate:

(i) Copy of the ODM 03528;

(ii) Copies of all correspondence received and sent;

(iii) Documentation of attempted and successful contacts with the individual (or such individual's parent, guardian, or legal custodian, as applicable);

(iv) Documentation of the MCO in which the individual is enrolled, when applicable;

(v) Documentation of contacts with or forms provided by the medical provider;

(vi) Information received from other counties when an individual's case is an inter-county transfer; and

(vii) Documentation of support services requested and/or provided and referrals made on an individual's behalf, and the CDJFS' efforts to fulfill the referrals and/or requests. At a minimum the documentation shall contain:

(a) Steps taken by the CDJFS to ensure the requested support services are provided, and whether or not the individual received the requested support services;

(b) A copy of all documentation of services requested by an individual (or such individual's parent, guardian, or legal custodian, as applicable) and provided or facilitated by the CDJFS;

(d) Any communication or forms provided by the medical provider.

(c) The CDJFS shall identify, when applicable, any services or functions required in this rule which are contracted out to other entities. A copy of the contract shall be provided to ODM. The CDJFS shall also describe accountability and monitoring measures, along with timeframes when monitoring takes place to ensure the contracted entities are completing all required functions and that these functions are in accordance with applicable state and federal rules.

(d) The CDJFS shall submit a new or amended HSIP to ODM when there has been a change, including but not limited to, agency address, CDJFS director, Healthchek coordinator, or where the responsibility for healthchek is organizationally located within the agency. The HSIP shall be submitted to ODM within ten business days of the change.

(4) Release of information. The CDJFS shall, when necessary, obtain a HIPAA-compliant signed authorization for release of information that is compliant with the Health Insurance Portability and Accountability Act of 1996 (HIPAA). The ODM 03397 "Authorization for the Release or Use of Protected Health Information (PHI)" shall be used when the CDJFS needs additional medical information from the individual or the individual's provider.

(5) Provider recruitment. The CDJFS is required to take steps to recruit and maintain a network of fee-for-service providers of medical, dental, vision, and hearing services that is adequate to meet the screening and treatment needs of healthchek eligible individuals. The CDJFS may make use of a variety of methods including personal visits, telephone calls, and letters to recruit providers.

(6) Mandatory training. The CDJFS' healthchek coordinator, or such coordinator's designee(s), shall attend available annual and other pertinent healthchek trainings offered by ODM. For video conferences or other training delivered electronically, verification shall consist of proof of the individual's attendance and submission of an evaluation form to the appropriate state monitored e-mail box within three days of the training. Verification of attendance at in-person training shall be documented by the healthchek coordinator, or such coordinator's designee(s), by signing the attendance log.

Last updated March 4, 2025 at 7:54 AM

History

Effective: March 1, 2025
Promulgated Under: 111.15

Ohio Adm.Code 5160:1-2-16 Medicaid: pregnancy related services (PRS).

(A) The purpose of this rule is to outline the responsibilities of the administrative agency to inform a pregnant woman eligible for medical assistance about the benefits and importance of pregnancy related services (PRS), to make requested or needed referrals to support services, and to provide non-medical support services that promote healthy birth outcomes in accordance with 42 C.F.R. 440.210 (as in effect October 1, 2023).

(B) Definitions.

(1) "Administrative agency," for the purpose of this rule, means the county department of job and family services (CDJFS).

(2) "Individual" for the purpose of this rule, means a pregnant woman eligible for medical assistance, as verified by either self-declaration or medical verification, including during the postpartum period.

(3) ODM 03515 "Pregnancy Related Services Implementation Plan" (PRSIP) means the document submitted by the administrative agency describing how it delivers PRS to pregnant women in its county and identifies which entities are responsible for ensuring the delivery of PRS.

(4) ODM 03528 "Healthchek and Pregnancy Related Services Information Sheet" means the document given to individuals by the administrative agency to meet the informing requirement of this rule.

(5) "Postpartum period," for the purpose of this rule, is the same as defined in rule 5160:1-1-01 of the Administrative Code.

(6) "Pregnancy-related services" (PRS) are those services that are necessary for the health of the pregnant woman and fetus, or that have become necessary as a result of the individual having been pregnant. These include, but are not limited to, prenatal care, delivery, postpartum care, and family planning services.

(7) "PRS coordinator" means the administrative agency employee who is responsible for the execution of the PRSIP.

(8) "Support services" are non-medical services offered or provided by the administrative agency to assist the individual and may include arranging or providing transportation, making medical appointments, accompanying the individual to medical appointments, and making referrals to community and other social services. Support services will be coordinated with the individual's medicaid-contracted managed care organization (MCO), where applicable.

(1) Complete and sign the ODM 03528 to verify understanding of PRS and Healthchek services;

(2) Complete, sign, and return the ODM 03528 to identify the need for services for the individual and/or the individual's children.

(D) Administrative agency responsibilities. The administrative agency shall:

(1) Inform individuals in its county about PRS within sixty days of the eligibility determination. Contact shall be made through either verbal or written forms of communication or a combination of the two described as follows:

(a) Provide the ODM 03528.

(b) Assist individuals with care coordination and referrals as requested via the ODM 10257 "Report of Pregnancy (ROP)" and ODM 10207 "Pregnancy Risk Assessment Communication (PRAF)."

(i) The benefits and importance of early and continual prenatal and postpartum care.

(ii) The special supplemental food program for women, infants and children (WIC).

(iii) The services covered by PRS as described in Chapter 5160-4 of the Administrative Code.

(iv) The benefits of healthchek services as described in rule 5160-1-14 of the Administrative Code.

(v) Transportation services and scheduling assistance available to individuals, when needed and upon request, in accordance with Chapter 5160-15 of the Administrative Code.

(vi) Availability of transportation services through the individual's MCO. The transportation services shall be provided by the administrative agency if not available from the MCO.

(vii) Transportation services and scheduling assistance available to infants during the first year of life.

(viii) Medical and non-medical support services to include but not limited to:

(a) The "Help Me Grow" (HMG) program;

(b) Maternal, child and family health (MCFH) clinics;

(d) Social services and other community services;

(e) Child care and head start; and

(f) The program for children and youth with special health care needs.

(ix) Availability of assistance for scheduling medical appointments, as requested by the individual.

(x) A list of medicaid prenatal care providers, when requested, available to the community.

(2) Inform individuals enrolled in an MCO that they should contact the MCO for medical care options and referrals.

(3) Re-inform the individual of the benefits of healthchek services as soon as possible after an infant's birth.

(4) Refer the individual to support services as requested verbally, in writing, or via the ODM 03528 and ensure:

(a) Referrals are made for medical and non-medical support services, as requested.

(b) Coordination between the individual, medical provider, MCO, or other entity where a referral is made.

(5) Provide a copy of the ODM 03528 (when applicable) (to the individual's MCO.

(6) Make a second attempt to contact the individual by alternate means when written information about PRS sent to the individual is returned as undeliverable.

(7) Submit a new or amended ODM 03515 to the Ohio department of medicaid (ODM), when there has been a change, including but not limited to, agency address, director, PRS coordinator, or where the responsibility for PRS is located within the agency. The ODM 03515 shall be submitted to ODM within ten business days of a change.

(8) Obtain a Health Insurance Portability and Accountability Act of 1996 (HIPAA) compliant signed authorization for release of information, ODM 03397 "Authorization for the Release or Use of Protected Health Information", when additional medical information is needed from the individual.

(9) Maintain a listing of fee-for-service providers who have expressed a willingness to furnish non-medicaid covered services at little or no expense to the individual. It is recognized that the ability of the administrative agency to recruit and maintain an adequate provider network depends on the existence of appropriate providers within a reasonable geographic area.

(10) Maintain documentation in a secure file for each eligible individual. The file shall consist of permanent records, either hard copy or electronically stored, containing the following information, when appropriate:

(a) Copy of the ODM 03528, ODM 10207, ODM 10257, or other referral forms received by the administrative agency;

(b) Copy of correspondence received and sent;

(d) Documentation of the MCO in which the individual is enrolled;

(e) Information received from another county when the individual is an intercounty transfer;

(f) Documentation of all service requests and steps taken by the administrative agency to connect the individual with the requested services; and

(g) Records of transportation services provided.

(E) Each administrative agency PRS coordinator, or such coordinator's designee(s), shall attend annual and other pertinent trainings offered by ODM. Verification of attendance shall be provided for all trainings and an evaluation form shall be sent to the state email box within three days of completion of the training. Verification of attendance at in-person training shall be documented by the PRS coordinator or such coordinator's designee(s) by signing the attendance log.

Last updated January 14, 2026 at 11:46 PM

History

Effective: December 13, 2024
Promulgated Under: 111.15

Chapter 5160:1-3 Medicaid for the Aged Blind and Disabled

Ohio Adm.Code 5160:1-3-01 Medicaid: coverage for the aged, blind, or disabled.

(A) The medicaid program provides coverage for individuals who meet the aged, blind, or disability status requirements as set forth in section 1902 of the Social Security Act (as in effect October 1, 2022). The provisions of Chapter 5160:1-3 of the Administrative Code establish eligibility criteria, standards, and procedures that apply to individuals enrolling in an aged, blind, or disabled categorical coverage group.

(B) The rules of this chapter are organized as follows:

(1) Rules under principal rule 5160:1-3-02 of the Administrative Code set forth base eligibility requirements of the aged, blind, or disabled eligibility covered groups.

(2) Rules under principal rule 5160:1-3-03.1 of the Administrative Code set forth income eligibility requirements.

(3) Rules under principal rule 5160:1-3-05.1 of the Administrative Code set forth resource eligibility requirements.

Last updated June 25, 2025 at 6:00 PM

History

Effective: July 1, 2023
Promulgated Under: 111.15

Ohio Adm.Code 5160:1-3-02 Medicaid: criteria for age, blindness, or disability.

(A) The medicaid program provides coverage for individuals who have been determined to meet the criteria for the limiting physical factors of age, blindness, or disability as set forth in section 1902 of the Social Security Act (as in effect on October 1, 2024). Age is determined by county departments of job and family services (CDJFSs). Blindness and disability are determined by either the social security administration (SSA) or the Ohio department of medicaid (ODM) in accordance with rule 5160:1-3-02.9 of the Administrative Code.

(B) The criteria for age, blindness, and disability are as follows:

(1) Age: An individual who is age sixty-five years or older meets the requirement for medicaid on the basis of age. Verification of age is required.

(2) Blindness: An individual is considered to be blind when he or she has:

(a) Central visual acuity of 20/200 or less in the better eye with use of a correcting lens; or

(b) An eye with limitation in the field of vision so that the widest diameter of the visual field subtends an angle no greater than twenty degrees.

(3) Disability. Disability is defined differently for adults and children. An individual is disabled when the individual is:

(a) An adult who is unable to do any substantial gainful activity by reason of any medically determinable physical or mental impairment or combination of impairments which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than twelve months.

(b) A child under the age of eighteen who has a medically determinable physical or mental impairment or combination of impairments that causes marked and severe functional limitations, and that can be expected to cause death, or that has lasted or can be expected to last for a continuous period of not less than twelve months. No individual under the age of eighteen who engages in substantial gainful activity may be considered disabled.

(C) When the SSA makes a finding of presumptive disability based upon the available evidence which reflects a high degree of probability that the individual will meet the disability requirements, the applicant for medical assistance meets the disability requirements necessary to qualify for medical assistance. When it is later determined that the SSA decision was erroneously made and the individual was without fault in the determination, no attempt shall be made to recover payments for medical assistance made on behalf of the individual.

Last updated June 16, 2025 at 8:02 AM

History

Effective: June 9, 2025
Promulgated Under: 111.15

Ohio Adm.Code 5160:1-3-02.1 Medicare premium assistance programs (MPAP).

(A) This rule sets forth the eligibility criteria and benefits for the medicare premium assistance programs (MPAP). The programs are: qualified medicare beneficiary (QMB), specified low-income medicare beneficiary (SLMB), qualified individual (QI-1), and qualified disabled and working individual (QDWI).

(B) Definitions.

(1) "Eligible," for the purpose of this rule, means an individual meets all the requirements to enroll in MPAP.

(2) "Enrolled," for the purpose of this rule, means an individual is eligible for, and in receipt of benefits under a medicare health plan through the social security administration (SSA).

(3) "Family," for the purposes of MPAP, means the following persons living in the same household as the individual for whom medicare premium assistance is sought or received:

(a) The individual;

(b) When the individual is a minor, the biological parents, adoptive parents, step-parents, legal guardians, or legal custodians of the individual;

(d) The minor biological, adopted, or stepchild(ren) of the individual and of any persons described in paragraphs (B)(3)(b) and (B)(3)(c) of this rule.

(4) "Family of the size involved" means "family" as defined in paragraph (B)(3) of this rule.

(5) "MPAP" means any or all of the medicare premium assistance programs: QMB, SLMB, QI-1, and QDWI.

(6) "MPAP resource limit" means the maximum amount of countable resources allowed under section 1905(p)(1) of the Social Security Act (as in effect October 1, 2025), as adjusted annually according to the change in the consumer price index for urban areas (CPI-U).

(7) "Qualified," for the purpose of this rule, means an individual is eligible to receive benefits under a medicare health plan, whether or not the individual has applied for those benefits.

(8) "QDWI" means the qualified disabled and working individual program established by section 1905(s) of the Social Security Act (as in effect October 1, 2025). This program is sometimes referred to as the qualified working disabled individuals (QWDI) program.

(9) "QI-1" means the qualified individual group, described in section 1902(a)(10)(E)(iv) of the Social Security Act (as in effect October 1, 2025).

(10) "QMB" means the qualified medicare beneficiary group described in section 1905(p)(1) of the Social Security Act (as in effect October 1, 2025).

(11) "SLMB" means the specified low-income medicare beneficiary group described in section 1902(a)(10)(E)(iii) of the Social Security Act (as in effect October 1, 2025).

(1) The QMB income standard is one hundred per cent of the federal poverty level for the family of the size involved.

(2) The SLMB income standard is greater than one hundred per cent of the federal poverty level and up to a maximum one hundred twenty per cent of the federal poverty level for the family of the size involved.

(3) The QI-1 income standard is greater than one hundred twenty per cent of the federal poverty level and up to a maximum one hundred thirty-five per cent of the federal poverty level for the family of the size involved.

(4) The QDWI income standard is two hundred per cent of the federal poverty level for the family of the size involved.

(D) To be eligible for a medicare premium assistance program, an individual must meet all of the following conditions:

(1) Be qualified for coverage under medicare part A (part A).

(a) An individual otherwise qualified for QMB must be enrolled in either part A or medicare part B (part B) for the administrative agency to provide benefits under this rule.

(b) An individual otherwise qualified for SLMB must be enrolled in part A for the administrative agency to provide benefits under this rule.

(c) An individual otherwise qualified for QI-1 must be enrolled in part A for the administrative agency to provide benefits under this rule.

(d) An individual otherwise qualified for QDWI must be enrolled in part A under section 1818A of the Social Security Act (as in effect October 1, 2025). Coverage can be identified as being provided under section 1818A of the Social Security Act when the individual meets the following criteria:

(i) Has not reached sixty-five years of age;

(ii) Has lost disability benefits under Title II of the Social Security Act (as in effect October 1, 2025) solely due to earnings in excess of the substantial gainful activity (SGA) level established by the SSA;

(iii) Is paying a premium for part A coverage; and

(iv) Has provided no document or communication from the SSA indicating another basis for part A coverage.

(2) For QMB, SLMB, and QI-1, have countable resources that do not exceed the MPAP resource limit as defined in paragraph (B)(6) of this rule for an individual or the MPAP resource limit for a couple (the individual and the individual's spouse). Countable resources shall be determined in accordance with Chapter 5160:1-3 of the Administrative Code.

(3) For QDWI, have countable resources that do not exceed twice the maximum amount of resources that an individual or couple (the individual and the individual's spouse) may have under the supplemental security income (SSI) program. Countable resources shall be determined in accordance with Chapter 5160:1-3 of the Administrative Code.

(4) Have countable income, as determined in accordance with paragraph (E) of this rule, within the MPAP income standards as set forth in paragraph (C) of this rule.

(5) For QI-1 and QDWI, be otherwise ineligible for medical assistance in accordance with Chapters 5160:1-3, 5160:1-4, 5160:1-5, and 5160:1-6 of the Administrative Code.

(6) Meet the application, conditions of eligibility, and verification requirements set forth in Chapter 5160:1-2 of the Administrative Code.

(E) Countable income shall be determined in accordance with Chapter 5160:1-3 of the Administrative Code.

(1) The annual cost of living adjustment (COLA) shall be deducted from the individual's income beginning in January of each year and continuing through the end of the month after the month in which the updated federal poverty guidelines are published in the Federal Register.

(2) The income of both the individual and the individual's spouse shall be determined in accordance with rule 5160:1-3-03.1 of the Administrative Code and applying all exclusions listed in rule 5160:1-3-03.2 of the Administrative Code, except that the twenty-dollar general income exclusion and the exclusion of the first sixty-five dollars of earned income shall be applied only once to a married couple in the MPAP eligibility determination.

(3) The deeming provisions set forth in rule 5160:1-3-03.3 of the Administrative Code do not apply to MPAP eligibility determinations.

(F) Application of income standards.

(1) When the individual is a minor, the countable income of the following individuals is combined and compared to the income standards set forth in paragraph (C) of this rule for the family of the size involved:

(a) The individual;

(b) The individual's biological parents, adoptive parents, step-parents, legal guardians, or legal custodians; and

(2) The income of the individual combined with the income of the individual's spouse is compared to the income standards set forth in paragraph (C) of this rule for the family of the size involved.

(G) Application of resource standards.

(1) The countable resources of the individual combined with the countable resources of the individual's spouse are compared to the resource standards set forth in paragraphs (D)(2) and (D)(3) of this rule.

(2) The deeming provisions set forth in rule 5160:1-3-05.20 of the Administrative Code do not apply to MPAP eligibility determinations.

(H) Coordination of enrollment. When the individual is eligible for benefits under this rule, the county department of job and family services (CDJFS) shall coordinate the individual's receipt of benefits.

(1) When the individual is or has ever been in receipt of part A or part B benefits, the CDJFS shall approve MPAP benefits for the individual in the electronic eligibility system.

(2) When the individual has never received part A or part B benefits, the CDJFS shall:

(a) Inform the individual that the Ohio department of medicaid (ODM) can not pay medicare premiums until the individual has enrolled in part A or part B through the SSA;

(b) Advise the individual to apply for part A or part B benefits through the SSA, and advise the individual that the CDJFS will assist upon request;

(c) Advise the individual to report the approval of part A or part B benefits to the CDJFS immediately, so payment of premiums can be approved; and

(d) Approve MPAP benefits for the individual in the electronic eligibility system upon being informed that the individual has been enrolled in part A or part B by the SSA.

(I) Coverage periods.

(1) The effective date of QMB coverage is the first day of the month after the month in which the administrative agency approves QMB benefits. No retroactive coverage is available for QMB.

(2) Eligibility for SLMB benefits begins no earlier than the third month prior to the month of application, provided the individual met all eligibility criteria including enrollment in part A during the three-month period.

(3) Eligibility for QI-1 benefits begins no earlier than the third month prior to the month of application, provided the individual met all eligibility criteria including enrollment in part A during the three-month period.

(4) Eligibility for QDWI benefits begins no earlier than the third month prior to the month of application, provided the individual met all eligibility criteria including enrollment in part A during the three-month period.

(5) Eligibility for payment of medicare premiums under this rule ends on the earliest of the following dates:

(a) The last day of the month in which the individual dies;

(b) The last day of the last month in which the individual is enrolled in part B benefits;

(c) The last day of the last month in which the individual meets the eligibility criteria for MPAP, if notice was provided to the centers for medicare and medicaid services (CMS) no later than the twenty-fifth day of the second month of ineligibility; or

(d) The last day of the second month before CMS receives notice the individual was no longer eligible for MPAP, when notice was not provided within the time limit identified in paragraph (I)(5)(c) of this rule.

(J) Benefits.

(1) When the individual is eligible for QMB, the administrative agency shall pay the individual's:

(a) Premiums for part B and, when a premium is charged, for part A;

(b) Medicare deductibles;

(d) Medicare coinsurance costs.

(2) When the individual is eligible for SLMB or QI-1, the administrative agency shall pay the individual's part B premiums.

(3) When the individual is eligible for QDWI, the administrative agency shall pay the individual's part A premiums.

(4) The medicare prescription drug benefit program (part D) is not covered by MPAP.

(K) Administrative agency responsibilities. The administrative agency shall:

(1) Explore eligibility for medical assistance and for all MPAP categories when a medical assistance applicant is qualified for part A. The agency shall advise the individual:

(a) Of the categories of medical assistance or MPAP for which the individual is eligible, the individual's right to decline payment of premiums, co-pays, or coinsurance costs, and the effect of declining MPAP payments; and

(b) That when the individual is qualified for benefits under part A or part B, ODM is prohibited from paying for prescriptions on behalf of that individual, whether or not a premium would be charged for those benefits.

(2) Determine the individual's eligibility for QMB and when eligible:

(a) Approve QMB benefits effective the month after the administrative agency approves QMB coverage; and

(b) For individuals who are not receiving free part A, but who could receive part A benefits by paying a premium, coordinate enrollment in parts A and B with the SSA.

(3) Determine the individual's eligibility for SLMB and, when eligible, approve SLMB benefits in accordance with paragraph (I)(2) of this rule.

(4) Determine the individual's eligibility for QI-1 and, when eligible, approve QI-1 benefits in accordance with paragraph (I)(3) of this rule.

(5) Determine the individual's eligibility for QDWI and, when eligible, approve QDWI benefits in accordance with paragraph (I)(4) of this rule.

(6) Deny benefits under this rule when:

(a) Any criterion under this rule is not met; or

(b) Any of the conditions for denial set forth in rule 5160:1-2-01 of the Administrative Code are met.

(7) Discontinue benefits under this rule when:

(a) An individual no longer meets the eligibility criteria for any covered group under this rule;

(b) Any of the conditions for discontinuance set forth in rule 5160:1-2-01 of the Administrative Code are met; or

(8) Coordinate enrollment with the individual, the SSA, and ODM's buy-in unit.

(L) Individual responsibilities.

(1) Inform the CDJFS of any actions by the SSA on the individual's application for part A or part B, or any changes in the individual's part A or part B coverage.

(2) Adhere to the individual responsibilities set forth in rule 5160:1-2-08 of the Administrative Code.

Last updated November 5, 2025 at 9:07 AM

History

Effective: November 1, 2025
Promulgated Under: 111.15

Ohio Adm.Code 5160:1-3-02.2 Medicare buy-in.

(A) This rule sets forth:

(1) The eligibility criteria for benefits under the medicare part B (part B) buy-in agreement between the social security administration (SSA) and the Ohio department of medicaid (ODM), which allows ODM to pay part B (supplemental medical insurance) premiums for certain individuals even when those individuals are not eligible for a medicare premium assistance program (MPAP) set forth in rule 5160:1-3-02.1 of the Administrative Code; and

(2) The beginning date of payment of part B benefits under this rule; and

(3) The date and effect of termination of benefits under part B buy-in.

(4) The process of coordinating enrollment with ODM and the SSA.

(B) Definitions.

(1) "Medicare buy-in" means the program and process of paying part A and/or part B benefits on behalf of an eligible individual.

(2) "Part B buy-in" means the agreement under which ODM pays part B premiums on behalf of an eligible individual.

(C) Eligibility criteria. To be eligible for payment of the part B premium under the medicare buy-in agreement, an individual must meet all three of the following requirements:

(1) Be eligible for part B.

(2) Be eligible for a category of medical assistance other than:

(a) Breast and cervical cancer project as set forth in rules 5160:1-5-02 to 5160:1-5-02.4 of the Administrative Code; or

(b) Presumptive eligibility as set forth in rule 5160:1-2-13 of the Administrative Code.

(3) Be receiving at least one of the following:

(a) Medicare premium assistance under rule 5160:1-3-02.1 of the Administrative Code.

(b) One of the following types of cash assistance:

(i) Ohio works first (OWF); or

(ii) Supplemental security income (SSI); or

(iii) Residential state supplement.

(d) Medical assistance under the grandfathering provisions set forth in rule 5160:1-3-02.6 of the Administrative Code.

(e) Foster care maintenance payments or adoption assistance payments as set forth in rule 5160:1-2-14 of the Administrative Code.

(f) Medical assistance as a result of section 1619(b) of the Social Security Act (as in effect October 1, 2023) as set forth in rule 5160:1-3-02.5 of the Administrative Code.

(g) Deemed cash assistance under Pub.L.No. 94-48.

(h) Long-term care services in a Title XIX certified nursing facility (NF) or intermediate care facility for individuals with intellectual disabilities (ICF-IID).

(i) Home and community-based services (HCBS), including the program of all-inclusive care for the elderly (PACE), under a waiver described in agency 5160 of the Administrative Code.

(D) Coordination of enrollment. When an individual is eligible for benefits under this rule or would be eligible if the individual was enrolled in part A or part B, the county department of job and family services (CDJFS) shall coordinate the individual's receipt of benefits. When the individual:

(1) Is or has ever been in receipt of part A or part B benefits, the CDJFS shall approve part B buy-in benefits for the individual in the electronic eligibility system.

(2) Has never received part A or part B benefits, the CDJFS shall:

(a) Inform the individual that ODM cannot pay medicare premiums until the individual has enrolled in part A or part B through the SSA; and

(b) Advise the individual to apply for part A or part B benefits, and advise the individual that the CDJFS will assist upon request; and

(c) Advise the individual to report the approval of part A or part B benefits to the CDJFS immediately, so payment of premiums can be approved; and

(d) Approve part B buy-in benefits for the individual in the electronic eligibility system upon being informed that the individual has been enrolled by the SSA in part A or part B.

(E) Coverage period.

(1) Start date.

(a) For MPAP benefits under rule 5160:1-3-02.1 of the Administrative Code, the beginning date for payment of premiums is addressed in those rules. When an individual is eligible for MPAP benefits under rule 5160:1-3-02.1 of the Administrative Code and also eligible for part B buy-in under this rule, payment of part B premiums begins on the earlier of the coverage date under rule 5160:1-3-02.1 of the Administrative Code or the coverage date under this rule.

(b) For individuals eligible for payment of premiums under the part B buy-in agreement, eligibility begins:

(i) The first month an individual is eligible for both medicare and cash assistance as defined in paragraph (C)(3)(b) of this rule; or

(ii) The first day of the second month after the administrative agency made the determination the individual was eligible for medical assistance, when the individual is not in receipt of cash assistance as defined in paragraph (C)(3)(b) of this rule.

(2) Termination date. Eligibility for payment of medicare premiums under this rule ends on the earliest of the following dates:

(a) The last day of the month in which the individual dies; or

(b) The last day of the month in which the individual is entitled to part B benefits; or

(c) The last day of the last month in which the individual meets the eligibility criteria for part B buy-in benefits, when notice was provided to the centers for medicare and medicaid services (CMS) no later than the twenty-fifth day of the second month of ineligibility; or

(d) The last day of the second month before CMS received notice the individual was no longer eligible for part B buy-in benefits, when notice was not provided within the time limit identified in paragraph (E)(2)(c) of this rule.

(F) Retroactive termination. An individual's part B premium payment under buy-in can be terminated retroactively for as many as two months before the state's notice to CMS that the individual is no longer eligible.

(1) After CMS receives notice from ODM, CMS sends the individual a notice stating the individual is responsible for paying part B premiums beginning with the month following the last month of buy-in coverage. Because of administrative delays, an individual can already be in the third month after buy-in termination and owe three months of part B premiums before receiving notice that buy-in coverage has been terminated.

(2) The individual may request equitable relief from CMS under certain conditions specified by CMS in its notice.

Last updated June 25, 2025 at 5:54 PM

History

Effective: November 1, 2023
Promulgated Under: 111.15

Ohio Adm.Code 5160:1-3-02.3 Medicaid: coverage for individuals receiving supplemental security income (SSI) benefits.

(A) This rule describes eligibility for medical assistance for aged, blind, or disabled individuals who receive SSI benefits authorized by the social security administration under Title XVI of the Social Security Act (as in effect October 1, 2023).

(B) Eligibility criteria. To be eligible for coverage under this group an individual must be receiving SSI benefits based on the social security administration's determination of eligibility for SSI payments. In addition, certain requirements specific to medical assistance must be met in order for an individual to be eligible under this group. Failure to comply with the following requirements will prevent an individual from being determined eligible under this provision:

(1) Consistent with rule 5160:1-2-10 of the Administrative Code:

(a) An individual must assign to the state of Ohio any rights to medical support and payments for medical care from any third party; and

(b) An individual must cooperate with the child support enforcement agency (CSEA) in establishing the paternity of any child eligible for medical assistance and in obtaining medical support and payments for medical care from any third party, in accordance with 42 C.F.R. 433.147 (as in effect October 1, 2023); and

(c) An individual must cooperate with the administrative agency in identifying and providing information to assist the state with pursuing any third party who may be liable to pay for care and services.

(2) An individual who is the beneficiary of a trust must provide documentation of the trust as required by rule 5160:1-3-05.2 of the Administrative Code.

Last updated June 25, 2025 at 5:53 PM

History

Effective: January 1, 2024
Promulgated Under: 111.15

Ohio Adm.Code 5160:1-3-02.4 Medicaid: coverage for the categorically needy.

(A) This rule describes eligibility for aged, blind, or disabled individuals who meet the income and resource requirements of the supplemental security income (SSI) program authorized by the social security administration (SSA) under Title XVI of the Social Security Act (as in effect October 1, 2022) but who do not receive cash benefits under the program. Eligibility for this program shall be determined for applications for medical assistance filed on or after the August 1, 2016 effective date of this rule.

(B) Eligibility criteria. To be eligible under this group, an individual must meet all of the following critiera:

(1) Be aged, blind, or disabled; and

(2) Determinations of blindness and disability must be in accordance with SSA policy; and

(3) Have countable income, as determined under Chapter 5160:1-3 of the Administrative Code, which does not exceed the income standard described in rule 5160:1-3-03.5 of the Administrative Code; and

(4) Have countable resources, as determined under Chapter 5160:1-3 of the Administrative Code, which do not exceed the resource limit described in rule 5160:1-3-05.1 of the Administrative Code; and

(5) Not be receiving cash benefits from the SSI program; and

(6) Meet the conditions of eligibility outlined in rule 5160:1-2-10 of the Administrative Code.

(C) Retroactive coverage is available for this program in accordance with rule 5160:1-2-01 of the Administrative Code, but coverage shall not begin prior to the August 1, 2016 effective date of this rule and shall not provide reimbursement of services rendered prior to the August 1, 2016 effective date of this rule.

Last updated September 21, 2026 at 8:23 AM

History

Effective: July 1, 2023
Promulgated Under: 111.15

Ohio Adm.Code 5160:1-3-02.5 Medicaid: supplemental security income (SSI) recipients qualifying under section 1619 of the Social Security Act for continued medical assistance coverage.

(A) This rule describes the eligibility criteria for continued medical assistance coverage for an individual who is receving SSI benefits under section 1619 of the Social Security Act.

(B) Section 1619 of the Social Security Act (as in effect October 1, 2022) comprises two basic provisions:

(1) Section 1619(a) extends special SSI cash to individuals whose earnings preclude eligibility for regular SSI cash benefits. Individuals in 1619(a) status may still receive an SSI cash benefit in addition to the individual's earned income.

(2) Section 1619(b) extends medicaid coverage to individuals whose earnings, although high enough to preclude eligibility for regular SSI cash benefits or special SSI cash benefits under section 1619(a), may not be enough for medical care.

(C) To determine initial medicaid eligibility for sections 1619(a) and 1619(b), the administrative agency shall verify that the individual is currently in 1619(a) or 1619(b) status, as determined by the social security administration.

(D) Protection of benefits under 1619 status.

(1) An individual who has been determined eligible for medicaid because of 1619 status is protected from losing medicaid benefits under this provision as long as the individual remains in 1619(a) or (b) status.

(2) The individual may have income or resources in excess of the medicaid standards and remain eligible for medicaid under the 1619 provisions.

(3) When the individual's 1619 status ends, the individual's medicaid protection is lost.

Last updated May 30, 2025 at 9:17 AM

History

Effective: July 1, 2023
Promulgated Under: 111.15

Ohio Adm.Code 5160:1-3-02.6 Medicaid: grandfathering provisions and deemed eligibility.

(A) Various grandfathering provisions and deemed eligibility requirements were enacted to assure that aged, blind, or disabled individuals previously eligible for cash assistance and medicaid under former programs of aid would not be disadvantaged by eligibility conditions when the supplemental security income (SSI) program was implemented.

(B) Definitions.

(1) "Cash assistance," for the purpose of this rule, means the receipt of at least one of the following: Ohio works first (OWF), SSI, residential state supplement (RSS), or the former programs of aid known as aid for dependent children (ADC), aid for the aged (AFA), aid for the blind (AFB), and aid for the disabled (AFD).

(2) "Essential spouse," for the purpose of this rule, means one who is living with the individual whose needs were included in determining the amount of cash assistance and who is determined essential to the individual's well-being.

(C) Under the grandfathering provisions, certain individuals who were eligible for medicaid in December 1973 are entitled to continued medicaid eligibility coverage even though they may not meet the medicaid eligibility requirements imposed beginning in January 1974 for the coverage of the aged, blind, or disabled.

(1) The grandfathered groups are the following:

(a) Individuals receiving mandatory state supplements as described in 42 C.F.R. 435.130 (as in effect October 1, 2024): an individual who is the recipient of mandatory state supplement payments (SSP) administered by the social security administration is automatically eligible for medicaid.

(b) Individuals who are essential spouses as described in 42 C.F.R. 435.131 as in effect October 1, 2024): any individual who was eligible in December 1973 as an essential spouse remains eligible under all of the following criteria:

(i) The aged, blind, or disabled spouse continues to meet the December 1973 eligibility requirements of the applicable cash assistance programs;

(ii) The essential spouse continues to be the spouse of and lives with the spouse described in paragraph (C)(1)(b)(i) of this rule; and

(iii) The essential spouse continues to meet the conditions that were in effect in December 1973 under the applicable cash assistance program for having his or her needs included in computing the payment to the individual described in paragraph (C)(1)(b)(i) of this rule.

(c) Blind or disabled individuals eligible in 1973 as described in 42 C.F.R. 435.133 (as in effect October 1, 2024): an individual who was eligible for medicaid in December 1973 because the individual met the definition of blindness or disability in effect under the former programs of AFB or AFD and meets all of the following criteria:

(i) The individual meets all current requirements for medicaid eligibility except for blindness or disability;

(ii) The individual was eligible for medicaid in December 1973 as blind or disabled, whether or not the individual received cash assistance in December 1973;

(iii) For each consecutive month after December 1973, the individual has continued to meet the December 1973 criteria for blindness or disability; and

(iv) For each consecutive month after December 1973, the individual has continued to meet all other eligibility requirements which were in effect December 1973.

(d) Individuals who lost eligibility for SSI due to an increase in retirement, survivors, and disability insurance (RSDI) as described in 42 C.F.R. 435.134 (as in effect October 1, 2024): individuals eligible despite the October 1972 twenty per cent general increase:

(i) An individual who would currently be eligible for SSI or cash assistance except for the amount of increased income resulting from the October 1972 twenty per cent general increase in RSDI is eligible for medicaid if, for the month of August 1972, the individual met the following criteria:

(a) The individual was eligible for and receiving cash assistance under the ADC, AFA, AFB, or AFD programs, and

(b) The individual received and was entitled to monthly RSDI benefits.

(ii) Only the October 1972 RSDI increase is disregarded. Any subsequent increases in RSDI are not disregarded.

(iii) Although the amount of the October 1972 RSDI increase is disregarded in determining financial eligibility, the individual must meet all of the current eligibility requirements for medicaid.

(e) Institutionalized individuals continuously eligible since 1973 as described in 42 C.F.R. 435.132 (as in effect October 1, 2024): an individual who was eligible for medicaid in December 1973 as an inpatient or resident of a Title XIX institution and for each consecutive month after December 1973 meets all of the following criteria:

(i) Continues to meet the requirements for medicaid eligibility that were in effect in December 1973 for institutionalized individuals;

(ii) Remains institutionalized; and

(iii) Is determined to continue to need institutional care.

(f) Individuals who would be eligible for SSI but not for RSDI COLA increases since April 1977 (Pickle Amendment Group) as described in 42 C.F.R. 435.135 (as in effect October 1, 2024): an individual receiving RSDI and meets the following criteria:

(i) Became ineligible for SSI after April 1977; and

(ii) Would continue to be eligible for SSI if all of the RSDI cost-of-living increases received by the individual, the individual's spouse or other family member after April 1977 were deducted from current RSDI benefits.

(g) Ineligible for SSI due to requirements prohibited by Medicaid as described in 42 C.F.R. 435.122 (as in effect October 1, 2024): individuals who would be eligible for SSI or residential state supplements except for an eligibility requirement used in those programs that is specifically prohibited under medicaid.

(2) Failure to meet any one of the conditions listed in paragraph (C)(1) of this rule renders the individual ineligible for grandfathered status under the blind or disabled grandfathering provisions.

(3) An individual described in paragraph (C)(1)(c) of this rule permanently loses grandfathered status when the individual fails to meet any December 1973 eligibility requirement for any one month.

(4) Any change in circumstances requires a redetermination of eligibility based upon all the conditions set forth in paragraph (C)(1) of this rule.

(5) Eligibility under a grandfathered group does not apply to individuals in a long-term care facility or enrolled in a home and community-based services waiver.

(D) Under deemed eligibility, certain individuals who were ineligible for SSI, due to receipt of social security benefits, are entitled to continued medicaid coverage for the aged, blind, or disabled if certain criteria are met.

(1) The deemed eligibility groups are the following:

(a) Disabled widows(ers) ineligible for SSI or RSS due to increase in RSDI as described in 42 C.F.R. 435.137 (as in effect October 1, 2024): disabled widows(ers) who became ineligible for SSI or RSS benefits as a result of the elimination of the additional reduction factor for disabled widows(ers) under age sixty and meet all of the following criteria:

(i) Entitled to a monthly RSDI benefit for December 1983;

(ii) Entitled to and received a social security widow(er)'s disability benefit in January 1984;

(iii) Became ineligible for SSI benefits in the first month in which the increase in social security disabled widows(ers) benefits, as a result of the elimination of the additional reduction factor, was received;

(iv) Continuously entitled to widow(er)'s disability benefits from the first month that the increase was received;

(v) Would be eligible for SSI or RSS if the increase in RSDI benefits due to the elimination of the reduction factor and subsequent cost-of-living adjustments in RSDI benefits were excluded; and

(vi) Filed a medicaid application or renewal on or before June 30, 1988 for deemed eligibility.

(b) Disabled adult children as described in section 1634 of the Social Security Act (as in effect October 1, 2024): disabled individuals who have attained the age of eighteen and received SSI benefits on the basis of blindness or disability which began before he or she attained the age of twenty-two and meet all of the following criteria:

(i) Entitled to social security child's insurance benefits on the basis of disability or an increase in the amount of the child's insurance benefits which are payable;

(ii) Became ineligible for SSI benefits solely because of their receipt of social security child's insurance benefits or increase in social security child's insurance benefits; and

(iii) Would be eligible for SSI if the social security child's insurance benefits were excluded.

(c) Disabled widows(ers) ineligible for SSI due to early receipt of social security as described in 42 C.F.R. 435.138 (as in effect October 1, 2024): disabled widows(ers) at least age sixty who became ineligible for SSI as a result of the receipt of widows(ers) social security disability benefits and meet all of the following criteria:

(i) Receives widows(ers) social security disability benefits;

(ii) Became ineligible for SSI benefits solely because of the receipt of widows(ers) social security disability benefits;

(iii) Received a SSI benefit in the month before the month of receipt of widows(ers) social security disability benefits;

(iv) Not entitled to medicare part A; and

(v) Although the amount of the widows(ers) social security disability benefits is excluded in determining financial eligibility, the individual must meet all of the current eligibility requirements for medical assistance.

(2) Any changes in circumstances requires a redetermination of eligibility based upon all conditions set forth in paragraph (D)(1) of this rule.

(3) Eligibility under a deemed group does not apply to individuals in a long-term care facility or enrolled in a home and community-based services waiver.

Last updated July 1, 2025 at 7:58 AM

History

Effective: July 1, 2025
Promulgated Under: 111.15

Ohio Adm.Code 5160:1-3-02.9 Medicaid: disability determination process.

(A) This rule addresses the process of determining blindness or disability for non-citizen emergency medical assistance (NCEMA), medicaid buy-in for workers with disabilities (MBIWD), Ohio workability, retroactive coverage for a deceased individual, or the specialized recovery services (SRS) program.

(B) Definitions.

(1) "Administrative agency," for the purpose of this rule, means the county department of job and family services (CDJFS).

(2) "Current medical information" means medical records that originated within eighteen months of the date of initial application.

(3) "Deferred" means the delay in the determination for a disability packet due to incomplete or an insufficient amount of current medical information for the disability determination area (DDA) to approve, deny, or continue the blindness or disability claim.

(4) "Disability begin date" means the date the individual is otherwise eligible for medical assistance and meets the limiting physical factor.

(5) "Disability determination" is the process by which the DDA determines whether the individual meets the social security administration's (SSA's) definition of "blind" or "disabled" for medical assistance eligibility. The DDA determines blindness and disability in accordance with SSA policy.

(6) "Disability packet" consists of all required forms specified in paragraph (C) of this rule and all available current medical information to support the individual's blindness or disability claim. The disability packet is submitted by the administrative agency to the DDA for a disability determination.

(7) "Disability review date" means the date, determined by the DDA, that the individual's current blindness or disability approval will expire.

(8) "Limiting physical factor" is a non-financial eligibility criterion consisting of a physical or mental characteristic or impairment, or a combination of physical or mental characteristics or impairments, that may limit the individual's ability to work. An individual meets the limiting physical factor by meeting the criteria of age, blindness, or disability as set forth in rule 5160:1-3-02 of the Administrative Code.

(9) "SSA disability" means a determination of blindness or disability, as set forth in section 1902 of the Social Security Act (as in effect October 1, 2023), by the SSA.

(1) Determine eligibility for medical assistance in accordance with the eligibility rules contained in Chapters 5160:1-1 to 5160:1-6 of the Administrative Code.

(2) Determine that the limiting physical factor is met and do not submit a disability packet to the DDA when the individual:

(a) Is sixty-five years of age or older; or

(b) Has been approved for SSA disability for the individual's own blindness or disability.

(3) Determine that the limiting physical factor is not met and submit a disability packet to the DDA for a disability determination when the individual is potentially eligible for one of the following:

(a) NCEMA, except for routine labor and delivery, as described in rule 5160:1-5-06 of the Administrative Code;

(b) MBIWD, in accordance with rule 5160:1-5-03 of the Administrative Code, when an individual has not been determined disabled by the SSA;

(c) Ohio workability, in accordance with rule 5160:1-5-04 of the Administrative Code, when an individual has not been determined disabled by the SSA;

(d) Medical assistance for an individual who has died and retroactive eligibility is requested in accordance with rule 5160:1-2-01 of the Administrative Code; or

(e) SRS, in accordance with rule 5160:1-5-07 of the Administrative Code, when an individual has not been determined disabled by the SSA.

(i) The administrative agency is only required to submit the ODM 03605 "CDJFS Referral to DDU" (rev. 8/2021) as referenced in paragraph (C)(11) of this rule. No other forms or documentation listed in this rule are required to be completed by the administrative agency for an SRS referral to DDA.

(ii) DDA will have access to electronic health records maintained by the recovery manager in order to make an accurate disability determination.

(4) Contact the DDA nurse manager to request an expedited disability decision from the SSA for an individual who has an initial disability application that has been pending for ninety days or longer. The CDJFS shall not submit a disability packet for these individuals.

(5) Presume the limiting physical factor is met and do not submit a disability packet to the DDA for a disability determination when the individual is determined to have a presumptive disability by the SSA and has an application for SSA disability pending.

(6) Upon request, assist the individual with obtaining medical documentation to support the blindness or disability claim, including, when necessary, using administrative funds to assist the individual with receiving a medical, psychological, or eye examination to determine whether the individual is blind or disabled.

(7) Obtain and/or assist the individual with obtaining all available current medical information that pertains to the individual's alleged impairment(s) or combination of impairments, as well as any other information requested by the DDA, and submit the information along with the disability packet. This includes existing medical information, tests, services, or records from other entities such as the SSA, opportunities for Ohioans with disabilities, workers' compensation, etc.

(8) Provide the forms listed in this paragraph to the individual, the individual's legal representative, another person applying on behalf of the individual, or the treating physician(s).

(a) ODM 07302 "Basic Medical" (rev. 7/2018);

(b) ODM 07308 "Mental Functional Capacity Assessment" (rev. 7/2018) when the individual has or appears to have a mental impairment; and

(9) Complete the ODM 07004 "Social Summary Report for Disability Determination" (rev. 7/2018).

(10) Obtain signed copies of form ODM 03397 "Authorization for the Release or Use of Protected Health Information (PHI)" (rev. 6/2021) from the individual for all providers who have or may have current medical information.

(11) Complete the ODM 03605 "CDJFS Referral to DDU" (rev. 8/2021).

(12) Submit the disability packet to the DDA for a blindness or disability determination for an individual with potential eligibility as described in paragraph (C)(3) of this rule.

(13) Resubmit the initial disability packet and any additional information to the DDA for a final decision when the DDA has deferred a disability determination and the administrative agency is unable to obtain all of the requested additional medical information.

(D) Individual responsibilities. When the individual alleges a blindness or disability, the individual shall assist the administrative agency with obtaining all available current medical information that supports the blindness or disability claim.

(E) DDA responsibilities.

(1) The DDA shall approve, deny, or defer disability determinations, and shall notify the administrative agency via the electronic eligibility system.

(2) The DDA shall determine the disability begin date and end date, as appropriate, for approved blindness or disability claims, and shall inform the administrative agency via the electronic eligibility system.

(3) In accordance with paragraph (C)(13) of this rule, when the initial disability packet is resubmitted to the DDA because the administrative agency was unable to obtain the requested additional medical information, the DDA shall make a final decision on the case based upon the information available in the initial disability packet, and shall notify the administrative agency of the decision via the electronic eligibility system.

(F) Discontinuance of an MBIWD or Ohio workability DDA-approved individual. When an MBIWD or Ohio workability DDA-approved individual is discontinued from medical assistance and reapplies:

(1) Within twelve months after the disability begin date, the individual meets the limiting physical factor for the remainder of the twelve months. The administrative agency shall not submit a new disability packet to the DDA. The administrative agency shall apply the existing disability review date.

(2) More than twelve months after the disability begin date, the limiting physical factor is not met. The administrative agency shall submit a new disability packet to the DDA for a new disability determination, in accordance with paragraphs (C) to (E) of this rule.

(G) Eligibility for medical assistance when SSA denials are appealed.

(1) When the SSA makes a decision denying SSA disability, the individual has a right to appeal the SSA decision.

(2) An individual shall not be eligible for medical assistance programs, where blindness or disability is an eligibility requirement, during the SSA appeals process.

Last updated August 13, 2025 at 7:39 AM

History

Effective: August 11, 2025
Promulgated Under: 111.15

Ohio Adm.Code 5160:1-3-03.1 Medicaid: income.

(A) This rule describes how income, as defined in rule 5160:1-1-01 of the Administrative Code, is treated for the purpose of determining eligibility for medical assistance for an aged, blind, or disabled individual.

(B) Treatment of income.

(1) Eligibility for medical assistance is dependent in part upon the amount of monthly income available to or received by the individual.

(a) Gross income, prior to any deductions or exclusions, that can be reliably anticipated is considered available when calculating countable income for a month. Thus, when an individual is receiving a pension or is regularly employed or self-employed, the expected amount of income is counted.

(i) Wages are counted as earned income in the calendar month in which they are received, even when all of the work which produced the wages was performed in a prior month.

(ii) When the time of receipt of the income is at the individual's discretion, the individual shall promptly request such wages.

(iii) When the payment of wages is deferred at the individual's request, the administrative agency shall determine when the wages would normally have been paid and allocate them as income for the month in which the wages would have normally been paid. The administrative agency shall assume the wages were payable in equal segments throughout the applicable period and determine eligibility accordingly. When the payment of wages is deferred due to circumstances beyond the control of the individual, the administrative agency shall consider the wages as income when the income is actually received.

(b) Receipt of cash, income in-kind, or something of value in a particular month is considered income to the individual for that month. Any portion of the income which is retained by an individual into the next month becomes a resource.

(2) All income, except income excluded in rule 5160:1-3-03.2 of the Administrative Code, shall be considered when determining the amount of income that is available to an individual.

(3) When an eligible individual resides with an ineligible spouse or parent(s), a portion of the ineligible spouse's or parent's income shall be deemed as available income to the eligible individual. This deeming of income is subject to conditions and limitations as described in rule 5160:1-3-03.3 of the Administrative Code.

(4) Net earnings from self-employment are the gross income from any trade or business minus allowable deductions for that trade or business.

(a) When the individual has filed taxes for the previous year, use all tax forms that were filed with the internal revenue service (IRS).

(b) When the individual has not filed taxes for the previous year, the following may be used:

(i) Business records including receipts for the costs of doing business, or

(ii) Estimated net income.

(5) The monthly income allowance (MIA) from an institutionalized individual to a community spouse, as described in rules 5160:1-6-07 and 5160:1-6-07.1 of the Administrative Code, shall be treated as unearned income to the community spouse in the determination of the community spouse's eligibility for medical assistance.

(C) Under certain circumstances, the amount of income determined available to an individual may be greater than the amount of income that the individual actually receives for personal use. The following types of income deductions are not subtracted from the individual's countable income for purposes of determining eligibility for medical assistance. This list is not all-inclusive.

(1) Court-ordered income deductions.

(a) This includes child and spousal support, even when such support is paid directly to the former spouse or child's guardian by the employer or benefit payer.

(b) A division of marital property in a divorce settlement, which may include a pension or retirement plan, is not considered a court-ordered income deduction.

(i) The portion of a pension or retirement plan that is paid to an individual as part of a divorce decree is considered unearned income to the individual and must be included in the individual's patient liability calculation as set forth in rules 5160:1-6-07 and 5160:1-6-07.1 of the Administrative Code.

(ii) The portion of a pension or retirement plan that is paid to a former spouse as part of a divorce decree is not considered income to the owner of the pension or retirement plan.

(iii) A payment received from a pension or retirement plan as part of a divorce decree that meets the definition of a lump-sum payment in accordance with rule 5160:1-3-05.8 of the Administrative Code, is considered unearned income in the month received and as a countable resource in the month following the month of receipt.

(2) Deductions due to a repayment of an overpayment, loan, or other debt, unless the amount being withheld to reduce a previous overpayment was included when determining the amount of unearned income for a previous month in the determination of medical assistance eligibility.

(3) Garnishments and liens placed against earned or unearned income of the individual, regardless of the purpose for the garnishment or lien.

(D) The following items are not considered income, in accordance with 20 C.F.R. 416.1103 (as in effect October 1, 2025). This list is not all-inclusive:

(1) A personal service performed for an individual is not income to the individual where the service is not convertible to cash.

(2) Payments made on behalf of an individual under credit life or credit disability policies directly to loan companies, mortgage companies, etc.

(3) Money an individual borrows or money received as the repayment of the principal of a bona fide loan. Any interest received on the money loaned is unearned income. When the proceeds of the loan are retained in the month following the month of receipt, they are counted as a resource.

(4) A bill paid directly to a creditor or vendor by a third party on behalf of the individual, unless payment is for food or shelter, to include:

(a) A premium payment for supplementary medical insurance.

(b) Medical insurance premiums.

(5) An arrearage of child support which is payable to an individual on behalf of an adult child unless the individual retains the income and does not give it to the adult child.

(6) Receipts from the sale, exchange or replacement of a resource are not income but remain resources.

(7) A rebate, refund, or other return of money an individual has already paid. The money returned is not income.

(8) Any amount refunded on income taxes already paid.

(9) The replacement of an individual's income that was lost, stolen, or destroyed and was previously used when determining eligibility.

(10) A return of erroneously received payments.

(11) Cash or in-kind assistance from a governmental or nongovernmental program for medical or social services that are not food or shelter.

(E) Verification of income.

(1) The individual's statements of source and amount of income are subject to verification. At the time of application and renewal, the income of the individual and household member(s) whose income affects the individual shall be verified electronically or documents shall be required to be submitted which verify all sources of income. When necessary, the administrative agency shall obtain a signed release of information and contact other sources to verify income.

(a) When the administrative agency is unable to verify the income through electronic sources, the administrative agency will contact the individual to collect the information needed. When the individual declares the verifications cannot be accessed or submitted, the individual's statement shall be accepted.

(b) When the administrative agency is unable to make contact with the individual, a request for information or verification documents shall be sent electronically, via postal mail, or personally delivered to the individual as set forth in rule 5160:1-2-01 of the Administrative Code.

(2) An individual's report of income is subject to verification when a review is conducted by the Ohio department of medicaid (ODM) program integrity compliance section.

(3) The individual has the burden of verifying the sources and amounts of income, and has the responsibility of reporting income changes to the administrative agency in accordance with rule 5160:1-2-08 of the Administrative Code.

(4) When an individual claims to have no income at the time of application or renewal, the administrative agency shall review the application or renewal for inconsistencies requiring resolution. The individual is responsible for supporting the claim of no income; however, when verification is not available and the individual has cooperated with the administrative agency in trying to obtain verification, the administrative agency may process the application or renewal based on the individual's statement unless available information conflicts with the attestation. Reference rule 5160:1-2-10 of the Administrative Code for additional information regarding acceptable verification.

(5) When income in-kind is received, the administrative agency shall determine whether in-kind support and maintenance is being received in accordance with rule 5160:1-3-03.8 of the Administrative Code.

Last updated July 15, 2026 at 7:45 AM

History

Effective: July 15, 2026
Promulgated Under: 111.15

Ohio Adm.Code 5160:1-3-03.2 Medicaid: income exclusions.

(A) When determining eligibility for medical assistance for an individual who is aged, blind, or disabled, certain types of income, including income from certain sources, are not counted. This rule sets forth the types of income that are to be excluded, and the order in which they are excluded from the individual's income.

(B) Definitions.

(1) "Blind work expense" (BWE) means the portion of the individual's earned income used to meet any expenses reasonably attributable to the earning of the income when the individual is blind; and

(a) Is under age sixty-five; or

(b) Is age sixty-five or older and received supplemental security income (SSI) payments due to blindness for the month before attaining age sixty-five.

(2) "Countable income" means the total earned and unearned income minus the income exclusions set forth in this rule. Countable income is compared to the appropriate income standard when determining eligibility for medical assistance.

(3) "Exclusion" means an amount of income which does not count when determining eligibility for medical assistance.

(C) Order of exclusions. Unearned income exclusions are applied before earned income exclusions. The specific order of exclusions are described in paragraphs (D) to (F) of this rule.

(D) Unearned income exclusions.

(1) Unearned income excluded by federal laws other than the Social Security Act, in accordance with the appendix to subpart K of 20 C.F.R 416 (as in effect October 1, 2025) unless otherwise noted. The exclusions listed in this paragraph are applied before the exclusions listed in paragraph (D)(2) of this rule:

(a) 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).

(b) Child care assistance under the Child Care and Development Block Grant Act (Pub. L. No. 113-186).

(c) 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, 2025).

(d) 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, 2025):

(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.

(e) Payments made to individuals under the Energy Employees Occupational Illness Compensation Program Act of 2000 (Pub. L. No. 106-398).

(f) Federal food and nutrition programs:

(i) Supplemental nutrition assistance program (SNAP), formerly known as food stamps or food assistance;

(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).

(g) Student financial assistance received under the Higher Education Act of 1965 (as in effect October 1, 2025) or bureau of Indian affairs is excluded from income and resources, 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.

(h) Home energy assistance provided on the basis of need, in accordance with 20 C.F.R. 416.1157 (as in effect October 1, 2025).

(i) Matching funds that are deposited into individual development accounts (IDAs), either demonstration project or temporary assistance for needy families (TANF) funded, in accordance with 42 U.S.C. 604 (as in effect October 1, 2025).

(j) 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, 2025).

(k) Restitution payments under the Aleutian and Pribilof Island Restitution Act in accordance with 50 U.S.C. 4236 (as in effect October 1, 2025).

(l) Payments to victims of Nazi persecution.

(m) 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).

(n) 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).

(o) Radiation exposure compensation trust fund payments, in accordance with the Radiation Exposure Compensation Act of 1990 (Pub. L. No. 101-426).

(p) 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.

(q) 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 to 506 (as in effect October 1, 2025). These payments are to be documented and identifiable from countable insurance.

(r) Payments made to Native Americans as listed in section IV of the appendix to subpart K of 20 C.F.R. 416, as provided by Federal statutes other than the Social Security Act (as in effect October 1, 2025).

(s) Payments from the Ricky Ray Hemophilia Relief 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. Ill).

(t) 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.

(2) Unearned income excluded by the Social Security Act, in accordance with 20 C.F.R. 416.1124 (as in effect October 1, 2025) unless otherwise noted. The exclusions listed in this paragraph are applied after the exclusions listed in paragraph (D)(1) of this rule, and in the following order:

(a) Any public agency's refund of taxes on real property or food.

(b) Assistance based on need which is provided under a program which uses income as a factor of eligibility and is wholly funded by a state or political subdivision. Residential state supplement (RSS) payments are included in this category.

(c) Grants, scholarships, fellowships, or gifts used for paying educational expenses are either excluded or countable, depending upon their use:

(i) Any portion of a grant, scholarship, fellowship, or gift used for paying tuition, fees, or other necessary educational expenses at any educational institution, including vocational or technical education, is excluded from income.

(ii) Any portion of such educational assistance that is not used to pay current tuition, fees, or other necessary educational expenses but is set aside to be used for paying this type of educational expense at a future date is excluded from income in the month of receipt. When these funds are not spent after nine months, they become a countable resource as of the tenth month following receipt.

(iii) Any portion of a grant, scholarship, fellowship, or gift that is not used or set aside for paying tuition, fees, or other necessary educational expenses is income in the month received and a resource the month after the month of receipt, when retained.

(d) Food which an individual or the individual's spouse grows or raises when it is consumed by the household.

(e) 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.

(f) The first sixty dollars of infrequent or irregular unearned income received in a calendar quarter.

(g) Alaska senior benefits program payments.

(h) Foster care payments.

(i) Any interest earned on an excluded burial fund and any appreciation in the value of an excluded burial arrangement which are left to accumulate and become a part of that burial fund.

(j) Support and maintenance assistance based on need:

(i) Provided in-kind by a private non-profit agency; or

(ii) Provided in cash or in-kind by a supplier of home heating oil or gas, or by a private or municipal utility company.

(k) One-third of child support payments made by an absent parent.

(l) Twenty dollar general income exclusion. This exclusion does not apply to income/assistance based on need that uses income as a factor of eligibility and is wholly or partially funded by the federal government or by a non-governmental agency, in accordance with 20 C.F.R. 416.1124(c)(12)(as in effect October, 1, 2025). Catholic charities and the salvation army are non-governmental agencies.

(m) Unearned income used to fulfill an approved plan to achieve self-support (PASS).

(n) Federal housing assistance, in accordance with 1612(b)(14) of the Social Security Act (as in effect October 1, 2025), provided by:

(i) The office of housing and urban development (HUD); or

(ii) The U.S. department of agriculture's rural housing service (RHS), formally known as the farmers home administration (FHA).

(o) Any interest earned on an excluded burial space purchase agreement when left to accumulate as part of the value of the agreement.

(p) The value of any commercial transportation ticket which is received as a gift and is not converted to cash.

(q) Payments from a state compensation fund for victims of crime.

(r) 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.

(s) Combat fire pay received from the uniformed services.

(t) Interest on a dedicated account in a financial institution for an individual under the age of eighteen, that is maintained by a representative payee, the sole purpose of which is to receive and maintain past-due SSI benefits which are allowed to be paid into such an account, and the use of which is restricted by section 1631(a)(2)(F) of the Social Security Act (as in effect October 1, 2025).

(u) Gifts to children with life-threatening conditions, in accordance with section 1612(b)(22) of the Social Security Act (as in effect October 1, 2025), from an organization described in section 501(c)(3) of the Internal Revenue Code of 1986, within the following limitations:

(i) In-kind gifts not converted to cash; and

(ii) The first two thousand dollars of any cash gifts within a calendar year.

(v) Interest and dividend income from a countable resource or from a resource excluded under a federal statute other than section 1613(a) of the Social Security Act (as in effect October 1, 2025).

(w) A state annuity paid by a state, to an individual or the individual's spouse, on the basis of the state's determination that the individual is a veteran and is blind, disabled, or aged.

(E) Earned income excluded by the Social Security Act, in accordance with 20 C.F.R. 416.1112 (as in effect October 1, 2025) unless otherwise noted. The exclusions listed in this paragraph are applied after the unearned income exclusions, and in the following order:

(1) Earned income tax credit payments and child tax credit payments.

(2) The first thirty dollars of infrequent or irregular earned income received in a calendar quarter.

(3) Student earned income exclusion (SEIE):

(a) Earned income of blind or disabled student children under the age of twenty-two, up to the SEIE monthly limit, and not more than the SEIE yearly limit. The SEIE monthly and yearly limits are updated and published annually in a medicaid eligibility procedure letter that includes standards and limits that have been updated due to the social security administration's cost of living adjustment (COLA).

(b) Available to a student attending school to include college, university, or a course of vocational or technical training designed to prepare students for gainful employment.

(4) Any portion of the twenty-dollar monthly general income exclusion which has not been excluded from unearned income in that same month.

(5) The first sixty-five dollars of earned income in a month.

(6) Earned income of disabled individuals used to pay impairment-related work expenses (IRWEs), as described in 20 C.F.R. 404.1576 (as in effect October 1, 2025).

(7) One-half of remaining earned income in a month.

(8) BWEs, as defined in paragraph (B) of this rule.

(9) Earned income used to fulfill an approved plan to achieve self-support (PASS).

(F) As a state-selected option under section 1902(r)(2) of the Social Security Act (as in effect October 1, 2025), exclude all income received from temporary employment with the decennial census.

(G) Unused exclusions.

(1) Exclusions never reduce earned or unearned income below zero.

(2) Unused portions of a monthly exclusion cannot be carried over for use in subsequent months.

(3) Unused earned income exclusions are never applied to unearned income.

(4) Other than the twenty-dollar general income exclusion, no unused unearned income exclusion may be applied to earned income.

(H) The twenty-dollar general and sixty-five-dollar earned income exclusions are applied only once to an eligible couple, even when both members have income, since the couple's earned income is combined in determining eligibility for medical assistance.

Last updated June 18, 2026 at 11:35 PM

History

Effective: April 15, 2026
Promulgated Under: 111.15

Ohio Adm.Code 5160:1-3-03.3 Medicaid: deeming of income.

(A) This rule describes the process for calculating the amount of income to deem from an ineligible spouse or ineligible parent when determining eligibility for medical assistance for an eligible spouse or eligible child.

(1) When an eligible spouse resides in the same household with an ineligible spouse, or an eligible child under age eighteen resides in the same household with an ineligible parent(s), a portion of the income and resources of such spouse or parent are included in determining the eligible spouse's or eligible child's financial eligibility for medical assistance for the aged, blind, or disabled.

(2) For spouse-to-spouse deeming to apply, the eligible spouse must be eligible based on his or her own income.

(B) Definitions. For the purposes of this rule:

(1) "Allocation" means an amount deducted from income subject to deeming, which is considered to be set aside for the support of another individual.

(2) "Child" means an individual under age eighteen who lives in a household with one or both parents and who is neither married nor the head of household. The deeming of parental income applies through the month in which the child attains eighteen years of age. An eligible or ineligible child's income is never deemed to parent(s) or sibling(s).

(3) "Deemed income" means income attributed to another person whether or not the income is actually available to the person to whom it is deemed.

(4) "Eligible child" means a child in the household who has applied for medical assistance for the blind or disabled, and who meets all the applicable non-financial eligibility criteria for medical assistance.

(5) "Eligible parent" means a parent in the household who has applied for medical assistance for the aged, blind, or disabled, and who meets all the applicable non-financial eligibility criteria for medical assistance.

(6) "Eligible spouse" means the member of the married couple who has applied for medical assistance for the aged, blind, or disabled, and who meets all the applicable non-financial eligibility criteria for medical assistance.

(7) "Household" means the eligible spouse, the ineligible spouse, and any of the couple's children or the children of either member of the couple; or the eligible child, the eligible child's parent(s), and other children of the parent(s).

(a) A household does not exist when an individual or a group of individuals does not have a residence. In such a case, only the eligible individual's income is used to determine eligibility for medical assistance.

(b) When a child is born in an institution (e.g., a hospital), the child is a member of the household at the time of birth unless the parents have completed the required paperwork to give the child up for adoption or the child has been placed in the temporary custody of a public children's services agency (PCSA) or private child placing agency (PCPA).

(c) An eligible individual or an ineligible spouse or ineligible parent who is temporarily absent, as defined in rule 5160:1-1-01 of the Administrative Code, is still considered to be a member of the household for deeming purposes.

(8) "Ineligible child" means a child in the household who has not applied for medical assistance for the blind or disabled.

(9) "Ineligible parent" means an eligible child's parent who has not applied for medical assistance for the aged, blind, or disabled.

(10) "Ineligible spouse" means the member of the married couple who has not applied for medical assistance for the aged, blind, or disabled.

(11) "Parent" means a natural or adoptive father or mother living in the same household as the eligible child. The income of a stepparent who lives with the eligible child is deemed to the child only when the natural or adoptive parent also lives in the household with the stepparent and the eligible child. When the natural or adoptive parent divorces a stepparent and the child is living with the stepparent, the stepparent is not considered a parent or spouse for deeming purposes.

(12) "Spouse" means a person who is legally married to another under Ohio law.

(C) In accordance with 20 C.F.R. 416.1161 (as in effect October 1, 2024), when determining the income of an ineligible spouse, an ineligible parent, or of an ineligible child in the household, the following items shall not be considered income:

(1) Income excluded by federal laws other than the Social Security Act as described in rule 5160:1-3-03.2 of the Administrative Code;

(2) Items not considered income as described in rule 5160:1-3-03.1 of the Administrative Code;

(3) Any public income-maintenance (PIM) payments, as defined in 20 C.F.R. 416.1142(a) (as in effect October 1, 2024), received by the ineligible spouse, ineligible parent(s), or ineligible child in the household, and any income which was counted or excluded in calculating the amount of that payment;

(4) Any of the income of the ineligible spouse or ineligible parent that is used to determine the amount of a PIM payment to someone else;

(5) Any portion of a grant, scholarship, fellowship, or gift used or set aside to pay tuition, fees, or other necessary educational expenses;

(6) Money received for providing foster care to an ineligible child;

(7) The value of supplemental nutrition assistance program (SNAP), formerly known as food stamps or food assistance, and the value of foods donated by the United States department of agriculture commodity supplemental food program;

(8) Food raised and consumed by members of the household;

(9) Tax refunds on income, real property, or food purchased by the family;

(10) Income used to fulfill an approved plan to achieve self-support (PASS), as defined in 20 C.F.R. 416.1181 (as in effect October 1, 2024);

(11) The amount of court-ordered child support payments paid by a household member for a child outside the home;

(12) The value of in-kind support and maintenance;

(13) Alaska longevity bonus payments made to an individual who is a resident of Alaska and who, prior to October 1, 1985, met the twenty-five-year residency requirement for receipt of such payments in effect prior to January 1, 1983, and was eligible for supplemental security income (SSI);

(14) Disaster assistance as described in 20 C.F.R. 416.1150 and 416.1151 (as in effect October 1, 2024);

(15) Income received infrequently or irregularly, as defined in 20 C.F.R. 416.1112(c)(2) and 416.1124(c)(6) (as in effect October 1, 2024);

(16) Blind work expenses, as defined in rule 5160:1-3-03.2 of the Administrative Code, of the ineligible spouse or parent;

(17) Income of the ineligible spouse or ineligible parent which was paid under a federal, state, or local government program to provide the eligible individual with chore, attendant, or homemaker services;

(18) Certain support and maintenance assistance as described in 20 C.F.R. 416.1157(c) (as in effect October 1, 2024);

(19) Housing assistance in accordance with 20 C.F.R 416.1124(c)(14) (as in effect October 1, 2024);

(20) The value of a commercial transportation ticket as described in 20 C.F.R. 416.1124(c)(16) (as in effect October 1, 2024); however, when such a ticket is converted to cash, the cash is income in the month the ineligible spouse or ineligible parent receives the cash;

(21) Refunds of federal income taxes and advances made by an employer relating to an earned income tax credit, as described in 20 C.F.R. 416.1112(c) (as in effect October 1, 2024);

(22) Payments from a fund established by a state to aid victims of crime, as described in 20 C.F.R. 416.1124(c)(17) (as in effect October 1, 2024);

(23) Relocation assistance in accordance with 20 C.F.R 416.1124(c)(18) (as in effect October 1, 2024);

(24) Combat pay received from one of the uniformed services pursuant to 37 U.S.C. 310 (as in effect October 1, 2024);

(25) Impairment-related work expenses, as described in 20 C.F.R. 404.1576 (as in effect October 1, 2024), incurred and paid by an ineligible spouse or ineligible parent, when the ineligible spouse or ineligible parent receives disability benefits under title II of the Social Security Act;

(26) Interest earned on excluded burial funds and appreciation in the value of excluded burial arrangements which are left to accumulate and become part of separate burial funds, and interest accrued on and left to accumulate as part of the value of agreements representing the purchase of excluded burial spaces, as described in 20 C.F.R. 416.1124(c)(9) and (15) (as in effect October 1, 2024);

(27) Interest and dividend income from a countable resource or from a resource excluded under a federal statute other than section 1613(a) of the Social Security Act, in accordance with 20 C.F.R. 416.1124(c)(22) (as in effect October 1, 2024);

(28) Earned income of a student as described in 20 C.F.R. 416.1112(c)(3) (as in effect October 1, 2024); and

(29) Any additional increment in pay, other than any increase in basic pay, received while serving as a member of the uniformed services when:

(a) The ineligible spouse or ineligible parent received the pay as a result of deployment to or service in a combat zone; and

(b) The ineligible spouse or ineligible parent was not receiving additional pay immediately prior to deployment to or service in a combat zone.

(D) When the eligible spouse or eligible parent(s) is/are receiving Ohio works first (OWF) or SSI payments, then the payments themselves and any of the OWF- or SSI-eligible individual's own income that was used to compute eligibility for such payments are not considered available for deeming.

(E) When an eligible spouse is living in the same household with an ineligible spouse who has income, perform the following steps to calculate the amount of income to deem to the eligible spouse in accordance with 20 C.F.R. 416.1163 (as in effect October 1, 2024):

(1) Determine the ineligible spouse's income, applying any appropriate exclusions listed in paragraph (C) of this rule.

(2) Deduct the appropriate allocation for each ineligible child in the household:

(a) There is no allocation for an ineligible child receiving PIM payments as described in paragraph (C)(3) of this rule.

(b) The allocation amount is the current SSI federal benefit rate (FBR), as published annually in the Federal Register, for a couple minus the current SSI FBR for an individual.

(c) The allocation for each ineligible child in the household is reduced by the amount of that ineligible child's income, minus any appropriate exclusions listed in paragraph (C) of this rule.

(d) The ineligible child allocation(s) must first be taken from the ineligible spouse's unearned income; any remaining allocation amount will be subtracted from the ineligible spouse's earned income.

(3) When the ineligible spouse's remaining income after subtracting the ineligible child allocation(s) is less than or equal to the current SSI FBR for a couple minus the current SSI FBR for an individual:

(a) Do not deem any income to the eligible spouse.

(b) Combine the eligible spouse's unearned and earned income, applying the appropriate exclusions listed in rule 5160:1-3-03.2 of the Administrative Code.

(c) When the eligible spouse's countable income is less than or equal to the current income standard for an individual, the eligible spouse is financially eligible for medical assistance.

(4) When the ineligible spouse's remaining income after subtracting the ineligible child allocation(s) is greater than the current SSI FBR for a couple minus the current SSI FBR for an individual, treat the spouses as if they were an eligible couple:

(a) Combine both the ineligible spouse's post-allocation unearned and earned income and the eligible spouse's unearned and earned income, applying any appropriate exclusions listed in rule 5160:1-3-03.2 of the Administrative Code.

(b) Subtract the twenty-dollar general exclusion from the couple's combined unearned income; when there is less than twenty dollars of unearned income, subtract the remainder of the exclusion from the couple's combined earned income.

(c) Subtract sixty-five dollars from the couple's combined earned income, then subtract one-half of the remaining earned income.

(d) When the couple's countable income is less than or equal to the current income standard for a couple, the eligible spouse is financially eligible for medical assistance.

(F) When an eligible child(ren) reside(s) with an ineligible parent(s), perform the following steps to calculate the amount of income to deem to the eligible child(ren):

(1) Determine the income of each ineligible parent, applying any appropriate exclusions listed in paragraph (C) of this rule.

(2) Deduct the appropriate allocation for each ineligible child in the household:

(a) There is no allocation for an ineligible child receiving PIM payments as described in paragraph (C)(3) of this rule.

(b) The allocation amount is the current SSI federal benefit rate (FBR), as published annually in the Federal Register, for a couple minus the current SSI FBR for an individual.

(c) The allocation for each ineligible child in the household is reduced by the amount of that ineligible child's income, minus any appropriate exclusions listed in paragraph (C) of this rule.

(d) The ineligible child allocation(s) must first be taken from the ineligible parent(s) combined unearned income; any remaining allocation amount will be subtracted from the ineligible parent(s)'s combined earned income.

(3) Subtract the twenty-dollar general exclusion from the combined unearned income of the ineligible parent(s); when there is less than twenty dollars of unearned income, subtract the remainder of the exclusion from the combined earned income of the ineligible parent(s).

(4) Subtract sixty-five dollars from the combined earned income of the ineligible parent(s), then subtract one-half of the remaining earned income.

(5) Combine the remaining earned and unearned income of the ineligible parent(s).

(6) Subtract the appropriate parental living allowance for each ineligible parent.

(a) There is no parental living allowance deducted for an ineligible parent who receives PIM payments as described in paragraph (C)(3) of this rule.

(b) When one ineligible parent resides in the household with the child(ren), subtract the current SSI FBR for an individual.

(c) When two ineligible parents (or one ineligible parent and one ineligible stepparent) reside in the household with the child(ren), subtract the current SSI FBR for a couple.

(d) When both ineligible natural or adoptive parents and one ineligible stepparent reside in the household with the child(ren), subtract both the current SSI FBR for a couple and the current SSI FBR for an individual.

(7) Divide the remaining income by the number of eligible children in the household, and the resulting amount (rounded to the second decimal place) is deemed to each eligible child.

(8) Any income deemed to an eligible child from an ineligible parent is added to the eligible child's own unearned income.

(9) Combine the eligible child's unearned and earned income, applying any appropriate exclusions listed in rule 5160:1-3-03.2 of the Administrative Code.

(10) When the eligible child's resulting countable income is less than or equal to the current income standard for an individual, the eligible child is financially eligible for medical assistance.

(G) When a household is comprised of an ineligible spouse, an eligible spouse, and one or more eligible children, the ineligible spouse's income is deemed first to the eligible spouse and the remainder deemed to the eligible child(ren).

(1) Determine the income of the ineligible spouse, applying any appropriate exclusions listed in paragraph (C) of this rule.

(2) Deduct the appropriate allocation for each ineligible child in the household, as described in paragraph (E)(2) of this rule.

(a) Do not deem any income to the eligible spouse or eligible child(ren); and

(b) Compare the eligible spouse's and each eligible child(ren)'s own countable income, applying any appropriate exclusions listed in rule 5160:1-3-03.2 of the Administrative Code, to the current income standard for an individual.

(c) When the eligible spouse's and each eligible child(ren)'s own income is less than or equal to the current income standard for an individual, the eligible spouse and each eligible child(ren) is financially eligible for medical assistance.

(4) When the ineligible spouse's remaining income after subtracting the ineligible child allocation(s) is greater than the current SSI FBR for a couple minus the current SSI FBR for an individual:

(b) Subtract the twenty-dollar general exclusion from the couple's combined unearned income; when there is less than twenty dollars of unearned income, then subtract the remainder of the exclusion from the couple's combined earned income.

(c) Subtract sixty-five dollars from the couple's combined earned income, then subtract one-half of the remaining earned income.

(d) When the couple's countable income is less than or equal to the current income standard for a couple, the eligible spouse is financially eligible for medical assistance and no income is deemed to the eligible child(ren).

(e) When the couple's countable income is greater than the current income standard for a couple, the eligible spouse is not financially eligible for medical assistance.

(f) The amount of the couple's income in excess of the need standard for a couple is divided by the number of eligible children in the household and the resulting amount (rounded to the second decimal place) is deemed to each eligible child.

(5) Any income deemed to an eligible child under paragraph (G)(4)(f) of this rule is added to the eligible child's own unearned income.

(6) Combine each eligible child's unearned and earned income, applying any appropriate exclusions listed in rule 5160:1-3-03.2 of the Administrative Code.

(7) When each eligible child's resulting countable income is less than or equal to the current income standard for an individual, the eligible child is financially eligible for medical assistance.

Last updated August 6, 2026 at 6:39 AM

History

Effective: February 15, 2026
Promulgated Under: 111.15

Ohio Adm.Code 5160:1-3-03.5 Medicaid: application of income standards.

(A) The purpose of this rule is to set forth the application of income standards used in eligibility determinations of medical assistance for aged, blind, or disabled individuals.

(B) Definitions.

(1) "Income standard" means the income limit above which an individual is ineligible for a given category of medical assistance for the aged, blind, or disabled.

(2) "Couple income standard" is equal to the current supplemental security income (SSI) benefit rate for a couple. The updated figure is published annually by the social security administration.

(3) "Individual income standard" is equal to the current supplemental security income (SSI) benefit rate for an individual. The updated figure is published annually by the social security administration.

(1) For an individual, countable income is compared to the appropriate individual income standard.

(2) For a married couple:

(a) When both members of the married couple are categorically eligible, countable income is compared to the appropriate couple income standard.

(b) When only one member of the married couple is categorically eligible, countable income may be compared to either the individual income standard or the couple income standard, in accordance with the deeming provisions set forth in rule 5160:1-3-03.3 of the Administrative Code.

Last updated June 9, 2025 at 3:37 PM

History

Effective: June 8, 2025
Promulgated Under: 111.15

Ohio Adm.Code 5160:1-3-03.6 Medicaid: treatment of rental income.

(A) The purpose of this rule is to describe the calculation and treatment of rental income and expenses for medical assistance eligibility determinations.

(B) Definitions.

(1) "Net rental income" means gross rent less the ordinary and necessary expenses paid in the same taxable year. Net rental income is treated as unearned income unless the individual is in the business of renting properties, in which case the income is treated as earned income from self-employment.

(2) "Ordinary and necessary expenses" are those expenses necessary for the production or collection of rental income. In general, these expenses include interest on debts, state and local taxes on real and personal property, state and local taxes on motor fuel, general sales taxes, and expenses for managing or maintaining property.

(3) "Rent" means a payment which an individual receives for the use of real or personal property, such as land, housing, or machinery.

(1) Identify countable rental income.

(a) Rental deposits.

(i) Rental deposits are not income to the landlord while subject to return to the tenant.

(ii) Rental deposits used to pay rental expenses become income to the landlord at the point of use.

(b) Do not consider rents received in months prior to the individual's eligibility for medical assistance.

(2) Calculate allowable expenses.

(a) Deductible expenses include:

(i) Interest and escrow portions of a mortgage payment (at the point the payment is made to the mortgage holder).

(ii) Real estate insurance.

(iii) Repairs (i.e., minor correction to an existing structure).

(iv) Property taxes.

(v) Lawn care.

(vi) Snow removal.

(vii) Advertising for tenants.

(viii) Utilities.

(b) Nondeductible expenses include:

(i) Depreciation or depletion of property.

(ii) Principal portion of a mortgage payment.

(iii) Capital expenditures (i.e., an expense for an addition or increase in the value of property which is subject to depreciation for income tax purposes).

(i) In multiple family residences, if the units in the building are of approximately equal size, prorate allowable expenses based on the number of units designated for rent compared to the total number of units. If the units are not of approximately equal size, prorate allowable expenses based on the number of rooms in the rental units compared to the total number of rooms in the building. The rooms do not have to be occupied.

(ii) For rooms in a single residence, prorate allowable expenses based on the number of rooms designated for rent compared to the number of rooms in the house.

(a) Do not count bathrooms as rooms in the house.

(b) Basements and attics are counted only if they have been converted to living spaces (e.g., recreation rooms).

(iii) For rented land, prorate expenses based on the percentage of total acres that are for rent.

(d) Do not consider expenses paid in months prior to the individual's eligibility for medical assistance.

(e) Expenses are deducted when paid, not when incurred.

(3) Subtract the deductible expenses paid in a month from gross rent received in the same month.

(a) If deductible expenses exceed gross rent in a month, subtract the excess expenses from the next month's gross rent and continue doing this as necessary until the end of the tax year in which the expenses are paid.

(b) If there are still excess expenses, subtract them from the gross rent received in the month prior to the month the expenses were paid and continue doing this as necessary to the beginning of the tax year involved.

(4) Use evidence from the previous months to estimate net rental income for the next twelve months; however, deduct only predictable expenses (e.g., utilities, interest payments, taxes, etc.).

(5) If an unpredictable expense is reported at a later date (e.g., a repair), deduct the expense in the month paid. If the expense exceeds the rent for that month, recalculate the rest of the estimated period in accordance with paragraph (C)(3) of this rule.

(6) Absent evidence to the contrary, apportion net rental income in proportion to the percentage of ownership. If the gross rent is split between the individual and another joint owner before expenses are paid, deduct expenses paid by the individual from the individual's portion of the gross rent.

(D) Verification of income and expenses. Use documents in the individual's possession (e.g., bills, receipts, etc.) to verify the gross rent and the dates received, and expenses and the dates paid. The individual's most recent federal income tax return including "Schedule E" may assist with identifying past expenses and estimating future rental income.

(1) The administrative agency will contact the individual to collect the information needed. If the individual declares the verifications cannot be accessed or submitted, the individual's statement is to be accepted.

(2) If the administrative agency is unable to make contact with the individual, a written (electronic or paper) request for the necessary information or verification documents is to be sent as set forth in rule 5160:1-2-01 of the Administrative Code.

(3) If a determination cannot be made regarding whether an expense is allowable (e.g., whether the expense is an incidental repair or a capital expenditure), the administrative agency may contact the internal revenue service (IRS) for assistance.

Last updated September 2, 2025 at 8:14 AM

History

Effective: September 1, 2025
Promulgated Under: 111.15

Ohio Adm.Code 5160:1-3-03.7 Medicaid: treatment of sick pay and sick leave.

(A) The purpose of this rule is to set forth the treatment of sick pay and sick leave for eligibility for medical assistance.

(B) Definitions.

(1) "Sick pay" means a payment made to or on behalf of an employee by an employer or a private third party for sickness or accident disability.

(2) "Sick leave" means a paid absence from duty for personal or family medical reasons and is considered a continuation of salary.

(1) Sick pay is treated as earned income (wages) when the individual receives sick pay within six months after stopping work and the income is not attributable to the employee's own contributions toward a sick pay plan.

(2) Sick pay is treated as unearned income when:

(a) The individual receives sick pay within six months after the individual stops working and the income is attributable to the employee's own contributions toward a sick pay plan; or

(b) The individual receives sick pay more than six months after stopping work.

(3) To determine the six months' period after the individual stops working:

(a) Begin with the first day of non-work; and

(b) Include the remainder of the calendar month in which work stops; and

(D) Treatment of sick leave.

(1) Sick leave payments are treated as earned income.

(2) Sick leave that is donated to the individual is treated the same as if it was the individual's own leave.

Last updated June 9, 2025 at 3:37 PM

History

Effective: June 8, 2025
Promulgated Under: 111.15

Ohio Adm.Code 5160:1-3-03.8 Medicaid: in-kind support and maintenance.

(A) This rule sets forth how in-kind support and maintenance is valued for the purpose of determining eligibility for medical assistance.

(B) Definitions.

(1) "Actual value" is the dollar amount that an individual paid for an item or service, or for his/her share of an item or service.

(2) "Fair market value" is the dollar amount for which an item would sell on the local open market.

(3) "Household" is a personal place of residence in which individuals share common living quarters and that functions as a single economic unit.

(4) "Household of another income standard" is equal to two-thirds of the income standard for an individual or couple as applicable.

(5) "In-kind support and maintenance" is unearned income in the form of shelter, or something that can be used to get shelter, that a person is given or receives because someone else pays for it.

(6) "Living in household of another" means that an individual is living in a household other than his or her own household as defined in paragraph (B)(7) of this rule.

(7) "Living in own household" means that:

(a) The individual has ownership interest or life estate in the home;

(b) The individual is liable for payment of any part of a rental charge;

(d) The individual lives in a non-institutional care situation.

(8) "Non-institutional care situation" means:

(a) The individual has been placed by a public or private agency under a specific program of protective placement;

(b) The placement is in a private household that is licensed or otherwise approved by the state to provide protective care;

(c) The placing agency retains responsibility for continuing supervision of the need for placement and of the services provided; and

(d) The individual, the placing agency, or some other party pays for the services provided, or has a written agreement to pay for the services provided.

(9) "Presumed maximum value" is one-third of the value of the individual income standard, as set forth in rule 5160:1-3-03.5 of the Administrative Code, plus twenty dollars.

(10) "Public assistance household" is a household in which the individual and at least one other household member receive some type of public income-maintenance payments, including but not limited to Ohio works first (OWF), supplemental nutrition assistance program (SNAP), supplemental security income (SSI), disaster relief and emergency assistance, or state or local government assistance programs based on need.

(11) "Shelter" means living quarters for an individual in the individual's permanent living arrangement.

(12) "Shelter costs" means rent, mortgage payments, real property taxes, heating fuel, gas, electricity, water, sewerage, and garbage collection services.

(1) The support and maintenance is identified as excluded in accordance with rule 5160:1-3-03.2 of the Administrative Code;

(2) The support and maintenance is received from another member of a public assistance household; or

(3) The individual receives SSI and the social security administration does not reduce the individual's SSI benefit because of in-kind support and maintenance.

(D) In-kind support and maintenance received by an individual is countable unearned income and is valued by applying:

(1) The household of another income standard when:

(a) The individual is a recipient of SSI benefits and receives the one-third reduction in the SSI benefit; or

(b) The individual lives for an entire month in another person's household, and receives both food and shelter for the entire month from someone living in that household.

(2) The presumed maximum value when the individual:

(a) Receives in-kind support and maintenance but lives in his or her own household;

(b) Does not live for the entire month in another person's household;

(d) Receives in-kind support and maintenance from someone outside the household.

(3) The fair market value or actual value, whichever is less, when the individual demonstrates:

(a) The fair market value of any in-kind support and maintenance received, minus any payment the individual makes for them, is less than the presumed maximum value; or

(b) The actual amount someone else pays for the individual's in-kind support and maintenance is less than the presumed maximum value.

Last updated June 9, 2025 at 3:38 PM

History

Effective: June 8, 2025
Promulgated Under: 111.15

Ohio Adm.Code 5160:1-3-03.10 Medicaid: retirement funds.

(A) This rule describes how retirement funds are treated for the purpose of determining eligibility for medical assistance.

(B) Definitions.

(1) "Defined benefit retirement plan," also known as a "traditional pension plan," means an employer-sponsored retirement benefit that is not accessible until the individual has met specific eligibility criteria outlined in the retirement plan contract. A defined benefit plan provides a fixed, pre-established benefit to an individual for life.

(2) "Defined contribution retirement plan," also referred to as a "money purchase plan," means a retirement plan where a company's contributions are based on a fixed percentage of an individual's compensation, to be contributed annually.

(3) "Payout status," refers to an individual taking regular, periodic payments from the individual's retirement plan.

(4) "Qualified joint and survivor annuity (QJSA)" means the required benefit distribution method for defined benefit retirement plans, defined contribution retirement plans, and target benefit retirement plans. A QJSA provides a life annuity to the individual and a survivor annuity to the individual's spouse after the individual's death.

(5) "Regular, periodic payments," for the purpose of this rule, means predictable, uniform amounts paid at a consistent interval for a period of time greater than one year. Intervals for payments may include monthly, quarterly, or annually.

(6) "Required minimum distributions (RMDs)" means withdrawals an individual is required to take from qualifying retirement plans once the individual reaches a specific age as determined by the life expectancy tables published by the internal revenue service (IRS).When RMDs are taken according to IRS rules, the funds are considered to be in payout status.

(7) "Retirement funds" refer to money that is saved and invested within a retirement plan, designed to provide unearned income to supplant or supplement earned income when employment ends.

(8) "Retirement plan" refers to a structured approach to saving and investing for retirement. A retirement plan can be set up by employers, individuals, or other institutions such as unions or the government. Retirement plans include, but are not limited to: public and private pensions, disability or retirement plans, defined benefit employer pension plans, profit sharing pension plans, 403(b) pension plans, money purchase pension plans, employee stock ownership plans, individual retirement accounts (IRAs), Keogh pension plans, Roth IRAs, simplified employee pension plans (SEP-IRAs), and 401k pension plans; or any other pension or retirement plans authorized under sections 401, 403, or 408 of the Internal Revenue Code (IRC) as outlined in 26 U.S.C. (as in effect October 1, 2025), or any other enacted IRC provisions providing for pension or retirement plans or any other similar financial vehicles administered by an individual, employer, or union.

(9) "Spousal consent" means the formal agreement or approval given by one spouse for the other spouse to engage in certain legal or financial actions that may affect their joint interests, particularly in matters related to property, financial transactions, or retirement benefits.

(10) "Target benefit retirement plan" means a retirement plan where contributions are based on projected retirement benefits. The distributions at retirement that an individual in a target-benefit plan receives is based on the performance of the investments and are, therefore, not guaranteed.

(1) A retirement fund in which an individual has the legal ability to receive regular, periodic payments, or guaranteed lifetime payments shall be treated as a source of unearned income.

(a) When an individual has the choice between regular, periodic payments and a lump sum payment, the individual must choose regular, periodic payments for the funds to be treated as unearned income.

(b) When an individual elects a lump sum payment rather than regular, periodic payments, the lump sum payment shall be considered in accordance with rule 5160:1-3-05.8 of the Administrative Code.

(c) When a retirement fund requires RMDs, the individual must take RMDs in accordance with IRS rules for the funds to be considered unearned income.

(i) When an individual is not old enough to qualify to take RMDs, the individual must take regular, periodic payments from the individual's retirement account in order for the funds to be considered unearned income.

(ii) An individual who is not required to take RMDs due to age is not mandated to take a specific payment amount, but the amount and interval of the individual's payments must be uniform.

(iii) Regular, periodic payments for an individual who is not old enough to take RMDs may be calculated using the IRS life expectancy tables, but this is not required until the individual reaches the age specified in IRS rules.

(d) When a retirement fund does not require RMDs, such as with a Roth IRA, the individual must take regular, periodic payments from the individual's retirement account in order for the funds to be considered unearned income.

(i) The amount and interval of the individual's payments must be uniform, but a specific payment amount is not mandated.

(ii) Regular, periodic payments may be calculated using the IRS life expectancy tables or the social security administration (SSA) actuarial charts if desired, but an individual may choose the individual's own payment calculation method.

(2) The individual is required to obtain the maximum available amount of payment from the individual's retirement fund.

(a) When a retirement fund requires RMDs, taking RMDs is considered taking the maximum available payment amount from the fund.

(b) When a retirement fund does not require RMDs, taking regular, periodic payments of a uniform amount, at a uniform interval, is considered taking the maximum available amount of payment from the fund, regardless of the amount of the payment.

(c) When a retirement fund requires benefits to be distributed in the form of a QJSA, the amount paid to the surviving spouse must be no less than fifty percent of the amount of the annuity paid during the individual's lifetime per 29 U.S.C. 1055(d)(1)(A) (as in effect October 1, 2025). The minimum spousal survivor benefit elected for a QJSA must be fifty percent, regardless of spousal consent.

(i) A QJSA may be verified by either a QJSA notice provided to the individual prior to receiving the benefit or a letter from the retirement plan administrator.

(ii) A QJSA shall be considered in accordance with rule 5160:1-3-05.3 of the Administrative Code.

(d) When the maximum available amount of payment requires the individual's spouse to consent to a waiver of the spouse's survivor benefits, the individual must document a good faith attempt to obtain the consent, and whether consent was obtained or refused. When spousal consent is not obtained from a retirement fund that does not require the QJSA retirement distribution method, such as some 403(b) retirement plans, the individual must elect the minimum spousal survivor benefit required by the plan.

(3) When permitted in a retirement plan, the individual may elect a lesser payment in order to retain a minimum survivor benefit for a child who has a documented blindness or disability, as defined in rule 5160:1-3-02 of the Administrative Code.

(4) When the retirement fund is determined to not be income, then the retirement fund shall be evaluated as a potential resource. A retirement fund cannot be both income and a resource at the same time.

(5) A retirement fund converted into an annuity shall be considered in accordance with rule 5160:1-3-05.3 of the Administrative Code.

(D) Retirement funds treated as a resource.

(1) The retirement fund shall be evaluated as a potential resource only after it is determined to not be income.

(2) A retirement fund is a countable resource when the individual or the individual's spouse has an ownership interest in the retirement fund, has the legal ability to convert the fund to cash, and is not legally able to receive regular, periodic payments from the fund.

(a) The value of a retirement fund is the amount an individual can currently withdraw from the fund. If there is a penalty for early withdrawal, the fund's value is the amount available to an individual after penalty deduction.

(b) The value of a retirement fund may be determined by an account statement, documentation describing the retirement fund, or a letter from the retirement plan administrator.

(3) When there is a financial penalty imposed by the retirement plan administrator in order to convert the account to cash, the amount of the countable resource is the net amount payable to the individual after deducting the penalty. The amount payable shall not be further reduced by the amount of any tax incurred by the individual as a result of the conversion of the account to cash.

(4) A retirement fund is not a resource when an individual must terminate employment in order to obtain any lump sum or payments.

(5) A retirement fund determined to be a resource in accordance with this paragraph, which is owned by an ineligible spouse or parent or spouse of an ineligible parent, shall not be considered for deeming purposes described in rule 5160:1-3-05.20 of the Administrative Code.

(E) Administrative agency responsibilities.

(1) The administrative agency must evaluate any retirement fund of which the individual is a beneficiary.

(2) The administrative agency shall obtain the summary plan description (SPD) or other documentation describing the rights and benefits under the retirement fund. A letter from the retirement plan administrator may also be obtained to make the determinations required under this rule.

(F) Individual responsibilities. An individual is required to provide all available documentation to assist the administrative agency with evaluating any retirement fund of which the individual is a beneficiary.

Last updated March 2, 2026 at 8:35 AM

History

Effective: March 1, 2026
Promulgated Under: 111.15

Ohio Adm.Code 5160:1-3-05.1 Medicaid: resource requirement.

(A) This rule describes how resources are treated for purposes of determining eligibility for medical assistance.

(B) Definitions.

(1) "Countable resources" mean those resources remaining after all exclusions have been applied.

(2) An "encumbrance" means a claim, lien, charge, or liability attached to and binding on an identified piece of real or personal property.

(3) "Equity value" means the fair market value of a resource minus any encumbrance on it.

(4) "Fair market value" of a resource means the going price, for which real or personal property can reasonably be expected to sell on the open market, in the particular geographic area involved.

(5) "Geographic area" means the area covered by radio, television, newspaper, and other media serving the area where the individual lives and where the property is located.

(6) "Personal property" means any property that is not real property. The term includes, but is not limited to, such things as cash, jewelry, household goods, tools, life insurance policies, automobiles, promissory notes, etc.

(7) "Real property" means land, including buildings or immovable objects, attached permanently to the land.

(8) "Resources" is defined in rule 5160:1-1-01 of the Administrative Code.

(9) "Resource limit" means the maximum combined value of all resources an individual can have an ownership interest in and still qualify for medical assistance.

(a) For an individual, the resource limit is two thousand dollars.

(b) For a married couple, whether both are eligible or one is ineligible, the resource limit is three thousand dollars.

(10) "Trust" is defined in rule 5160:1-3-05.2 of the Administrative Code.

(C) Treatment of non-excluded resources and determination of resource availability. The administrative agency shall evaluate and calculate the value of all resources held by an individual and the individual's spouse. An individual is ineligible for medical assistance when he or she has an ownership interest in resources with an aggregate or total countable value greater than the resource limit. The following provisions govern that process.

(1) Receipt and retention of cash or in-kind items.

(a) An individual or the individual's spouse may receive cash or in-kind items during a calendar month (the "month of receipt"). The administrative agency must treat the cash or in-kind items as a potential source of countable income for the month of receipt under the rules governing income.

(b) When the individual or the individual's spouse retains the cash or in-kind items beyond the month of receipt, the administrative agency shall determine the availability of the cash or in-kind items as a potential countable resource under the rules governing resources.

(c) Receipt of cash or in-kind items from the sale or exchange of timber, minerals, or other like items that are part of the land must be governed by this provision.

(d) When the individual or the individual's spouse receives cash or in-kind items as the result of an exchange, sale, replacement, or conversion of a resource, the administrative agency must consider the availability of the cash or in-kind items effective the month following the month of receipt under the rules governing the treatment of resources.

(2) Changes in the value of resources.

(a) The administrative agency shall review any change (increase or decrease) in the total value of an individual's resources when the change may affect the individual's eligibility for medical assistance.

(b) The review shall be initiated by the administrative agency based upon information derived from any reliable source indicating the value of an individual's available resources has increased or decreased.

(c) The administrative agency shall conduct the review of any changes in the value of resources upon discovery of the changes.

(3) Discovery of previously unknown ownership interests.

(a) Any individual alleging lack of knowledge of an ownership interest in a resource must provide a signed statement attesting to the lack of knowledge and explaining the circumstances resulting in its discovery.

(b) The individual shall obtain supporting documentation, which may include signed statements from other individuals who are familiar with the individual's situation, confirming the individual's claim.

(c) When the administrative agency obtains both the signed statement and adequate supporting documentation from the individual, the administrative agency shall not count an individual's ownership interest as an available resource during any period in which the individual was unaware of the ownership interest.

(d) The administrative agency shall evaluate the value of previously unknown ownership interests, including any monies (interest, dividends, or other earnings) that have accumulated on it, under income-counting rules for that item.

(e) When the signed statement or the supporting documentation is not provided, the administrative agency shall count an individual's ownership interest as an available resource during any period in which the individual claimed to be unaware of the ownership interest. When appropriate, the administrative agency shall evaluate the individual for overpayment or potential fraud in accordance with rule 5160:1-2-04 of the Administrative Code.

(4) Shared ownership.

(a) When the individual shares ownership with another person (co-owner) and the individual is unable to make the resource available because one of the owners cannot be located, the cost of a legal action is prohibitive, or the individual was unsuccessful in a legal action, the resource is not countable. Availability of the resource shall be reexamined at each eligibility review.

(b) When the co-owner is the individual's spouse, parent (when the individual is under age eighteen), or child under age eighteen, the ability to use or dispose of the resource exists for the individual unless he or she provides documentation to the contrary.

(5) Continuing verification.

(a) The administrative agency shall verify the value of real and personal property with each application or renewal and any time information is provided indicating a change in the individual's resources may have occurred.

(b) The administrative agency shall record the verification and place all supporting documents in the case record.

(6) Property that has not been sold.

(a) This provision governs real and personal property that has not been sold. When an individual owns property affecting his or her eligibility for medical assistance and the property has not been sold, it will not be counted as an available resource as long as the individual continues to list the property for sale at an amount equal to the fair market value determined by the county auditor, where available, or any other knowledgeable source.

(b) Real property that was the principal place of residence must first be considered in accordance with rule 5160:1-3-05.13 of the Administrative Code before the provisions of this paragraph are applied.

(c) The inability to sell property may result from legal technicalities, general economic conditions in the community, or the inability to find a buyer. In order for property to be excluded as a countable resource, the individual has the burden of producing reliable documentation establishing one of the following:

(i) The individual may produce documentation from two different types of knowledgeable sources in the geographic area who agree that although the property is listed for sale, the property has not been sold due to an attribute of the property or the market or both.

(a) In the case of real property, knowledgeable sources are limited to the following entities who have experience in the sale or valuation of the type of real property in question: county auditors, real estate brokers, real estate agents, real estate appraisers, United States department of agriculture (USDA) rural development service center offices, USDA farm service agency service center offices, banks, savings and loan associations, mortgage companies and similar lending institutions, and the county extension service offices.

(b) In the case of personal property, knowledgeable sources are limited to the following: any professional, business owner or operator, or expert who has experience in the sale, trade, restoration, or valuation of the type of personal property in question.

(ii) The individual may produce documentation showing an actual but unsuccessful sale attempt has been made.

(a) In the case of real property, the documentation must show that the property has been, and is currently, listed for sale in a newspaper or with a for sale by owner website, real estate agent, real estate broker, or real estate firm in the geographic area. The documentation may include a listing agreement with a real estate agent, broker, or firm, or a written statement signed by a real estate agent, broker, or firm confirming that the real property has an active status with the multiple listing service (MLS). The property is a countable resource until it is listed for sale.

(b) The property must be listed for sale at an amount equal to the fair market value determined by the county auditor, where available, or any other knowledgeable source.

(c) The real estate agent, broker, or firm must verify that no reasonable offer to purchase the property has been declined. An offer is reasonable when it is not less than ninety per cent of the fair market value established by the county auditor, where available, or any other knowledgeable source.

(d) When the individual receives an offer for the property that is less than ninety per cent of the fair market value established by the county auditor, where available, or any other knowledgeable source, the low offer may be an indication that the value is incorrect.

(e) When it appears that the stated market value is incorrect, either the individual or the administrative agency may obtain an appraisal from a second source to set a more accurate value. A second appraisal is not necessary when the purchase offer is so low that it is obviously unreasonable.

(f) The individual has the right to rebut the value of the property by obtaining an appraisal of the property.

(iii) The individual may produce documentation showing good cause.

(a) A good cause exception may be requested by the individual or the individual's authorized representative.

(b) Good cause exists when the individual was prevented by circumstances beyond his or her control from listing the property for sale.

(D) Resources of family members, households, and non-citizens.

(1) The resources of spouses residing together are addressed in accordance with the deeming of resources in rule 5160:1-3-05.20 of the Administrative Code.

(2) The administrative agency shall apply the resource limit for an individual effective the month following the month a married couple separates or divorces or one member dies.

(3) The resources of a child under the age of eighteen are addressed in accordance with the deeming of resources in rule 5160:1-3-05.20 of the Administrative Code.

(4) The resources of a non-citizen and sponsor(s) are addressed in accordance with the sponsor-to-non-citizen deeming requirements in accordance with rule 5160:1-3-05.20 of the Administrative Code.

(E) Resources that are determined to be excluded from the applicable resource limit for medical assistance remain excluded at the time of the individual's death. Excluded resources are part of the deceased individual's estate and are subject to the estate recovery provisions in accordance with section 5162.21 of the Revised Code.

(F) The entrance fee for individuals residing in a continuing care retirement community or a life care community must be considered an available resource in accordance with rule 5160:1-6-02.3 of the Administrative Code.

Last updated August 7, 2026 at 3:44 PM

History

Effective: April 1, 2022
Promulgated Under: 111.15

Ohio Adm.Code 5160:1-3-05.2 Medicaid: trusts.

(A) This rule defines the treatment of a trust for the purposes of determining eligibility for medical assistance programs. This rule is only enforceable to the same extent as section 5163.21 of the Revised Code.

(B) Definitions.

(1) "Beneficiary" means any person benefiting in some way from the trust. The beneficiary can be the grantor or another person. There may be more than one beneficiary of a trust.

(2) "Grantor" means any person who creates a trust. For purposes of this rule, the term grantor includes:

(a) An individual;

(b) An individual's spouse;

(c) A person, including a court or administrative body, with legal authority to act in place of, or on behalf of, an individual or the individual's spouse; and

(d) A person, including a court or administrative body, acting at the direction or upon the request of an individual or the individual's spouse.

(3) "Irrevocable trust" means a trust that cannot be revoked by the grantor or terminated by a court. A trust terminating only upon the occurrence of an event outside the control or direction of the beneficiary or the grantor is irrevocable.

(4) "Legal instrument or device similar to a trust" means any legal instrument, device, or arrangement that is not called a trust under state law, but is similar to a trust. This includes, but is not limited to, escrow accounts, investment accounts, partnerships, contracts, and other similar arrangements. To constitute a legal instrument or device similar to a trust, all of the following must be present.

(a) There must be a person holding, managing, retaining, or administering the property. For the purpose of this rule, the person holding, managing, retaining or administering the property is referred to as the trustee.

(b) The trustee must have an equitable, legal, or fiduciary duty to hold, manage, retain, or administer the property for the benefit of another person. For the purpose of this rule, this other person is referred to as the beneficiary.

(5) "Payment" means any disbursal from the principal or income of the trust. A payment may include actual cash, non-cash or property disbursements, or the right to use and occupy real property.

(6) "Payments to or for the benefit of the individual" means any payment to any person resulting in any direct or indirect benefit to the individual.

(7) "Person" has the same meaning as set forth in section 1.59 of the Revised Code and includes an individual, corporation, business trust, estate, trust, partnership, and association.

(8) "Revocable trust" means a trust that can be revoked by the grantor or the beneficiary. For the purposes of the medicaid program, the following trusts are "revocable trusts" even when the terms of the trust state it is irrevocable:

(a) A trust providing the trust can be terminated only by a court; or

(b) A trust terminating upon the happening of an event, when the event can occur at the direction or control of the grantor, the beneficiary, or the trustee.

(9) "Testamentary trust" means a trust that is established by a will. This type of trust does not take effect until after the death of the person (testator) who created the trust.

(10) "Trust," for the purpose of this rule, means any arrangement in which a grantor transfers property (real or personal) to a trust with the intention that it be held, managed, or administered by a trustee(s) for the benefit of the grantor or certain designated individuals (beneficiaries). In this rule, the term trust includes any legal instrument or device that is similar to a trust.

(11) "Trustee" means any person who manages a trust. A trustee manages a trust's principal and income for the benefit of the beneficiaries.

(1) Category one: self-settled trusts established before August 11, 1993, also referred to as medicaid qualifying trusts.

(a) A trust, or legal instrument or device similar to a trust, falls under this category when it meets all the following criteria:

(i) The trust was established before August 11, 1993;

(ii) The trust was not established by a will;

(iii) The trust was established by the individual;

(iv) The individual is or may become the beneficiary of all or part of the trust; and

(v) Payment from the trust is determined by one or more trustees who are permitted to exercise any discretion with respect to the distribution to the individual.

(b) The amount of the trust deemed to be an available resource to the individual is the maximum amount of payments that may be permitted under the terms of the trust to be distributed to the individual, assuming the full exercise of discretion by the trustee or trustees. The maximum amount includes only amounts that may be, but are not, distributed from either the income (interest) or principal of the trust.

(d) The availability of a trust in this category shall be considered whether or not:

(i) The medicaid qualifying trust is irrevocable or is established for purposes other than to enable a grantor to qualify for medicaid, or medicare premium assistance programs described in rule 5160:1-3-02.1 of the Administrative Code; and

(ii) The trustee actually exercises discretion.

(2) Category two: self-settled trusts established on or after August 11, 1993.

(a) A trust, or legal instrument or device similar to a trust, falls under this category when it meets all of the following criteria:

(i) The trust was established on or after August 11, 1993;

(ii) The assets of the individual were used to form all or part of the corpus of the trust;

(iii) The trust was not established by a will; and

(iv) The trust was established by the individual, the spouse of the individual, a person, including a court or administrative body, with legal authority to act in place of or on behalf of the individual or on behalf of the spouse of the individual, or a person, including a court or administrative body, acting at the direction or upon the request of the individual or the spouse of the individual.

(b) Revocable trusts in this category are treated as follows.

(i) The corpus of the trust is considered a resource available to the individual.

(ii) Payments from the trust to, or for the benefit of, the individual are considered unearned income.

(i) When there are any circumstances under which payment from the trust could be made to, or for the benefit of, the individual, the portion from which payments could be made is considered a resource available to the individual. The administrative agency shall not take into account when payments can be made. A payment that can be made only in the future satisfies this provision.

(ii) Any payments actually made to, or for the benefit of, the individual from either the corpus or income are considered unearned income.

(d) Where a trust is funded with assets of another person or persons, as well as assets of the individual, the rule provisions governing this category of trust applies only to the portion of the trust attributable to the individual.

(e) The availability of a trust in this category is considered without regard to:

(i) The purpose for which a trust is established;

(ii) Whether the trustees have or exercise any discretion under the trust;

(iii) Any restrictions on when or whether distributions may be made from the trust; or

(iv) Any restrictions on the use of distributions from the trust.

(3) Category three: exempt trusts. The principal or income from any one of these trusts is exempt from being counted as a resource.

(a) Special needs trusts are not countable resources. A trust qualifies as a special needs trust when the following conditions are met.

(i) The trust contains the assets of an individual under age sixty-five. The trust may also contain the assets of other individuals.

(a) When such a trust was established for a disabled individual under age sixty-five, the exception for the trust continues even after the individual becomes age sixty-five, provided the individual continues to be disabled as defined in rule 5160:1-3-02 of the Administrative Code.

(b) The trust cannot be added to or otherwise augmented after the individual reaches age sixty-five, with the exception of income earned by the trust.

(ii) The individual is disabled as defined in rule 5160:1-3-02 of the Administrative Code.

(iii) The trust is established for the benefit of the individual.

(iv) The trust is established by one of the following:

(a) The individual, if established on or after December 13, 2016;

(b) A parent;

(d) A legal guardian of the individual; or

(e) A court.

(v) The trust requires, upon the death of the individual, the state will receive all amounts remaining in the trust, up to an amount equal to the total amount of medical assistance paid on behalf of the individual.

(vi) Cash distributions to the individual are counted as unearned income. All other distributions from the trust are treated under the rules governing in-kind income.

(vii) Distributions from an individual's special needs trust to the same individual's own achieving a better life experience (ABLE) account shall be treated in accordance with rule 5160:1-3-05.14 of the Administrative Code.

(b) Qualified income trusts (QIT) are not countable resources. A trust qualifies as a QIT when the trust meets the requirements in rule 5160:1-6-03.2 of the Administrative Code.

(c) Pooled trusts are not countable resources. A trust qualifies as a pooled trust only when all of the following conditions are met.

(i) The trust contains the assets of an individual of any age who is disabled as defined in rule 5160:1-3-02 of the Administrative Code.

(ii) A separate account is maintained for each beneficiary of the trust but, for purposes of investment and management of funds, the trust pools the funds in these accounts.

(iii) Accounts in the trust are established by the individual, the individual's parent, grandparent, or legal guardian, or a court solely for the benefit of individuals who are disabled.

(iv) To the extent that any amounts remaining in the beneficiary's account upon the death of the beneficiary are not retained by the trust, the trust pays to the state the amount remaining in the account equal to the total amount of medical assistance paid on behalf of the beneficiary. To meet this requirement, the trust must include a provision specifically providing for such payment.

(v) Cash distributions to the individual are counted as unearned income. All other distributions from the trust are treated under the rules governing in-kind income.

(vi) Distributions from an individual's pooled trust to the same individual's own achieving a better life experience (ABLE) account shall be treated in accordance with rule 5160:1-3-05.14 of the Administrative Code.

(d) Supplemental services trusts are not countable resources. A trust qualifies as a supplemental services trust only when it meets the requirements of section 5815.28 of the Revised Code.

(i) Any person may establish a trust under section 5815.28 of the Revised Code only for another person who is eligible to receive services through one of the following agencies: the department of developmental disabilities; a county board of developmental disabilities; the department of mental health and addiction services.

(a) The administrative agency shall not determine eligibility for another agency's program.

(b) An individual must provide documentation from one of these agencies establishing that the individual was determined to be eligible for services from that agency at the time of the creation of the trust.

(c) An individual may provide an order from a court of competent jurisdiction that states the individual was eligible for services from one of the agencies at the time of the creation of the trust.

(ii) At the time the trust is created, the trust principal does not exceed the maximum amount permitted. In 2006, the maximum amount permitted was two hundred twenty-two thousand dollars. The maximum amount each year thereafter is the prior year's amount plus two thousand dollars.

(iii) The administrative agency shall review the trust to determine whether it complies with the remaining provisions of section 5815.28 of the Revised Code.

(iv) Payments from supplemental services trusts are exempt as long as the payments are for supplemental services as defined in section 5815.28 of the Revised Code. All supplemental services shall be purchased by the trustee, not through direct cash payments to the beneficiary.

(e) When a trust is represented to be an exempt trust, but the administrative agency determines that it does not meet the requirements for one of the exempt trusts, then it is not an exempt trust and will fall under one of the four other categories of trusts.

(4) Category four: trusts established by someone else for the benefit of the individual.

(a) A trust, or legal instrument or device similar to a trust, falls under this category when it meets the following criteria:

(i) The trust is created by someone other than the individual;

(ii) The trust names the individual as a beneficiary; and

(iii) The trust is funded with assets or property that the individual never held an ownership interest in prior to the establishment of the trust.

(b) Any portion of a trust in this category is an available resource only when the trust permits the trustee to expend principal, corpus, or assets of the trust for the individual's medical care, care, comfort, maintenance, health, welfare, general well-being, or a combination of these purposes. The trust is still considered an available resource even when the trust contains any of the following types of provisions:

(i) Any provision prohibiting the trustee from making payments that would supplant or replace medicaid or public assistance, or other government assistance;

(ii) Any provision prohibiting the trustee from making payments that would impact or affect the individual's right or ability or opportunity to receive medicaid, or public assistance, or other government assistance; or

(iii) Any provision attempting to prevent the trust or its corpus or principal from counting as an available resource under this rule.

(c) A trust in this category normally considered as an available resource is not counted as an available resource under the following circumstances.

(i) When the trust contains a clear statement requiring the trustee to preserve a portion of the trust for another beneficiary or remainderman, then that portion of the trust is not counted as an available resource. Terms of a trust granting discretion to preserve a portion of the trust do not qualify as a clear statement requiring the trustee to preserve a portion of the trust.

(ii) When the trust contains a clear statement requiring the trustee to use a portion of the trust for a purpose other than the medical care, care, comfort, maintenance, welfare, or general well-being of the individual, then that portion of the trust is not counted as an available resource. Terms of a trust that grant discretion to limit the use of a portion of the trust do not qualify as a clear statement requiring the trustee to use a portion of the trust for a particular purpose.

(iii) When the trust contains a clear statement limiting the trustee to making fixed periodic payments, then the trust is not counted as an available resource; however, the payments are treated under the rules governing income. Terms of a trust that grant discretion to limit payments do not qualify as a clear statement requiring the trustee to make fixed periodic payments.

(iv) When the trust contains a clear statement requiring the trustee to terminate the trust if it is counted as an available resource, then it is not counted as an available resource. Terms of a trust granting discretion to terminate the trust do not qualify as a clear statement requiring the trustee to terminate the trust.

(v) When any person obtains a judgment from a court of competent jurisdiction expressly preventing the trustee from using part or all of the trust for the medical care, care, comfort, maintenance, welfare, or general well-being of the individual, then the trust or that portion subject to the court order is not counted as a resource.

(vi) When the trust is specifically exempt from counting as an available resource by this rule, another rule, the Revised Code, or the U.S. Code, it is not counted as a resource.

(vii) When the individual presents a final judgment from a court demonstrating that he or she was unsuccessful in a civil action against the trustee to compel payments from the trust, then it is not counted as an available resource.

(viii) When the individual presents a final judgment from a court demonstrating that in a civil action against the trustee the individual was only able to compel limited or periodic payments, then it is not counted as an available resource; however, the payments are treated under rules governing income.

(ix) When the individual provides written documentation showing the cost of a civil action brought to compel payments from the trust are cost prohibitive, then it is not counted as an available resource.

(d) For trusts under this category, even when the trust is not counted as an available resource, any actual payments from the trust to the individual are treated under the rules governing income.

(5) Category five: trusts established by will for the benefit of a surviving spouse.

(a) A trust, or legal instrument or device similar to a trust, can be established by the will of a deceased spouse.

(i) When there are any circumstances under which payment from the trust could be made to, or for the benefit of, the surviving spouse, the portion from which payments could be made is considered an available resource. The administrative agency shall not take into account when payments can be made. A payment that can be made only in the future satisfies this provision.

(ii) Any payments actually made to, or for the benefit of, the surviving spouse from either the corpus or income are considered unearned income.

(D) This rule supersedes all previous rules governing trusts and the administrative agency shall apply it prospectively to all determinations and renewals of eligibility for all individuals. Any determination or renewal made in accordance with this rule shall not be affected by or governed by any prior eligibility determinations made under former rules governing trusts nor shall this rule be applied retroactively to determine an individual's eligibility or liability for any prior period.

Last updated June 26, 2025 at 2:17 AM

History

Effective: March 1, 2024
Promulgated Under: 111.15

Ohio Adm.Code 5160:1-3-05.3 Medicaid: annuities.

(A) This rule describes the treatment of annuities for the purpose of determining eligibility for medical assistance.

(B) Definition. An "annuity" provides fixed, periodic payments, either for life or a term of years.

(1) When an individual purchases an annuity, the individual generally pays the entity issuing the annuity a lump sum of money, in return for which the issuing entity promises regular payments in a specified amount to the individual or designated beneficiary.

(2) Annuity payments may continue for a fixed period of time or for the lifetime of the individual or designated beneficiary.

(3) The annuity typically contains a remainder clause under which, when the annuitant dies, the contracting entity converts whatever is remaining in the annuity into a lump sum and pays it to a designated beneficiary.

(1) Any resource meeting the definition of an annuity in paragraph (B) of this rule shall be considered an excluded resource.

(2) Any payments from an annuity shall be considered unearned income to the individual or designated beneficiary.

Last updated June 25, 2025 at 6:51 PM

History

Effective: June 12, 2025
Promulgated Under: 111.15

Ohio Adm.Code 5160:1-3-05.4 Medicaid: cash and checking and savings accounts and time deposits.

(A) This rule describes the treatment of cash, checking and savings accounts, and time deposits for the purpose of determining eligibility for medical assistance.

(B) Definitions.

(1) "Cash" means money on hand or available in the form of currency or coins. Foreign currency or coins are cash to the extent that they can be exchanged for U.S. currency.

(a) Monthly income is not counted when evaluating cash on hand.

(b) The individual's statement of actual cash on hand is accepted without verification.

(2) "Checking account" or "savings account" is the same as having cash on hand because deposits are payable on demand. An individual should be able to withdraw money from a checking account or savings account on the same day the individual requests it.

(3) "Dedicated account" means an account in a financial institution, the sole purpose of which is to receive and maintain supplemental security income (SSI) past-due benefits which are required or allowed to be paid into such an account and the use of which is restricted by section 1631(a)(2)(F) of the Social Security Act (as in effect October 1, 2024).

(4) "Depository account", for the purpose of this rule, means a checking account, savings account, or time deposit at a financial institution that allows money to be deposited and withdrawn by the account owner.

(5) "Depository account signature card" means a contract with the financial institution that shows who has access to the depository account and whether or not the signatures of more than one owner of the depository account are needed to withdraw funds.

(6) "Passbook" means a financial institution record which shows deposits, withdrawals, and interest.

(7) "Past-due benefits" mean any of the following:

(a) SSI benefits due but unpaid which accrue prior to the month payment was effectuated;

(b) SSI benefits due but unpaid which accrue during a period of suspension from SSI payments for which the individual was subsequently determined to have been eligible; or

(8) "Time deposit" means a contract between an individual and a financial institution whereby the individual agrees to leave funds on deposit for a specified period and the financial institution agrees to pay interest at a specified rate for that period.

(a) Certificates of deposit (CDs) and saving certificates are common forms of time deposits.

(b) Withdrawal of a time deposit before the specified period expires incurs a penalty, which usually is imposed against the principal. This penalty does not prevent the time deposit from being a resource, but does reduce its value as a resource. On rare occasions, the terms of a time deposit will prohibit early withdrawal.

(1) When the individual is:

(a) The account owner and has the legal right to withdraw funds from the account, all of the funds in the account are a resource to the individual.

(b) A co-owner of the account with another individual who is applying for or in receipt of medical assistance, the funds in the account are equally divided and a resource to each of the co-owners.

(c) A co-owner of the account with someone who is not applying for or in receipt of medical assistance, all of the funds in the account are a resource to the individual.

(2) The depository account signature card identifies who has access to the funds. In the absence of the depository account signature card, a statement from the financial institution is acceptable documentation.

(3) When a depository account is co-owned and the amount of funds has an effect on the individual's eligibility for medical assistance, the administrative agency shall inform the individual of his or her right to provide evidence rebutting full or partial ownership of the funds in the account.

(4) When the individual requests to rebut ownership of the funds, the individual must provide:

(a) A statement that includes:

(i) Who owns the funds;

(ii) Why there is a co-owned account;

(iii) Who made deposits to and withdrawals from the account; and

(iv) How the individual spent withdrawals.

(b) A corroborating statement from each of the co-owners.

(c) Evidence showing the individual can no longer withdraw funds from the account when the individual does not own any funds in the account; or

(d) Evidence showing the individual was removed from the account or the removal of the funds owned by the co-owner(s), and redesignation of the account when the individual owns only a portion of the funds.

(5) When the co-owner of the depository account is incompetent or a minor, it is unnecessary to obtain a corroborating statement from that person. That person's incompetency or age may be the reason why the claimant is listed as a depository account co-owner. In the event this occurs, the administrative agency shall:

(a) Obtain a corroborating statement from a third party who has knowledge of the circumstances surrounding the establishment of the co-owned depository account.

(b) Make the decision without a corroborating statement if there is no third party and document the basis for the decision and why no corroborating statement was obtained.

(6) When, following the evaluation of ownership, it is determined that the individual's share of the resource is within the allowable limit, medical assistance is to be approved or continued.

(7) If the authority to withdraw money from the depository account does not belong to those whose names are shown on the depository account, that fact must be documented in the individual's case record.

(D) The checking or savings account is not a resource when:

(1) The account restricts the right to withdraw funds from the account to a specific account owner;

(2) Withdrawals from the account require authorization from a third party;

(3) Use is restricted by a court order; or

(4) The account is restricted to a special purpose.

(E) Time deposits.

(1) When the owner of a time deposit cannot under any circumstances withdraw funds before the time deposit matures, it is not a resource. The time deposit becomes a resource (not income) on the date of maturity, and may affect countable resources in the month in which the time deposit matures. If the owner has no access to the interest before the time deposit matures, accrued interest is not a resource and is income in the month the deposit matures.

(2) When an individual has transferred his or her resources into a time deposit in which early withdrawal is prohibited, a determination of whether an improper transfer has occurred must be completed in accordance with rule 5160:1-6-06.5 of the Administrative Code. The determination shall include consideration of the length of the period of inaccessibility, the individual's life expectancy, and the amount of the time deposit.

(3) A time deposit for which early withdrawal is prohibited is still considered a countable resource for the purposes of determining a community spouse resource allowance for an institutionalized individual as described in rule 5160:1-6-04 of the Administrative Code.

(4) A time deposit's resource value at any given time, if early withdrawal is permitted, is the amount the owner would receive upon withdrawing it at that time, excluding interest paid that month. Generally, this is the amount originally deposited; plus accrued interest for past months; minus any penalty specified on the time deposit certificate for early withdrawal.

(F) Verifying depository accounts.

(1) A checking account is verified by examining the printout from online banking or the last monthly bank statement and the checkbook record to arrive at the current bank balance. A copy of the monthly bank statement and checkbook record shall be retained in the case record.

(a) When the printout or statement shows deposit and withdrawal activity or cash flow inconsistent with the individual's stated financial situation, the administrative agency shall investigate fully to establish the source of income.

(b) When the printout, bank statement, or checkbook record is not available or there is some reason to doubt the accuracy of the checkbook record, verification shall be obtained by contact with the financial institution after obtaining the individual's written authorization.

(2) A savings account is verified by examining the printout from online banking, last monthly bank statement, or current balance of the passbook.

(a) The administrative agency shall retain a copy of the page(s) that show activity in the last sixty days. When the printout, bank statement, or passbook shows deposit and withdrawal activity inconsistent with the individual's stated financial situation, the administrative agency shall investigate fully to establish the source of income.

(b) When the printout, bank statement, or passbook is not available or appears to have been materially altered, the administrative agency shall obtain verification by contact with the financial institution after securing the individual's written authorization.

(3) A time deposit is verified by viewing the time deposit certificate or document and the account records of interest accrual. The administrative agency may also obtain verification of the time deposit or early withdrawal provisions by contacting the financial institution after securing the individual's authorization. All the information obtained shall be retained in the individual's case record.

(4) The administrative agency will contact the individual to collect the information needed. If the individual declares the verifications cannot be accessed or submitted, the individual's statement is to be accepted.

(5) If the administrative agency is unable to make contact with the individual, a written (electronic or paper) request for the necessary information or verification documents is to be sent as set forth in rule 5160:1-2-01 of the Administrative Code.

(G) Dedicated account.

(1) Past-due benefits deposited into a dedicated financial institution account and any accrued interest or other earnings on such an account are excluded from income and resources.

(2) For any month that funds other than accrued interest or other earnings on the account are commingled in this account, the exclusion does not apply to any funds in the account.

(a) An exception is when the financial institution requires the individual to deposit money to open an account, such as a minimum deposit, a small amount of other funds can be used to open the dedicated account.

(i) The funds that were used to open the account are not excluded as a resource and must be removed from the account once the account has been established and the past-due benefits paid into it.

(ii) The funds that were used to open the account must be withdrawn before the end of the month following the month that the past-due benefits are paid.

(b) Funds other than those described in paragraph (G)(2)(a) of this rule shall not be deposited into a dedicated account.

(3) The individual's representative payee must provide verification that a dedicated account has been established. The verification must include the name and address of the financial institution, account number, account title, type of account, and the amount of money in the account.

(4) The individual's representative payee shall use funds in the account to pay for the following allowable expenses: education or job skills training, personal needs assistance, special equipment, housing modification, medical treatment, therapy or rehabilitation, or any other item or service that the social security administration determines to be appropriate provided that such expense benefits the individual and, in the case of personal needs assistance, special equipment, housing modification, therapy or rehabilitation, or other approved item, is related to the impairment (or combination of impairments) of the individual. These expenditures do not affect an individual's income or resources.

(5) Restrictions on the use of funds in a dedicated account continue to apply during a period of suspension from SSI payments, non-pay status, and SSI eligibility but no payment.

(a) The exclusion of the funds in the account from the individual's countable resources continues to apply until SSI eligibility is terminated.

(b) Once an individual's SSI eligibility has been terminated, the exclusion of the funds in a dedicated account cannot be carried over if the individual establishes a new period of SSI eligibility by filing a new application for SSI. Any remaining funds are a countable resource.

(c) Reopening of a prior period of SSI eligibility following termination is not a new period of eligibility and, therefore, the exclusion may be reapplied.

(6) When an individual receives past-due benefits that may be, but have not yet been, deposited into a dedicated account, the payment is excluded from resources for nine months until the payee deposits the payment into a dedicated account.

(7) Subsequent past-due payments, after a dedicated account has been established, are not required to be deposited into the dedicated account.

Last updated October 6, 2025 at 8:01 AM

History

Effective: October 6, 2025
Promulgated Under: 111.15

Ohio Adm.Code 5160:1-3-05.5 Medicaid: promissory notes, property agreements, and loans.

(A) This rule describes the treatment of promissory notes, property agreements, and loans for the purpose of determining eligibility for medical assistance.

(B) Definitions.

(1) "Promissory note" means a written, unconditional promise signed by a person to pay a specified sum of money at a specified time, or on demand, to the person, corporation, or institution named on the note. It may be given in return for goods, money loaned, or services rendered. A promissory note making periodic payments is not considered an annuity.

(2) "Property agreement" means a pledge or security of particular property for the payment of a debt or the performance of some other obligation within a specified period.

(a) Property agreements on real estate generally are referred to as mortgages but also may be called real estate or land contracts, contracts for deed, deeds of trust, etc.

(b) Personal property agreements (e.g., pledges of crops, fixtures, inventory, etc.) are commonly known as chattel mortgages.

(1) A promissory note or property agreement is an available resource.

(a) The resource value is its outstanding principal balance unless the individual furnishes evidence that it has a lower cash value.

(b) The property itself is not a resource.

(2) Payments received by an individual toward the principal balance of a promissory note or property agreement are not income. The interest portion of payments received is unearned income to the individual.

(3) A copy of the property agreement must be recorded with the county auditor, county recorder, or other appropriate government agency charged with the responsibility of recording property agreements.

(a) For the purpose of this rule, a property agreement is not considered effective until the date it is recorded with the county auditor, county recorder, or other appropriate government agency charged with the responsibility of recording property agreements. The administrative agency shall disregard any property agreement that is not properly recorded and shall consider the entire property as an available resource to the individual.

(b) For the purpose of this rule, the property agreement recording date held by the appropriate government agency is considered the date of transfer.

(4) Documentation must be provided by the individual verifying his or her proportionate share of the note or agreement when ownership of the note or agreement is shared.

(5) A promissory note or property agreement has no value when the individual adequately documents that the obligations under the promissory note or property agreement were discharged by order of a bankruptcy court.

(D) Loans held by an individual.

(1) Money an individual borrows or money received as the principal repayment of a bona fide loan is not considered income.

(a) Any interest received on money loaned is unearned income.

(b) Retained proceeds of a loan in the month following the month of receipt are counted as a resource.

(2) The value of the loan is the outstanding balance due as of the individual's application date for medical assistance.

Last updated June 9, 2025 at 3:40 PM

History

Effective: June 9, 2025
Promulgated Under: 111.15

Ohio Adm.Code 5160:1-3-05.6 Medicaid: burial funds and contracts.

(A) This rule describes the treatment of burial funds and burial contracts for the purpose of determining eligibility for medical assistance.

(B) Definitions.

(1) "Burial funds" are revocable burial contracts, revocable burial trusts, other revocable burial arrangements (including the value of certain installment contracts for burial spaces), cash, financial accounts (checking or savings accounts), or other financial instruments with a definite cash value (e.g., stocks, bonds, etc.).

(2) "Prepaid burial contract" means an agreement whereby the buyer pays in advance for a burial that the seller agrees to furnish upon the death of the buyer or other designated individual.

(1) Up to one thousand five hundred dollars for each person shall be excluded in burial funds set aside for:

(a) The burial expenses of the individual; and

(b) The burial expenses of the individual's spouse.

(2) Burial funds must be clearly designated for the individual's or the individual's spouse's burial and must be kept separate from nonburial-related assets in order to be excluded.

(3) The burial funds exclusion is separate from and in addition to the burial space exclusion described in rule 5160:1-3-05.7 of the Administrative Code.

(4) Any accural of interest or appreciation in the value of excluded burial funds is excluded from resources and income, even when the total value of the burial funds exceeds one thousand five hundred dollars.

(5) Expenses included for burial funds purposes are generally those related to preparing a body for burial and any services prior to burial including transportation of the body, embalming, cremation, flowers, clothing, services of the funeral director and staff, etc.

(6) Any burial funds that exceed the burial funds exclusion are combined with all other countable resources and compared to the resource limit described in rule 5160:1-3-05.1 of the Administrative Code.

(D) Irrevocable prepaid burial contracts.

(1) Irrevocable prepaid burial contracts are not a resource.

(2) Any portion of the contract that represents burial funds reduces the amount available under the burial funds exclusion described in paragraph (C) of this rule.

(3) Any portion of the contract that represents the purchase of a burial space has no effect on the burial funds exclusion.

(E) Revocable or salable prepaid burial contracts.

(1) When a prepaid burial contract is revocable or salable it is a countable resource and treated as a burial fund.

(2) Any portion of the contract that clearly represents the purchase of a burial space is excludable as a countable resource when it meets the requirements of rule 5160:1-3-05.7 of the Administrative Code.

(3) The value of a revocable or salable burial contract is:

(a) The amount payable to the buyer upon revocation; or

(b) When the contract is not revocable but is salable, its fair market value.

(F) Burial space contract.

(1) The burial space exclusion described in rule 5160:1-3-05.7 of the Administrative Code is applied to any single-purpose burial space contract when:

(a) The contract lists all of the burial spaces and either includes a value for each space or the total value of all the spaces combined; and

(b) The seller's obligations to provide those items is not contingent on further payment, as in certain installment contracts (i.e., the items are actually being held for the individual's future use).

(2) Treat the burial space contract as burial funds when:

(a) The unidentified portion of a contract implies that it covers only burial spaces but does not identify some or all of the spaces or does not include either a value for each burial space or the total of all the spaces combined; and

(b) The amount paid on an installment contract for burial spaces when the contract does not entitle the individual to the spaces until the full purchase price has been paid.

(G) Life insurance funded burial contracts.

(1) A life insurance funded burial contract involves an individual owning/purchasing a life insurance policy on his or her own life and then assigning, revocably or irrevocably, either the ownership or proceeds of the policy to a third party, generally a funeral provider. The purpose of the assignment is to fund a burial contract.

(a) Assignment of ownership.

(i) Revocable assignment of ownership.

(A) The burial space exclusion described in rule 5160:1-3-05.7 of the Administrative Code does not apply because the funeral provider has not received payment and no purchase of burial spaces has been made. The provider has no obligation to provide any spaces until the individual dies and, therefore, no spaces are being held for the individual.

(B) The resource value of the burial contract is equal to the cash surrender value (CSV) of the life insurance policy, subject to the burial funds exclusion described in paragraph (C) of this rule.

(ii) Irrevocable assignment of ownership.

(A) The burial space exclusion described in rule 5160:1-3-05.7 of the Administrative Code shall apply when the individual has:

(i) Title to and/or possesses a burial space intended for the individual's use; or

(ii) A contract with a funeral service company for a specified burial space for the individual's burial.

(B) Any portion of the burial contract that represents the purchase of a burial space has no effect on the burial funds exclusion described in paragraph (C) of this rule.

(C) The life insurance policy and burial contract are not resources. The face value (FV) of the burial funds portion of the contract, if any, is subject to the burial funds exclusion described in paragraph (C) of this rule.

(b) Assignment of proceeds.

(i) Revocable assignment of proceeds.

(A) The burial space exclusion described in rule 5160:1-3-05.7 of the Administrative Code does not apply to the CSV of the life insurance policy because the funeral provider has not received payment and no purchase of burial spaces has been made. The provider has no obligation to provide any spaces until the individual dies and, therefore, no spaces are being held for the individual.

(B) The resource value of the burial contract is equal to the CSV of the life insurance policy.

(i) When the FV of all life insurance policies on the individual's life is one thousand five hundred dollars or less, the CSV is excluded under the life insurance exclusion described in rule 5160:1-3-05.12 of the Administrative Code.

(ii) When the FV of all life insurance policies exceeds one thousand five hundred dollars, treat the CSV of the policies according to the burial funds exclusion described in paragraph (C) of this rule.

(ii) Irrevocable assignment of proceeds. The irrevocable assignment of proceeds is not permitted by insurance companies without requiring the irrevocable assignment of ownership.

(2) When an individual irrevocably transfers ownership of a revocable life insurance policy that funds a burial contract to a trust established by a funeral company, the resource value of the policy is evaluated in accordance with rule 5160:1-3-05.2 of the Administrative Code based on the date of the transfer.

(a) When a life insurance policy is placed irrevocably in a trust prior to January 1, 2000, evaluate the resource value of the policy in accordance with rule 5160:1-3-05.2 of the Administrative Code. The policy's CSV is not a resource when the individual does not have the legal authority to revoke or terminate the trust or to direct the use of the trust assets for his or her own support and maintenance.

(b) When a life insurance policy is placed irrevocably in a trust on or after January 1, 2000, the policy's CSV is a resource when the arrangement constitutes a trust established with the individual's funds. However, it is not a resource when the arrangement constitutes a purchase of goods and services by the individual and the subsequent establishment of a trust with the funeral provider's funds.

(c) The CSV of the burial funds portion of the contract is subject to the burial funds exclusion described in paragraph (C) of this rule.

(3) Life insurance funded burial contracts are not burial insurance.

(4) Dividend accumulations of a life insurance policy as part of the value of the policy or the prepaid burial contract are not excluded. Dividend accumulations are separate resources and must be designated separately in order to qualify for the burial funds exclusion.

(H) Burial insurance.

(1) Burial insurance is a contract whose terms prevents the use of its proceeds for anything other than payment of the insured's burial expenses.

(2) Treat burial insurance as burial funds described in paragraph (C) of this rule.

(3) The value of the burial insurance policy is the FV of the policy.

(I) Contracts for both burial funds and burial spaces. When a contract does not indicate which amounts represent the purchase of burial spaces and which amount represents burial funds, and which parts, if any, are irrevocable, the entire contract shall be considered a resource in the form of burial funds.

Last updated June 9, 2025 at 3:38 PM

History

Effective: June 8, 2025
Promulgated Under: 111.15

Ohio Adm.Code 5160:1-3-05.7 Medicaid: burial spaces.

(A) This rule describes the treatment of burial spaces for the purpose of determining eligibility for medical assistance.

(B) Definitions.

(1) "Agreement," for the purpose of this rule, means a contract with a burial provider for a burial space held for the individual or a member of the individual's immediate family.

(2) "Burial space," means a burial plot, gravesite, crypt, mausoleum, casket, urn, niche, or other repository customarily and traditionally used for the deceased's bodily remains. The term also includes a contract for care and maintenance of the gravesite, sometimes referred to as an endowment or perpetual care and necessary and reasonable improvements or additions to such spaces, including but not limited to vaults, headstones, markers, plaques, burial containers (e.g., for caskets), and arrangements for the opening and closing of the gravesite.

(3) "Immediate family" includes the individual's:

(a) Parents, including adoptive parents;

(b) Minor or adult children, including adopted and stepchildren;

(d) Spouses of immediate family when the marriage is in effect at the time of determination or renewal of eligibility for medical assistance.

(C) A burial space or burial space contract, described in rule 5160:1-3-05.6 of the Administrative Code, which represents the purchase of a burial space held for the burial of the individual, the individual's spouse, or the individual's immediate family is an excluded resource, regardless of value.

(D) A burial space is held for an individual when he or she currently has:

(1) Title to and/or possesses a burial space intended for the individual's use (e.g., has title to a burial plot or owns a burial urn stored for his or her own use); or

(2) A contract with a funeral service company for specified burial spaces for the individual's burial (i.e., an agreement which represents the individual's current right to the use of the items at the amount shown).

(E) Until the purchase price is paid in full, a burial space is not held for an individual under an installment sales contract or similar device and the installment payments shall be considered burial funds in accordance with rule 5160:1-3-05.6 of the Administrative Code.

(F) Administrative agency responsibilities. The administrative agency shall:

(1) Determine whether the burial space is held for the individual, the individual's spouse, or the individual's immediate family when the agreement shows the purchase of a specified burial space at a specified price.

(2) Of items that serve the same purpose, exclude only one per person. For example, exclude a cemetery lot and a casket for the same person, but not a casket and an urn.

(3) When the agreement calls for installment payments, determine whether the value of the burial space must be treated as burial funds in accordance with rule 5160:1-3-05.6 of the Administrative Code.

Last updated September 23, 2025 at 12:39 PM

History

Effective: June 8, 2025
Promulgated Under: 111.15

Ohio Adm.Code 5160:1-3-05.8 Medicaid: lump-sum payments.

(A) This rule describes the treatment of lump-sum payments for purposes of determining eligibility for medical assistance.

(B) Definition. "Lump-sum payment" means income which is accrued over two or more months or a money payment which is not related to any time period, such as a death benefit or inheritance.

(C) An anticipated nonrecurring lump-sum payment is considered unearned income unless otherwise excluded. It is unearned income in the month received and a countable resource in the month following the month of receipt. The following are some types of anticipated lump-sum payments that are considered unearned income:

(1) Gifts, prizes, or awards.

(2) Retirement or pension funds.

(3) Judgments and out-of-court settlements.

(4) Proceeds received as the beneficiary of a life insurance policy, including social security lump-sum death benefits.

(5) Workers compensation payments when received as a lump-sum.

(D) An unanticipated nonrecurring lump-sum payment is not considered unearned income in the month of receipt and is a resource in the month following the month of receipt. The following are some types of unanticipated lump-sum payments that are considered resources, that are not unearned income:

(1) Proceeds received from the surrender or maturing of insurance policies.

(2) Proceeds received for the sale of real property.

(3) Replacement of income that was lost, destroyed or stolen if the original income was used to determine eligibility.

(E) Retroactive payments from supplemental security income (SSI) or retirement, survivors, disability insurance (RSDI) are unearned income in the month received and excluded as countable resources for nine months following the month of receipt. The source, amount, and the date of receipt of the retroactive payment must be verified and the information recorded in the case record.

(1) As long as the funds from the retroactive payment are not spent, they are excluded for the full nine month period. Unspent money must be identifiable from other resources for this exclusion to apply. The money may be commingled with other funds, but if this is done in such a fashion that the retroactive amount can no longer be separately identified, that amount will count toward the resource limit.

(2) Once the money is spent, this exclusion does not apply to items purchased with the money even if the nine month period has not expired. However, other exclusions may apply.

(F) Federal income tax refunds, and advance payments with respect to refundable income tax credits, are not considered income and are excluded as a countable resource for a period of twelve months beginning the month after the month of receipt, in accordance with 26 U.S.C. 6409 (as in effect October 1, 2023).

(G) Medicaid buy-in for workers with disabilities (MBIWD) premium refunds, as described in rule 5160:1-5-03 of the Administrative Code, are not considered unearned income in the month of receipt and are excluded as a countable resource for a period of twelve months beginning the month of receipt.

(H) When an individual eligible for medical assistance receives a lump-sum payment, he or she may increase his or her personal property holdings up to the maximums allowed. Then the administrative agency compares the amount received to the amount of medicaid payments made on behalf of the individual.

(1) When the lump-sum is equal to or less than medicaid payments, the individual is given a choice of:

(a) Purchasing household goods or personal effects, as described in rule 5160:1-3-05.10 of the Administrative Code, to ensure that resources remain within allowable limits; or

(b) Using some or all of the lump-sum payment to pay personal debts; or

(c) Using some or all of the lump-sum payment for his or her own personal care, including but not limited to hygiene products, toiletries, and assistance with daily living activities; or

(d) Repaying the medicaid program for medicaid payments made on his or her behalf in order to preserve continuing eligibility for medical assistance. The amount paid by medicaid for past care can be recovered only when the individual agrees and when the repayment amount will continue to ensure the individual's resources remain within the allowable limits; or

(e) Requesting that his or her medical assistance be discontinued.

(2) When the lump-sum is in excess of medicaid payments for the individual, the excess amount shall be counted as an available resource. When the amount exceeds the maximum resource limit, medical assistance shall be discontinued and the individual will not be required to use any of the lump-sum as repayment of past medicaid payments.

Last updated June 26, 2025 at 2:21 AM

History

Effective: January 1, 2024
Promulgated Under: 111.15

Ohio Adm.Code 5160:1-3-05.9 Medicaid: dividends and interest.

(A) This rule describes the treatment of dividends and interest for the purpose of determining eligibility for medical assistance.

(B) Definitions. "Dividends" and "interest", for the purpose of this rule, are returns on financial institution accounts. A cash gift or incentive payment to open an account is considered interest.

(1) A countable resource, the dividends and interest are excluded.

(2) Excluded under a federal statute other than the Social Security Act, the dividends and interest are excluded.

(3) Excluded under section 1613(a) of the Social Security Act as described in rule 5160:1-3-05.14 of the Administrative Code, the dividends and interest may or may not be excluded, depending on the specific resource.

Last updated June 25, 2025 at 6:00 PM

History

Effective: June 8, 2025
Promulgated Under: 111.15

Ohio Adm.Code 5160:1-3-05.10 Medicaid: household goods and personal effects as resources.

(A) This rule describes the treatment of household goods and personal effects for the purpose of determining eligibility for medical assistance.

(B) Definitions.

(1) "Encumbrance" is defined in rule 5160:1-3-05.1 of the Administrative Code.

(2) "Household goods," for the purpose of this rule, are all personal property customarily found in or near the home and used on a regular basis in connection with the maintenance, use, and occupancy of the premises. This encompasses items necessary for an adequate standard of sustenance, accommodation, comfort, information, and entertainment of occupants and guests. Such items include furniture, household appliances, carpets, dishes, cooking and eating utensils, televisions, and personal computers.

(3) "Personal effects," for the purpose of this rule, are items of personal property normally held and recognized as incidental items intended for personal use by one or more household members. Such items include clothing, personal jewelry, pets, personal care items, musical instruments, books, or items of cultural or religious significance.

(D) Items acquired or held for their value or as an investment are not considered household goods or personal effects and are countable resources. Such items can include but are not limited to gems, jewelry that is not worn or held for family significance, collectibles, or animals for investment purposes.

(1) The fair market value is the countable resource amount.

(2) When there is an encumbrance on the items, the equity value is the countable resource amount.

Last updated June 18, 2026 at 1:05 PM

History

Effective: June 8, 2025
Promulgated Under: 111.15

Ohio Adm.Code 5160:1-3-05.11 Medicaid: automobiles and other modes of transportation as resources.

(A) This rule describes the treatment of automobiles and other modes of transportation for purposes of determining eligibility for medical assistance.

(B) Definitions. For the purposes of this rule:

(1) "Automobile" means any vehicle used for transportation. It can include, in addition to cars and trucks: motorcycles, boats, snowmobiles, animal-drawn vehicles, and animals.

(2) "Deemor" means an individual whose income and resources are subject to deeming, including ineligible parents, sponsors of non-citizens, ineligible spouses, and essential persons.

(3) "Equity value" has the same meaning as in rule 5160:1-1-01 of the Administrative Code.

(4) "Fair market value" has the same meaning as in rule 5160:1-1-01 of the Administrative Code.

(C) One automobile is excluded for the individual, regardless of value, when a member of the individual's household uses the automobile for transportation.

(1) For the purpose of determining the community spouse resource allowance for couples when one spouse is institutionalized, one automobile is considered totally excluded, regardless of its use and value in accordance with rule 5160:1-6-04 of the Administrative Code.

(2) When an automobile is not excluded, count the equity value of the automobile as a resource.

(3) When an individual, couple, or deemor owns more than oneautomobile, any automobile other than the one wholly excluded is a resource in the amount of its equity value, unless the automobile can be excluded under another rule (e.g., property essential for self-support).

(4) When an individual owns more than one automobile, the exclusion applies to the automobile with the greater equity value, regardless of which automobile is actually used.

(5) The equity value for all additional automobiles, except leased automobiles, is counted as a resource.

(6) The equity value for all vehicles that are not used for transportation (e.g., pleasure boats) or excluded under another rule (e.g., necessary for self-employment) is counted as a resource. These vehicles are considered countable personal effects.

(D) For the purpose of determining whether a vehicle is used for transportation, accept the individual's account of its use. When a vehicle is not being used for transportation, determine the reason why.

(1) A temporarily broken-down vehicle normally used for transportation still qualifies as an excluded automobile.

(2) An automobile that is permanently inoperable or has been junked does not qualify as an excluded automobile.

(3) An automobile that is used only as a recreational vehicle (e.g., a boat used weekends on the lake) does not qualify as an excluded automobile.

(4) Vehicles that do not meet the definition of an automobile are personal effects. The value they have as a resource is their equity value, and the personal effects exclusion, described in rule 5160:1-3-05.10 of the Administrative Code, does not apply to them.

(E) The fair market value of an automobile is determined by the average trade-in value shown for the automobile in the j.d. power online guide (formerly the "National Automobile Dealers Association [NADA] Guide"). The description of the vehicle must be complete enough to enable the administrative agency to locate the vehicle in the j.d. power online guide. The description is to include the year, make, model, number of doors, equipment, etc. Absent evidence to the contrary, assume the automobile to be in average condition.

(1) When the j.d. power online guide cannot be used (e.g., animal-drawn vehicle), obtain a fair market value estimate from a disinterested knowledgeable source such as a used automobile dealer or an automobile insurance company.

(2) When an individual disagrees with the value of an automobile, or in cases of antique or collectible automobiles that are not listed in the j.d. power online guide, the value of the automobile may be obtained by a written appraisal of the automobile's fair market value from a disinterested knowledgeable source. The administrative agency is not bound by this appraisal but the appraisal is to be considered in the evaluation of the automobile.

(3) The fair market value of an antique or collectible automobile often fluctuates, so the current fair market value of these automobiles should always be verified.

Last updated September 29, 2026 at 1:06 PM

History

Effective: October 9, 2026
Promulgated Under: 111.15

Ohio Adm.Code 5160:1-3-05.12 Medicaid: life insurance.

(A) This rule describes how life insurance policies are treated for the purpose of determining medical assistance eligibility.

(B) Definitions of terms contained within life insurance policies.

(1) "Accelerated life insurance payments" means some or all of the proceeds from the life insurance policy are paid out to the policy owner prior to the death of the insured.

(2) "Beneficiary" means an individual or entity named in the contract to receive the policy proceeds upon the death of the insured.

(3) "Cash surrender value (CSV)" means the monetary equity value that the policy acquires over time. The owner of a policy can obtain its CSV only by turning the policy in for cancellation before it matures or the insured dies. A loan against a policy reduces its CSV. The value usually increases with the age of the policy.

(4) "Dividend accumulations" are dividends which accrue in an account that the insurance company controls for the policy owner. The policy owner can access the funds without penalty at any time without affecting the policy's face value or CSV. Dividend accumulations cannot be excluded from resources under the life insurance exclusion, even when the policy that pays the accumulations is excluded from resources. Unless they can be excluded under another provision, the accumulations are a countable resource.

(5) "Dividend additions" are amounts of insurance purchased with dividends and added to the policy, increasing its death benefit and CSV. The table of CSVs that comes with a policy does not reflect the added CSV of any dividend additions.

(6) "Dividends," for the purpose of this rule, means periodically (annually, as a rule), the insurer may pay a share of any surplus company earnings to the policy owner as a dividend. Depending on the life insurance company and type of policy involved, dividends can be applied to premiums due, paid by check to the owner, or by an addition or accumulation to an existing policy.

(7) "Face value" means the amount of basic death benefit contracted for at the time the policy is purchased. It is the amount to be paid out when the insured dies.

(8) "Insured" means the individual whose life is covered by the life insurance policy.

(9) "Insurer" means the company or association which contracts with the policy owner.

(10) "Life insurance policy" means a contract under which the insurer agrees to pay a specified amount to a designated beneficiary upon the death of the insured.

(11) "Owner" means the individual with the right to change such a policy. This is normally the person who pays the premiums.

(12) "Term life insurance" means an insurance policy that provides coverage for a specified period at a guaranteed rate and which usually does not have a CSV. Policy owners have the option of converting some term life policies into universal life or whole life insurance policies.

(13) "Universal life insurance" means an insurance policy that provides insurance over a specified period with greater flexibility regarding premium payment and potential for higher internal rates of return.

(14) "Whole life insurance" means an insurance policy that applies part of the premium payments to build CSV for the policy owner.

(C) A life insurance policy is a countable resource to the policy owner for medical assistance purposes when it generates a CSV. Its value as a resource is the amount of the CSV.

(1) The total CSV of all life insurance policies for an individual is excluded when the total face value of the policies is equal to or less than one thousand five hundred dollars for any one individual. When the total face value of all life insurance policies for any one individual is more than one thousand five hundred dollars, then the total CSV of all the policies for that individual is counted toward the applicable resource limit. Policies for which a CSV has not yet accrued are still considered available when determining the total face value of the individual's life insurance policies.

(2) Life insurance policies for which no CSV will ever accrue (e.g., term life insurance) are not considered when determining the face value of the insurance policies and are excluded from all computations. In addition, burial insurance policies are not considered when computing face value. Burial insurance is insurance which by its terms can only be used to pay the burial expense of the insured and will not accrue any CSV.

(3) When the face value of all countable life insurance policies on an ineligible individual exceeds one thousand five hundred dollars and deeming is required, the CSV of the policies is combined with the ineligible individual's other countable resources and appropriately deemed to the eligible individual.

(D) The individual must submit all life insurance policies that the individual and the individual's spouse own. The following information must be recorded in the case record:

(1) Name of insured;

(2) Name of policy owner;

(3) Type of insurance (whole life, universal life, or term life);

(4) Date the policy was purchased;

(5) Maturity date of policy, when specified;

(6) Face value;

(7) Cash surrender value, when applicable;

(8) Amount of loans outstanding against the policy, when applicable;

(9) For term insurance, amount of premium and frequency;

(10) Contact information for the insurance company to include address and phone number;

(11) Policy number;

(12) Information regarding whether the life insurance policy pays dividends and, when it does, what option the policy owner selected for his or her disposition (i.e., accumulations, additions, applied to premiums, paid by check); and

(13) The current amount of the dividend accumulations, if any.

(E) Factors to consider when determining whether a life insurance policy is a resource:

(1) When the policy does not have a CSV due to the type of policy, further examination is not necessary. When the policy does have a CSV, the administrative agency must distinguish between the owner of the policy and the insured.

(2) The owner of the policy is the only individual who can receive the proceeds under the cash surrender provisions of the policy. Therefore, it is not material that the individual (or individual's spouse) is the insured individual when the individual is not also the owner of the policy. When this is the case, there is no resource available to the individual.

(3) A life insurance policy is an available resource only when the policy is owned by the individual or person whose resources are deemed to the individual. When the consent of another person is needed to surrender a policy for its full CSV, the policy is available as a resource after the individual has obtained the consent of the other person. The individual must make a reasonable effort to obtain consent. When consent cannot be obtained, the policy is not available to the individual. Any doubt regarding potential availability must be resolved by contacting the insurance company. The individual's inability to obtain consent to surrender the policy for CSV must be evaluated to determine whether an improper transfer occurred.

(4) The exclusion of a total of one thousand five hundred dollars face value of countable insurance policies applies to each individual separately and does not mean an average of one thousand five hundred dollars per person. An individual and the individual's spouse are each allowed one thousand five hundred dollars but not any combination of values for a three thousand dollar total for both.

(5) CSV of a policy is determined by contacting the insurance company when there is any question regarding the policy's current value.

(6) The insurance exclusion does not apply to a matured endowment policy since the owner may elect to receive the total face value at any time. When the individual leaves the matured policy on deposit with the insurance company, it is no longer classified as insurance but is considered an investment at interest (the same as money in a savings account).

(F) Evaluating the insurance policy.

(1) Face value. The face value on the insurance policy may be labeled the "face amount," "sum insured," "amount of insurance," or "amount of this policy."

(a) The face value does not include additional benefits payable because of special conditions such as double indemnity riders, which apply in the event of accidental death.

(b) When the face value cannot be determined, the insurance company or local agent must be contacted for clarification. For example, the insurance company must be contacted to clarify the value when there has been a lapse in the policy because of nonpayment of premiums which results in some other insurance option becoming effective. When the information is obtained by telephone, the name, title, and telephone number of the person contacted, and the name and address of the insurance company and the details of the conversation must be documented in the case record.

(2) Cash surrender value. To compute the CSV of a life insurance policy, it is necessary to know whether the premiums are up-to-date or in default (have not been paid) and to read the conditions in the policy affecting CSV. The anniversary date of a policy is the same day and month as the date of issuance. Verification of the CSV must be obtained from the insurance company when the CSV, on its own or in conjunction with other resources, is close to the applicable resource limit.

(3) Dividends.

(a) Dividend additions.

(i) The face value of dividend additions are not included when determining whether a life insurance policy is countable or excluded as a resource.

(ii) When the life insurance policy is a countable resource, include the CSV of dividend additions when determining the resource value of the policy.

(iii) When the life insurance policy is an excluded resource, the CSV of the dividend additions is not included when determining the individual's countable resources.

(b) Dividend accumulations.

(i) Dividend accumulations are not excluded under the life insurance provision, even when the life insurance policy that pays the dividend accumulation is excluded.

(ii) Unless the dividend accumulations are excluded under another provision, dividend accumulations are countable as a resource, even when the life insurance policy is excluded because the policy's face value is one thousand five hundred dollars or less.

(c) Dividends count as income when the total face value of all the life insurance policies on any one person does not exceed one thousand five hundred dollars. Dividends are excluded as income when the life insurance policy is countable as a resource.

(d) The individual must submit the most recent annual dividend statement issued by the company for each life insurance policy, when applicable.

(4) An owner's failure to pay the premiums on the life insurance policy or failure to elect an option within a certain period of time after defaulting on the premiums generally causes an option to apply automatically. The CSV is usually applied by the company along with any dividends to buy extended life insurance. Under these circumstances, the face value of the life insurance is uncertain and there is a possibility that a certain option or options have come into play. It is necessary for the insurance company to compute the actual CSV before a determination of eligibility can be made. The current face value and CSV must be obtained from the insurance company.

(5) When an individual has borrowed on a life insurance policy, the amount of the CSV depends upon the outstanding loan. Under these circumstances, the administrative agency must contact the insurance company to determine the amount of the CSV.

(G) Treatment of accelerated life insurance payments.

(1) Most accelerated payment plans fall into three basic types, depending on the circumstances which cause or trigger the payments to be accelerated. These types are the following:

(a) Long-term care model, which allows the policy owners to access the death benefits should they require extended confinement in a care in a facility or, in some instances, home health care services at home;

(b) Dread disease or catastrophic illness model, which allows policy owners to access the death benefits of the contract in order to care for the insured during any specified covered condition; and

(c) Terminal illness model, which allows policy owners to access the death benefits of the contract when the insured is diagnosed with a terminal illness where death is expected to occur within a specified period.

(2) Some companies refer to these types of payments as "living needs" or "accelerated death" payments.

(3) Depending on the type of accelerated payment plan, receipt of accelerated payments may reduce the policy's face value and CSV.

(4) Accelerated payments are not "benefits" for purposes of exploring potential income. It is not required that a policy owner apply for accelerated payments as a condition of obtaining or retaining eligibility for medical assistance.

(5) Since accelerated payments can be used to meet food or shelter needs, the payments are income in the month received and a resource when retained into the following month and not otherwise excludable.

(6) The receipt of an accelerated payment is not treated as a conversion of a resource for medical assistance purposes.

Last updated June 25, 2025 at 6:00 PM

History

Effective: June 8, 2025
Promulgated Under: 111.15

Ohio Adm.Code 5160:1-3-05.13 Medicaid: treatment of the home.

(A) This rule describes the treatment of an individual's home for purposes of determining eligibility for medical assistance.

(B) Definitions.

(1) "Home," for the purpose of this rule, means any property in which an individual has an ownership interest and which serves as the individual's principal place of residence. Home includes the structures and land appertaining to the home property. Appertaining land must adjoin the land on which the home property is located and must not be separated by intervening land property owned by others.

(2) "Principal place of residence" means the dwelling considered to be the individual's established or principal home and to which, when absent, the individual intends to return. Principal place of residence can be real or personal property, fixed or mobile, and located on land or water.

(a) Only one dwelling may be established as the principal place of residence.

(b) The administrative agency must obtain a signed statement, declaring the principal place of residence, when there is an indication the individual resides in or has ownership of more than one place.

(C) The home lived in, owned by, and considered the principal place of residence by the individual, the couple, or the parents with whom the eligible child is living is an excluded resource, regardless of value.

(1) For the value of the home to be excluded:

(a) The home must be the principal place of residence of the individual, the individual's spouse, or a parent with whom the eligible child is living; and

(b) The deed to the home must be in the name of the individual, the individual's spouse, or the name of the eligible child's parent; or

(c) The home must be deeded to a revocable trust so long as the principal of the trust remains a resource of the individual or the individual's spouse.

(2) The home is no longer considered to be the principal place of residence and shall be treated as a countable resource when the individual does not intend to return to the home.

(3) A temporary absence from the home does not affect the principal place of residence exclusion so long as the individual provides a signed statement of intent to return to the home and has not established permanent residence elsewhere.

(4) When the individual leaves the home with no intent of returning, the home remains an excluded resource for as long as:

(a) A spouse or dependent relative of the individual continues to live in the home while the individual is receiving long-term care services, in accordance with Chapter 5160:1-6 of the Administrative Code.

(i) Dependency may be of any kind (e.g., financial, medical, etc.).

(ii) Relative means:

(a) Child, stepchild, or grandchild;

(b) Parent, stepparent, or grandparent;

(d) Brother, sister, stepbrother or stepsister, half brother or half sister;

(e) Cousin; or

(f) In-law.

(b) The sale of the home would cause undue hardship, due to loss of housing for the co-owner of the property and the co-owner provides a signed statement that the co-owner:

(i) Uses the property as the co-owner's principal place of residence; and

(ii) Would have to move when the property was sold; and

(iii) Has no other readily available housing.

(c) The individual leaves the home due to domestic abuse and has not established a new principal place of residence, or has not taken action to render the home no longer excludable.

(d) The property satisfies the provisions governing the treatment of property essential for self-support described in rule 5160:1-3-05.19 of the Administrative Code.

Last updated June 26, 2025 at 2:21 AM

History

Effective: March 1, 2024
Promulgated Under: 111.15

Ohio Adm.Code 5160:1-3-05.14 Medicaid: resource exclusions.

(A) This rule describes excluded resources for the purpose of determining medical assistance eligibility for an individual who is aged, blind, or disabled.

(B) Resource exclusions.

(1) Resources excluded by federal laws other than the Social Security Act, in accordance with 20 C.F.R. 416.1236 (as in effect October 1, 2025), unless otherwise noted. This list contains unspent income from exempt sources:

(a) Agent orange settlement payments received on or after January 1, 1989, under the Agent Orange Compensation Exclusion Act (Pub. L. No. 101-201).

(b) 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, 2025).

(c) Restitution payments under the Aleutian and Pribilof Island Restitution Act in accordance with 50 U.S.C. 4236 (as in effect October 1, 2025).

(d) Payments to victims of Nazi persecution.

(e) Payments received under the Radiation Exposure Compensation Act of 1990 (Pub. L. No. 101-426).

(f) Austrian social insurance payments, based in whole or in part, on wage credits paid under paragraphs 500 to 506 of the Austrian General Social Insurance Act (as in effect October 1, 2025).

(g) Payments received from the Dutch government as a result of the Netherlands' Benefit Act for victims of persecution from 1940-1945 (Dutch acronym, WUV) (Pub. L. No. 103-286).

(h) Payments made to Native Americans as listed in section IV of the appendix to subpart K of 20 C.F.R. 416, as provided by federal statutes other than the Social Security Act (as in effect October 1, 2025).

(i) Payments from the Ricky Ray Hemophilia Relief 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. Ill).

(j) 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)(26) of the Social Security Act (as in effect October 1, 2025).

(k) 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, 2025):

(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.

(l) Payments received under the Energy Employees Occupational Illness Compensation Program Act of 2000 (Pub. L. No. 106-398). Interest received on any unspent payment is a countable resource.

(m) Student financial assistance received under the Higher Education Act of 1965 (as in effect October 1, 2025) or bureau of Indian affairs is excluded from income and resources, 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.

(n) Home energy assistance payments or allowances in accordance with 20 C.F.R. 416.1157 (as in effect October 1, 2025).

(o) Contributions, matching funds, or interest in individual development accounts (IDAs), either demonstration project or temporary assistance for needy families (TANF) funded, in accordance with 42 U.S.C. 604 (as in effect October 1, 2025).

(p) 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.

(q) Funds and interest held in an account under the Stephen Beck, Jr., Achieving a Better Life Experience (ABLE) Act of 2014 (Pub. L. No. 113-295):

(i) A contribution to an ABLE account by another individual or by a third party is neither income nor a resource to the ABLE account holder. When the individual who made the contribution later requests medical assistance for long-term care services, the contribution will be evaluated in accordance with rule 5160:1-6-06 of the Administrative Code.

(ii) A distribution from an ABLE account may be used to pay for a qualified disability expense (QDE). A QDE is any expense related to the blindness or disability of the individual and made for the benefit of the individual. QDEs include but are not limited to:

(a) Education;

(b) Housing;

(d) Employment training and support;

(e) Assistive technology;

(f) Health;

(g) Prevention and wellness;

(h) Financial management and administrative services;

(i) Legal fees;

(j) Expenses for ABLE account oversight and monitoring;

(k) Funeral and burial; and

(l) Basic living expenses.

(iii) A distribution from an ABLE account with the intent of paying for a QDE, except for housing, is excluded as income and will be excluded as a resource while:

(a) The individual continues to maintain the ABLE account;

(b) The distribution is unspent;

(d) The individual's intent to use the distribution for a QDE, other than housing, has not changed.

(i) When the intent has changed and the individual spent the distribution for a non-QDE or for housing, the distribution is counted as a resource for the month in which the distribution was spent.

(ii) When the intent has changed and the individual has decided to use the distribution for a non-QDE or for housing, but has not yet spent the distribution, the retained portion of the distribution is a countable resource the first day of the month following the month in which the intent changed.

(iv) A distribution from an ABLE account with the intent of paying for a non-QDE or for a housing expense is:

(a) Not countable income.

(b) A countable resource when retained into the following month.

(2) Resources excluded by the Social Security Act, in accordance with 20 C.F.R. 416.1210 (as in effect October 1, 2025), unless otherwise noted:

(a) Household goods and personal effects of a reasonable value as described in rule 5160:1-3-05.10 of the Administrative Code.

(b) One automobile or other mode of transportation as described in rule 5160:1-3-05.11 of the Administrative Code.

(d) The home considered the principal place of residence as described in rule 5160:1-3-05.13 of the Administrative Code.

(e) Real or personal property considered essential to the means of self-support as described in rule 5160:1-3-05.19 of the Administrative Code.

(f) Certain burial funds and contracts as described in rule 5160:1-3-05.6 of the Administrative Code.

(g) Value of a burial space as described in rule 5160:1-3-05.7 of the Administrative Code.

(h) Cash or in-kind replacement received from any source for purposes of replacing or repairing an excluded resource which is lost, damaged, or stolen. Any interest earned on such cash payments is not income. The total amount of cash (including interest earned) or the value of the in-kind replacement is excluded as a resource for a period of nine months from the date of receipt.

(i) When the exclusion time expires and the individual has not used all of the cash, any remaining cash (as well as interest earned on such cash) is a countable resource effective the first day of the month following the month in which the time period expires.

(ii) The exclusion time may be extended for good cause for a reasonable period not to exceed an additional nine months (a total of eighteen months from the date the cash is received).

(iii) Good cause may be found when circumstances beyond the individual's control:

(a) Prevent repair or replacement of the lost, damaged, or stolen property; or

(b) Keep the individual from contracting for such repair or replacement.

(iv) Any cash and interest retained become a resource the first day of the month following the month in which the eighteen-month period ends.

(v) Temporary housing received by an individual whose home was destroyed or damaged is also excluded for a period of nine months beginning with the month the temporary housing is first provided. For purposes of this rule, temporary housing includes the value of support and maintenance. When a home is damaged or destroyed and temporary housing is furnished to an individual who owned the home, any form of in-kind support and maintenance is not counted as income.

(i) Funds held in a plan to achieve self-support (PASS) account in accordance with section 1613(a)(4) of the Social Security Act (as in effect October 1, 2025).

(j) Federal tax refunds and advance tax payments with respect to refundable credits received on or after January 1, 2010, are excluded for twelve months beginning the month following the month of receipt under the American Taxpayer Relief Act of 2012 (Pub. L. No. 112-240).

(k) Funds or interest held in a dedicated account in a financial institution for an individual under the age of eighteen, that is maintained by a representative payee, from past-due supplemental security income (SSI) benefits that exceed six times the monthly SSI payment which are allowed to be deposited into such an account, and the use of which is restricted by section 1631(a)(2)(F) of the Social Security Act (as in effect October 1, 2025), are excluded as income and resources as defined in rule 5160:1-3-05.4 of the Administrative Code.

(l) Payments received from a fund established by a state to aid victims of crime are excluded for nine months beginning the month following the month of receipt in accordance with section 1613(a)(9) of the Social Security Act (as in effect October 1, 2025). Interest earned on any unspent payment is a countable resource.

(m) Relocation assistance in accordance with section 1613(a)(10) of the Social Security Act (as in effect October 1, 2025).

(i) Payments 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 projects in the acquisition of real property are excluded with no time limits.

(ii) Relocation assistance payments from a state or local government are excluded for nine months.

(iii) Interest earned on unspent relocation assistance is a countable resource.

(n) Grants, scholarships, fellowships, and gifts used or intended to be used to pay the cost of tuition, fees, or other necessary educational expenses, in accordance with section 1613(A)(15) of the Social Security Act (as in effect October 1, 2025) are excluded for nine months.

(o) Filipino veteran equity compensation fund payments in accordance with section 1002 of the American Recovery and Reinvestment Act of 2009 (Pub. L. No. 111-5). Interest earned on the payment is a countable resource.

(p) Value of food or assistance provided under federal food and nutrition programs.

(q) Unspent portion of retroactive SSI and retirement, survivors, and disability insurance (RSDI) payments are excluded for nine months following the month of receipt in accordance with section 1613(a)(7) of the Social Security Act (as in effect October 1, 2025).

(r) Payments provided for flood mitigation activities under section 1324 of the National Flood Insurance Act of 1968 (Pub. L. No. 109-64).

(s) Payments 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 in accordance with section 1613(a)(6) of the Social Security Act (as in effect October 1, 2025).

(t) The value of federal housing assistance in accordance with section 1613(a)(8) of the Social Security Act (as in effect October 1, 2025) provided by:

(i) The office of housing and urban development (HUD); or

(ii) The U.S. department of agriculture's rural housing service (RHS), formally known as the farmers home administration (FHA).

(u) Gifts to children with life-threatening conditions in accordance with section 1613(a)(13) of the Social Security Act (as in effect October 1, 2025) from an organization described in section 501(c)(3) of the Internal Revenue Code of 1986, within the following limitations:

(i) In-kind gifts not converted to cash.

(ii) The first two thousand dollars of any cash gifts within a calendar year.

(iii) Interest or dividends earned on any gift is a countable resource.

(v) Restitution payments for misused benefits for beneficiaries of RSDI, special benefits for certain world war II veterans, and SSI are excluded for nine months following the month of receipt in accordance with section 1613(a)(14) of the Social Security Act (as in effect October 1, 2025). Payments are made to the beneficiary or the beneficiary's representative payee in the amount equal to the benefits misused in the following situations:

(i) The misuse resulted from the negligent failure of the social security administration (SSA) to investigate or monitor a representative payee; or

(ii) An organization or individual payee misused the benefits, without regard to whether SSA was negligent.

(w) A state annuity paid by a state, to an individual or the individual's spouse, on the basis of the state's determination that the individual is a veteran and is blind, disabled, or aged in accordance with section 1613(a)(16) of the Social Security Act (as in effect October 1, 2025).

(C) Payments or benefits listed in this rule that have been commingled with countable resources need to be identifiable in order to be excluded as a resource.

(D) Administrative agency responsibilities.

(1) Evaluate interest received on excluded resources in accordance with rule 5160:1-3-05.9 of the Administrative Code.

(2) Consider any resource purchased with funds listed in this rule as not automatically excluded and subject to medicaid resource requirements.

Last updated April 15, 2026 at 1:44 PM

History

Effective: April 15, 2026
Promulgated Under: 111.15

Ohio Adm.Code 5160:1-3-05.16 Medicaid: home replacement exclusion.

(A) This rule describes the application of the home replacement exclusion for the purpose of determining eligibility for medical assistance. When the home is being replaced due to loss or damage resulting from a disaster, refer to rule 5160:1-3-05.14 of the Administrative Code.

(B) Definitions.

(1) "Proceeds" mean the net payments received by the seller after satisfaction of all encumbrances and sale expenses.

(2) "Sale expenses" mean all expenses that must be paid by the seller in connection with the sale of the home, including but not limited to broker fees, commissions, legal fees, mortgage-related fees such as points paid by the seller, inspection and settlement fees, and transfer and other accrued taxes paid by the seller.

(C) The home replacement exclusion allows an individual to sell an excluded home that was the individual's principal place of residence without having the proceeds of the sale count as a resource if used for the purchase of, and costs incidental to occupying, another excluded home.

(1) This exclusion from resources applies to the proceeds of the sale of the excluded home when used or obligated to purchase and occupy another excluded home by the last day of the third full month following the month of receipt.

(2) When the home is not replaced within this period, the proceeds are to be counted as a resource beginning with the month following the month they were received by the individual.

(3) The exclusion does not apply to interest earned on the proceeds of the sale.

(4) The administrative agency shall not implement the exclusion until the statement described in paragraph (E) of this rule is obtained.

(D) The home replacement exclusion period begins on the date the proceeds of the sale are received by the individual. The home replacement exclusion period ends on the last day of the third full month following the month the proceeds are received.

(E) When the individual states that the home is being replaced, the administrative agency shall obtain a signed statement from the individual containing the following required information:

(1) Date and amount of proceeds received from the sale of the home; and

(2) The individual's intent to replace the home with another home by a specific date that is on or before the last day of the third full month following the month of receipt of the proceeds; and

(3) An acknowledgement that any proceeds of the sale not used for another excluded home by the date identified in paragraph (E)(2) of this rule are to count as a resource in determining eligibility for medical assistance beginning on a specific date that is the first day of the first month following receipt of the proceeds.

(F) The administrative agency shall verify the amount of the proceeds and the date they were received by obtaining a copy of the settlement sheet or other documents prepared at settlement and received by the individual from the sale.

(G) By the last day of the month in which the home replacement exclusion period expires, the administrative agency shall contact the individual to verify the date and amount of any allowable costs or deductions for the replacement home by obtaining written evidence (e.g., contracts, bills, receipts, settlement sheets) regarding the replacement home.

(1) The administrative agency shall charge any retained proceeds not used or contracted to be used toward the replacement home before expiration of the home replacement exclusion period as a resource beginning with the month following the month of receipt.

(2) When the individual has not replaced the home as intended, all of the proceeds will count as a resource beginning with the month following the month of receipt.

Last updated October 6, 2025 at 8:01 AM

History

Effective: October 6, 2025
Promulgated Under: 111.15

Ohio Adm.Code 5160:1-3-05.17 Medicaid: life estates.

(A) This rule describes the treatment of life estates for the purposes of determining eligibility for medical assistance.

(B) Definitions.

(1) "Date of signature" is the date on which an individual with authority to transfer the physical property actually signed the life estate instrument.

(2) "Individual," for the purpose of this rule, has the same meaning as in rule 5160:1-1-01 of the Administrative Code.

(3) "Life estate" means an ownership interest in physical property wherein one person holds the right to possess, use, and obtain profits from the physical property for the extent of the person's lifetime, while another person holds the actual ownership interest in the physical property.

(a) A life estate is a form of legal ownership.

(b) A life estate is usually created through an instrument, such as a deed, a will, or by operation of law.

(c) A life estate instrument often identifies remaindermen who will take possession of the physical property upon the expiration of the life estate.

(d) A life estate owner, also known as a life tenant, owns a life estate property only for the duration of time specified in the life estate instrument. Only the individual who owns the life estate can sell interest in the life estate. The life estate owner cannot take any action concerning the interest of the remainderman.

(4) "Recording date" means the date that the life estate deed is recorded with the county auditor, county recorder, or other appropriate government agency charged with the responsibility for recording real estate transfers and titles.

(5) A "remainderman" is a person who inherits or is entitled to inherit physical property in a life estate. A remainderman has an ownership interest in the physical property but normally does not have the right to possess and use the property until the expiration of the life estate.

(1) The life estate owner has the right to possess, use, and obtain profits from the physical property and to sell his or her life estate interest.

(2) The remainderman has the right to sell his or her interest in the physical property even before the life estate interest expires, but the life estate owner still retains rights to use the physical property until the expiration of the life estate.

(D) Categories of life estates.

(1) Life estates established with the individual's property.

(a) A life estate held by an individual falls within this category when the life estate is established with property in which the individual held an ownership interest.

(b) When the individual has the right to transfer or sell the life estate, the life estate's fair market value is considered a countable resource unless it qualifies as an excluded resource as described in rule 5160:1-3-05.14 of the Administrative Code.

(2) Life estates not established by the individual.

(a) A life estate held by an individual falls within this category when the life estate is established with physical property that the individual did not hold an ownership interest in at the time of the establishment of the life estate.

(E) When the life estate is the individual's principal place of residence, as described in rule 5160:1-3-05.13 of the Administrative Code, the fair market value of the life estate is excluded as a resource.

(F) Effective date of the creation of a life estate.

(1) For life estates that are recorded within six months after the date of signature, the date of signature is the date of transfer.

(2) When a life estate is recorded more than six months after the date of signature, the individual must produce documentation from other sources verifying that the transfer occurred on the date of signature rather than the date of recording.

(a) Such documentation may consist of financial records from lending institutions, tax records from governmental agencies, or records from other agencies or private or public institutions.

(b) The individual may provide statements of persons holding a remainder interest, or other persons who participated in the creation of the life estate.

(G) Calculating the fair market value of a life estate.

(1) The administrative agency must first determine the fair market value of the physical property as established by the county auditor. When a valuation by a county auditor is unavailable, the value shall be based upon a valuation by the appropriate governmental agency charged with the responsibility for valuation of real property.

(2) The administrative agency must deduct from the fair market value of the physical property all liens and encumbrances that have been placed against the property.

(3) The administrative agency must deduct from the fair market value of the physical property all liens and encumbrances that have been placed against the life estate.

(4) After deductions, the balance is the equity value of the physical property.

(5) The administrative agency must multiply the equity value of the physical property by the product that corresponds to the life estate owner's age at the time of determination for medical assistance on the following life estate table:

| AGE | LIFE ESTATE | REMAINDER | | --- | --- | --- | | 0 | .97188 | .02812 | | 1 | .98988 | .01012 | | 2 | .99017 | .00983 | | 3 | .99008 | .00992 | | 4 | .98981 | .01019 | | 5 | .98938 | .01062 | | 6 | .98884 | .01116 | | 7 | .98822 | .01178 | | 8 | .98748 | .01252 | | 9 | .98663 | .01337 | | 10 | .98565 | .01435 | | 11 | .98453 | .01547 | | 12 | .98329 | .01671 | | 13 | .98198 | .01802 | | 14 | .98066 | .01934 | | 15 | .97937 | .02063 | | 16 | .97815 | .02185 | | 17 | .97700 | .02300 | | 18 | .97590 | .02410 | | 19 | .97480 | .02520 | | 20 | .97365 | .02635 | | 21 | .97245 | .02755 | | 22 | .97120 | .02880 | | 23 | .96986 | .03014 | | 24 | .96841 | .03159 | | 25 | .96678 | .03322 | | 26 | .96495 | .03505 | | 27 | .96290 | .03710 | | 28 | .96062 | .03938 | | 29 | .95813 | .04187 | | 30 | .95543 | .04457 | | 31 | .95254 | .04746 | | 32 | .94942 | .05058 | | 33 | .94608 | .05392 | | 34 | .94250 | .05750 | | 35 | .93868 | .06132 | | 36 | .93460 | .06540 | | 37 | .93026 | .06974 | | 38 | .92567 | .07433 | | 39 | .92083 | .07917 | | 40 | .91571 | .08429 | | 41 | .91030 | .08970 | | 42 | .90457 | .09543 | | 43 | .89855 | .10145 | | 44 | .89221 | .10779 | | 45 | .88558 | .11442 | | 46 | .87863 | .12137 | | 47 | .87137 | .12863 | | 48 | .86374 | .13626 | | 49 | .85578 | .14422 | | 50 | .84743 | .15257 | | 51 | .83674 | .16126 | | 52 | .82969 | .17031 | | 53 | .82028 | .17972 | | 54 | .81054 | .18946 | | 55 | .80046 | .19954 | | 56 | .79006 | .20994 | | 57 | .77931 | .22069 | | 58 | .76822 | .23178 | | 59 | .75675 | .24325 | | 60 | .74491 | .25509 | | 61 | .73267 | .26733 | | 62 | .72002 | .27998 | | 63 | .70696 | .29304 | | 64 | .69352 | .30648 | | 65 | .67970 | .32030 | | 66 | .66551 | .33449 | | 67 | .65098 | .34902 | | 68 | .63610 | .36390 | | 69 | .62086 | .37914 | | 70 | .60522 | .39478 | | 71 | .58914 | .41086 | | 72 | .57261 | .42739 | | 73 | .55571 | .44429 | | 74 | .53862 | .46138 | | 75 | .52149 | .47851 | | 76 | .50441 | .49559 | | 77 | .48742 | .51258 | | 78 | .47049 | .52951 | | 79 | .45357 | .54643 | | 80 | .43659 | .56341 | | 81 | .41967 | .58033 | | 82 | .40295 | .59705 | | 83 | .38642 | .61358 | | 84 | .36998 | .63002 | | 85 | .35359 | .64641 | | 86 | .33764 | .66236 | | 87 | .32262 | .67738 | | 88 | .30859 | .69141 | | 89 | .29526 | .70474 | | 90 | .28221 | .71779 | | 91 | .26955 | .73045 | | 92 | .25771 | .74229 | | 93 | .24692 | .75308 | | 94 | .23728 | .76272 | | 95 | .22887 | .77113 | | 96 | .22181 | .77819 | | 97 | .21550 | .78450 | | 98 | .21000 | .79000 | | 99 | .20486 | .79514 | | 100 | .19975 | .80025 | | 101 | .19532 | .80468 | | 102 | .19054 | .80946 | | 103 | .18437 | .81563 | | 104 | .17856 | .82144 | | 105 | .16962 | .83038 | | 106 | .15488 | .84512 | | 107 | .13409 | .86591 | | 108 | .10068 | .89932 | | 109 | .04545 | .95455 |

(H) When the individual disagrees with the county auditor's determination of the fair market value of the physical property as described in paragraph (G)(1) of this rule, the individual may have a licensed real estate broker perform an appraisal of the property's value, which may be substituted as the fair market value of the physical property in paragraph (G)(1) of this rule. Such appraisal services may be provided through the use of administrative funds when the individual is unable to obtain an appraisal due to insufficient personal funds.

(I) Administrative agency responsibilities. The administrative agency shall:

(1) Determine the effective date of the creation of a life estate.

(2) Accept the statements of persons holding a remainder interest, or other persons who participated in the creation of the life estate, only upon a finding that their statements are corroborated and credible.

(3) Use the date of recording as the effective date of the creation of the life estate when the individual fails to produce documentation verifying that the transfer occurred on the date of signature.

(4) When the life estate has not been recorded, the administrative agency shall request that the individual verify transfer by recording the life estate and, unless the life estate was created within the prior six months, provide documentation as required in paragraph (F)(2) of this rule. When the individual does not provide documentation that the life estate has been recorded, disregard the life estate and consider the entire property as an available resource to the individual.

Last updated June 25, 2025 at 5:53 PM

History

Effective: February 1, 2024
Promulgated Under: 111.15

Ohio Adm.Code 5160:1-3-05.18 Medicaid: stocks, mutual funds, and bonds.

(A) This rule describes the treatment of stocks, mutual funds, and bonds for the purpose of determining eligibility for medical assistance.

(B) Stocks held by an individual, including preferred stocks, warrants and rights, and stock option purchases.

(1) Stock shares represent ownership in a business corporation. Their value shifts with demand and may fluctuate widely.

(2) The fair market value of publicly traded stock as of the first moment of a given month is its closing price on the last business day of the preceding month. The stock closing price, on a given day, can usually be found in the next day's regulator or financial newspaper. The value of over-the-counter stocks are shown on a "bid" and "asked" basis. The bid price is used to determine the stock's value.

(a) When the closing or bid price of a stock is not shown, a local securities firm must determine its value.

(b) The stock of some corporations not publicly traded is held within close groups and traded very infrequently. The sale of such stock is often handled privately and subject to restrictions. The burden of proof for establishing the value of this kind of stock is on the individual. The preferred evidence is a letter or other written statement from the firm's accountants giving their best estimate of the stock's value and the basis for the estimate, and can include the most recent sale, the most recent offer from outsiders, the fair market value of assets less debts on them, cessation of activity and sale of assets, and bankruptcy.

(3) The county prosecutor or the administrative agency's legal staff shall be consulted for assistance with determining the value of the stock when the verification of the fair value of the stock of a closely held corporation is questionable, including when there are indications that the extent of an individual's ownership is being manipulated to reduce the value of the stock as a countable resource.

(4) When the ownership of the stock is shared (i.e., more than one name is on the face of the stock certificate), each owner owns an equal share of the value of the stock.

(5) Shares of stock in an Alaskan native regional or village corporation, as defined in 43 U.S.C. 1601 - 1624 (as in effect October 1, 2023), are excluded from resources.

(D) The fair market value of a municipal, corporate, or government bond is counted as a resource. When the ownership of a bond is shared, each owner owns an equal share of the fair market value of the bond.

(E) The current redemption value of a U.S. savings bond is a countable resource. When the ownership of the U.S. savings bond is shared, each owner owns equal shares of the redemption value of the bond.

Last updated June 9, 2025 at 3:39 PM

History

Effective: June 8, 2025
Promulgated Under: 111.15

Ohio Adm.Code 5160:1-3-05.19 Medicaid: real or personal property essential to self-support.

(A) This rule describes exclusions when real or personal property is essential to an individual's means of self-support.

(B) Definitions. For the purposes of this rule:

(1) "Basic daily living needs" means any food, basic clothing, basic shelter, and any medical care that are not provided by medicaid. Items for entertainment or leisure are not basic daily living needs.

(2) "Equity value" has the same meaning as in rule 5160:1-1-01 of the Administrative Code.

(3) "Fair market value" has the same meaning as in rule 5160:1-1-01 of the Administrative Code.

(4) "Maximum allowable equity" means the equity value of an income-producing property, up to a maximum of six thousand dollars.

(5) "Net annual return" means the profit a property generates in a year after all operating expenses, taxes, and fees are subtracted.

(6) "Six per cent return requirement" means a nonbusiness income-producing property that produces a net annual return of at least six per cent of the excluded equity of the property.

(1) Property used in a trade or business, government permits that represent authority granted by a government agency to engage in an income-producing activity, or property used by an individual as an employee for work.

(a) Is excluded as a resource regardless of value or the rate of return.

(b) Government permits include any permit, license, or similar instrument issued by a federal, state, or local government agency.

(2) Nonbusiness real or personal property used to produce goods or services essential to basic daily living needs.

(a) Up to six thousand dollars of the equity value is excluded, regardless of rate of return.

(b) Any portion of the property's equity value in excess of six thousand dollars is a countable resource.

(c) Nonbusiness property used to produce goods or services includes growing produce or livestock solely for personal consumption in the individual's household or performing activities essential to the production of food solely for home consumption.

(3) Nonbusiness income-producing property.

(a) Up to six thousand dollars of equity value is excluded as a resource when the property produces a net annual return equal to at least six per cent of the excluded equity.

(b) Any property that does not produce a net annual return equal to at least six per cent of the excluded equity of the property is a countable resource with the following exceptions:

(i) When the property produces less than a six per cent return, an exclusion can apply when the lower return is for reasons beyond the individual's control and there is a reasonable expectation that the property will again produce a six per cent return. Otherwise, none of the equity value is excluded.

(ii) When the earnings decline was for reasons beyond the individual's control, up to twenty-four months are to be allowed for the property to resume producing a six per cent return. The twenty-four month period begins with the first day of the tax year following the tax year in which the return dropped to below six per cent.

(iii) When the tax return shows that the property has operated at a loss for the two most recent years or longer, the property cannot be excluded unless the individual submits current receipts and records to show that the property currently is producing a six per cent return.

(c) When an individual owns more than one piece of nonbusiness income-producing property, the six per cent return requirement applies individually to each property and the six thousand dollar equity value limit applies to the total equity value of all the properties combined that meet the six per cent return requirement.

(D) For any of the exclusions to apply, the property is to be in current use in the type of activity that qualifies it as essential.

(E) Property not in current use. When the property is not in current use, it must be for reasons beyond the individual's control and there must be a reasonable expectation that the use will resume within twelve months of the last use.

(1) Property not in current use is to be excluded for twelve months as essential for self-support when the property has been in use and there is reasonable expectation that the use will resume. The individual is to provide a signed statement of last date of use, reason the property is not in use, and when the individual expects to resume the self-support activity.

(2) When an individual alleges that self-support property is not in current use because of a disabling condition of the individual, the individual is to provide a signed statement of the nature of the condition, the date the individual ceased the self-support activity, and when the individual intends to resume activity to receive up to an additional twelve months.

(3) When the individual does not intend to resume the self-support activity, the property is a countable resource in the month after the month of last use.

(4) When, after property has been excluded because an individual intends to resume self-support activity, the individual decides not to resume such activity, the exclusion ceases to apply as of the date of the change of intent. The property is a resource in the following month.

(F) Individual responsibilities. The individual is to:

(1) Provide a copy of the tax return for the tax year prior to application or renewal when the property is used in a trade or business in order for the administrative agency to determine the net income earned by the individual.

(2) Provide pertinent documents and a signed statement when the individual alleges owning a government license, permit, or other property that represents government authority to engage in an income-producing activity, and has value as a resource. The statement is to include:

(a) The type of license, permit, or other property;

(b) The name of the issuing agency, when appropriate;

(c) Whether the law requires such license, permit, or property for engaging in the income-producing activity at issue; and

(d) How the license, permit, or other property is being used; or

(e) Why the license, permit, or other property is not being used.

(3) Provide a signed statement when the individual alleges owning items used for work as an employee. The statement is to include:

(a) The name, address, and telephone number of the employer;

(b) A general description of the items;

(d) Whether the items are currently being used.

(4) Provide a signed statement when the individual alleges owning property used to produce goods or services essential to basic daily living needs. The statement is to include:

(a) A description of the property;

(b) How the property is used; and

(G) Administrative agency responsibilities. The administrative agency is to:

(1) Determine whether the property qualifies under one of the three categories identified in paragraph (C) of this rule when the individual asserts the property is essential for self-support.

(2) Determine whether to exclude equity in property that provides either a product or a service that supplies basic daily living needs for the individual as described in paragraph (C)(2) of this rule.

(a) When the property does provide basic daily living needs for the individual, then the individual's equity up to a maximum of six thousand dollars is not to be counted as a resource. Any equity in excess of six thousand dollars is to be counted as a resource.

(b) When the property does not provide basic daily living needs for the individual, then the entire equity is a countable resource.

(3) Determine whether to exclude equity from nonbusiness income-producing property described in paragraph (C)(3) of this rule as follows:

(a) Determine the equity value of the property.

(b) Determine the maximum allowable equity for the property up to six thousand dollars.

(c) Multiply the property's maximum allowable equity by six per cent to obtain six per cent of the excluded equity of the property.

(d) Determine the net annual return on the property.

(e) Compare six per cent of the excluded equity value of the property to the net annual return of the property to determine if the property produced a net annual return of at least six per cent of the excluded equity value.

(i) When the net annual return from the property is equal to or greater than six per cent of the excluded equity value of the property as calculated in paragraph (G)(3)(e) of this rule, then the maximum allowable equity is not counted as a resource. Any equity value over the maximum allowable equity value is considered a resource.

(ii) When an individual has more than one property, each property shall be independently evaluated for the six per cent return requirement. The six thousand dollar equity exclusion applies to the combined equity values of all properties meeting the six per cent return requirement. Any combined equity value over six thousand dollars is considered a resource.

(iii) Any property that does not have a net annual return equal to at least six per cent of the excluded equity must be counted as a resource unless the individual meets an exception from paragraph (C)(3)(b) of this rule. A property that meets an exception from paragraph (C)(3)(b) of this rule is still limited to a maximum equity exclusion of six thousand dollars per year.

(4) Apply only the provision that is most beneficial to the individual when the individual's property falls under more than one of the categories in paragraph (C) of this rule.

(5) Request any other documentation necessary to fully and adequately distinguish between the income from the income-producing property, and income from other sources.

(6) Consider the individual's entire equity as a countable resource when the individual fails to cooperate with providing the appropriate documentation.

Last updated September 29, 2026 at 1:06 PM

History

Effective: October 9, 2026
Promulgated Under: 111.15

Ohio Adm.Code 5160:1-3-05.20 Medicaid: deeming of resources.

(A) This rule describes the deeming of resources from an ineligible spouse to an eligible spouse or from ineligible parent(s) to an eligible child who are living in the same household when determining eligibility for medical assistance.

(B) Definitions. For the purposes of this rule:

(1) "Child" means an individual under age eighteen who lives in the household with one or both parents and is neither married nor the head of household. The deeming of parental resources applies through the month in which the eligible child attains eighteen years of age. An eligible or ineligible child's resources are never deemed to parent(s) or sibling(s).

(2) "Deemed resources" means resources attributed to another person whether or not the resource is actually available to the person to whom they are deemed.

(3) "Eligible child" means a child in the household who has applied for medical assistance for the blind or disabled, and who meets all the applicable non-financial and income eligibility criteria for medical assistance.

(4) "Eligible spouse" means the member of a married couple who has applied for medical assistance for the aged, blind, or disabled, and who meets all the applicable non-financial and income eligibility criteria for medical assistance.

(5) "Household" means the eligible spouse, ineligible spouse, and any of the couple's children or the children of either member of the couple; or the eligible child, and the eligible child's parent(s), and other children of the parent(s).

(a) A household does not exist when an individual or a group of individuals does not have a residence. In such a case, only the eligible individual's resources are used to determine eligibility for medical assistance.

(b) When a child is born in an institution (e.g., hospital), the child is a member of the household at the time of birth unless the parents have completed the required paperwork to surrender the child for adoption or the child has been placed in the temporary custody of a public children's services agency (PCSA) or private child placing agency (PCPA).

(6) "Ineligible child" means a child in the household who has not applied for medical assistance for the blind or disabled.

(7) "Ineligible parent" means an eligible child's parent who has not applied for medical assistance for the aged, blind, or disabled.

(8) "Ineligible spouse" means the member of the married couple who has not applied for medical assistance for the aged, blind, or disabled.

(9) "Parent" means a natural or adoptive father or mother living in the same household as the eligible child. The resources of a stepparent who lives with the eligible child are deemed to the eligible child only when the natural or adoptive parent also lives in the household with the stepparent and eligible child. When the natural or adoptive parent divorces a stepparent and the eligible child is living with the stepparent, the stepparent is not considered a parent for deeming purposes.

(10) "Spouse" means a person who is legally married to another under Ohio law.

(C) When deeming resources from an ineligible spouse to an eligible spouse, only the resources of those two individuals are considered. When deeming resources from ineligible parent(s) to an eligible child, only the resources of the parent(s) are considered.

(D) Retirement funds, described in rule 5160:1-3-03.10 of the Administrative Code, owned by an ineligible spouse, parent(s), or sponsor are excluded from resources for deeming purposes.

(E) Spouse to spouse deeming.

(1) When an eligible spouse and an ineligible spouse live together, all resources are combined and the couple is permitted resources in the amount described in rule 5160:1-3-05.1 of the Administrative Code in addition to what is excluded as described in rule 5160:1-3-05.14 of the Administrative Code.

(2) The couple's resource limit is not affected by whether the spouse of the eligible individual is eligible or ineligible for medical assistance.

(3) When the couple's countable resources are less than or equal to the resource limit for a couple described in rule 5160:1-3-05.1 of the Administrative Code, the eligible spouse is resource eligible for medical assistance.

(4) When spouses are no longer living together, each person is considered as an individual living alone beginning the month after separation. The individual resource limit, as described in rule 5160:1-3-05.1 of the Administrative Code, is then applicable.

(a) For the month of separation, the spouses are treated as an eligible couple or as an eligible spouse and ineligible spouse living together in the same household with a resource limit for a couple described in rule 5160:1-3-05.1 of the Administrative Code.

(b) In the month after the month of separation, resources are computed separately because each person is considered to be an individual without a spouse.

(F) Parent to child deeming.

(1) The resource limit for a child is described in rule 5160:1-3-05.1 of the Administrative Code in addition to what is excluded as described in rule 5160:1-3-05.14 of the Administrative Code.

(2) The resources of an eligible child consist of his or her own resources plus the resources that are deemed to the eligible child from the child's parent(s).

(3) When determining the amount of resources to be deemed to an eligible child, the resources of the eligible child and of the ineligible parent(s) are computed separately and both the eligible child and the parent(s) are each allowed all of the resource exclusions they would normally be eligible for in their own right. Only one home and one automobile are excluded.

(a) After the exclusions are applied, only the countable resources over the resource limit of the parent(s) living in the household are deemed to the eligible child when there is only one eligible child.

(i) When there is one parent in the household the parental resource limit is two thousand dollars.

(ii) When both parents are in the household the parental resource limit is three thousand dollars.

(iii) When both natural or adoptive parents and a stepparent are in the household the parental resource limit is two thousand dollars for one natural or adoptive parent plus three thousand dollars for the other natural or adoptive parent with the stepparent.

(b) When there is more than one eligible child, the resources available for deeming are shared equally among the eligible children.

(4) An eligible child is not eligible for medical assistance when the child's own countable resources plus the value of the parent(s)'s resources deemed to the eligible child exceed the resource limit for a child described in rule 5160:1-3-05.1 of the Administrative Code.

Last updated February 17, 2026 at 8:18 AM

History

Effective: February 15, 2026
Promulgated Under: 111.15

Chapter 5160:1-4 Medicaid for Families and Children

Ohio Adm.Code 5160:1-4-01 MAGI-based medicaid: household composition and income.

(A) This rule describes household composition and income calculations under 42 C.F.R. 435.603 (as in effect October 1, 2025) when determining an individual's eligibility for modified adjusted gross income (MAGI) based medical assistance. This rule does not apply to determinations for categories of medical assistance on the basis of age, blindness, or disability, or which only cover an individual's medicare premium or cost-sharing.

(B) Definition. "Person" for the purpose of this rule, means someone in the family or household of an individual applying for or receiving medical assistance.

(1) For the tax year in which the eligibility determination is being made, household composition and family size are determined for each individual as follows:

(a) When an individual expects to file a federal income tax return and does not expect to be claimed as a tax dependent, the household composition is the individual, the individual's spouse if they live together, and all persons whom the individual expects to claim as a tax dependent as determined under 42 C.F.R. 435.603(f)(1) (as in effect October 1, 2025).

(b) When an individual expects to be claimed as a tax dependent, the household composition is the taxpayer, the taxpayer's spouse if they live together, the individual, and all other persons whom the taxpayer expects to claim as a tax dependent as determined under 42 C.F.R. 435.603(f)(2) (as in effect October 1, 2025), unless the individual meets one of the following exceptions:

(i) The individual is a tax dependent of someone other than a spouse or parent.

(ii) The individual is a child under the age of nineteen living with both parents who do not expect to file taxes jointly.

(iii) The individual is a child under the age of nineteen who expects to be claimed as a tax dependent by a non-custodial parent.

(c) When an individual does not expect to file a federal income tax return or to be claimed as a tax dependent, or it is unclear if the individual will be claimed as a tax dependent, the household composition is determined under 42 C.F.R. 435.603(f)(3)(as in effect October 1, 2025) as follows:

(i) When the non-filer is an adult, the household includes the individual, the individual's spouse if living together, and the individual's children under the age of nineteen.

(ii) When the non-filer is a child under the age of nineteen, the household includes the individual, the individual's parents if living with the individual, and the individual's siblings under the age of nineteen if living with the individual.

(a) When the individual (non-filer child) is married, the spouse of the individual is also included in the household.

(b) When the individual (non-filer child) has children, the individual's children are also included in the household.

(2) When determining the family size of a household containing at least one pregnant woman, each pregnant woman is counted as herself plus:

(a) One; or

(b) The number of indicated fetuses. The pregnant woman shall provide a statement from a doctor or nurse verifying the pregnancy, including the expected date of confinement and the number of unborn fetuses (if greater than one), when the increase in family size makes her income-eligible for medical assistance.

(3) When determining the household of a married couple who live together, each spouse will always be included in the other spouse's household, regardless of tax filing status and regardless of whether either spouse is claimed as a tax dependent.

(4) When determining the household of a natural, adoptive, or step-parent and a child who live together, the parent will always be included in the child's household, regardless of tax filing status and regardless of whether the child is claimed as a tax dependent.

(D) Determining household income.

(1) MAGI-based income is determined in accordance with 42 C.F.R. 435.603 (as in effect October 1, 2025) for:

(a) The individual; and

(b) Each person in the individual's household.

(2) The individual's household income is the sum of the individual's MAGI-based income plus the MAGI-based income of each person in the individual's household, excluding only the income from the following individuals who are not expected to be required to file a tax return under section 6012(a)(1) of the Internal Revenue Code (as in effect October 1, 2025) for the taxable year in which eligibility is being determined for medical assistance, whether or not the individual files a tax return:

(a) A child included in the household of his or her natural, adoptive, or step-parent; or

(b) A tax dependent who meets the definition of a qualifying child or qualifying relative under 26 U.S.C. 152 (as in effect October 1, 2025).

(3) Reasonably predictable changes (RPC) methodology. To account for a reasonably predictable increase or decrease in future income, such as recurring seasonal or temporary employment, the projected income shall be prorated equally over a twelve-month period, in accordance with 42 C.F.R. 435.603(h)(3) (as in effect October 1, 2025). A reasonably predictable increase or decrease in income shall be verified by a signed employment contract, a history of predictable fluctuations in income, or other clear indication of the future income change. When verification of the future change is not available, the individual's self-attestation may be used.

(4) Qualified lottery winnings and qualified lump-sum income, in the amount of eighty thousand dollars or more, which are received in a single payment on or after January 1, 2018, are counted as income in the month received and over a period up to one hundred twenty months under the Bipartisan Budget Act (BBA) of 2018 (Pub. L. No. 115-97). The total winnings are divided into equal installments over each month as described:

(a) Lottery winnings up to the amount of seventy-nine thousand nine hundred ninety-nine dollars and ninety-nine cents are only counted in the month received.

(b) Lottery winnings between the amounts of eighty thousand dollars and eighty-nine thousand nine hundred ninety-nine dollars and ninety-nine cents are counted equally over a two-month period.

(c) Lottery winnings between the amounts of ninety thousand dollars and ninety-nine thousand nine hundred ninety-nine dollars and ninety-nine cents are counted equally over a three-month period.

(d) For each additional ten thousand dollars received in lottery winnings, above the amount of ninety-nine thousand nine hundred ninety-nine dollars and ninety-nine cents, add one month to the countable time period, up to a maximum of one hundred twenty months, and equally count the winnings in each month.

(5) Nominal payments to a parent mentor who is trained to assist families with children who do not have health insurance coverage and who is working with a grantee organization under section 2113 of the Social Security Act (as in effect October 1, 2025), are excluded as income under the Helping Ensure Access for Little ones, Toddlers, and Hopeful Youth by Keeping Insurance Delivery Stable (HEALTHY KIDS) Act (Pub. L. No. 115-120).

(6) Alimony payments.

(a) Alimony payments received as a result of a new divorce or separation agreement finalized after December 31, 2018, are not considered income to the recipient for MAGI budgeting under the Tax Cuts and Jobs Act (Pub. L. No. 115-97).

(b) Alimony payments received as a result of a divorce or separation agreement modified after December 31, 2018, are not considered income to the recipient for MAGI budgeting only if the modification was for the purpose of the Tax Cuts and Jobs Act (Pub. L. No. 115-97).

(7) Student loan debt discharged due to the death or permanent and total disability of the student is not included as income for MAGI budgeting beginning with tax year 2018 under the Tax Cuts and Jobs Act (Pub. L. No. 115-97).

(8) The following deductions are not allowable for MAGI budgeting under the Tax Cuts and Jobs Act (Pub. L. No. 115-97):

(a) Moving expenses beginning with tax year 2018, except for specified active duty military.

(b) Alimony paid under a new divorce or separation agreement finalized after December 31, 2018.

(c) Alimony paid under a divorce or separation agreement modified after December 31, 2018, if the modification was for the purpose of the Tax Cuts and Jobs Act.

(d) Tuition and fees for qualified education expenses for postsecondary education. Scholarships, awards, or fellowship grants used for education purposes and not for living expenses are still excluded as income as described in 42 C.F.R. 435.603(e)(2) (as in effect October 1, 2025).

(9) Before comparing an individual's household income to the highest income standard under which the individual may be determined eligible using MAGI-based methodologies, deduct a dollar amount equal to five per cent of the federal poverty level (FPL) for the individual's family size.

Last updated June 1, 2026 at 8:48 AM

History

Effective: June 1, 2026
Promulgated Under: 111.15

Ohio Adm.Code 5160:1-4-02 MAGI-based medicaid: coverage for children younger than nineteen years of age.

(A) This rule describes the eligibility criteria for a child from birth until the individual reaches nineteen years of age in accordance with 42 C.F.R. 435.118 (as in effect October 1, 2025) for applications for medical assistance.

(B) Definition. "Child" means an individual younger than nineteen years of age.

(C) Eligibility criteria for coverage because a newborn child was born to a medicaid-eligible woman (deemed newborn). In accordance with 42 C.F.R. 435.117 (as in effect October 1, 2025), a child is automatically eligible for medical assistance as of the child's date of birth, and remains eligible until the child reaches the age of one, provided the birth mother has applied for, been determined eligible for, and is receiving medical assistance on the date of the child's birth.

(1) Coverage under this paragraph also applies to newborns under the following circumstances:

(a) When labor and delivery services were furnished prior to the date of application and the birth mother's medicaid eligibility is based on retroactive coverage in accordance with 42 C.F.R. 435.915 (as in effect October 1, 2025).

(b) When the birth mother is receiving non-citizen emergency medical assistance (NCEMA) in accordance with rule 5160:1-5-06 of the Administrative Code.

(i) Restricted from payment of services as referenced in rule 5160:1-1-03 of the Administrative Code; and

(ii) Within twelve months of the date of her most recent medicaid application or renewal.

(d) When the birth mother is in the custody of a public children services agency (PCSA) or private child placing agency (PCPA).

(e) When the birth mother is in receipt of adoption or foster care assistance under Title IV-E.

(f) When the birth mother is in receipt of state or federal adoption assistance.

(g) When the birth mother loses medicaid eligibility after the birth of the newborn.

(h) When the birth mother is no longer a member of the newborn's household at any time prior to the newborn reaching the age of one.

(2) For newborns described in this paragraph, the administrative agency must:

(a) Upon verbal or written notification of the newborn's birth from any individual or entity reporting the birth:

(i) Verify, in the electronic eligibility system, that the birth mother was eligible for and received medicaid on the date of the child's birth, and

(ii) Approve the child's eligibility for medicaid without delay and without consideration of household composition or income.

(b) Not require an application for the child or a renewal of eligibility prior to the month of the child's first birthday.

(d) Complete a renewal of eligibility when the child reaches the age of one.

(D) Eligibility criteria for coverage because an individual is a child under nineteen years of age.

(1) A child's family size and household income shall be calculated as described in rule 5160:1-4-01 of the Administrative Code.

(2) When the child is not covered by other creditable coverage, the child's household income must not exceed two hundred six per cent of the federal poverty level for the family size.

(3) When the child is covered by other creditable coverage, the child's household income must not exceed one hundred fifty-six per cent of the federal poverty level for the family size.

(4) A child receiving medical coverage under this paragraph remains eligible:

(a) Through the end of the month in which the child turns nineteen years of age, if the child remains otherwise eligible in accordance with rule 5160:1-2-10 of the Administrative Code, and the individual responsibilities described in rule 5160:1-2-08 of the Administrative Code are met; or

(b) Until the end of an inpatient stay during which inpatient services are being furnished, if the child is found eligible under this paragraph on or after his or her eighteenth birthday and turns nineteen years of age during the inpatient stay.

Last updated June 1, 2026 at 8:48 AM

History

Effective: June 1, 2026
Promulgated Under: 111.15

Ohio Adm.Code 5160:1-4-03 MAGI-based medicaid: coverage for Ribicoff and former foster care children.

(A) This rule describes the eligibility criteria for applications for medical assistance for individuals:

(1) Who are nineteen or twenty years of age; or

(2) Who aged out of foster care, are younger than twenty-six years of age, and are not otherwise eligible for a mandatory category of coverage under the medicaid state plan. An individual who is eligible for coverage both as a former foster care child and under the coverage described in section 1902(a)(10)(A)(i)(VIII) of the Social Security Act (as in effect October 1, 2025) shall be placed in the former foster care eligibility category.

(B) Eligibility criteria for coverage because an individual is nineteen or twenty years of age in accordance with 42 C.F.R. 435.222 (as in effect October 1, 2025).

(1) The individual must be nineteen or twenty years of age.

(2) The individual's family size and household income must be calculated as described in rule 5160:1-4-01 of the Administrative Code.

(3) The individual's household income must not exceed fourty-four per cent of the federal poverty level for the family size.

(C) Eligibility criteria for coverage because an individual aged out of foster care in accordance with 42 C.F.R. 435.150 (as in effect October 1, 2025).

(1) The individual must:

(a) Be at least eighteen years of age and younger than twenty-six years of age;

(b) Have been in foster care:

(i) Under the responsiblity of the state of Ohio on the individual's eighteenth birthday, or at the time of aging out of the state's foster care program, regardless of the date the individual aged out of foster care; or

(ii) Under the responsibility of any state on the individual's eighteenth birthday, or at the time of aging out of that state's foster care program, when the indivdual aged out of foster care on or after January 1, 2023;

(d) Cooperate in establishing eligibility, which includes signing and dating the application in accordance with rule 5160:1-2-08 of the Administrative Code.

(2) Under this paragraph, there is no income test for coverage because an individual aged out of foster care.

Last updated June 1, 2026 at 8:48 AM

History

Effective: June 1, 2026
Promulgated Under: 111.15

Ohio Adm.Code 5160:1-4-04 MAGI-based medicaid: coverage for pregnant individuals.

(A) This rule describes eligibility for pregnant individuals as described in 42 C.F.R. 435.116 (as in effect on October 1, 2023) for applications for medical assistance.

(B) Eligibility criteria for coverage because an individual is pregnant.

(1) The individual must be female and pregnant.

(2) A statement from the individual, a physician, or managed care organization (MCO) is sufficient verification of pregnancy, unless the administrative agency has information contradicting the individual's statement. Self-attestation of pregnancy is acceptable unless available information conflicts with the attestation or the woman is pregnant with more than one fetus.

(3) The individual's household income must not exceed two hundred per cent of the federal poverty level for the family size. For the purpose of this rule, family size includes the number of fetuses.

(4) An individual who is in her postpartum period, as defined in rule 5160:1-1-01 of the Administrative Code, is also eligible under the criteria described in this rule.

(1) Once established, eligibility for a pregnant individual continues throughout the pregnancy and postpartum period.

(2) An individual is eligible for postpartum coverage if she was eligible for medical assistance on the date the pregnancy ended. This includes a birth mother whose labor and delivery services were furnished prior to the date of application and who is determined eligible for retroactive coverage of labor and delivery services as described in rule 5160:1-2-01 of the Administrative Code.

(D) Administrative agency responsibilities. The administrative agency must:

(1) Calculate a pregnant individual's family size and household income as described in rule 5160:1-4-01 of the Administrative Code.

(2) When a pregnant woman attests to carrying more than one fetus and the increased family size makes her income eligible for medical assistance, the administrative agency shall require the woman to provide verification of pregnancy, including the expected date of delivery and the number of unborn fetuses, from a licensed medical professional.

(3) Not discontinue eligibility for a pregnant individual during the pregnancy or postpartum period, unless the individual dies, moves out of state, or requests that coverage be discontinued.

(E) Individual responsibilities. A pregnant woman must provide verification of pregnancy from a licensed medical professional, including the expected date of delivery and the number of unborn fetuses, only when requested by the administrative agency.

Last updated March 1, 2024 at 8:12 AM

History

Effective: March 1, 2024
Promulgated Under: 111.15

Ohio Adm.Code 5160:1-4-05 MAGI-based medicaid: coverage for a parent or caretaker relative residing with a child.

(A) This rule describes the eligibility requirements for parents and caretaker relatives residing with children as described in 42 C.F.R. 435.110 (as in effect October 1, 2024), transitional medical assistance as described in section 1925 of the Social Security Act (as in effect October 1, 2024), and extended medical assistance as described in section 1931 of the Social Security Act (as in effect October 1, 2024).

(B) Eligibility criteria for coverage when an individual is a parent or caretaker relative residing with a child.

(1) The individual must be residing with a dependent child under the age of eighteen. An individual is considered to be residing with the child even if the child is temporarily absent with the intent to return home.

(2) The individual must be the child's parent or caretaker relative, or a spouse residing with the child's parent or caretaker relative.

(3) The individual's household income must not exceed ninety per cent of the federal poverty level for the family size.

(1) To be eligible for TMA or EMA an individual must have:

(a) Been enrolled in medical assistance coverage as a parent or caretaker relative as described in paragraph (B) of this rule for at least three of the six months immediately preceding the loss of eligibility.

(b) Becomes ineligible for medical assistance as a parent or caretaker relative as a result of:

(i) Increased earned income, to be eligible for the first six-month period of TMA. Verification of increased income is not required and can be self-declared.

(ii) Increased collection of spousal support, to be eligible for EMA. Verification of increased income is not required and can be self-declared.

(2) Duration of eligibility.

(a) A parent or caretaker relative is eligible for:

(i) Up to two six-month periods of TMA.

(a) The first six-month period of TMA beginning the first day of the month following the expiration of the required notice period under rule 5101:6-2-04 of the Administrative Code for discontinuance of coverage as a parent or caretaker relative.

(b) The second six-month period of TMA beginning the month immediately following the completion of the first six-month period when the parent or caretaker relative:

(i) Received continuous TMA for the entire first six-month period;

(ii) Met the quarterly request for financial information requirements for the first six-month period described in paragraph (D) of this rule; and

(iii) Has average gross monthly earned income minus employment-related child care expenses (if applicable) that does not exceed one hundred eighty-five per cent of the federal poverty level for the family size.

(ii) Four months of EMA beginning the first day of the month following the expiration of the required notice period under rule 5101:6-2-04 of the Administrative Code for discontinuance of coverage as a parent or caretaker relative.

(b) The child of the parent or caretaker relative will remain eligible for medical assistance regardless of the parent or caretaker relative's increased earned income or spousal support for a continuous period of twelve months under rule 5160:1-2-14 of the Administrative Code. At the end of that twelve-month period, the child becomes eligible for any remaining months of TMA or EMA for which the parent or caretaker relative is eligible, ending in the same month as TMA or EMA ends for the parent or caretaker relative.

(c) The child of the parent or caretaker relative eligible under this rule loses TMA or EMA eligibility at the end of the month in which he or she reaches age nineteen.

(3) Resuming interrupted spans of TMA eligibility.

(a) An individual whose span of TMA was interrupted because the individual became eligible for coverage under paragraph (B) of this rule is eligible for a new span of TMA when the individual subsequently loses eligibility under paragraph (B) of this rule due to an increase in earned income and meets the criteria in paragraph (C)(1)(a) of this rule.

(b) An individual whose span of TMA was interrupted because the individual became eligible for coverage under paragraph (B) of this rule is eligible for any remaining months of the original TMA span when the individual subsequently loses eligibility under paragraph (B) of this rule due to an increase in earned income and does not meet the criteria in paragraph (C)(1)(a) of this rule.

(4) Repeated spans of eligibility. There is no limit to the number of times an individual may receive coverage under TMA or EMA, provided the individual meets all of the relevant criteria for the coverage each time.

(D) Quarterly request for financial information for TMA. The parent or caretaker relative must report his or her gross earned income and employment-related child care expenses (if applicable) quarterly to the administrative agency by the fifth business day of the fourth, seventh, and tenth months of TMA coverage.

(E) Administrative agency responsibilities. The administrative agency must:

(1) Calculate a parent's or caretaker relative's family size and household income as described in rule 5160:1-4-01 of the Administrative Code for parent or caretaker relative eligibility.

(2) Send a quarterly request for financial information to the parent or caretaker relative no later than the third week of the third, sixth, and ninth months of TMA coverage.

(3) Update the electronic eligibility system with information reported from the quarterly request for financial information.

(4) Determine eligibility for the second six-month period of TMA.

(5) Consider an individual's eligibility for TMA or EMA as part of the renewal process described in rule 5160:1-2-01 of the Administrative Code and the pre-termination review (PTR) process described in rule 5160:1-1-01 of the Administrative Code.

(a) Verify in the electronic eligibility system the individual was receiving medical assistance in previous months. Approve TMA or EMA when an individual meets the requirements in paragraph (C) of this rule;

(b) Deny or discontinue TMA or EMA when:

(i) There is no longer a dependent child under the age of eighteen residing with the parent or caretaker relative; or

(ii) The parent or caretaker relative:

(a) Become eligible for another medical assistance covered group;

(b) No longer has earned income for TMA;

(d) Fails to report gross earned income and employment-related child care expenses (if applicable) quarterly for TMA;

(e) Is over income for the second six-month period of TMA;

(f) Receives four months of EMA; or

(g) Receives twelve months of TMA.

Last updated October 8, 2025 at 1:31 PM

History

Effective: October 6, 2025
Promulgated Under: 111.15

Ohio Adm.Code 5160:1-4-06 Medicaid: coverage for individuals in receipt of adoption or foster care assistance.

(A) This rule describes eligibility criteria for medical assistance for individuals who are in receipt of:

(1) Adoption or foster care assistance under Title IV-E of the Social Security Act (as in effect October 1, 2023); or

(2) State foster care assistance; or

(3) State adoption assistance subsidies; or

(4) State adoption assistance in accordance with 42 C.F.R. 435.227 (as in effect October 1, 2023).

(B) Individual or authorized representative responsibilities. The individual or authorized representative must:

(1) Sign and date the application in accordance with rule 5160:1-2-08 of the Administrative Code; and

(2) Meet the conditions of eligibility described in rule 5160:1-2-10 of the Administrative Code; and

(3) Cooperate in establishing eligibility; and

(4) Report changes that impact the eligibility criteria identified in this rule in accordance with rule 5160:1-2-08 of the Administrative Code.

(C) Eligibility criteria for an individual in receipt of adoption or foster care assistance under Title IV-E of the Social Security Act (as in effect October 1, 2023).

(1) The individual must:

(a) Meet the age requirements identified in Chapter 5101:2-47 of the Administrative Code and be in the custody of a public children services agency (PCSA), private child placing agency (PCPA), or Title IV-E agency and in receipt of Title IV-E foster care maintenance payments; or

(b) Meet the age requirements identified in Chapter 5101:2-49 of the Administrative Code and have a Title IV-E adoption agreement in effect, whether or not an adoption assistance payment is being made or a judicial decree of adoption has been issued.

(2) When the individual receives adoption or foster care assistance under Title IV-E of the Social Security Act and meets the eligibility criteria under this paragraph, there is no income or resource test required to be eligible for medical assistance.

(D) Eligibility criteria for an individual in receipt of kinship guardianship assistance program (KGAP) payments under Title IV-E of the Social Security Act (as in effect October 1, 2023).

(1) The individual must:

(a) Meet the eligiblity requirements identified in rule 5101:2-46-02 or rule 5101:2-55-02 of the Administrative Code; and

(b) Have a current IV-E KGAP or IV-E kinship guardianship assistance program connections to twenty-one (KGAP C21) agreement in effect.

(2) When the individual receives KGAP payments under Title IV-E of the Social Security Act and meets the eligiblity criteria under this paragraph, there is no income or resource test required to be eligible for medical assistance.

(E) Eligibility criteria for an individual in receipt of state foster care assistance.

(1) The individual must:

(a) Be in the custody of a PCSA, PCPA, or Title IV-E agency; and

(b) Be in receipt of state foster care assistance.

(2) When the individual receives state foster care assistance and meets the eligibility criteria under this paragraph, there is no income or resource test required to be eligible for medical assistance.

(3) Eligibility is coterminous with receipt of foster care assistance and ends on the date the child's foster care placement ends, subject to a pre-termination review as defined in rule 5160:1-1-01 of the Administrative Code.

(F) Eligibility criteria for an individual in receipt of a state adoption maintenance subsidy.

(1) The individual must:

(a) Meet the age requirements identified in rule 5101:2-44-06 of the Administrative Code; and

(b) Have a state adoption agreement in effect, whether or not a judicial decree of adoption has been issued.

(2) When the individual receives a state adoption maintenance subsidy and meets the eligibility criteria under this paragraph, there is no income or resource test required to be eligible for medical assistance.

(G) Eligibility criteria for an individual in receipt of state adoption assistance in accordance with 42 C.F.R. 435.227 (as in effect October 1, 2023).

(1) The individual must:

(a) Be under the age of twenty-one; and

(b) Have been determined by the PCSA responsible for determining state adoption maintenance subsidy program eligibility to have special needs for medical or rehabilitative care that may be a barrier to the adoptive placement, as described in rule 5101:2-44-05.1 of the Administrative Code, or have a state adoption subsidy agreement in effect with another state, as described in rule 5101:2-44-05.2 of the Administrative Code; and

(c) Have been receiving or eligible to receive medicaid prior to the execution of the adoption agreement, under any category of medical assistance.

(2) When the individual receives state adoption assistance, has special needs for medical or rehabilitative care, and meets the eligibility criteria under this paragraph, there is no income or resource test required to be eligible for medical assistance.

(H) An individual who meets eligibility requirements identified in rule 5101:2-56-02 of the Administrative Code and is in receipt of state KGAP payments is not eligible for medical assistance under this rule on the basis of receiving KGAP payments.

Last updated June 25, 2025 at 6:40 PM

History

Effective: January 1, 2024
Promulgated Under: 111.15

Chapter 5160:1-5 Medicaid Special Covered Groups

Ohio Adm.Code 5160:1-5-01 Medicaid: the residential state supplement (RSS) program.

(A) RSS provides cash assistance to aged, blind, or disabled adults who are eligible for medical assistance and who have increased needs due to a medical condition which is not severe enough to require institutionalization. The RSS cash payment is used together with the individual's income to help prevent institutionalization and to deinstitutionalize those aged, blind, or disabled adults who have been placed in long-term care facilities and who can return to the community through an alternative living arrangement.

(B) Definitions.

(1) "Countable income," for the purpose of this rule, means income remaining after exclusions.

(2) "Income standard," for the purpose of this rule, means the aggregate of the allowable fee standard and the personal needs allowance as defined in rule 5122-36-05 of the Administrative Code.

(3) "Individual," for the purpose of this rule, means a person who is applying for or receiving RSS benefits.

(4) "Institutional placement," for the purpose of this rule, means placement in a public medical institution, a hospital which has a provider agreement with the Ohio department of medicaid, or a Title XIX certified long-term care facility (LTCF).

(5) "OhioMHAS" means the Ohio department of mental health and addiction services.

(6) "RSS living arrangement" means an arrangement listed in paragraph (A) of rule 5122-36-02 of the Administrative Code.

(7) "RSS" means the residential state supplement program implemented under section 5119.41 of the Revised Code.

(8) "RSS protected date," for the purpose of this rule, means the signature date on a completed "Residential State Supplement (RSS) Referral for Enrollment" (ODM 07120) or an electronic equivalent, or a "Residential State Supplement (RSS) Program Application" (DMHAS-7046).

(9) "Temporary institutional placement," for the purpose of this rule, means placement, not to exceed ninety days, in a public medical institution, a hospital which has a provider agreement with the Ohio department of medicaid, or a Title XIX certified long-term care facility (LTCF).

(1) To be eligible for the RSS program an individual must:

(a) Be determined eligible for medical assistance in accordance with Chapter 5160:1-3 of the Administrative Code;

(b) Meet the financial eligibility requirements described in paragraph (E) of this rule;

(d) Meet the criteria for at least a protective level of care as defined in rule 5160-3-06 of the Administrative Code;

(e) Meet the non-financial requirements described in paragraph (I) of this rule; and

(f) Not require more than one hundred twenty days of skilled nursing care within a twelve month period.

(2) When an individual no longer meets all the criteria of this rule, the individual is no longer eligible for the RSS program, unless, according to division (H) of section 5119.41 of the Revised Code, the individual no longer meets the criteria solely by reason of his or her living arrangement, as long as he or she has continued to reside in the same living arrangement since November 15, 1990.

(D) RSS registration and enrollment process. The RSS application process is initiated upon receipt of all of the following:

(1) An application for medical assistance, if the individual is not currently in receipt of medical assistance;

(2) Non-financial verifications from OhioMHAS as described in paragraph (I) of this rule; and

(3) A completed ODM 07120 or electronic equivalent from OhioMHAS verifying that the individual has been selected for placement in the RSS program.

(a) When the individual submits a completed ODM 07120 either at the county department of job and family services (CDJFS) or by mail, a copy of the ODM 07120 will be forwarded to OhioMHAS to register the individual for the RSS program.

(b) When a completed ODM 07120 or electronic equivalent has been submitted to OhioMHAS, it shall be made available to the Ohio department of medicaid and the CDJFS for the determination of eligibility in accordance with paragraph (C) of this rule.

(c) The date the signed ODM 07120 or electronic equivalent is completed and submitted to OhioMHAS will be considered the date of application.

(E) Financial eligibility.

(1) The definitions of earned and unearned income in Chapter 5160:1-1 of the Administrative Code are applicable to the RSS program.

(2) When an individual and his or her spouse reside in the same RSS living arrangement and both have appropriate levels of care, the CDJFS shall determine their RSS financial and resource eligibility collectively, utilizing the appropriate couple income standard as defined in rule 5160:1-3-03.5 of the Administrative Code.

(3) When an individual and his or her spouse reside in the same RSS living arrangement and only one of them has an appropriate level of care, the CDJFS shall determine RSS financial and resource eligibility utilizing the appropriate individual income standard as defined in rule 5160:1-3-03.5 of the Administrative Code. The spouse who does not have the necessary level of care shall have eligibility for medical assistance determined as an individual, except that income cannot be deemed to or from the RSS eligible spouse.

(4) The treatment of income for RSS shall be the same as the treatment of income for medical assistance in accordance with rule 5160:1-3-03.1 of the Administrative Code, with the following exceptions:

(a) Supplemental security income (SSI) is countable income in the RSS program.

(b) When an individual has countable income equal to or in excess of the income standard, the individual is ineligible for RSS.

(5) When the RSS individual's countable income is less than the income standard, but the individual's RSS enrollment is not yet completed, the CDJFS shall pend the RSS application until the RSS enrollment determination is completed.

(6) When the RSS individual's countable income is less than the income standard, the individual is eligible for an RSS payment.

(F) Resource eligibility shall be determined in accordance with rule 5160:1-3-05.1 of the Administrative Code.

(G) Determination of RSS payment.

(1) The RSS payment to the individual shall be equal to the difference between the individual's income after all allowable deductions and disregards and the income standard.

(2) The approval date for the RSS payment cannot precede the date of placement in an appropriate RSS living arrangement or the date when all financial and non-financial eligibility requirements are met including appropriate level of care, whichever occurs last.

(3) When an individual leaves an RSS living arrangement after the monthly RSS payment has been made, and does not begin residence in another eligible RSS living arrangement, the individual shall be responsible for returning the RSS payment. The return amount shall be prorated from the date the individual leaves the RSS living arrangement.

(4) When an individual leaves an RSS living arrangement and moves to another RSS living arrangement and the monthly RSS payment has been made to the individual, a second monthly RSS payment will not be made for the new living arrangement.

(5) When an individual moves from a nursing facility or a personal residence into an RSS living arrangement on the first day of the month and is otherwise eligible for RSS, the individual is eligible for a full month's RSS payment.

(6) When an individual moves into an RSS living arrangement on a date other than the first day of the month and is otherwise eligible for RSS, the first month's payment is calculated according to the following formula:

(a) Determine the regular monthly RSS payment in accordance with paragraph (G)(1) of this rule.

(b) Divide the monthly RSS payment amount by the number of days in the month to arrive at the daily supplement amount. Round amounts up to the next whole cent.

(c) Multiply the daily supplement amount by the actual number of days of RSS placement in the month. The actual number of days of RSS placement in the month includes the day that the individual moves into the RSS living arrangement through the last day of the month. Round amounts up to the next whole cent.

(d) The resulting product is the prorated RSS payment.

(H) Temporary institutional placement.

(1) RSS benefits are intended to allow an individual to maintain and pay for the RSS living arrangement in which he or she intends to live when discharged from temporary institutional placement.

(2) Individuals in a temporary institutional placement are potentially eligible to receive full uninterrupted RSS benefits during the first ninety days of institutional placement.

(3) Individuals are eligible for continued RSS benefits provided the following criteria are met:

(a) The individual must be eligible for an RSS payment both the month prior to and the first month of temporary institutional placement;

(b) The individual period of temporary institutional placement is not likely to exceed ninety consecutive days, beginning the day after the day of admission; and

(4) OhioMHAS shall submit written documentation to the CDJFS that the criteria listed in paragraph (H)(3) of this rule has been met by the earlier of:

(a) Ninety days after the date of admission to the temporary institutional placement; or

(b) The date of release from the temporary institutional placement.

(5) RSS payments and all of the individual's income are exempt from consideration as income in the long-term care post-eligibility treatment of income calculation for individuals temporarily entering an LTCF.

(a) This income exemption continues through the last day of the month in which the temporary period of institutional placement ends.

(b) Effective the month following the month in which the temporary period of institutional placement ends, when the RSS individual remains in an institutional placement, the CDJFS must stop the RSS payment.

(6) The CDJFS shall continue RSS payments to all individuals meeting the criteria outlined in paragraph (H)(3) of this rule.

(7) Any RSS payments made under paragraph (H) of this rule are not overpayments if the individual's actual stay exceeds the expected stay of not more than ninety days.

(8) Prior notice in accordance with division 5101:6 of the Administrative Code is required to stop RSS payments.

(9) Upon notification from OhioMHAS that the RSS living arrangement or provider's license or certification has expired or has been suspended or revoked, the CDJFS shall provide prior notice that the individual's RSS eligibility will be discontinued because the individual no longer resides in an RSS living arrangement. Hearing rights shall be provided in accordance with division 5101:6 of the Administrative Code.

(I) OhioMHAS responsibilities. OhioMHAS shall:

(1) Determine the individual's non-financial eligibility for the RSS program in accordance with rule 5122-36-02 of the Administrative Code.

(2) Determine whether the individual is residing in an appropriate living arrangement in accordance with rule 5122-36-02 of the Administrative Code.

(3) Document that the individual meets the criteria for at least a protective level of care pursuant to rule 5122-36-02 of the Administrative Code.

(4) Participate in state hearings resulting from non-financial RSS eligibility criteria decisions.

(5) Provide non-financial verifications as described in paragraphs (H) and (I) of this rule to the CDJFS in order for the CDJFS to determine RSS financial eligibility for the individual.

(6) Inform the CDJFS of any change in the individual's or couple's RSS non-financial eligibility criteria or RSS placement.

(7) Maintain a census of all individuals who receive RSS payments and the RSS living arrangement in which each individual currently resides.

(8) Confirm that the individuals who receive RSS payments are residing in the RSS living arrangement on record.

(J) CDJFS responsibilities. The CDJFS shall:

(1) Inform OhioMHAS of the individual's eligibility for medical assistance and the amount of the calculated RSS payment.

(2) Inform OhioMHAS of any adverse actions regarding the individual's eligibility for RSS cash assistance or RSS medicaid.

(3) Verify that the individual is not receiving services through a home and community-based services (HCBS) waiver.

(4) Verify that the individual is not a participant in a program of all-inclusive care for the elderly (PACE).

(5) Verify that the individual is not enrolled in a medicare- or medicaid-certified hospice program.

(6) For an individual who is not already receiving medical assistance, determine eligibility for medical assistance and RSS financial eligibility upon receipt of the items described in paragraph (D) of this rule.

(a) The CDJFS shall determine retroactive eligibility for medical assistance in accordance with rule 5160:1-2-01 of the Administrative Code for coverage of non-RSS medical services.

(b) The CDJFS shall explore eligibility for the medicare premium assistance programs (MPAP) in accordance with rule 5160:1-3-02.1 of the Administrative Code.

(7) For an individual who is receiving medical assistance, upon receipt of the ODM 07120 or electronic equivalent, determine whether the individual meets the RSS financial eligibility criteria. The CDJFS must notify OhioMHAS of the results of the RSS determination.

(8) Not delay the determination of eligibility for other assistance programs when RSS eligibility is still pending.

(9) Not treat the level of care determination for RSS eligibility as evidence that the limiting physical factor requirement for medical assistance eligibility, as defined in rule 5160:1-3-02 of the Administrative Code, has been met.

(10) When RSS income or resource eligibility is not met in accordance with Chapter 5160:1-3 of the Administrative Code, the CDJFS shall deny the RSS application. The denial notice shall be sent to the individual and authorized representative, or legal guardian, if one has been indicated on the application. A copy of the denial notice shall also be issued to OhioMHAS.

(11) Inform OhioMHAS of any change in the individual's or couple's medical assistance and/or RSS financial eligibility.

(12) When an individual leaves an RSS living arrangement, and does not begin residence in another eligible RSS living arrangement, the CDJFS must determine the individual's continued eligibility for medical assistance.

(13) Discontinue the individual or couple from the RSS program when the CDJFS is notified by OhioMHAS that the individual or couple no longer meets the non-financial eligibility requirements or when the CDJFS determines that the individual or couple no longer meets the financial eligibility requirements for the RSS program.

(14) Confirm in the case record that the individual has received a level of care determination for the RSS program that meets the criteria outlined in paragraph (C)(1) of this rule, document that OhioMHAS has confirmed that the individual is residing in an appropriate RSS living arrangement, and document the approved RSS payment amount.

(K) Individual responsibilities.

(1) The individual shall cooperate with the CDJFS in order to determine financial eligibility for RSS.

(2) The individual shall cooperate with OhioMHAS in order to determine non-financial eligibility for RSS.

(3) The individual is responsible for reporting changes within ten days to the CDJFS in accordance with rule 5160:1-2-08 of the Administrative Code.

Last updated June 18, 2026 at 8:41 AM

History

Effective: August 1, 2025
Promulgated Under: 111.15

Ohio Adm.Code 5160:1-5-02 Medicaid: breast and cervical cancer project (BCCP).

(A) This rule describes the medicaid breast and cervical cancer project.

(B) Rules 5160:1-5-02 to 5160:1-5-02.4 of the Administrative Code set forth the eligibility requirements for participation in the breast and cervical cancer project. The Breast and Cervical Cancer Prevention and Treatment Act of 2000 (BCCPTA), in accordance with Pub. L. No. 106-354 and 42 U.S.C. 1396a(a)(10)(A)(ii) (as in effect October 1, 2024), authorizes an optional category of medicaid to provide full medical assistance benefits to certain individuals who need treatment for breast or cervical cancer, breast or cervical pre-cancerous conditions, and/or breast or cervical early stage cancer. The goals of the BCCPTA are as follows:

(1) To improve access to needed breast and cervical cancer treatment for uninsured individuals identified under the national breast and cervical cancer early detection program as needing such treatment;

(2) To facilitate the prompt enrollment in medical assistance and immediate access to services for individuals who are in need of treatment for breast or cervical cancer;

(3) To ensure that needed treatment begins as early as possible; and

(4) To coordinate activities between medicaid and public health agencies, including but not limited to application procedures and case management.

Last updated June 2, 2025 at 8:01 AM

History

Effective: June 1, 2025
Promulgated Under: 111.15

Ohio Adm.Code 5160:1-5-02.1 Medicaid: breast and cervical cancer project (BCCP) definitions.

(A) This rule contains definitions generally used for BCCP.

(B) Definitions.

(1) "Breast and Cervical Cancer Project (BCCP) medicaid" means the category of medicaid for qualified individuals in need of treatment for breast or cervical cancer, including pre-cancerous conditions and early stage cancer. BCCP medicaid is administered by the Ohio department of medicaid (ODM) in coordination with the Ohio department of health (ODH).

(2) "Breast or cervical cancer diagnosis", for the purpose of BCCP medicaid, means that a treating health professional has made a general determination that breast or cervical cancer(s) or pre-cancerous condition(s) exist(s). For the purposes of BCCP medicaid, breast or cervical cancer diagnosis does not require the determination of the specific stage or grade of cancer or pre-cancerous conditions.

(a) "Breast or cervical cancer diagnosis" includes metastasized cancer known or presumed by a treating health professional as a complication of breast or cervical cancer.

(b) "Date of diagnosis" is the date of the screening or diagnostic service which the treating health professional utilized to determine the individual's breast or cervical cancer diagnosis.

(c) "Pre-cancerous" means a condition, which, if left untreated is known or presumed by a treating health professional to develop into cancer.

(3) "Centers for Disease Control and Prevention (CDC) Title XV grantee" means an entity receiving funds under a cooperative agreement with the CDC to support activities related to the national breast and cervical cancer early detection program.

(4) "Individual", for the purpose of BCCP medicaid, means a man or woman in need of or receiving treatment for breast or cervical cancer, breast or cervical pre-cancerous conditions, and/or breast or cervical early stage cancer or eligible for BCCP medicaid.

(5) "The National Breast and Cervical Cancer Early Detection Program (NBCCEDP)" means the program of the CDC established under Title XV of the Public Health Service Act, and the Breast and Cervical Cancer Mortality Prevention Act of 1990 (Pub. L. No. 101-354).

(6) "The Ohio Department of Health Breast and Cervical Cancer Project (ODH BCCP)" means NBCCEDP funded by the CDC and administered by the Ohio department of health (ODH).

(a) "ODH BCCP breast and cervical cancer screening provider" means an entity which has entered into a written agreement with the ODH BCCP to provide specified breast and cervical cancer screening and diagnostic services for ODH BCCP enrollees.

(b) "ODH BCCP designated local agency or subgrantee" means an entity which has received a grant from ODH to implement specified activities of the ODH BCCP.

(c) "ODH BCCP enrollee" means an individual determined by ODH BCCP, or its designated local agencies or subgrantees, to meet the eligibility requirements (e.g., age and income) for participation in the ODH BCCP.

(d) "ODH BCCP regional case manager" means an individual who determines an individual's eligibility for BCCP, enrolls individuals, schedules services with health care providers, and provides case management to individuals.

(7) "Screened for breast or cervical cancer under NBCCEDP" means that a breast or cervical cancer screening was provided, in full or in part, by CDC Title XV funds or was provided by any other provider/entity which ODH elects to accept as providing screening activities for ODH BCCP.

(a) For the purposes of BCCP medicaid, breast or cervical cancer screening includes diagnostic test(s) following a breast or cervical cancer screening.

(b) For the purposes of BCCP medicaid, case management services provided by a CDC Title XV grantee are not considered breast or cervical cancer screening.

(8) "Treatment" means the provision of medical services to control, minimize, or eliminate cancer or pre-cancerous cells of the breast or cervix. "Treatment" includes the provision of hormonal therapies to prevent recurrence of cancer following breast cancer surgery, radiation, and/or chemotherapy. Monitoring services alone (e.g., Papanicolaou smears, pelvic examinations, clinical breast examinations, mammograms) for recurrence or new primary cancers are not considered treatment.

(a) "Needs treatment" means that according to a written certification by the individual's treating health professional, which is documented by the ODH BCCP, a breast or cervical cancer screening indicates that the individual is in need of treatment for breast or cervical cancer. Individuals who are determined to require only monitoring services (e.g., Papanicolaou smears, pelvic examinations, clinical breast examinations, mammograms) are not considered to need treatment.

(b) "No longer receives treatment for breast or cervical cancer" means:

(i) The individual's course of treatment of breast or cervical cancer is completed, or

(ii) The individual chooses to delay or decline available treatment options.

(c) "Treating health professional" means an individual licensed to provide breast or cervical cancer diagnosis and/or treatment services.

(d) "Treatment period" means the period of time, according to a written certification by the individual's treating health professional, needed for the completion of treatment of the individual's breast or cervical cancer or pre-cancerous condition. A treatment period lasting more than twelve months from initial eligibility requires both a review of continuing medicaid eligibility and verification of need for continued treatment.

(9) "Uninsured" means not having creditable coverage for health care services.

(a) For the purposes of determining eligibility under BCCP medicaid, the following are considered creditable coverage:

(i) Health insurance benefits consisting of medical care (provided directly, through insurance or reimbursement, or otherwise, and including items and services paid for as medical care) under any hospital or medical service policy or certificate, hospital or medical service plan contract;

(ii) Health maintenance organization contract offered by a health insurance issuer;

(iii) Medicare, parts A or B; and,

(iv) Medicaid.

(b) For the purposes of determining eligibility under BCCP medicaid, creditable coverage does not include:

(i) Limited scope coverage such as those which only cover dental, vision, or long-term care;

(ii) Coverage for only a specified disease or illness; or

(iii) Coverage which excludes treatment for breast or cervical cancer, including situations whereby a period of exclusion has been applied, such as for a pre-existing condition, or the individual has exhausted the health insurance plan's covered benefits.

Last updated July 29, 2025 at 10:10 PM

History

Effective: June 1, 2025
Promulgated Under: 111.15

Ohio Adm.Code 5160:1-5-02.2 Medicaid: breast and cervical cancer project (BCCP): eligibility requirements.

(A) This rule describes the eligibility criteria for BCCP medicaid.

(B) An individual shall meet all of the following criteria to be eligible for BCCP medicaid:

(1) Be screened for breast or cervical cancer under the national breast and cervical cancer early detection program (NBCCEDP).

(a) An individual is not required to obtain screening for both breast and cervical cancer as a condition of eligibility for participation in the NBCCEDP.

(b) Individuals screened for breast or cervical cancer under the NBCCEDP in a state other than Ohio must be determined eligible for the Ohio department of health (ODH) BCCP and must utilize the ODH BCCP case management services and Ohio's BCCP medicaid application process as outlined in rule 5160:1-5-02.4 of the Administrative Code.

(c) Individuals determined eligible for ODH BCCP who have been screened for breast or cervical cancer by a provider who does not participate in, or was not paid for by ODH BCCP are still considered to be screened under NBCCEDP.

(2) Be in need of treatment for breast or cervical cancer, precancerous conditions, or early stage cancer, as indicated by a treating health professional, based on the centers for disease control and prevention (CDC) NBCCEDP screening.

(3) Be uninsured as defined in rule 5160:1-5-02.1 of the Administrative Code.

(4) Must not meet the eligibility criteria of any other medicaid program described in Chapters 5160:1-3, 5160:1-4, 5160:1-5, and 5160:1-6 of the Administrative Code.

(5) Be under sixty-five years of age.

(6) Meet all other non-financial eligibility requirements applicable to medicaid applicants described in Chapters 5160:1-1 and 5160:1-2 of the Administrative Code.

(C) Effective date of BCCP medicaid. As defined in rule 5160:1-2-01 of the Administrative Code, the effective date is the first day of the month that the Ohio department of medicaid (ODM) receives an application for BCCP medicaid and the individual meets all eligibility requirements described in this rule.

(1) Retroactive eligibility shall be explored as described in rule 5160:1-2-01 of the Administrative Code.

(2) The first month of BCCP medicaid coverage may be a partial month of coverage based on the date of diagnosis of breast or cervical cancer, pre-cancerous conditions, or early stage cancer. "Date of diagnosis" is defined in rule 5160:1-5-02.1 of the Administrative Code.

(D) BCCP medicaid shall be discontinued:

(1) When the individual no longer meets one or more of the eligibility criteria for BCCP medicaid described in this rule.

(2) When a finding is made that the individual was determined eligible for ODH BCCP when such determination was made in error and ODH BCCP eligibility did not exist.

(3) When a finding is made that the individual was not screened for breast or cervical cancer under NBCCEDP.

(4) When the individual no longer receives treatment for breast or cervical cancer, pre-cancerous conditions, or early stage cancer. "Treatment" and "no longer receives treatment for breast or cervical cancer" are defined in rule 5160:1-5-02.1 of the Administrative Code.

(5) When the treatment period has ended and ODM has not received the required documents with verification of continued need for treatment.

(a) ODM may presume that an individual is receiving treatment for the duration of the treatment period.

(b) A treatment period lasting more than twelve months from the beginning month of BCCP eligibility requires ODM to perform a review of the individual's continuing BCCP medicaid eligibility, in accordance with rule 5160:1-5-02.4 of the Administrative Code.

(6) When the individual obtains creditable health coverage as defined in rule 5160:1-5-02.1 of the Administrative Code.

(7) When the individual reaches sixty-five years of age.

(8) When the individual meets eligibility criteria of any other category of medical assistance. When the individual is determined eligible for any other category of medical assistance, the last day of BCCP medicaid coverage will be the last day of the month prior to the month the new category of medical assistance begins.

(9) When the individual fails to cooperate with the eligibility determination or renewal process, including the determination of eligibility for other categories of medical assistance.

(a) To facilitate immediate access to services for individuals who are in need of treatment for breast or cervical cancer, BCCP medicaid coverage shall be approved for a period of time while an eligibility determination for other categories of medical assistance is conducted.

(b) When the individual fails to cooperate with the determination of eligibility for other categories of medical assistance as required, the last day of BCCP medicaid coverage will be the last day of the month following the month in which eligibility for BCCP medicaid coverage was approved, in accordance with paragraph (D)(9)(a) of this rule.

(E) ODH or its designated local agencies or subgrantees shall:

(1) Determine the individual eligible for the ODH BCCP.

(2) Screen for all other medical assistance categories before determining the individual eligible for ODH BCCP.

(F) ODM shall:

(1) Screen all BCCP medicaid applicants for potential eligibility in other medical assistance categories as described in rule 5160:1-5-02.4 of the Administrative Code.

(2) Require BCCP medicaid applicants to provide information regarding income and/or resources to screen the applicant for potential eligibility for other medical assistance categories.

(3) Not provide BCCP medicaid coverage, including retroactive coverage, for any period of time preceding the date of diagnosis of breast or cervical cancer, pre-cancerous conditions, or early stage cancer.

(G) Individuals who do not meet citizenship or immigration status eligibility requirements may be eligible for coverage for an emergency medical condition as described in rule 5160:1-5-06 of the Administrative Code.

Last updated June 2, 2025 at 8:02 AM

History

Effective: June 1, 2025
Promulgated Under: 111.15

Ohio Adm.Code 5160:1-5-02.4 Medicaid: breast and cervical cancer project (BCCP): application and renewal process.

(A) This rule describes the application and renewal process for the breast and cervical cancer project (BCCP).

(B) The BCCP medicaid application and renewal process shall:

(1) Be coordinated between the Ohio department of medicaid (ODM), Ohio department of health (ODH) BCCP, and ODH BCCP designated local agencies and/or subgrantees,

(2) Be coordinated with ODH BCCP case management services, and

(3) Support the goals of the Breast and Cervical Cancer Prevention and Treatment Act of 2000 (BCCPTA) (Pub. L. No. 106-354), identified in rule 5160:1-5-02 of the Administrative Code.

(C) ODH BCCP and its designated local agencies or subgrantee(s) responsibilities. The ODH BCCP and its designated local agencies or subgrantee(s) shall:

(1) Provide the ODM 07161 "Ohio Breast and Cervical Cancer Project (BCCP) Medicaid Application" (rev. 9/2017) to ODH BCCP enrollees screened for breast or cervical cancer under the centers for disease control and prevention's (CDC) national breast and cervical cancer early detection program (NBCCEDP) and referred for breast or cervical cancer diagnostic evaluation.

(2) Provide the ODM 07161 to ODH BCCP enrollees screened for breast or cervical cancer under the CDC NBCCEDP who are receiving treatment for breast or cervical cancer, pre-cancerous conditions, or early stage cancer.

(3) Notify in writing ODH BCCP enrollees described in paragraphs (C)(1) and (C)(2) of this rule to return the completed ODM 07161 to the designated ODH BCCP regional case manager.

(D) ODH BCCP regional case manager responsibilities.

(1) The application process. The ODH BCCP regional case manager shall:

(a) Provide to ODM the completed ODM 07161 and ODM 7160 "Healthcare Provider's Treatment Plan" (rev. 9/2017) within five business days of receipt of the diagnostic information when:

(i) The ODH BCCP enrollee has submitted the ODM 07161; and

(ii) The ODH BCCP screening provider notifies the designated ODH BCCP regional case manager that, as a result of the screening, a treating health professional has determined the ODH BCCP enrollee needs treatment for breast or cervical cancer, pre-cancerous conditions, or early stage cancer.

(b) Notify the ODH BCCP enrollee in writing within five business days of the receipt of the diagnostic information, that the ODM 07161 must be submitted to the designated ODH BCCP regional manager when:

(i) The enrollee has not submitted the ODM 07161; and

(c) Notify the ODH BCCP enrollee in writing within five business days that the ODM 07161 will not be submitted to ODM when:

(i) The ODH BCCP enrollee submits the ODM 07161; and

(ii) The diagnostic results indicate that the ODH BCCP enrollee does not need treatment for either breast or cervical cancer, pre-cancerous conditions, or early stage cancer.

(2) The renewal process. The ODH BCCP regional case manager shall:

(a) Provide to ODM the completed ODM 07160 within five business days of receipt of notification from the treating health professional when the individual has been found to need continued treatment for either breast or cervical cancer, pre-cancerous conditions, or early stage cancer.

(b) Notify the individual in writing within five business days that the ODM 07160 will not be submitted to ODM when the treating health professional notifies the designated ODH BCCP case manager the individual has been found to not need continued treatment for either breast or cervical cancer, pre-cancerous conditions, or early stage cancer.

(E) ODM responsibilities. ODM shall:

(1) Make available to ODH BCCP and its designated local agencies or subgrantees the ODM 07161 and ODM 07160.

(2) Be responsible for all determinations of BCCP medicaid eligibility, including retroactive eligibility.

(3) Use available sources of information in the eligibility determination including:

(a) Information contained in the ODM 07160 and ODM 07161; and

(b) Information in the case record to determine whether the individual is currently enrolled in medical assistance or has a pending application for medical assistance.

(4) Use the eligibility criteria set forth in rule 5160:1-5-02.2 of the Administrative Code.

(5) Complete all determinations of eligibility within forty-five days of receipt of a completed ODM 07161 or medical assistance renewal form.

(a) A delay in the eligibility determination or renewal shall not be a basis for granting eligibility; and

(b) An application pending for more than forty-five days shall not be the sole basis for denial.

(6) Renew BCCP medicaid eligibility:

(a) Prior to the completion of the lesser of:

(i) The individual's treatment period; or

(ii) Twelve months continuous eligibility in BCCP medicaid.

(b) When ODM receives an ODM 07160 indicating a change in the individual's circumstances, including completion of treatment prior to the original determined treatment period.

(d) When the individual turns sixty-five years of age.

(7) Provide written notice to the BCCP medicaid recipient:

(a) That information is required for the determination of BCCP medicaid eligibility, and

(b) To return required completed renewal materials to the county department of job and family services (CDJFS).

(F) Individual responsibilities. The individual shall:

(1) Submit a completed ODM 07161 to the designated ODH BCCP regional case manager.

(2) Cooperate with ODM in the application and renewal processes, as described in rule 5160:1-2-08 of the Administrative Code.

(G) An individual may apply for a new period of BCCP medicaid eligibility after BCCP medicaid discontinuance.

(1) A period of BCCP medicaid eligibility shall begin each time an individual:

(a) Is screened for breast or cervical cancer under the CDC NBCCEDP, and

(b) Is found, as a result of the CDC NBCCEDP screening, to need treatment of breast or cervical cancer, pre-cancerous conditions, or early stage cancer, and

(d) Is determined by ODM to meet all eligibility criteria for BCCP medicaid as described in rule 5160:1-5-02.2 of the Administrative Code.

(2) Individuals who have completed a treatment period, have had their BCCP medicaid eligibility discontinued, and subsequently have been found to have new, recurrent, or metastasized breast or cervical cancer, pre-cancerous conditions, or early stage cancer:

(a) Shall be recertified as eligible for the ODH BCCP to reestablish BCCP medicaid eligibility; and

(b) Shall submit a new ODM 07161 to reestablish BCCP medicaid eligibility.

(3) Individuals who have not completed their treatment period, have had their BCCP medicaid eligibility discontinued, and have been found to have new, recurrent, or metastasized breast or cervical cancer:

(a) Do not need to be recertified as eligible for the ODH BCCP to reestablish BCCP medicaid eligibility; and

(b) Shall submit a new ODM 07161 to reestablish BCCP medicaid eligibility.

(H) Screening for potential eligibility for other medical assistance categories by ODM and/or the CDJFS at application and renewal.

(1) When information on the ODM 07161 or medical assistance renewal form indicates the individual is not potentially eligible for any other medical assistance category, income and asset information is not needed and ODM shall determine eligibility for BCCP medicaid.

(2) When information on the ODM 07161 or medical assistance renewal form indicates the individual is potentially eligible for any other medical assistance categories, the individual shall provide income and asset information to screen for eligibility for other medical assistance categories.

(a) When income or asset information indicates the individual does not appear eligible for any other medical assistance category, no additional income or asset information is needed and ODM shall determine eligibility for BCCP medicaid.

(b) When income or asset information indicates the individual appears eligible for any other medical assistance category, the individual shall be:

(i) Notified of potential eligibility;

(ii) Given instructions for submission of additional information required to make a determination of eligibility for other medical assistance categories; and

(iii) Notified by the CDJFS in writing to complete and submit additional information required to the CDJFS in the individual's county of residence.

(a) When the CDJFS determines the applicant eligible for any other category of medical assistance, the CDJFS will discontinue BCCP medicaid in accordance with paragraph (D)(8) of rule 5160:1-5-02.2 of the Administrative Code and approve the category for which the individual is eligible.

(b) When the CDJFS determines the individual ineligible for any other medical assistance category, the CDJFS will notify ODM and ODM will maintain the BCCP medicaid case.

Last updated June 2, 2025 at 8:02 AM

History

Effective: June 1, 2025
Promulgated Under: 111.15

Ohio Adm.Code 5160:1-5-03 Medicaid: medicaid buy-in for workers with disabilities (MBIWD).

(A) This rule governs the eligibility requirements for the medical assistance programs authorized under sections 1902(a)(10)(A)(ii)(XV) and (XVI) of the Social Security Act (as in effect October 1, 2025). Medicaid buy-in for workers with disabilities (MBIWD) enables certain individuals to increase their income and resources without the risk of losing medical assistance coverage.

(B) Definitions.

(1) "Basic covered group" means the individuals meeting all criteria in paragraph (C)(1) of this rule.

(2) "Countable income," for the purpose of this rule, means total monthly income less exclusions.

(3) "Countable resources," for the purpose of this rule, means those resources remaining after all exclusions have been applied.

(4) "Income," for the purpose of this rule, means gross monthly earned income and gross monthly unearned income.

(5) "Individual," for the purpose of this rule, means the applicant for or recipient of MBIWD.

(6) "Individual with a medically improved disability" means an individual who is a recipient of MBIWD in the basic covered group but who no longer meets the disability criterion as defined in paragraph (C)(1)(b) of this rule.

(7) "Medicaid buy-in for workers with disabilities (MBIWD)" means the component of the medicaid program established under sections 5163.09 to 5163.098 of the Revised Code and includes the basic covered group and the medically improved covered group.

(8) "Medically improved covered group" means the individuals meeting all criteria in paragraph (C)(2) of this rule.

(9) "Resource eligibility limit for MBIWD" means countable resources limited to the amount specified under section 5163.092 of the Revised Code.

(10) "Social security disability insurance (SSDI)" means the program established under Title II of the Social Security Act (as in effect October 1, 2025).

(11) "Supplemental security income (SSI)" means the program established under Title XVI of the Social Security Act (as in effect October 1, 2025).

(12) "Work" or "working," for the purpose of this rule, means full- or part-time employment or self-employment from which state or federal income and payroll taxes are paid or withheld.

(1) To be eligible for the MBIWD basic covered group an individual must:

(a) Meet the conditions of eligibility described in rule 5160:1-2-10 of the Administrative Code;

(b) Meet the definition of disability used by the social security administration (SSA), except that employment, earnings, and substantial gainful activity must not be considered when determining whether the individual meets the disability criterion for MBIWD. An individual may be eligible for MBIWD regardless of whether the individual is receiving SSI or SSDI;

(d) Meet the financial eligibility requirements described in paragraph (D) of this rule; and

(e) Be working.

(2) To be eligible for the MBIWD medically improved covered group an individual must:

(a) Have participated in the MBIWD basic covered group as defined in paragraph (C)(1) of this rule the previous calendar month and continue to meet all eligibility criteria described in paragraph (C) of this rule except that the individual no longer meets the disability criterion defined in paragraph (C)(1)(b) of this rule; and

(b) Work at least forty hours per month earning at least state or federal minimum wage, whichever is lower.

(3) An individual participating in MBIWD with a medically improved disability, whose medical condition is determined to have regressed may be reevaluated for the MBIWD basic covered group in accordance with paragraph (C)(1) of this rule.

(4) When the individual is eligible for MBIWD under the basic or medically improved group and ceases to work, the individual may continue to participate in MBIWD for up to six months beginning the first day of the month after the month the individual is no longer working when:

(a) The individual intends to return to work or look for a new job; and

(b) The individual continues to meet all other eligibility requirements for MBIWD.

(D) Financial eligibility.

(1) For the purpose of determining whether an individual is income eligible for MBIWD, the administrative agency must compare the individual's countable income to two hundred fifty per cent of the federal poverty level (FPL) for one person. Only the individual's income is considered when determining eligibility for MBIWD.

(a) From the individual's income, apply exclusions in accordance with rule 5160:1-3-03.2 of the Administrative Code, then round down to the nearest whole dollar.

(b) When the amount determined in paragraph (D)(1)(a) of this rule is no more than two hundred fifty per cent of the FPL, the individual meets the income eligibility requirement for MBIWD.

(i) An additional annual amount up to twenty thousand dollars of earned income shall be excluded.

(ii) The twenty thousand dollar earned income exclusion may be applied wholly or in part in any month to reduce the individual's countable income to no more than two hundred fifty per cent of the FPL. This exclusion begins the first month the individual would otherwise be eligible for MBIWD except for income and continues within a twelve-month period until the twenty thousand dollars is exhausted.

(2) For the purpose of determining whether an individual meets the resource eligibility requirement for MBIWD, an individual's countable resources must not exceed the resource eligibility limit for MBIWD as defined in paragraph (B) of this rule.

(a) Only the individual's resources are considered when determining resource eligibility for MBIWD. In the case of resources which are jointly owned, the administrative agency must consider the total amount of the resource available to the individual in accordance with rule 5160:1-3-05.1 of the Administrative Code.

(b) For the purpose of determining resource eligibility for MBIWD, resources are excluded in accordance with rule 5160:1-3-05.14 of the Administrative Code.

(E) Receipt of long-term care services, as defined in rule 5160:1-6-01.1 of the Administrative Code, is not a cause for discontinuance or denial of an individual's eligibility for MBIWD.

(F) Individuals eligible for MBIWD are not subject to a patient liability as described in rule 5160:1-6-07 or 5160:1-6-07.1 of the Administrative Code.

(G) Administrative agency responsibilities. The administrative agency shall:

(1) Determine eligibility for MBIWD as described in this rule.

(2) Verify the individual's disability in accordance with paragraph (C)(1)(b) of this rule.

(3) Explore eligibility for qualified medicare beneficiary (QMB) and specified low-income medicare beneficiary (SLMB) programs in accordance with rule 5160:1-3-02.1 of the Administrative Code. MBIWD individuals are not eligible for the qualified individual (QI-1) or qualified disabled and working individuals (QDWI) medicare premium assistance programs.

(H) Individual responsibilities. The individual shall provide the information necessary to establish eligibility, cooperate with the verification process, and report changes in accordance with rule 5160:1-2-08 of the Administrative Code.

Last updated April 1, 2026 at 8:30 AM

History

Effective: April 1, 2026
Promulgated Under: 111.15

Ohio Adm.Code 5160:1-5-04 Medicaid: Ohio workability.

(A) This rule governs the eligibility requirements for the medical assistance program authorized under section 1902(a)(10)(A)(ii)(XIII) of the Social Security Act (as in effect October 1, 2025). Ohio workability enables certain working disabled individuals aged sixty-five or older to increase their income and resources without the risk of losing medical assistance coverage.

(B) Definitions.

(1) "Countable income," for the purpose of this rule, means total monthly income less exclusions.

(2) "Countable resources," for the purpose of this rule, means those resources remaining after all exclusions have been applied.

(3) "Income," for the purpose of this rule, means gross monthly earned income and gross monthly unearned income.

(4) "Individual," for the purpose of this rule, means the applicant for or recipient of Ohio workability.

(5) "Ohio workability" means the component of the medicaid program established under section 5163.063 of the Revised Code.

(6) "Resource eligibility limit for Ohio workability" means countable resources limited to fourteen thousand eight hundred forty-eight dollars in calendar year 2024, adjusted annually with the consumer price index for all items for all urban consumers for the previous calendar year (CPI-U), as published by the United States bureau of labor statistics, effective beginning with calendar year 2025.

(7) "Social security disability insurance (SSDI)" means the program established under Title II of the Social Security Act (as in effect October 1, 2025).

(8) "Supplemental security income (SSI)" means the program established under Title XVI of the Social Security Act (as in effect October 1, 2025).

(9) "Work" or "working," for the purpose of this rule, means employment or self-employment from which state or federal income and payroll taxes are paid or withheld.

(1) Meet the conditions of eligibility described in rule 5160:1-2-10 of the Administrative Code;

(2) Meet the definition of disability used by the social security administration (SSA), except that employment, earnings, and substantial gainful activity must not be considered when determining whether the individual meets the disability criterion for Ohio workability. An individual may be eligible for Ohio workability regardless of whether the individual is receiving SSI or SSDI;

(3) Be at least sixty-five years of age;

(4) Meet the financial eligibility requirements described in paragraph (D) of this rule; and

(5) Be working.

(D) Financial eligibility.

(1) For the purpose of determining whether an individual is income eligible for Ohio workability, the administrative agency must compare the individual's countable income to two hundred fifty per cent of the federal poverty level (FPL) for one person. Only the individual's income is considered when determining eligibility for Ohio workability.

(a) From the individual's income, apply exclusions in accordance with rule 5160:1-3-03.2 of the Administrative Code, then round down to the nearest whole dollar.

(b) When the amount determined in paragraph (D)(1)(a) of this rule is no more than two hundred fifty per cent of the FPL, the individual meets the income eligibility requirement for Ohio workability.

(i) An additional annual amount up to twenty thousand dollars of earned income shall be excluded.

(ii) The twenty thousand dollar earned income exclusion may be applied wholly or in part in any month to reduce the individual's countable income to no more than two hundred fifty per cent of the FPL. This exclusion begins the first month the individual would otherwise be eligible for Ohio workability except for income and continues within a twelve-month period until the twenty thousand dollars is exhausted.

(2) For the purpose of determining whether an individual meets the resource eligibility requirement for Ohio workability, an individual's countable resources must not exceed the resource eligibility limit for Ohio workability as defined in paragraph (B) of this rule.

(a) Only the individual's resources are considered when determining resource eligibility for Ohio workability. In the case of resources which are jointly owned, the administrative agency must consider the total amount of the resource available to the individual in accordance with rule 5160:1-3-05.1 of the Administrative Code.

(b) For the purpose of determining resource eligibility for Ohio workability, resources are excluded in accordance with rule 5160:1-3-05.14 of the Administrative Code.

(E) Receipt of long-term care services, as defined in rule 5160:1-6-01.1 of the Administrative Code, is not a cause for discontinuance or denial of an individual's eligibility for Ohio workability.

(F) Individuals eligible for Ohio workability are not subject to a patient liability as described in rule 5160:1-6-07 or 5160:1-6-07.1 of the Administrative Code.

(G) Administrative agency responsibilities. The administrative agency shall:

(1) Determine eligibility for Ohio workability as described in this rule.

(2) Verify the individual's disability in accordance with paragraph (C)(2) of this rule.

(3) Explore eligibility for qualified medicare beneficiary (QMB) and specified low-income medicare beneficiary (SLMB) programs in accordance with rule 5160:1-3-02.1 of the Administrative Code. Ohio workability individuals are not eligible for the qualified individual (QI-1) or qualified disabled and working individuals (QDWI) medicare premium assistance programs.

Last updated April 1, 2026 at 8:30 AM

History

Effective: April 1, 2026
Promulgated Under: 111.15

Ohio Adm.Code 5160:1-5-05 Medicaid: refugee medical assistance (RMA).

(A) This rule describes a time-limited medical assistance program, funded through the office of refugee resettlement (ORR), that provides a medical screening through contracted refugee health screening providers and other medical services. There is no resource limit for an individual described in this rule.

(B) Definitions.

(1) "Countable income," for the purpose of this rule, has the same meaning as in rule 5160:1-3-03.2 of the Administrative Code.

(2) "Current incurred medical expense," for the purpose of this rule, means a medical bill or a portion of a medical bill that:

(a) Includes:

(i) A medically necessary medical item or service provided to the individual or to the individual's family member during the month for which the individual is seeking to obtain RMA eligibility through the spenddown process;

(ii) An expense the individual or family member is liable to pay, regardless of whether the individual or family member has already paid it; and

(iii) A transportation expense, as defined in paragraph (B)(14) of this rule, incurred by the individual or family member during the month for which the individual is seeking to obtain RMA eligibility through the spenddown process.

(b) Does not include:

(i) An expense that has already been used in the spenddown process as a basis for approving RMA eligibility for any individual; or

(ii) An expense the individual or family member has not yet incurred for a medical item or service because it has not yet been provided.

(3) "Derivative T visa," for the purpose of this rule, means either a T-2, T-3, T-4, or T-5 visa issued to certain family members of victims of a severe form of trafficking who may be eligible for RMA benefits when the visa holder meets refugee program eligibility requirements.

(4) "Family member," for the purpose of this rule:

(a) For an individual of any age, means:

(i) The individual's spouse or deceased spouse, unless a court has eliminated the individual's duty of medical support to such spouse;

(ii) The individual's natural or adopted child under the age of eighteen, including a deceased child, unless a court has eliminated the individual's duty of medical support to such child; and

(iii) The individual's former spouse, including a deceased former spouse, provided the individual has a duty of medical support to the former spouse.

(b) For an individual under age eighteen, also includes:

(i) The individual's natural or adoptive parent, unless a court has eliminated such parent's duty of medical support to the individual;

(ii) The individual's sibling (including half-sibling) under the age of eighteen, who lives with the individual;

(iii) The individual's deceased parent, provided the surviving parent who lives with the individual had a duty of medical support to the deceased parent at the time of his or her death; and

(iv) The individual's deceased sibling (including half-sibling) provided the deceased sibling lived with the individual at the time of his or her death, and a parent who lives with the individual had a duty of medical support to the deceased sibling at the time of his or her death.

(5) "Income," for the purpose of this rule, is determined in the same way as defined in rule 5160:1-3-03.1 of the Administrative Code.

(6) "Incurred," for the purpose of this rule, means that the individual or family member has become liable to pay a medical bill as defined in paragraph (B)(8) of this rule. An expense is incurred on the date liability for the expense arises.

(7) "Individual," for the purpose of this rule, means an applicant for or a recipient of RMA who is not a United States (U.S.) citizen and meets one of the following definitions of immigration status under the Immigration and Nationality Act (INA) (as in effect October 1, 2024), as verified by documentation issued by the U.S. department of state, U.S. department of homeland security, or U.S. department of justice:

(a) Paroled as a refugee or asylee under section 212(d)(5) of the INA (as in effect October 1, 2024);

(b) Admitted to the U.S. as a refugee under section 207 of the INA (as in effect October 1, 2024);

(d) A Cuban or Haitian entrant in accordance with requirements in 45 C.F.R. part 401 (as in effect October 1, 2024);

(e) An Amerasian from Vietnam who is admitted to the U.S. as an immigrant pursuant to section 584 of the Foreign Operations, Export Financing, and Related Programs Appropriations Act of 1988 (as contained in section 101(e) of Pub. L. No. 100-202), and amended by the 9th proviso under migration and refugee assistance in title II of the Foreign Operations, Export Financing, and Related Programs Appropriations Act, 1989 (Pub. L. No. 100-461, as amended);

(f) A victim of a severe form of trafficking as identified in 22 U.S.C. 7105(b)(1) (as in effect October 1, 2024) and certain family members, as identified in the Trafficking Victims Protection Reauthorization Act of 2003 (TVPRA) (Pub. L. No. 108-193). A victim of a severe form of trafficking is awarded a certification letter from ORR and is potentially eligible for RMA as described in 28 C.F.R. 1100.33 (as in effect October 1, 2024). Certain family members are awarded "Derivative T" visas and are potentially eligible for RMA; or

(g) Admitted as an Afghan or Iraqi special immigrant under section 101(a)(27) of the INA (as in effect October 1, 2024).

(8) "Medical bill," for the purpose of this rule, means an invoice for a medically necessary medical item or service provided to the individual or family member.

(9) "Medical insurance premiums," for the purpose of this rule, means the amount paid for insurance coverage for medical items or services such as health, dental, vision, long-term care, hospital, prescriptions, etc.

(10) "Medically necessary," for the purpose of this rule, has the same meaning as in rule 5160-1-01 of the Administrative Code.

(a) Medical insurance premiums as defined in paragraph (B)(9) of this rule are always considered medically necessary.

(b) The administrative agency may generally accept that medical expenses and bills submitted in the spenddown process are for items or services that were medically necessary. In an unusual situation, the administrative agency may question whether an item or service was medically necessary. In such a situation, the administrative agency will need to determine whether the item or service was medically necessary by following these steps:

(i) Contact the individual and assist the individual with gathering relevant information from the medical provider and other appropriate persons about the medical necessity of the item or service.

(ii) When the medical provider of the item or service indicates the item or service was not medically necessary, the administrative agency shall not use the expense for that item or service in the spenddown process.

(iii) When the medical provider of the item or service indicates the item or service was medically necessary, the administrative agency may use the expense for that item or service in the spenddown process in accordance with the other provisions of this rule. When the administrative agency questions the provider's statement regarding medical necessity, the administrative agency must ask the prior authorization unit (PAU) of the Ohio department of medicaid (ODM) to determine whether the item or service was medically necessary.

(iv) When the PAU determines the item or service was medically necessary, the administrative agency must use the expense for that item or service in the spenddown process in accordance with the other provisions of this rule. The PAU decision is for the sole purpose of determining whether the item or service was medically necessary. The PAU decision is not for the purpose of determining whether to prior authorize the item or service under rule 5160-1-31 of the Administrative Code, nor for the purpose of determining whether the item or service is payable by the medical assistance program.

(v) When the PAU determines the item or service was not medically necessary, the administrative agency shall not use the expense for that item or service in the spenddown process.

(11) "RMA need standard," for the purpose of this rule, means one hundred per cent of the federal poverty level (FPL) based on family size.

(12) "Spenddown amount," for the purpose of this rule, means the dollar amount by which the individual's countable income exceeds the applicable RMA need standard. The individual must satisfy the spenddown amount in accordance with paragraph (F) of this rule in order to become eligible for RMA for all or part of a given calendar month.

(13) "Subject to the spenddown process," for the purpose of this rule, means the individual:

(a) Has countable monthly income that exceeds the RMA need standard; and

(b) Is otherwise eligible for RMA.

(14) "Transportation expense," for the purpose of this rule, means a reasonable expense incurred by the individual or family member for transportation that is needed to obtain a medically necessary item or service.

(a) Transportation expenses include but are not limited to the following:

(i) Charges for public transportation;

(ii) Expenses related to the transportation such as parking fees and tolls;

(iii) The state mileage reimbursement rate as set by the Ohio office of budget and management for the use of a private motor vehicle owned by the individual or a family member, in effect on the date of travel;

(iv) The actual expense incurred by the individual or family member for transportation by a private motor vehicle not owned by the individual or family member;

(v) Overnight lodging expenses when overnight travel is needed to obtain the medical item or service;

(vi) Actual expenses for meals, up to thirty dollars per person per day, when overnight travel is required;

(vii) Attendant care costs and/or the costs of a companion when a medical provider verifies that an attendant and/or companion is required due to the age and/or physical or mental condition of the individual or family member; and

(viii) Expenses related to delivering a medical service or item to the individual or family member.

(b) Transportation expenses do not include the following:

(i) The cost of transportation provided to the individual or family member through county-administered transportation assistance;

(ii) Any transportation expenses excluded from income as an "impairment-related work expense" (IRWE) as described in 20 C.F.R. 404.1576 (as in effect October 1, 2024); or

(iii) Any transportation expense excluded from earned income as a "blind work expense" as defined in rule 5160:1-3-03.2 of the Administrative Code.

(c) The administrative agency may generally accept that transportation expenses submitted in the spenddown process are for transportation that was needed to obtain a medically necessary item or service and that the cost is reasonable. When the administrative agency questions whether a transportation expense was needed and/or reasonable, the administrative agency will need to determine whether the expense was needed and/or reasonable by following these steps:

(i) Contact the individual and assist the individual with gathering relevant information from the medical provider and other appropriate persons concerning all of the relevant circumstances including the following:

(a) The age, physical and mental condition, and transportation needs of the individual;

(b) The medical item or service for which the individual needed the transportation;

(d) The reasonableness of the expense based on the circumstances; and

(e) Any other relevant factors.

(ii) After considering all of the listed factors, when the administrative agency determines that the expense or a portion of the expense was not needed and/or not reasonable, the administrative agency shall not use the expense in the spenddown process.

(15) "Unpaid past medical expense" (UPME), for the purpose of this rule, means a medical bill or a portion of a medical bill, as defined in paragraph (B)(8) of this rule, that:

(a) Is still owed, and is not subject to payment by a third party who is legally obligated to pay the bill;

(b) Is not owed to a nursing facility (NF) or intermediate care facility for individuals with intellectual disabilities (ICF-IID) for services provided to a family member; and

(1) The individual shall be neither:

(a) Eligible for another category of medical assistance; nor

(b) A full-time student in an institution of higher education, except where such enrollment is approved by the state, or its designee, as part of an individual employability plan as described in rule 5101:1-2-40.1 of the Administrative Code.

(2) The individual meets the income requirements for RMA when:

(a) The individual's countable income is no more than the RMA need standard, or

(b) The individual whose countable income is more than the RMA need standard spends down countable income to the RMA need standard in accordance with the methods set forth in paragraph (F) of this rule.

(3) Continued eligibility of individuals who receive increased earnings from employment.

(a) Financial eligibility for RMA is based on the individual's income on the date of application.

(b) When an individual receiving RMA has increased earnings from employment, the earnings shall not affect the individual's continued eligibility for RMA.

(c) When an individual who qualified for another category of medical assistance becomes ineligible because of earnings from employment, the individual shall have his or her eligibility transferred to the RMA category without an RMA eligibility determination when the individual:

(i) Meets the non-financial eligibility criteria for RMA; and

(ii) Does not qualify for any other category of medical assistance; and

(iii) Has been residing in the U.S. less than the time-limited eligibility period for RMA as defined in paragraph (D) of this rule.

(d) An individual shall continue to receive RMA until he or she reaches the end of the time-limited eligibility period, as described in 45 C.F.R. 400.104 (as in effect October 1, 2024).

(i) For individuals eligible to receive RMA prior to May 5, 2025, the time limit is twelve months.

(ii) For individuals eligible to receive RMA on or after May 5, 2025, the time limit is four months.

(e) In cases where an individual is covered by employer-sponsored health insurance, any payment of RMA for that individual must be reduced by the amount of the third party payment.

(D) Eligibility period. An individual who meets the eligibility requirements of this rule may receive RMA for a time-limited period not to exceed the applicable time period determined in paragraph (C)(3)(d) of this rule, from the individual's date of entry or from the date status is granted, as listed on the individual's U.S. citizenship and immigration services (USCIS) documentation.

(E) Calculation of spenddown amount. When the individual's countable monthly income, as determined in accordance with rule 5160:1-3-03.1 of the Administrative Code, exceeds the RMA need standard, the administrative agency must calculate the amount, if any, of the monthly spenddown as follows:

(1) Determine the total amount of all monthly medical insurance premiums of the individual and family members. Do not round down. Subtract that amount from the individual's countable monthly income and round down to the nearest whole dollar.

(a) When the result is less than or equal to the applicable RMA need standard, the individual is eligible for RMA for the entire calendar month without any monthly spenddown amount.

(b) When the result is greater than the applicable RMA need standard, continue to paragraph (E)(2) of this rule.

(2) Determine the total amount of the individual's and family members' UPMEs as determined in accordance with paragraph (G)(2) of this rule. Do not round down. Subtract that amount from the result calculated in paragraph (E)(1) of this rule and round down to the nearest whole dollar.

(a) When the result is less than or equal to the applicable RMA need standard, the individual is eligible for RMA for the entire calendar month without any monthly spenddown amount.

(b) When the result is greater than the applicable RMA need standard, the amount that is over the need standard is the individual's monthly spenddown amount. In order to become eligible for RMA for all or part of the calendar month, the individual must satisfy the monthly spenddown amount through one of the methods set forth in paragraph (F) of this rule.

(F) Ways of meeting spenddown. When the individual has a monthly spenddown amount calculated in accordance with paragraph (E) of this rule, the individual may satisfy, or meet, the spenddown through one or more of the following methods, and must do so each calendar month in order to be eligible for RMA:

(1) Incurred. This method is frequently called "delayed spenddown."

(a) At the individual's option, the individual may satisfy spenddown for a calendar month by incurring a dollar amount of current medical expenses, as defined in paragraph (B)(6) of this rule, equal to or greater than the spenddown amount for the calendar month.

(b) An individual is eligible for RMA for a calendar month starting on the date the individual and/or family member(s) incurred the medical expenses that, combined with all other incurred medical expenses for the month, equal or exceed the individual's spenddown amount for the calendar month.

(2) Pay-in.

(a) At the individual's option, the individual may satisfy spenddown for the current calendar month by paying to the administrative agency the dollar amount of the spenddown amount for the current calendar month. When the dollar amount of the spenddown is satisfied, the individual is eligible for RMA for the entire calendar month.

(b) A third party may pay-in on behalf of the individual or a group of individuals subject to spenddown by making payments directly to the administrative agency from the third party's funds or other funds in the current calendar month in which eligibility is being sought. Such payments are not considered income, are not included in the individual's countable monthly income, and do not negatively affect the individual's RMA eligibility.

(c) Pay-in spenddown payments cannot be applied to retroactive months. Pay-in spenddown payments are restricted to payment for current or future calendar month(s) in which RMA eligibility through the spenddown process is being sought.

(3) Combination of methods.

(a) At the individual's option, the individual may meet the spenddown by using the incurred method described in paragraph (F)(1) of this rule for one or more calendar months, and the pay-in method described in paragraph (F)(2) of this rule for one or more other calendar months.

(b) At the individual's option, the individual may meet the spenddown by combining two methods in a single calendar month as follows:

(i) After the individual and/or family member has incurred an amount of current medical expenses for the calendar month that is less than the individual's spenddown amount for the calendar month, the administrative agency permits the individual to pay-in the difference between the current incurred medical expenses and the spenddown amount.

(ii) When the individual does so, the individual is eligible for RMA for the month starting on the date the individual or family member incurred the last current medical expense for the calendar month.

(4) Failure to satisfy spenddown for a calendar month. If the individual does not satisfy spenddown for a calendar month, the individual is not eligible for RMA for the calendar month. The individual may be eligible for a future calendar month in which the individual satisfies spenddown during the time-limited RMA period, not exceeding the applicable time period determined in paragraph (C)(3)(d) of this rule from the individual's date of entry or date status is granted.

(5) Documentation of a met spenddown liability must be submitted to the county department of job and family services (CDJFS) within three hundred sixty-five days of the date of service.

(G) Treatment of expenses.

(1) Treatment of current incurred medical expenses subject to payment by a third party:

(a) When written off by the provider: the expense is treated as a current incurred medical expense for the calendar month in which the item or service was provided.

(b) When paid, or subject to payment, by a third party that is not legally obligated to pay the expense for the individual or family member: the expense is treated as a current incurred medical expense for the calendar month in which the item or service was provided, even when it is paid by the third party later in the same or a subsequent month.

(c) When paid, or subject to payment, by a third party that is legally obligated to pay the expense or a portion of the expense for the individual or family member: the expense is not treated as a current incurred medical expense.

(d) When an agency or program provides a direct medical service based on out-of-pocket limits, or a "sliding" or "ability-to-pay" fee scale, only the amount the individual or family member is liable to pay for the service, including deductibles and co-pays, are treated as current incurred medical expenses.

(2) Treatment of UPMEs. For the purpose of calculating the spenddown amount, the amount of UPME to be subtracted is determined in accordance with this paragraph.

(a) A UPME is considered to have been incurred in the calendar month during which the provider supplied the item or service to the individual or family member.

(b) The individual is not required to pay or provide evidence of paying the UPME for RMA purposes.

(i) Incurred during a calendar month in which the individual or family member receiving the item or service was not eligible for another category of medical assistance.

(ii) Incurred during a calendar month in which the individual did not satisfy the monthly spenddown amount, even with the application of the bill.

(iii) Incurred for a medical item or service not payable under any category of medical assistance, regardless of an individual's eligibility during the calendar month in which the medical expense occurred, because the item or service was:

(a) Not covered by medical assistance;

(b) Supplied by a provider who was not participating in the medical assistance program; or

(d) The administrative agency shall assist the individual with choosing the amount of the UPME to apply, and the calendar month(s) for which to apply it. To assist the individual with making an informed decision, the administrative agency shall determine the minimum number of calendar months for which the UPME might be applied. To make this determination, the administrative agency shall:

(i) Determine the combined total of all the UPMEs of the individual and family members;

(ii) Divide the total UPME by the result calculated in paragraph (E)(1) of this rule;

(iii) The quotient is the minimum number of calendar months the UPME would allow the individual to meet the spenddown amount, assuming no changes in any factor that would affect the calculation of the spenddown amount.

(e) The amount of the UPME the administrative agency must subtract in the calculation of the spenddown amount in paragraph (E)(2) of this rule is either:

(i) The amount of the UPME the individual chooses to use; or

(ii) When the individual does not choose an amount to use, the difference between the result calculated in paragraph (E)(2) of this rule and the RMA need standard applicable to the individual.

(f) A UPME or portion of a UPME that the administrative agency applies toward the spenddown for a given calendar month cannot be used again in the spenddown process for a future calendar month.

(g) A UPME or portion of a UPME that the administrative agency does not apply toward the spenddown can be used to meet the spenddown for a future calendar month.

(3) Treatment of medical expenses used in the spenddown process. Any medical expenses of the individual or family member that are used in the spenddown process to approve the individual's RMA for a given calendar month remain the obligation of the individual or family member and are not payable by the RMA program.

(H) Spenddown during retroactive calendar months in which the individual incurred a medically necessary medical expense:

(1) The administrative agency must determine whether the individual is retroactively eligible, including eligibility through the spenddown process, in accordance with rule 5160:1-2-01 of the Administrative Code. RMA eligibility cannot begin prior to the individual's date of entry or date status was granted.

(2) When the individual is not retroactively eligible (even through the spenddown process), the individual may apply the medical expense as a UPME in the spenddown process for a calendar month in which the individual is otherwise eligible.

(3) When the individual is retroactively eligible (whether through the spenddown process or not):

(a) The individual may apply the UPME in the spenddown process for the retroactive calendar month only when the UPME is not payable for the individual under another category of medical assistance, as described in paragraph (G)(2)(c)(iii) of this rule; and

(b) The individual must apply the UPME to meet the spenddown for the retroactive calendar month(s) first, before using it to meet the spenddown for any subsequent calendar month.

(I) Administrative agency responsibilities.

(1) Accept an application, or electronic equivalent, for medical assistance as an application for RMA.

(2) In order to assist the individual with making informed decisions about the spenddown process, explain to and/or discuss with the individual the following:

(a) The various recurring and incurred spenddown medical expenses the individual may use in the spenddown process; and

(b) The methods for satisfying spenddown.

(3) Not require an individual to apply for or receive refugee cash assistance (RCA).

(4) Not require a face-to-face interview.

(5) Use actual countable individual income for the month of application. Do not average income prospectively when determining income eligibility for RMA.

(6) Determine eligibility for another category of medical assistance, as described in Chapter 5160:1-3, 5160:1-4 or 5160:1-5 of the Administrative Code, prior to determining eligibility for RMA.

(7) Call the trafficking verification line to confirm the validity of the certification letter or letter for children and to notify ORR of the benefits for which the individual has applied.

(8) Make eligible for RMA an individual who receives RCA and who meets the eligibility requirements of this rule.

(9) Obtain third-party liability information from an individual who has other health insurance.

(10) Explore retroactive eligibility for RMA, in accordance with rule 5160:1-2-01 of the Administrative Code. Retroactive eligibility cannot begin prior to the individual's date of entry or date status was granted.

(11) Issue the RMA card for the month within two business days after the individual submits verification showing that current incurred medical expenses for the month satisfy the spenddown amount for the calendar month.

(12) Implement and make available in writing reasonable policies and procedures for administering the pay-in spenddown method. The policies and procedures must:

(a) Permit and provide reasonable methods of accepting payments by third parties on behalf of individuals and groups of individuals subject to spenddown.

(b) Ensure that, at the individual's option, the individual will receive an RMA card for a month on or about the first day of the month by making his or her pay-in payment by a date chosen by the administrative agency near the end of the preceding month.

(i) When the administrative agency receives the individual's pay-in payment before the preceding month's cutoff date for benefit issuance, the administrative agency will authorize the issuance of the RMA card in the electronic eligibility system within two business days after the cutoff date; or

(ii) When the administrative agency receives the individual's pay-in payment on or after the preceding month's cutoff date for benefit issuance, the administrative agency will issue the RMA card within two business days after the administrative agency receives the individual's pay-in payment.

(c) Ensure that, at the individual's option, the individual may pay-in for a given calendar month at any time during the calendar month and that the administrative agency will issue the RMA card for the month within two business days after the administrative agency receives the individual's pay-in payment.

(d) Establish reasonable methods for accepting and accounting for pay-in payments, including but not limited to:

(i) Accepting cash payments;

(ii) Defining conditions for accepting checks or money orders; and

(iii) Establishing provisions for refunding or crediting unused pay-in amounts.

(e) Establish provisions for refunding the individual's pay-in payment for a month in the event the individual:

(i) Becomes eligible for medical assistance for the month through means other than the spenddown process;

(ii) Becomes ineligible for medical assistance for the month despite meeting the spenddown; or

(iii) Paid in more than the spenddown amount, whether due to the individual's error or to the administrative agency's error in calculating the spenddown amount.

(13) Document all pay-in spenddown payments in the electronic eligibility system and in the individual's case record, and issue a receipt to all individuals and third parties who make pay-in spenddown payments. The documentation and receipts must state:

(a) The date payment was received;

(b) The name of the person or entity from whom the payment was received;

(d) The calendar month of eligibility for which the pay-in payment will be used and the effective date of RMA for that month; and

(e) The amount of the payment and the form in which it was paid.

(14) Document in the electronic eligibility system and in the individual's case record:

(a) For each month's current incurred medical expenses and UPMEs submitted by or on behalf of the individual:

(i) The name of the provider of the medical item or service;

(ii) The item or service provided;

(iii) The date the item or service was provided;

(iv) The name of the individual or family member to whom the item or service was provided;

(v) The amount the individual or family member paid or is liable to pay for the item or service;

(vi) For UPMEs, the calendar month(s) for which the UPME or a portion of the UPME was used in the calculation of the spenddown amount; and

(vii) The amount still owed for the item or service.

(b) For current incurred medical expenses that require a decision by the PAU, as described in paragraph (B)(10) of this rule:

(i) The provider's statement;

(ii) The PAU decision; and

(iii) All other information related to the administrative agency's decision to use or not use a current incurred medical expense in the spenddown process.

(i) A description of which specific transportation expense(s) were not used; and

(ii) A clear explanation of the administrative agency's determination.

(15) Issue proper notice and hearing rights as set forth in division 5101:6 of the Administrative Code.

(16) Not deny RMA for an individual who is applying for medical assistance and does not anticipate satisfying spenddown in the month of application or in one or more future calendar months. Instead, the administrative agency shall cause the electronic eligibility system to give the individual the type of eligibility that will only issue an RMA card to the individual for those calendar months for which the individual satisfies the spenddown amount.

(17) Not propose to discontinue RMA for an individual who does not satisfy spenddown for one or more calendar months. Instead, the administrative agency shall cause the electronic eligibility system to give the individual the type of eligibility that will only issue an RMA card to the individual for those calendar months for which the individual satisfies the spenddown amount.

(J) Individual responsibilities. The individual shall:

(1) Provide:

(a) USCIS documentation of non-citizen status;

(b) The name of the resettlement agency, if any, that resettled the individual; and

(c) The information necessary to establish eligibility, cooperate with the verification process, and report changes in accordance with rule 5160:1-2-08 of the Administrative Code.

(2) Spend down to the RMA need standard when the countable income exceeds the RMA need standard.

(3) Cooperate with providing verification of any third-party liability or coverage of medical expenses as defined in rule 5160:1-2-10 of the Administrative Code.

(4) The individual must submit monthly to the administrative agency, by mail, facsimile, electronically, or in person, verification of the current incurred medical expenses the individual wishes to apply against his or her spenddown amount for the calendar month.

(a) Verifications may include unpaid bills, statements, invoices, paid receipts, etc.

(b) For each expense, the individual must provide the name of the provider, the item or service provided, the date the item or service was provided, the name of the individual or family member to whom the item or service was provided, and the amount the individual or family member paid or is liable to pay for the item or service.

Last updated December 4, 2025 at 2:20 PM

History

Effective: December 1, 2025
Promulgated Under: 111.15

Ohio Adm.Code 5160:1-5-06 Medicaid: non-citizen emergency medical assistance (NCEMA).

(A) In accordance with 42 U.S.C. 1396b(v), this rule describes eligibility criteria for coverage of the treatment of an emergency medical condition for certain individuals who do not meet the medicaid citizenship or satisfactory immigration status requirements described in rule 5160:1-2-11 or 5160:1-2-12 of the Administrative Code.

(B) Definition. "Emergency medical condition," for the purpose of this rule, means a medical condition with a sudden onset:

(1) Manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in:

(a) Placing the patient's health in serious jeopardy; or

(b) Serious impairment to bodily functions; or

(2) Including labor and delivery.

(3) Not including either:

(a) Routine prenatal or postpartum care; or

(b) Care and services related to an organ transplant procedure.

(1) Submit an application for medical assistance.

(a) Once approved for NCEMA, the eligibility span shall remain open for twelve months beginning with the month of application.

(b) Only emergency medical condition episodes will be eligible for payment of services.

(c) A new application is not needed for subsequent emergency medical condition episodes during the twelve-month span; however, the individual is responsible for reporting all emergency medical condition episodes to the administrative agency when they occur.

(2) Meet eligibility criteria for a category of medicaid, except that the individual:

(a) Does not meet the medicaid citizenship or satisfactory immigration status requirements set forth in rules 5160:1-2-11 and 5160:1-2-12 of the Administrative Code. The individual is not required to verify:

(i) Social security number; or

(ii) United States (U.S.) citizenship or immigration status.

(b) Is not required to apply for social security administration (SSA) benefits.

(D) Coverage for payment of NCEMA services for an individual who meets the criteria identified in paragraph (C) of this rule.

(1) Payment of services for an episode other than routine labor and delivery:

(a) Begins on the day on which the absence of immediate medical attention could reasonably be expected to result in placing the patient's health in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part; and

(b) Ends on the day on which the absence of immediate medical attention could no longer reasonably be expected to result in placing the patient's health in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part.

(2) Payment of services for routine labor and delivery:

(a) Begins on the date of admission for labor; and

(b) Ends at midnight on the day in which one of the following time periods falls:

(i) A maximum of two days (forty-eight hours) following a vaginal delivery; or

(ii) A maximum of four days (ninety-six hours) following a caesarean section delivery.

(E) Administrative agency responsibilities.

(1) Determine the payment coverage span for routine labor and delivery without submitting medical documentation to the disability determination area (DDA) and enter the payment coverage dates as described in paragraph (D)(2) of this rule into the electronic eligibility system.

(2) Submit medical documentation to the DDA for a determination of the covered dates of service when the time period for labor and delivery exceeds the time frames described in paragraph (D)(2) of this rule.

(3) Submit medical documentation to the DDA for emergency medical conditions other than routine labor and delivery and enter the eligibility span determined by the DDA into the electronic eligibility system.

(4) Upon request, assist the individual with obtaining medical documentation to support the NCEMA claim.

(5) Upon notification of an individual's subsequent emergency medical condition episode during his or her twelve-month eligibility period, obtain medical documentation to determine the new NCEMA payment coverage span and submit to DDA in accordance with paragraphs (E)(2) and (E)(3) of this rule.

(F) DDA responsibilities.

(1) Make all emergency medical condition determinations except for routine labor and delivery episodes as described in paragraph (D)(2) of this rule.

(2) Determine whether the individual received treatment for an emergency medical condition.

(3) Determine the payment coverage span for each emergency medical condition episode.

(4) Notify the administrative agency of the NCEMA determination and the payment coverage span via the electronic eligibility system.

Last updated December 1, 2023 at 9:39 AM

History

Effective: December 1, 2023
Promulgated Under: 111.15

Ohio Adm.Code 5160:1-5-07 Medicaid: specialized recovery services (SRS) program.

(A) This rule sets forth the eligibility criteria for a state plan home and community-based services (HCBS) benefit authorized under section 1915(i) of the Social Security Act (as in effect October 1, 2024). Section 1915(i) allows states the flexibility to provide HCBS to individuals who require less than an institutional level of care (LOC) and who would, therefore, not be eligible for HCBS under the more restrictive criteria of section 1915(c) waivers. The specialized recovery services (SRS) program provides targeted services to the following individuals described in rule 5160-43-02 of the Administrative Code:

(1) Individuals with severe and persistent mental illness (SPMI);

(2) Individuals who are active on the solid organ or soft tissue waiting list; or

(3) Individuals with certain diagnosed chronic conditions.

(B) Eligibility for the SRS program state plan HCBS benefit. An individual shall meet all of the following criteria to be eligible for the SRS program state plan HCBS benefit:

(1) Be at least twenty-one years of age.

(2) Have been determined to meet the definition of disability used by the social security administration (SSA) for purposes of supplemental security income (SSI) or social security disability insurance (SSDI) benefits.

(a) A disability determination is not required for individuals over sixty-five years of age who are active on the solid organ or soft tissue waiting list, or who have certain diagnosed chronic conditions.

(b) A disability determination is not required for individuals under sixty-five years of age who are diagnosed with end-stage renal disease (ESRD).

(3) Meet the clinical diagnostic, needs assessment, and risk criteria described in rule 5160-43-02 of the Administrative Code.

(4) Reside in a home and community-based setting consistent with the qualities identified in 42 C.F.R. 441.710 (as in effect October 1, 2024).

(5) Meet the financial and nonfinancial eligibility requirements of one of the following groups:

(a) Group one.

(i) Be in receipt of medical assistance, as described in Chapters 5160:1-1 to 5160:1-5 of the Administrative Code; and

(ii) Have countable income that does not exceed one hundred fifty per cent of the federal poverty level (FPL), as determined using the same rules used for determining the individual's medical assistance eligibility.

(b) Group two.

(i) Meet the conditions of eligibility outlined in rule 5160:1-2-10 of the Administrative Code;

(ii) Not be otherwise eligible for medical assistance; and

(iii) For the purpose of determining whether an individual is income eligible for the SRS program, the administrative agency shall compare the individual's countable income to one hundred fifty per cent of the FPL, as determined in accordance with Chapter 5160:1-3 of the Administrative Code.

(a) When the individual's countable income exceeds one hundred fifty per cent of the FPL, apply additional disregards in the following order:

(i) Twenty dollar personal needs disregard; then

(ii) Disregard income in the amount of the difference between one hundred fifty per cent of the FPL for an individual and three hundred per cent of the current supplemental security income (SSI) federal benefit rate (FBR) for an individual.

(b) When the amount determined in paragraph (B)(5)(b)(iii) of this rule is no more than one hundred fifty per cent of the FPL, the individual meets the income eligibility requirement for the SRS program.

(iv) There is no resource limit for individuals described in paragraph (B)(5)(b) of this rule.

(C) There is no retroactive eligibility for the SRS program state plan HCBS benefit. Coverage under this rule cannot begin prior to the first day of the month in which all financial, nonfinancial, and programmatic criteria are met.

(D) An individual who is receiving the state plan HCBS benefit cannot be concurrently enrolled in another HCBS authority, such as a section 1915(c) waiver. Subject to the individual's choice, he or she will be enrolled in the HCBS authority best meeting the totality of his or her needs regardless of the order in which the individual applied for or became eligible for HCBS.

Last updated June 25, 2025 at 6:35 PM

History

Effective: March 1, 2025
Promulgated Under: 111.15

Ohio Adm.Code 5160:1-5-08 Medicaid: state-funded medical assistance for non-citizen victims of trafficking.

(A) This rule describes the eligibility requirements for state-funded medical assistance for a non-citizen victim of a severe form of human trafficking.

(B) For purposes of this rule the following definitions apply unless otherwise stated.

(1) "Labor trafficking" means recruiting, harboring, transporting, or obtaining of a person for labor or services through the use of force, fraud, or intimidation for the purpose of involuntary servitude, debt bondage, or slavery.

(2) "Severe form of human trafficking" means sex trafficking or labor trafficking.

(3) "Sex trafficking" means recruiting, harboring, transporting, or obtaining of a person for the purpose of a commercial sex act where the commercial sex act is induced by force, fraud, or intimidation, or the person being induced to perform such act is under eighteen years of age.

(4) "T non-immigration status" is also known as the T Visa and provides immigration protection to victims of a severe form of human trafficking.

(1) To be eligible for medical assistance, the non-citizen victim of a severe form of human trafficking must:

(a) Have applied for, or be in the process of preparing to file an application with the United States citizenship and immigration services (USCIS) for, "T" non-immigration status; and

(b) Be an Ohio resident as described in rule 5160:1-2-10 of the Administrative Code; and

(2) An individual under this program is not required to provide a social security number.

(D) Financial eligibility.

(1) To have eligibility under this program, the individual must have countable monthly income at or below one hundred per cent of the federal poverty level (FPL) as determined in accordance with rules 5160:1-3-03.1 and 5160:1-3-03.2 of the Administrative Code. Only the individual's income is compared to the income standard. The FPL is adjusted annually.

(2) The deeming provisions set forth in rules 5160:1-3-03.1 and 5160:1-3-03.3 of the Administrative Code do not apply to the eligibility determination for a non-citizen victim of a severe form of human trafficking.

(E) Resource eligibility. There is no resource limit for individuals described in this rule.

(F) Retroactive eligibility. Eligibility for retroactive coverage of medical assistance shall be determined in accordance with rule 5160:1-2-01 of the Administrative Code.

(G) County department of job and family services (CDJFS) responsibilities. The CDJFS shall:

(1) Verify the individual has applied for, or is preparing to apply for, "T" non-immigration status with the USCIS.

(a) The CDJFS must accept the following documentation when the individual claims to have already applied for a "T" non-immigration status:

(i) Form I-797, "Notice of Action", issued by the USCIS; or

(ii) Completed Form I-914, "Application for T Non-Immigration Status"; or

(iii) Completed Form I-914, Supplement B, "Declaration of Law Enforcement Officer for Victim of Trafficking in Persons"; or

(iv) Printouts of case status queries from the USCIS website; or

(v) Other correspondence from USCIS regarding applications, such as appointment notices.

(b) When the individual is preparing to file for "T" non-immigration status, the CDJFS shall:

(i) Verify with a sworn written statement that the individual is a victim of a severe form of human trafficking and at least one item of additional credible evidence, including but not limited to any of the following:

(a) Police, government agency, or court records or files; or

(b) News articles; or

(c) Documentation from a social services agency, domestic violence center, rape crisis center, or a legal, clinical, or medical professional, or other professional to whom the individual has reported the crime; or

(d) A written statement from any other individual with knowledge of the circumstances that provided the basis for the claim; or

(e) Physical evidence; or

(f) A written notice from the federal agency of receipt of the visa application.

(ii) Determine whether the sworn statement is credible when the individual is unable to provide any of the additional evidence listed in this rule.

(2) Determine the individual does not qualify for another category of medical assistance.

(H) Individual responsibilities. The individual shall:

(1) Cooperate with the CDJFS to determine financial eligibility for medical assistance.

(2) Cooperate with the CDJFS to determine non-financial eligibility for medical assistance.

(3) Provide verification of any third-party liability or coverage of medical expenses as defined in rule 5160:1-2-10 of the Administrative Code.

(4) Cooperate with the child support enforcement agency (CSEA) in establishing the paternity of any medicaid eligible child and in obtaining medical support and payments as described in rule 5160:1-2-10 of the Administrative Code.

(5) Report changes within ten days to the CDJFS in accordance with rule 5160:1-2-08 of the Administrative Code. Changes include but are not limited to the following:

(a) Approval or denial of the application for "T" non-immigration status.

(b) Immigration status.

(i) Address; or

(ii) Phone number; or

(iii) Email address.

(d) Marital status.

(e) Income.

(f) Pregnancy status.

(6) File a formal application for "T" non-immigration status within one year of the application date for medical assistance. When the individual fails to file a formal application, eligibility for medical assistance will be discontinued, unless it can be determined that during the year the individual:

(a) Experienced a health crisis; or

(b) Has been unable, after reasonable attempts, to obtain the necessary information from a third party; or

(I) There is not a limitation on the amount of time the individual can receive coverage under this medical assistance category, provided the individual continues to meet all relevant eligibility criteria.

Last updated November 1, 2023 at 8:28 AM

History

Effective: November 1, 2023
Promulgated Under: 111.15

Chapter 5160:1-6 Long-Term Care

Ohio Adm.Code 5160:1-6-01 Medicaid: eligibility for medicaid payment for long-term care (LTC) services.

(A) This rule describes how an individual is determined eligible for medicaid payment for long-term care (LTC) services.

(B) In order to receive medicaid payment for LTC services, the individual must:

(1) Be eligible for medical assistance in accordance with Chapter 5160:1-3, 5160:1-4, 5160:1-5, or 5160:1-6, as applicable; and

(2) Meet any non-financial eligibility requirements for the type of LTC services requested; and

(3) Not be subject to a restricted medicaid coverage period, in accordance with rule 5160:1-6-06.5 of the Administrative Code.

(C) An individual receiving medicaid payment for LTC services may be subject to post-eligibility treatment of income in accordance with rules 5160:1-6-07 and 5160:1-6-07.1 of the Administrative Code.

Last updated June 25, 2025 at 11:17 PM

History

Effective: January 1, 2024
Promulgated Under: 111.15

Ohio Adm.Code 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 that does 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; or

(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

(5) "Dependent family member" means a child (natural, adoptive, or step), 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" (ESA) 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. The FMNA is equal to the current Ohio works first payment standard for the same number of applicable dependent family members.

(9) "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.

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

(11) "Home and community-based services" (HCBS) means services provided under a waiver authorized in accordance with 42 U.S.C. 1396n(c) (as in effect October 1, 2023).

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

(13) "Income" is defined in rule 5160:1-1-01 of the Administrative Code.

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

(15) "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 or PACE services by using the special income level (SIL) described in rule 5160:1-6-03.1 of the Administrative Code.

(16) "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.

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

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

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

(20) "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, 2023).

(21) "Minimum monthly maintenance needs allowance" (MMMNA) means a calculation to determine the amount of income needed from the IS to provide the monthly income allowance (MIA) to the CS. The MMMNA standard and the MMMNA maximum are used to calculate the MMMNA amount.

(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) "Minimum monthly maintenance needs allowance maximum or cap" (MMMNA maximum or cap) is calculated annually based on the social security administration (SSA) cost-of-living adjustment (COLA).

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

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

(26) "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.

(27) "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.

(28) "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).

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

(30) "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.

(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.

Last updated January 2, 2024 at 8:29 AM

History

Effective: January 1, 2024
Promulgated Under: 111.15

Ohio Adm.Code 5160:1-6-02 Medicaid: special resource rules when an individual is requesting or receiving medicaid payment for long-term care (LTC) services.

(A) This rule describes the application of resource rules when an individual is requesting or receiving medicaid payment for long-term care (LTC) services.

(B) Individuals requesting or receiving medicaid payment for LTC services are subject to the following resource rules:

(1) The home equity limit as described in rule 5160:1-6-02.1 of the Administrative Code.

(2) Evaluation of any qualified long-term care insurance policy as described in rule 5160:1-6-02.2 of the Administrative Code.

(3) Evaluation of any entrance fee when the individual is residing in a continuing care retirement community, life care community, or a philanthropic long-term care facility as described in rule 5160:1-6-02.3 of the Administrative Code.

Last updated October 1, 2025 at 8:12 AM

History

Effective: October 1, 2025
Promulgated Under: 111.15

Ohio Adm.Code 5160:1-6-02.1 Medicaid: home equity limit for individuals requesting or receiving medicaid payment for long-term care (LTC) services.

(A) This rule describes the treatment of the home equity limit for an individual requesting or receiving medicaid payment for long-term care (LTC) services.

(B) Definition. "Home equity limit" means the maximum amount of equity which an individual could have in the home and become or remain eligible for LTC services. The home equity limit of five hundred sixty thousand dollars will increase annually by the percentage increase in the consumer price index for all urban consumers (CPI-U) in accordance with section 5163.32 of the Revised Code.

(C) An individual shall not be eligible for LTC services when the individual's equity interest in the home, as defined in rule 5160:1-3-05.13 of the Administrative Code, exceeds the home equity limit.

(D) The home equity limit does not apply to an individual when any of the following persons are lawfully residing in the individual's home:

(1) The individual's spouse; or

(2) The individual's child who is under age twenty-one; or

(3) The individual's child who is age twenty-one or over and is blind or disabled as defined in Chapter 5160:1-3 of the Administrative Code.

(E) The home equity limit is applicable even when an individual is a recipient of qualified long-term care partnership (QLTCP) benefit payments, as described in rule 5160:1-6-02.2 of the Administrative Code. A QLTCP exclusion cannot offset or reduce home equity for the purposes of this rule.

(F) An individual who has been in receipt of LTC services since before January 1, 2006, without a break in eligibility for such services, is not subject to the home equity limit.

(G) The individual will not be subject to a denial or discontinuance of LTC services because of the home equity when the individual demonstrates that the denial or discontinuance will result in an undue hardship.

(1) An undue hardship exists when denial or discontinuance of LTC services would deprive the individual of:

(a) Medical assistance such that the individual's health or life would be endangered; or

(b) Food, clothing, shelter, or other necessities of life.

(2) The individual must first document that an attempt was made to reduce the home equity value below the home equity limit.

(3) An undue hardship exemption may be requested by the individual or, with the consent of the individual or the individual's authorized representative, by the nursing facility on behalf of the individual.

(4) Undue hardship does not exist when the individual has taken action to restrict access to the excess home equity.

(H) Nothing in this rule shall be construed as preventing an individual from using a reverse mortgage or home equity loan to reduce the total equity interest in the home.

Last updated September 14, 2025 at 10:08 PM

History

Effective: March 1, 2024
Promulgated Under: 111.15

Ohio Adm.Code 5160:1-6-02.2 Medicaid: treatment of qualified long-term care insurance policies.

(A) This rule describes the qualified long-term care partnership (QLTCP) program.

(B) Definitions.

(1) "Estate recovery" means the program set forth in rule 5160:1-2-07 of the Administrative Code.

(2) "Qualified long-term care partnership" (QLTCP) means the program established under section 5164.86 of the Revised Code, under which an individual's assets or resources are disregarded in eligibility determinations and at estate recovery in the amount of insurance benefit payments made to or on behalf of the individual who is a beneficiary of a QLTCP policy.

(1) On the date the policy was issued, the state in which the insured resided had in place an approved state plan amendment which provides, pursuant to 42 U.S.C. 1396p(b) (as in effect October 1, 2023), for the disregard of assets or resources in an amount equal to the insurance benefit payments made to or on behalf of an individual who is a beneficiary of a QLTCP policy; and

(2) The policy is a qualified long-term care insurance policy, as defined in 26 U.S.C. 7702B(b) (as in effect October 1, 2023); and

(3) The policy meets the requirements set forth by the Ohio department of insurance in section 3923.41 of the Revised Code, or, when purchased outside Ohio, meets the requirements of an approved state plan amendment, as described in paragraph (C)(1) of this rule, in the state of purchase.

(D) Upon the request for, or renewal of, a determination of eligibility for medicaid payment of long-term care (LTC) services, an individual's resources shall be disregarded up to the dollar amount of insurance benefit payments made to or on behalf of the individual who is a beneficiary of a QLTCP policy.

(1) The administrative agency shall determine eligibility for medical assistance in accordance with the rules contained in Chapters 5160:1-1 to 5160:1-6 of the Administrative Code.

(2) An individual may request a determination of eligibility for medicaid payment of LTC services before exhausting the benefits of a QLTCP policy. When an individual requests and is determined eligible for medicaid payment of LTC services before the QLTCP policy is exhausted, the QLTCP insurer must make payment for medical care to the maximum extent of the insurer's liability before medicaid funds may be used to pay providers for covered LTC services.

(3) When an individual has requested and been determined eligible for medicaid payment of LTC services, then the individual accumulates additional resources, the individual continues to be eligible for medicaid payment of LTC services to the extent that the total value of all disregarded resources does not exceed the individual's QLTCP disregard plus the applicable resource limit.

(4) A QLTCP disregard cannot reduce patient liability or cost of care.

(5) Proof of the amount of QLTCP benefits paid on behalf of the individual who is applying for or receiving medical assistance must be provided to the administrative agency to verify the amount of the resource disregard.

(6) The QLTCP disregard is only available to the individual on whose behalf the qualifying QLTCP benefits were paid.

(E) Improper transfers of assets, as described in rule 5160:1-6-06 of the Administrative Code, are treated as follows when there is a QLTCP disregard.

(1) When an individual becomes eligible for medicaid payment of LTC services through the application of a QLTCP disregard, then the individual makes a transfer of disregarded assets that would otherwise be considered an improper transfer, no restricted medicaid coverage period (RMCP) applies. The disregarded value of the transferred asset continues to be considered part of the individual's QLTCP disregard.

(2) When an individual becomes eligible for medicaid payment of LTC services through the application of a QLTCP disregard after making a transfer that would otherwise be considered an improper transfer:

(a) When the value of the individual's remaining countable assets plus the value of the transferred assets is less than or equal to the individual's QLTCP disregard plus the applicable resource limit, no RMCP applies. The disregarded value of the transferred asset is considered part of the individual's QLTCP disregard.

(b) When the value of the individual's remaining countable assets plus the value of the transferred assets is greater than the individual's QLTCP disregard plus the applicable resource limit:

(i) The individual's remaining QLTCP disregard is determined by adding the individual's original QLTCP disregard amount to the applicable resource limit, then subtracting the individual's current countable resources and any amounts that had previously been transferred without an RMCP as a result of a QLTCP disregard.

(ii) The individual's remaining QLTCP disregard is subtracted from the amount that would otherwise have been considered improperly transferred. The difference is the amount improperly transferred; an RMCP is calculated for the difference in accordance with rule 5160:1-6-06.5 of the Administrative Code.

Last updated September 12, 2025 at 12:37 PM

History

Effective: January 1, 2024
Promulgated Under: 111.15

Ohio Adm.Code 5160:1-6-02.3 Medicaid: continuing care retirement communities, life care communities, and philanthropic long-term care facilities.

(A) The purpose of this rule is to describe the eligibility requirements for individuals residing in a continuing care retirement community (CCRC), life care community, or a philanthropic long-term care facility (PLTCF).

(B) Definitions.

(1) "CCRCs" and "life care communities" mean housing communities that provide different categories of care based on each resident's need over time. CCRCs and life care communities may range from independent living in an apartment, to assisted living, to full-time care in a nursing facility. Residents may move from one setting to another, based on their needs, but continue to live as part of the community. Generally, CCRCs require a written contract and an entrance fee, in addition to monthly fees. CCRCs and life care communities may also be PLTCFs.

(2) "Entrance fee" means a payment generally required for admission to a CCRC, life care community, or PLTCF and may vary in amount based on the type of housing accommodations and/or category of care.

(3) "PLTCF" means a not-for-profit long-term care facility.

(C) For purposes of determining or redetermining eligibility for medical assistance, an individual's entrance fee for admission to a CCRC or life care community shall be considered an available resource to the individual, in accordance with 42 U.S.C. 1396p (as in effect October 1, 2023), when all of the following conditions are met:

(1) The entrance fee can be used to pay for care, under the terms of the entrance contract, when other resources or income of the individual are insufficient; and

(2) The individual is eligible for a refund of any remaining entrance fee when the individual dies or terminates the contract and leaves the CCRC or life care community; and

(3) The entrance fee does not confer an ownership interest in the CCRC or life care community.

(D) Eligibility for medical assistance for individuals residing in a PLTCF.

(1) An individual residing in a PLTCF who has not entered into a life care contract must have eligibility for medical assistance determined in accordance with Chapter 5160:1-6 of the Administrative Code and the entrance fee paid to the PLTCF shall be considered an available resource.

(2) An individual residing in a PLTCF, who has entered into a life care contract with the PLTCF, is eligible for medical assistance, and the entrance fee shall not be considered an available resource, when all other eligibility requirements for medical assistance are fulfilled, and the following conditions are met:

(a) The PLTCF must provide evidence that it is financially unable to operate. The PLTCF must show that the total financial situation of the facility indicates an inability to fulfill its responsibilities under the life care contract; and

(b) The entrance fee would be depleted had the individual paid the facility at the medicaid long-term care rate for a comparable facility.

Last updated September 12, 2025 at 1:49 PM

History

Effective: January 1, 2024
Promulgated Under: 111.15

Ohio Adm.Code 5160:1-6-03 Medicaid: special income rules that may apply when an individual is requesting medicaid payment for long-term care services.

(A) The following income rules apply when an individual, regardless of age, is seeking medicaid payment for long-term care services.

(1) An individual ineligible for base eligibility due to excess income shall have his or her income eligibility determined using the special income level (SIL), in accordance with rule 5160:1-6-03.1 of the Administrative Code.

(2) When an individual's countable income is greater than the SIL, as determined in rule 5160:1-6-03.1 of the Administrative Code, the individual may establish a qualified income trust (QIT), in accordance with rule 5160:1-6-03.2 of the Administrative Code to become income eligible for medical assistance.

(B) These rules do not describe what is considered income for the purposes of determining eligibility for medical assistance.

Last updated October 1, 2025 at 8:14 AM

History

Effective: October 1, 2025
Promulgated Under: 111.15

Ohio Adm.Code 5160:1-6-03.1 Medicaid: determining financial eligibility for medical assistance using the special income level.

(A) This rule describes how to determine financial eligibility for medical assistance using the special income level (SIL). This rule does not describe how to determine non-financial eligibility criteria for medical assistance or for medicaid payment of long-term care services.

(B) An individual, regardless of age, who is ineligible under base eligibility due to excess income may be income eligible for medical assistance if his or her income is less than or equal to the SIL. The SIL is equal to three hundred per cent of the current supplemental security income (SSI) benefit payment rate for an individual.

(C) An individual who is income eligible under the SIL must also meet the resource requirements in rules 5160:1-3-05.1 and 5160:1-6-04 of the Administrative Code, as applicable, before his or her application for medical assistance can be approved.

(D) Only an individual who has been institutionalized for a continuous period of institutionalization, as defined in rule 5160:1-6-01.1 of the Administrative Code, may have his or her income eligibility determined using the SIL.

(E) When the individual is eligible under the SIL, eligibility for medical assistance will begin the first day of the month in which the continuous period of institutionalization began, and last, assuming all other eligibility criteria are met, until the individual is no longer institutionalized or receiving home and community-based (HCBS) or program of all-inclusive care for the elderly (PACE) services.

(F) When the individual is eligible under the SIL, the administrative agency shall calculate a patient liability in accordance with rules 5160:1-6-07 and 5160:1-6-07.1 of the Administrative Code, as applicable. The individual must pay the calculated patient liability to the long-term care (LTC) provider as applicable.

(G) When an individual's countable income is greater than the SIL, the individual may establish a qualified income trust (QIT) in accordance with rule 5160:1-6-03.2 of the Administrative Code to reduce his or her countable income to or below the SIL.

(H) Determine whether an individual's income is at or below the SIL as follows:

(1) Total only the individual's gross income, earned and unearned as defined in rule 5160:1-1-01 of the Administrative Code (do not include parental or spousal income), then exclude the following income types:

(a) Payments not considered income, in accordance with 20 C.F.R. 416.1103 (as in effect October 1, 2023), which includes veterans administration aid and attendance.

(b) Payments to victims of Nazi persecution.

(c) 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 October 1, 2023). These payments need to be documented and identifiable separate from countable insurance.

(d) 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).

(e) 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, 2023).

(f) Restitution payments under the Aleutian and Pribilof Island Restitution Act, in accordance with 50 U.S.C. 4236 (as in effect October 1, 2023).

(g) 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).

(h) 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).

(i) Radiation exposure compensation trust fund payments, in accordance with the Radiation Exposure Compensation Act of 1990 (Pub. L. No. 101-426).

(j) 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.

(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, 2023).

(l) Residential state supplement (RSS) payments to individuals, in accordance with rule 5160:1-5-01 of the Administrative Code.

(m) Payments from a state compensation fund for victims of crime.

(n) 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).

(o) 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).

(p) Payments made to individuals under the Energy Employees Occupational Illness Compensation Program Act of 2000 (Pub. L. No. 106-398).

(q) Assistance (other than wages or salaries) under the Older Americans Act of 1965 (Pub. L. No. 89-73).

(r) Student financial assistance received under the Higher Education Act (HEA) of 1965 (as in effect October 1, 2023) 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 education assistance programs; and

(ix) Work-study programs.

(s) 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, 2023).

(t) 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.

(u) Federal and state foster care payments received under title IV-B or title IV-E for a child currently living in the household.

(v) Federal or state adoption assistance payments received under title IV-B or title IV-E.

(w) Payments received under the kinship guardianship assistance program (KGAP), state KGAP, or kinship guardianship assistance program connections to twenty-one (KGAP C21).

(x) Child care assistance under the Child Care and Development Block Grant Act of 1990 (Pub. L. No. 113-186).

(y) 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, 2023).

(z) Payments made for supporting services or reimbursement of out-of-pocket expenses to volunteers participating in corporation for national and community services (CNCS, formerly ACTION) programs in accordance with 42 U.S.C. 1382a (as in effect October 1, 2023):

(i) AmeriCorps VISTA program;

(ii) Special and demonstration volunteer programs;

(iii) Retired senior volunteer program (RSVP);

(iv) Foster grandparents program; and

(v) Senior companion program.

(aa) 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;

(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).

(bb) 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.

(cc) 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).

(dd) Home energy assistance provided on the basis of need, in accordance with 20 C.F.R. 416.1157 (as in effect October 1, 2023).

(ee) 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.

(ff) 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, 2023).

(2) Compare the individual's gross countable income computed in paragraph (H)(1) of this rule to the SIL.

(3) When the individual's countable income is less than or equal to the SIL then the individual is income eligible for medical assistance.

Last updated September 15, 2025 at 3:53 AM

History

Effective: December 1, 2023
Promulgated Under: 111.15

Ohio Adm.Code 5160:1-6-03.2 Medicaid: use of qualified income trusts (QIT).

(A) This rule sets forth the requirements that must be met in order to establish and use a qualified income trust (QIT) (also referred to as a Miller trust) to become eligible for medicaid payment of long-term care services.

(B) Definitions

(1) "Beneficiary" is defined in rule 5160:1-3-05.2 of the Administrative Code.

(2) "Individual" is defined in rule 5160:1-6-01.1 of the Administrative Code.

(3) "Irrevocable trust" is defined in rule 5160:1-3-05.2 of the Administrative Code.

(4) "Primary beneficiary" means the "individual" as defined in paragraph (B)(2) of this rule.

(5) "Qualified Income Trust" (QIT) means a trust that allows an individual whose income is over the special income level (SIL), as described in rule 5160:1-6-03.1 of the Administrative Code, to have some or all of his or her income not be counted when determining medicaid eligibility by placing income in the trust.

(6) "QIT account" means the account that holds the income placed into a QIT.

(7) "Trustee" is defined in rule 5160:1-3-05.2 of the Administrative Code.

(C) A QIT can only be used to establish medicaid eligibility by an individual whose income is above the SIL, who is eligible for long-term care (LTC) services covered by the Ohio medicaid program, and who is subject to the calculation of patient liability under rules 5160:1-6-07 and 5160:1-6-07.1 of the Administrative Code.

(D) A QIT must be a valid trust under the law of Ohio or another state and meet the following requirements:

(1) The trust must be irrevocable.

(2) Only the individual's income can be placed into the QIT.

(3) The source(s) of income placed into the QIT must be identified.

(4) The individual cannot transfer or assign to the trust his or her right to receive income.

(5) No other property or resources, except for any interest earned on the trust corpus, can be placed into the QIT.

(6) The trust document must provide that the trust shall terminate upon the death of the primary beneficiary, at which point the remaining trust property shall be distributed to the Ohio department of medicaid or its successor up to an amount equal to the total medical assistance paid on behalf of the primary beneficiary; the trustee is prohibited from repaying other persons or creditors prior to this distribution.

(E) Income received in a frequency other than monthly shall be converted to a monthly income amount in accordance with rule 5160:1-2-02 of the Administrative Code to comply with the monthly income requirements described in this rule.

(F) In accordance with rules 5160:1-6-07 and 5160:1-6-07.1 of the Administrative Code, distributions from the trust shall be made in the following order, within thirty days from when the income is placed in the QIT account:

(1) A monthly personal or maintenance needs allowance for the primary beneficiary;

(2) A maintenance allowance for the spouse, if any, of the primary beneficiary and, when applicable, a maintenance allowance for family dependents;

(3) Health care costs in accordance with rules 5160:1-6-07 and 5160:1-6-07.1 of the Administrative Code. When income is used to help pay for LTC services or other medical care provided to the individual, the individual is considered to have received fair market value for the income placed in the trust, up to the amount actually paid for other medical care provided to the individual and to the extent that the payments purchased are at fair market value;

(4) The trustee may make payments in an amount up to fifteen dollars per month from the QIT account for bank fees, attorney fees, and other expenses required to establish and administer the trust. When fifteen dollars is insufficient to cover the cost to administer the trust, the individual can request that the payment amount be increased. Requests for an increased payment amount must be approved by the Ohio department of medicaid (ODM).

(G) The trust corpus is not counted as a resource available to the individual in determining his or her eligibility for medicaid.

(H) The establishment of the QIT must be documented, including the location of the QIT account, the QIT account number, and details regarding who has access to the QIT account. The title of the QIT account must clearly identify it as a QIT account in the name of the individual.

(I) When the individual's income cannot be automatically transferred or deposited into the QIT account each month, then the individual must provide ODM with documentation showing that the individual's income is being transferred or deposited into the QIT account on a monthly basis. Every effort should be made to have the individual's excess income transferred or deposited directly into the QIT account on a monthly basis.

(J) The properly executed QIT document, proof of the establishment of the QIT account, documentation of the required monthly deposit amount, and verification of monthly deposits from an income source or sources into the QIT account, including efforts to have income deposited directly into the QIT account, must be submitted along with the application for medicaid for an individual needing LTC services.

(K) Documentation of monthly deposits into the QIT must be presented at the individual's annual eligibility renewal or at the request of the administrative agency. When such documentation is not presented, any income that should have been placed into the QIT but was not will be considered available for purposes of determining the individual's medicaid eligibility for that month. Any medicaid payments made by the administrative agency during a period of ineligibility are subject to recovery under rule 5160:1-2-04 of the Administrative Code.

(L) The individual can elect to have all, or only a portion, of his or her income placed into the QIT account. Any income not placed into the QIT account will be counted as available to the individual when determining eligibility for medicaid.

(M) Income placed into the QIT is subject to the patient liability requirements as set forth in rules 5160:1-6-07 and 5160:1-6-07.1 of the Administrative Code. All income placed into a QIT is combined with any countable income not placed into the QIT to arrive at a base income figure to be used in the patient liability calculation. The base income figure is used for post-eligibility distributions.

(N) Distributions or payments from the QIT, other than as authorized by this rule, may be considered a transfer of assets for less than fair market value and subject to the transfer of assets penalties in accordance with rule 5160:1-6-06.5 of the Administrative Code. When income placed into the QIT exceeds the amount paid out of the QIT in accordance with paragraph (F) of this rule, the excess income may be subject to the transfer of assets provisions as set forth in rule 5160:1-6-06.5 of the Administrative Code.

(O) Payments made from the QIT directly to the individual or to a third-party for food or shelter are counted as unearned income to the individual in the month received.

(P) Payments to a third-party that are not authorized under paragraph (F) or (O) of this rule, are subject to the transfer of assets penalties as set forth in rule 5160:1-6-06.5 of the Administrative Code.

(Q) When transfer of assets penalties result in an undue hardship, the individual may request an undue hardship exemption in accordance with rule 5160:1-6-06.6 of the Administrative Code.

Last updated October 13, 2026 at 8:18 AM

History

Effective: October 12, 2026
Promulgated Under: 111.15

Ohio Adm.Code 5160:1-6-04 Medicaid: treatment of income and resources for an institutionalized spouse with a spouse in the community.

(A) This rule describes how to treat the income and resources of the institutionalized spouse (IS) and the community spouse (CS) for purposes of determining eligibility of the IS. When determining eligibility under this rule, the income and resources deeming provisions in Chapter 5160:1-3 of the Administrative Code do not apply.

(B) This rule only applies to the financial eligibility determination of the IS, who is:

(1) Requesting long-term care (LTC) payment of services, as described in rule 5160:1-6-01 of the Administrative Code, in a medical institution, home and community-based services (HCBS) waiver, or program of all-inclusive care for the elderly (PACE), for a continuous period of institutionalization as defined in rule 5160:1-6-01.1 of the Administrative Code; and

(2) Married to someone who is not in a medical institution, eligible for an HCBS waiver, or receiving PACE services. This spouse is called the CS.

(1) The IS's income is at or below the income limit applicable to the eligibility group for which he or she qualifies, as identified in Chapters 5160:1-3, 5160:1-4, 5160:1-5, and 5160:1-6 of the Administrative Code; and

(2) The couple's combined countable resources, when the IS is subject to a resource limit as described in the eligibility rules for the applicable medical assistance category, are equal to or less than the community spouse resource allowance (CSRA), as determined in paragraph (E)(5) of this rule, plus two thousand dollars.

(D) Treatment of income.

(1) During any month in which the IS is eligible for LTC services in a medical institution, HCBS waiver, or PACE, no income of the CS shall be considered available to the IS.

(a) When the IS's base eligibility is calculated using the modified adjusted gross income (MAGI) budgeting methodology, determine the MAGI household composition and family size in accordance with rule 5160:1-4-01 of the Administrative Code, under which a married individual's household includes his or her spouse if the spouses file their tax returns jointly or are living together.

(b) When using the MAGI budgeting methodology, the CS's income will not be included in the determination of household income.

(2) When determining each spouse's income, the following rules apply:

(a) When payment of income is made solely in the name of one spouse, the income shall only be considered available to that respective spouse, unless the income is from a trust or other instrument establishing ownership otherwise.

(b) When payment of income is made in the name of both spouses, with no trust or instrument establishing ownership otherwise, one-half of the income shall be considered available to each spouse.

(c) When payment of income is made in the name of both spouses and to another person, the income shall be considered available to each spouse in proportion to their interest. When the portion of interest is not specified, then one-half of the joint interest shall be considered available to each spouse.

(E) Treatment of resources.

(1) The IS, when subject to a non-MAGI budgeting methodology, is permitted to keep up to two thousand dollars in countable resources.

(2) A CS is permitted to keep a certain amount of the couple's combined countable resources called the community spouse resource allowance (CSRA).

(3) A CSRA must be calculated when an IS applies for LTC services unless the IS has base eligibility under a MAGI category, in accordance with Chapter 5160:1-4 of the Administrative Code, because MAGI budgeting does not have a resource limit.

(4) The CSRA is calculated as follows:

(a) Total all of the couple's combined countable resources, in accordance with Chapter 5160:1-3 of the Administrative Code, which were owned on the IS's snapshot date. Beginning on or after September 30, 1989, the snapshot date is the earlier of:

(i) The first day of the month in which the individual was an IS and was in a medical institution for a continuous period of institutionalization;

(ii) The first day of the month in which the individual was an IS and is expected to be in a medical institution for a continuous period of institutionalization; or

(iii) The day the IS applied for or requested HCBS or PACE services, as long as the IS meets the non-financial requirements to receive such services. When the IS ceases to meet the non-financial requirements for HCBS waiver or PACE enrollment, then the IS's base eligibility must be redetermined in accordance with Chapter 5160:1-3, 5160:1-4, or 5160:1-5 of the Administrative Code.

(b) The CSRA is the greatest of the following:

(i) One half of the total of the couple's combined countable resources or the community spouse maximum resource standard established annually by the centers for medicare and medicaid services (CMS), whichever is less;

(ii) The community spouse minimum resource standard established annually by CMS;

(iii) The amount established by a state hearing decision from a hearing requested under paragraphs (E)(11) and (E)(12) of this rule; or

(iv) The amount established under a court order.

(5) To determine whether the IS is resource eligible, deduct the CSRA from the total of the couple's current combined countable resources.

(a) When the remainder is less than or equal to two thousand dollars, the IS is resource eligible.

(b) When the remainder is greater than two thousand dollars, the IS is ineligible for medical assistance.

(6) When the CS fails to cooperate with the CSRA determination or refuses to make resources available to the IS as required by this rule, the IS shall not be ineligible because of resources determined in paragraph (E)(5) of this rule, when the countable resources that are solely owned by or titled to the IS are at or below two thousand dollars and one of the following conditions is met:

(a) The IS has assigned to the administrative agency any rights to support from the CS;

(b) The IS lacks the ability to execute an assignment due to physical or mental impairment; however, the administrative agency has the right to bring a support proceeding against a CS without such assignment; or

(c) The administrative agency determines that a denial of eligibility would cause an undue hardship. An undue hardship exists when the denial or termination of services would deprive the individual of medical care such that the individual's health or life would be endangered or deprive the individual of life necessities such as food, clothing, or shelter.

(7) An undue hardship under paragraph (E)(6) of this rule will not be granted when the IS transferred resources to the CS and the CS refuses to make resources in an amount above the CSRA available to the IS.

(8) When applicable, once the IS's initial eligibility is approved, the IS has twelve months from the date that eligibility was approved to transfer any resources that are owned or titled in his or her name, up to the CSRA amount, solely into the name of the CS. When the IS fails to transfer such resources within the twelve-month period, the IS's eligibility will be discontinued when the resources that remain in the IS's name are not at or below two thousand dollars.

(9) After the month in which the IS is determined eligible for medical assistance, no resources of the CS shall be considered available to the IS, for as long as the IS continues to remain eligible without a break in coverage.

(10) A CSRA calculation can be requested at any time by either spouse or by someone with the legal ability to act on the IS's behalf. A copy of the CSRA calculation will be maintained by the administrative agency.

(11) When either spouse considers the CSRA amount insufficient, either spouse or someone with the legal ability to act on his or her behalf can request a state hearing, in accordance with rule 5101:6-7-02 of the Administrative Code, regardless of whether the CSRA calculation is done in conjunction with an application for medical assistance.

(12) The CSRA may be increased to generate additional income to the CS when a hearing requested under rule 5101:6-7-02 of the Administrative Code results in a finding that all of the available income of the IS has been allocated to the CS and that income is not enough to bring the CS's income up to the minimum monthly maintenance needs allowance (MMMNA), as defined in rule 5160:1-6-01.1 of the Administrative Code.

Last updated April 10, 2026 at 9:51 AM

History

Effective: April 1, 2026
Promulgated Under: 111.15

Ohio Adm.Code 5160:1-6-05 Medicaid: treatment of income and resources for spouses who are both seeking medicaid payment for long-term care (LTC) services.

(A) This rule describes the treatment of income and resources for spouses who are both seeking medicaid payment for LTC services.

(B) When both spouses are expected to receive LTC services for less than thirty consecutive days, each spouse's eligibility must be determined in accordance with Chapter 5160:1-3 or 5160:1-4 of the Administrative Code and the rules in Chapter 5160:1-6 of the Administrative Code do not apply.

(C) When both spouses are likely to receive LTC services for more than thirty consecutive days, the following rules apply:

(1) When the spouses are no longer living together (for example, one spouse is residing in a medical institution and the other spouse is requesting enrollment in a home and community-based services (HCBS) waiver), determine each spouse's eligibility independently as follows:

(a) Determine whether one or both spouses have base eligibility under Chapter 5160:1-4 of the Administrative Code.

(b) When a spouse does not have base eligibility under Chapter 5160:1-4 of the Administrative Code, beginning the first month following the month the couple ceased to live together, treat the spouse as an individual and compare his or her income and resources to the individual income and resource standards in accordance with Chapter 5160:1-3 of the Administrative Code.

(c) When a spouse's income exceeds the individual income standard, then, when applicable, determine each spouse's eligibility under the special income level (SIL) as described in rule 5160:1-6-03.1 of the Administrative Code.

(2) When the spouses are living together in the community (for example, both spouses are requesting enrollment in an HCBS waiver):

(a) Determine whether one or both spouses have base eligibility under Chapter 5160:1-4 of the Administrative Code.

(b) When one or both of the spouses do not have base eligibility under Chapter 5160:1-4 of the Administrative Code, determine eligibility for one or both of the spouses in accordance with Chapter 5160:1-3 of the Administrative Code.

(c) When one or both of the spouses do not have base eligibility under Chapter 5160:1-3 of the Administrative Code, then determine both spouse's eligibility independently under the SIL.

(D) When both spouses reside in, or are admitted to, the same room of a medical institution, then the following rules apply:

(1) Determine whether one or both spouses have base eligibility under Chapter 5160:1-4 of the Administrative Code.

(2) When a spouse does not have base eligibility under Chapter 5160:1-4 of the Administrative Code, the spouse may choose to be considered as a couple or as an individual for the purposes of applying the individual or couple income standards under Chapter 5160:1-3 of the Administrative Code, whichever is more advantageous to the individual.

(3) When a spouse's income exceeds the income standards in Chapter 5160:1-3 of the Administrative Code, then the spouse's eligibility will be determined under the SIL.

(E) Hardship exception.

(1) When both spouses are seeking or receiving LTC services, one spouse may receive an amount that does not exceed the monthly income allowance (MIA) as calculated in rule 5160:1-6-07 or 5160:1-6-07.1 of the Administrative Code in the following circumstance:

(a) Only one spouse is subject to a patient liability; and

(b) The spouse who is not subject to the patient liability receives HCBS services and needs the additional income from his or her spouse to remain in the community.

(2) The amount of income received by the spouse under this section will be considered unearned income to that spouse.

Last updated December 1, 2023 at 9:41 AM

History

Effective: December 1, 2023
Promulgated Under: 111.15

Ohio Adm.Code 5160:1-6-06 Medicaid: transfer of assets.

(A) This rule implements section 1917 of the Social Security Act (as in effect October 1, 2025) and describes the treatment of transfers of assets when an institutionalized individual, as defined in rule 5160:1-6-01.1 of the Administrative Code, is seeking medicaid payment for long-term care (LTC) services. This rule, and rules 5160:1-6-06.1 to 5160:1-6-06.8 of the Administrative Code, only apply to institutionalized individuals.

(B) When the institutionalized individual (or his or her spouse) disposes of assets for less than fair market value on or after the look-back date specified in paragraph (C) of this rule, any such transfer will be presumed an improper transfer and will result in a restricted medicaid coverage period (RMCP) in accordance with rule 5160:1-6-06.5 of the Administrative Code.

(C) The look-back date is sixty months (five years) before the individual's baseline date, as defined in rule 5160:1-6-01.1 of the Administrative Code.

(1) When the individual is already eligible for medical assistance when he or she first becomes an institutionalized individual, the baseline date is the first date of institutionalization.

(2) When the individual is requesting enrollment on a home and community-based services (HCBS) waiver, the baseline date is the first date that the individual has both applied for medical assistance and requested enrollment on an HCBS waiver. These transfer of asset provisions only apply when the individual is eligible for medical assistance using the special income level (SIL).

(D) The following transfers are not considered improper:

(1) The title to the home was transferred to the institutionalized individual's spouse, child who is under twenty-one years of age, or child who is blind or disabled in accordance with section 1614 of the Social Security Act (as in effect October 1, 2025).

(2) The title to the home was transferred to the institutionalized individual's child (other than a child described in paragraph (D)(1) of this rule) who:

(a) Provided care to the institutionalized individual which permitted the institutionalized individual to reside at home rather than in a long-term care facility (LTCF) or be enrolled in an HCBS waiver;

(b) Resided in the home for a period of at least two years immediately preceding and on a continuous basis since the individual became an institutionalized individual; and

(c) Documents that he or she has fulfilled all of the requirements in paragraphs (D)(2)(a) to (D)(2)(c) of this rule by submitting both of the following forms:

(i) A completed and notarized ODM 10271 "Affidavit of Child Caregiver";

(a) Supporting documentation must be provided with the ODM 10271 to verify the type(s) of services provided to the individual, the frequency with which the services were provided, the duration of services provided, and who provided such services.

(b) The administrative agency may request additional verification that the child lives in the home.

(c) The administrative agency may request verification of the relationship between the institutionalized individual and the child.

(ii) The ODM 10272 "Physician Certification" or other written statement from the individual's attending physician stating the type(s) and duration of care that was required to delay the individual's institutionalization.

(3) The title to the home was transferred to the institutionalized individual's sibling who has an equity interest in the home and who was residing in the institutionalized individual's home for a period of at least one year immediately preceding the date the individual was admitted into a LTCF or enrolled on an HCBS waiver.

(4) The assets were transferred to or from (i.e., between the spouses) the institutionalized individual and his or her spouse, or to another for the sole benefit of the institutionalized individual's spouse.

(5) The assets were transferred to the institutionalized individual's child who is blind or disabled in accordance with section 1614 of the Social Security Act (as in effect October 1, 2025) (or to a trust, including an exempt trust described in rule 5160:1-3-05.2 of the Administrative Code), for the sole benefit of that child.

(6) The assets were transferred to a trust (including an exempt trust described in rule 5160:1-3-05.2 of the Administrative Code) created for the sole benefit of an individual under the age of 65 who is disabled, as defined in section 1614 of the Social Security Act (as in effect October 1, 2025).

(7) The institutionalized individual's income transferred to a qualified income trust (QIT) in accordance with rule 5160:1-6-03.2 of the Administrative Code.

(E) For transfers described in paragraphs (D)(4) to (D)(6) of this rule, to be considered for the sole benefit of the individuals described in such paragraphs, the instrument or document must provide for the spending of the funds involved for the benefit of the individual on a basis that is actuarially sound based on the life expectancy of the individual involved. When the instrument or document does not provide for such, any potential exemption from an RMCP, in accordance with rule 5160:1-6-06.5 of the Administrative Code, is void.

(F) Rebutting the presumption that a transfer was improper.

(1) The institutionalized individual, his or her spouse, or anyone acting on the institutionalized individual's behalf may make a satisfactory showing to the agency that the institutionalized individual or such individual's spouse intended to:

(a) Transfer the asset for fair market value or for other valuable consideration; or

(b) Transfer the asset exclusively for a purpose other than to qualify for medical assistance.

(2) The institutionalized individual, his or her spouse, or anyone acting on the institutionalized individual's behalf must provide a written explanation with supporting documentation which explains the following:

(a) The reason for transferring the asset for less than fair market value;

(b) The attempts that were made to transfer the asset for fair market value;

(d) The institutionalized individual's relationship to the person to whom the asset was transferred.

(e) The occurrence of one or more of the following after a transfer of the asset(s), while not conclusive, may indicate that the asset(s) was transferred exclusively for some purpose other than to qualify for medical assistance:

(i) Traumatic onset of disability or blindness (e.g., due to traffic accident); or

(ii) Diagnosis of a previously undetected disabling condition.

(f) Supporting documentation may include, but is not limited to, a contract, realtor agreements, sworn statements, third party statements, medical records, financial records, court records, and relevant correspondence.

(3) When the administrative agency determines that a transfer was not improper then no RMCP will be imposed with respect to that transfer.

(G) When the imposition of an RMCP would result in an undue hardship, the institutionalized individual may request an undue hardship exemption in accordance with rule 5160:1-6-06.6 of the Administrative Code.

(H) Verification of transfers.

(1) The administrative agency shall determine at the time of application, renewal, or any time upon discovery of a transfer whether the institutionalized individual executed an improper transfer.

(2) An institutionalized individual must inform the administrative agency of any transfers of real or personal property.

(3) The institutionalized individual must provide the administrative agency with documentation verifying any transfer and the details of any exchanges or transactions. When requested, the administrative agency shall assist the institutionalized individual with gathering such documentation.

Last updated October 7, 2025 at 11:17 PM

History

Effective: October 1, 2025
Promulgated Under: 111.15

Ohio Adm.Code 5160:1-6-06.1 Medicaid: treatment of annuity purchases and transactions.

(A) This rule describes the treatment of annuity purchases and transactions when an institutionalized individual is requesting medicaid payment for long-term care (LTC) services.

(B) The institutionalized individual, or his or her spouse, must disclose any interest that he or she has in an annuity, regardless of whether the annuity is irrevocable or is treated as an asset to the institutionalized individual or his or her spouse.

(C) Failure to comply with paragraph (B) of this rule will result in a denial or discontinuance of medical assistance for failure to cooperate as required by rule 5160:1-2-10 of the Administrative Code.

(D) Treatment of annuity purchases or transactions on or after February 8, 2006.

(1) Any purchase or annuity transaction, including annuities purchased by a spouse, shall be treated as an improper transfer subject to a restricted medicaid coverage period (RMCP) in accordance with rule 5160:1-6-06.5 of the Administrative Code unless:

(a) The state of Ohio is named as the remainder beneficiary in the first position for the total amount of medical assistance furnished to the institutionalized individual; or

(b) The state of Ohio is named as such a beneficiary in the second position for the total amount of medical assistance furnished to the institutionalized individual after the community spouse or minor or disabled child, or is named in the first position for the total amount of medical assistance furnished to the institutionalized individual when such spouse or a representative of such child disposes of any such remainder for less than fair market value.

(2) In addition to paragraph (D)(1) of this rule, when the annuity is purchased by or on behalf of an annuitant, as defined in rule 5160:1-3-05.3 of the Administrative Code, who has applied for medical assistance, the purchase of the annuity will be deemed an improper transfer subject to an RMCP even when the beneficiary naming requirements in paragraph (D)(1) of this rule are met, unless the annuity meets the conditions in either paragraph (D)(2)(a) or (D)(2)(b) of this rule:

(a) The annuity:

(i) Is an annuity described in subsection (b) or (q) of section 408 of the Internal Revenue Code of 1986 (as in effect October 1, 2023); or

(ii) Is an annuity that was purchased with proceeds from:

(a) An account or trust described in subsection (a), (c), or (p) of section 408 of such code; or

(b) A simplified employee pension (within the meaning of section 408(k) of such code); or

(b) The annuity meets all of the following requirements:

(i) The annuity is irrevocable and non-assignable; and

(ii) The annuity is actuarially sound as determined by the life expectancy tables published by the office of the actuary of the social security administration in accordance with 26 C.F.R. 20.2031-7 (as in effect October 1, 2023). For an annuity to be considered actuarially sound, the total amount of proceeds shall be designed to be dispersed in equal monthly payments with no anticipated lump-sum payment. The only allowable lump-sum payment is the refund provided when the annuitant dies prior to the end of the guaranteed period and is paid to the remainder beneficiary; and

(iii) The annuity provides for payments in equal amounts during the term of the annuity with no deferral and no balloon payments made.

(E) Transactions which occur on or after February 8, 2006, with respect to an annuity purchased prior to February 8, 2006, may subject the annuity to the requirements in paragraph (D) of this rule.

(1) Such transactions include any action taken by the institutionalized individual that changes the course of payments to be made by the annuity or the treatment of income or principal of the annuity. The actions include additions of principal, elective withdrawals, requests to change the distribution of the annuity, elections to annuitize the contract and similar actions taken by the institutionalized individual after February 8, 2006.

(2) Routine changes and automatic events that do not require any action or decision after the effective date of enactment are not considered transactions that would subject the annuity to the requirements in paragraph (D) of this rule. Routine changes include notification of an address change, death, divorce of a remainder beneficiary, or other similar transactions.

(F) Annuities purchased prior to February 8, 2006, are not subject to the requirements of this rule unless the requirements in paragraph (E) of this rule are met.

(G) When an annuity purchase or transaction is deemed improper then the full purchase price of the annuity is subject to an RMCP in accordance with rule 5160:1-6-06.5 of the Administrative Code. For an annuity purchase or transaction to be deemed improper the purchase or transaction must have occurred after the look-back date.

Last updated September 12, 2025 at 12:37 PM

History

Effective: January 1, 2024
Promulgated Under: 111.15

Ohio Adm.Code 5160:1-6-06.2 Medicaid: treatment of transfers involving a trust.

(A) This rule describes when transfers, by an institutionalized individual or his or her spouse, involving a trust are considered improper and subject to a restricted medicaid coverage period (RMCP) in accordance with rule 5160:1-6-06.5 of the Administrative Code.

(B) This rule does not affect whether the contents of the trust or payments or distributions from a trust are considered resources or income to the institutionalized individual for purposes of determining base eligibility under Chapters 5160:1-3, 5160:1-4, and 5160:1-5 of the Administrative Code.

(C) This rule applies to any revocable or irrevocable trust, as defined in rule 5160:1-3-05.2 of the Administrative Code, that contains assets of the institutionalized individual or his or her spouse, that was established (other than by will) on or after the look-back date by:

(1) The institutionalized individual;

(2) The institutionalized individual's spouse;

(3) A person, including a court or administrative body, with legal authority to act in place of or on behalf of the institutionalized individual or his or her spouse;

(4) A person, including any court or administrative body, acting at the direction or upon the request of the institutionalized individual or his or her spouse.

(D) In the case of a trust that meets the requirements of paragraph (C) of this rule, only the assets of the institutionalized individual or his or her spouse that are in the trust, are subject to the provisions of this rule.

(E) This rule shall apply without regard to:

(1) The purposes for which the trust was established;

(2) Whether the trustees have or exercise any discretion under the trust;

(3) Any restrictions on when or whether distributions may be made from the trust; or

(4) Any restrictions on the use of distributions from the trust.

(F) Unless otherwise permitted under this chapter, any payments or distributions from a revocable or irrevocable trust that are not made to the institutionalized individual or for the benefit of the institutionalized individual shall be considered improperly transferred and subject to an RMCP.

(G) Unless otherwise permitted under this chapter, any transfers to the trust for less than fair market value shall be considered improperly transferred and subject to an RMCP.

(1) "Fair market value," for the purposes of this rule, has the same meaning as in rule 5160:1-1-01 of the Administrative Code.

(2) An individual may rebut the presumption that a transfer was improper in accordance with rule 5160:1-6-06 of the Administrative Code.

(H) In the case of an irrevocable trust:

(1) Unless otherwise permitted under this chapter, if no payment can be made to the institutionalized individual or for the institutionalized individual's benefit, the assets of the trust will be considered improperly transferred and subject to an RMCP in accordance with rule 5160:1-6-06.5 of the Administrative Code.

(2) When determining the date that the assets of the trust were improperly transferred, the date of transfer is the date of the establishment of the trust or the date that payments or distributions to the individual were prohibited, whichever date is later.

(3) When determining the value of the transferred asset under this provision, the value of the trust is its value on the date when the trust was established or the date that payments or distributions to the individual were prohibited, whichever date is later.

(4) If any additional assets of the institutionalized individual or his or her spouse are added to the trust, such transfers will be considered separate improper transfers subject to an RMCP.

(I) If the imposition of an RMCP would result in an undue hardship, the institutionalized individual can request an undue hardship exemption in accordance with rule 5160:1-6-06.6 of the Administrative Code.

(J) This rule shall not apply to any of the following trusts:

(1) A special needs trust as described in rule 5160:1-3-05.2 of the Administrative Code, except when such a trust is added to or otherwise augmented after the individual reaches age sixty-five. Any such addition or augmentation by the individual, with his or her assets, after age sixty-five is considered an improper transfer and subject to a RMCP.

(2) A qualified income trust (QIT) as described in rule 5160:1-6-03.2 of the Administrative Code.

(3) A pooled trust as described in rule 5160:1-3-05.2 of the Administrative Code.

(4) A supplemental services trust as described in rule 5160:1-3-05.2 of the Administrative Code.

Last updated December 1, 2025 at 9:43 AM

History

Effective: December 1, 2025
Promulgated Under: 111.15

Ohio Adm.Code 5160:1-6-06.3 Medicaid: transfers involving life estates.

(A) This rule describes the treatment of transfers involving life estates when an institutionalized individual is requesting medicaid payment for long-term care services.

(B) The following steps must be taken to determine whether a transfer involving a life estate, as defined in rule 5160:1-3-05.17 of the Administrative Code, was an improper transfer in accordance with rule 5160:1-6-06 of the Administrative Code:

(1) Review the life estate instrument to determine the nature of the life estate and the rights, responsibilities, and restrictions placed on the life estate owner and the remainderman, as defined in rule 5160:1-3-05.17 of the Administrative Code.

(2) Determine the effective date of the creation of a life estate in accordance with rule 5160:1-3-05.17 of the Administrative Code.

(3) Calculate the fair market value of a life estate in accordance with rule 5160:1-3-05.17 of the Administrative Code.

(1) When the life estate was established within the applicable look-back period and the terms of the establishing instrument prohibit the life estate from being sold or transferred, the fair market value of the life estate will be presumed improperly transferred.

(2) When an institutionalized individual improperly transferred ownership of his or her home but retained a life estate in the home, the improper transfer amount, with respect to the home transfer, is the difference between the fair market value of the home and the fair market value of the life estate.

(D) Life estates held by an institutionalized individual.

(1) An institutionalized individual's purchase of a life estate interest in another individual's home within the applicable look-back period is presumed to be an improper transfer, unless the institutionalized individual resided in the home for a period of at least one year after the date of purchase. When such purchase is deemed improper, the fair market value of the life estate will be the improper transfer amount.

(2) When the purchase price of a life estate in another individual's home is greater than the fair market value of the life estate, the amount of the difference will be considered improperly transferred, even when the individual resided in the home for at least one year after the date of purchase.

(E) When an institutionalized individual transfers or sells a life estate held by the institutionalized individual within the applicable look-back period, the institutionalized individual must receive fair market value, calculated in accordance with rule 5160:1-3-05.17 of the Administrative Code, for the life estate. When the institutionalized individual receives less than fair market value for the life estate, the fair market of the life estate will be presumed improperly transferred.

Last updated September 12, 2025 at 12:37 PM

History

Effective: June 9, 2025
Promulgated Under: 111.15

Ohio Adm.Code 5160:1-6-06.4 Medicaid: transfers involving promissory notes, property agreements, and loans.

(A) This rule describes how to treat transfers involving promissory notes, property agreements, and loans held by an institutionalized individual, or his or her spouse, when the institutionalized individual is requesting medicaid payment for long-term care (LTC) services.

(B) Assets used to purchase or obtain a promissory note, property agreement, or loan are considered to be improperly transferred unless the the purchase of the note, agreement or loan was for fair market value and the terms of the promissory note, property agreement, or loan:

(1) Have a repayment term that is actuarially sound as determined in accordance with actuarial publications of the office of the chief actuary in 26 C.F.R. 20.2031-7 (as in effect on October 1, 2024);

(2) Provide for payments to be made in equal amounts during the term of the promissory note, property agreement, or loan, with no deferral and no balloon payments made;

(3) Prohibit cancellation of the balance upon the lender's death; and

(4) Allow for the transfer or sale of the note, agreement, or loan.

(C) When the promissory note, property agreement, or loan does not satisfy the requirements in paragraph (B) of this rule, the value of such note, agreement, or loan shall be its outstanding balance as of the date the institutionalized individual requests medicaid payment for LTC services and must be considered improperly transferred in accordance with rule 5160:1-6-06 of the Administrative Code.

(1) Any resulting restricted medicaid coverage period (RMCP) shall not be reduced based upon anticipated, estimated, or projected future payments made under the note, agreement, or loan.

(2) For any resulting RMCP to be reduced because of a repayment, the promissory note, property agreement, or loan must be repaid in full.

(D) When an institutionalized individual transfers or sells a promissory note, property agreement, or loan for an amount less than the outstanding balance of such note, agreement, or loan, the difference will be considered improperly transferred as of the note, agreement, or loan's sale date.

(E) The institutionalized individual may rebut the finding that the purchase or transfer of a promissory note, property agreement, or loan is improper by providing at least one of the following:

(1) Credible evidence from a knowledgeable source establishing that the fair market value was less than its outstanding principal balance. The knowledgeable source must:

(a) Be clearly identified and limited to the following:

(i) In the case of real property, entities who have experience in the sale or valuation of the type of real property in question: county auditors, real estate brokers, real estate agents, real estate appraisers, United States department of agriculture (USDA) rural development service center offices, USDA farm service agency service center offices, banks, savings and loan associations, mortgage companies and similar lending institutions, and the county extension service offices.

(ii) In the case of personal property, any professional, business owner or operator, or expert who has experience in the sale, trade, restoration, or valuation of the type of personal property in question.

(b) Provide a written explanation regarding its opinion of the fair market value; and

(c) Affirmatively indicate the decreased fair market value was not caused in whole or part by the terms of the note or agreement and the decrease in fair market value was entirely outside the control of the institutionalized individual or the institutionalized individual's representative(s).

(2) Documentation clearly showing the institutionalized individual received payments under the terms of the note or agreement prior to the sale, and such payments equal or exceed the difference between the sale price and the fair market value of assets originally given in exchange for the note or agreement; or

(3) Documentation clearly showing that the lower price of the note or agreement was accepted by the institutionalized individual as payment of a debt owed by the institutionalized individual to the purchaser.

Last updated September 12, 2025 at 12:37 PM

History

Effective: June 9, 2025
Promulgated Under: 111.15

Ohio Adm.Code 5160:1-6-06.5 Medicaid: restricted medicaid coverage period.

(A) This rule describes how to calculate and apply a restricted medicaid coverage period (RMCP), which is the period of time that long-term care (LTC) services will not be paid for by medicaid because the institutionalized individual improperly transferred an asset.

(B) RMCP calculation.

(1) Total the value of all improperly transferred assets.

(2) When the first month of requested payment of LTC services is less than a full calendar month, an initial pro-rated period of restricted coverage (IPPRC) shall be calculated as follows and is considered the first month of the RMCP:

(a) Determine the daily average private pay rate (APPR) for nursing facility services in Ohio by dividing the monthly APPR by the number of days in the month for which the first month of RMCP is being calculated. Round the result to the second decimal place.

(b) Multiply the daily APPR by the number of days from the first day of eligibility for requested LTC services through the last day of the month in which the institutionalized individual is eligible for medical assistance and would otherwise be receiving LTC services paid for by the medicaid program.

(3) Determine full months of RMCP as follows:

(a) Subtract the IPPRC from the total value of all improperly transferred assets, if applicable; then

(b) Divide by the monthly APPR.

(d) When there is a remaining fractional amount, calculate a partial month of restricted coverage.

(4) To determine the partial month of restricted coverage (PMRC):

(a) Multiply the APPR by the number of full months of restricted coverage; then

(b) Subtract that amount from the total value of the improperly transferred assets; then

(d) The remainder is the amount of the PMRC.

(1) When an institutionalized individual is receiving any category of medical assistance at the time the determination is made that assets were transferred for less than fair market value, the RMCP will be effective on the first day of the month following the expiration of the required notice period under rule 5160:6-2-04 of the Administrative Code.

(2) When an institutionalized individual is not receiving any category of medical assistance at the time the determination is made that assets were transferred for less than fair market value, the RMCP will be effective on the date on which the institutionalized individual is eligible for medical assistance and would otherwise be receiving LTC services paid for by the medicaid program but for the imposition of the RMCP.

(3) The RMCP cannot begin until the expiration of any already existing RMCP.

(4) Once the RMCP is imposed, it will not stop but will continue to run even when the individual subsequently stops receiving LTC services.

(5) The RMCP shall not be rounded down nor shall any PMRC be otherwise disregarded.

(6) Any PMRC shall be applied as follows:

(a) When an individual has a patient liability, the PMRC will be added to the institutionalized individual's patient liability in the first month of eligibility for LTC services. Refer to rules 5160:1-6-07 to 5160:1-6-07.2 of the Administrative Code for the determination of the patient liability.

(b) When an individual does not have a patient liability, the individual is responsible for paying his or her LTC provider the PMRC amount in the first month of eligibility for LTC services.

(D) When a court has entered an order against an institutionalized individual for the support of his or her spouse, an RMCP shall not apply to amounts of assets transferred pursuant to such order for the support of the spouse or a family member.

(E) Any improper transfer by a spouse that results in an RMCP for the institutionalized individual shall be applied as follows:

(1) When the spouse becomes an institutionalized individual, any remaining months of the RMCP shall be apportioned between the spouses.

(2) When one spouse ceases to be institutionalized, any remaining months of the RMCP that has been applicable to both spouses must be served by the spouse who continues to be institutionalized.

(F) Treatment of new or newly discovered improper transfer of assets.

(1) When a new improper transfer of assets occurs during an existing RMCP, a new RMCP shall be calculated using only the new improper transfers and the APPR in effect at the time of the calculation. The new RMCP shall be applied consecutively with the existing RMCP.

(a) When there is a PMRC calculated for both the existing RMCP and the new RMCP, combine the PMRCs.

(b) When the combined PMRCs are greater than or equal to the monthly APPR, the result shall be an additional month of RMCP and potentially a new PMRC amount. The additional month of RMCP and PMRC shall be applied at the end of the new RMCP.

(2) When improper transfers of assets that occurred prior to the existing RMCP are newly discovered after the RMCP was calculated, the existing RMCP shall be recalculated to include the newly discovered improper transfers and using the APPR in effect when the existing RMCP was calculated.

(G) When all of the assets that were improperly transferred are returned to the institutionalized individual, no RMCP will be imposed.

(1) Return of the assets in question to the institutionalized individual leaves the institutionalized individual with assets which must be counted in redetermining eligibility for medical assistance.

(a) Counting those assets as available may result in the institutionalized individual being ineligible for medical assistance for some or all of the original RMCP, as well as for a period of time after the assets are returned.

(b) The administrative agency must redetermine eligibility for each month in the original RMCP and include the returned assets as an available resource unless the asset would have otherwise been considered an excluded asset.

(c) When an exclusion does not apply, the asset is considered available to the institutionalized individual until the total countable assets have been reduced to the appropriate resource limit.

(2) When the asset was sold by the person who received it, the full market value of the asset must be returned to the institutionalized individual, either in cash or another form that is commensurate with the original value. A return of any amount less than the total value of all of the improperly transferred assets will have no effect on the RMCP as calculated in this rule.

(3) For the purpose of computing an overpayment under rule 5160:1-2-04 of the Administrative Code, the returned asset or its equivalent must be considered an available asset beginning in the month the asset was originally transferred.

(H) When an RMCP resulting from an improper transfer would result in an undue hardship, the institutionalized individual can request an undue hardship exemption in accordance with rule 5160:1-6-06.6 of the Administrative Code.

Last updated September 13, 2025 at 2:46 AM

History

Effective: January 1, 2024
Promulgated Under: 111.15

Ohio Adm.Code 5160:1-6-06.6 Medicaid: undue hardship exemption.

(A) This rule describes an undue hardship exemption for institutionalized individuals who are subject to a restricted medicaid coverage period (RMCP) described in rule 5160:1-6-06.5 of the Administrative Code.

(B) The institutionalized individual will not be subject to an RMCP when the imposition of the RMCP would cause an undue hardship.

(1) Medical care such that the institutionalized individual's health or life would be endangered; or

(2) Food, clothing, shelter, or other necessities of life.

(D) An undue hardship exemption may be requested by:

(1) The institutionalized individual; or

(2) The institutionalized individual's spouse; or

(3) A person, including a court or administrative body, with legal authority to act in place of or on behalf of the institutionalized individual or the individual's spouse; or

(4) A person, including any court or administrative body, acting at the direction or upon the request of the institutionalized individual or the individual's spouse.

(E) Any request for an undue hardship exemption must be made in writing and include the information and documentation necessary to demonstrate to the administrative agency that:

(1) An undue hardship exists.

(2) The institutionalized individual currently has no alternative income or resources available to provide the medical care or food, clothing, shelter, or other necessities of life that the institutionalized individual would be deprived of due to the imposition of the RMCP.

(3) A good faith effort to pursue all reasonable means to recover the transferred asset or the fair market value of the transferred asset was made, unless documentation provided shows that the cost of any such action would exceed the gross value of the assets subject to recovery. These actions may include:

(a) Seeking the advice of an attorney and pursuing legal or equitable remedies such as asset freezing, assignment, or injunction; or seeking modification, avoidance, or nullification of a court order, financial instrument, promissory note, loan, mortgage or other property agreement, or other similar transfer agreement; and

(b) Cooperating with any attempt to recover the transferred asset or the fair market value of the transferred asset.

(F) An undue hardship exemption shall not be granted when the institutionalized individual, or the individual's spouse, or anyone acting on their behalf, made the improper transfer after a previous request for a hardship exemption.

(G) Administrative agency responsibilities.

(1) The administrative agency shall provide notice to the institutionalized individual of the:

(a) Availability of an undue hardship exemption; and

(b) Approval or denial of any request for an undue hardship exemption.

(2) The administrative agency, on its own initiative, may consult with the county prosecutor to determine whether a civil or criminal action may be brought to recover the transferred assets or to compel restitution.

Last updated September 13, 2025 at 6:24 AM

History

Effective: January 1, 2024
Promulgated Under: 111.15

Ohio Adm.Code 5160:1-6-06.7 Medicaid: allegations of asset transfers by the social security administration.

(A) This rule describes the social security administration's (SSA) reporting requirements to the Ohio department medicaid (ODM) regarding alleged transfer of assets by supplemental security income (SSI) applicants.

(B) When an individual applies for SSI benefits, the SSA requests information from the applicant regarding any asset transfers and reports the information to ODM. The SSA notifies ODM of any resource transfer, regardless of when the transfer occurred.

(C) ODM forwards the information to the department of job and family services (DJFS) for the county in which the individual resides to determine whether any such transfers were improper in accordance with rule 5160:1-6-06 of the Administrative Code.

Last updated September 13, 2025 at 2:46 AM

History

Effective: January 1, 2024
Promulgated Under: 111.15

Ohio Adm.Code 5160:1-6-06.8 Medicaid: disposal of assets of individuals receiving services from the Ohio department of developmental disabilities and/or Ohio department of mental health and addiction services.

(A) This rule describes the disposal of assets of individuals who are receiving services from the Ohio department of developmental disabilities (DODD) and/or the Ohio department of mental health and addiction services (OhioMHAS) and who are in receipt of medical assistance.

(B) Individuals in receipt of medical assistance may have received or continue to receive services from DODD and/or OhioMHAS.

(1) DODD and OhioMHAS provide for any and all personal needs, e.g., recreational activities and services necessary to assure a better quality of life for individuals under their care. Many of these services are not covered by medicaid and exceed the individual's available personal income.

(2) DODD and OhioMHAS maintain records and documentation of expenses incurred on an individual's behalf that fall outside of the scope of coverage for medical assistance and exceed the individual's available income.

(3) When an individual receives a lump-sum payment or available assets are identified, DODD and OhioMHAS seek reimbursement for appropriately incurred expenses.

(C) When DODD and/or OhioMHAS are acting on behalf of the individual as the responsible party, legal guardian, etc., the appropriate department may dispose of the asset by increasing the individual's assets to the resource limit described in rule 5160:1-3-05.1 of the Administrative Code, by establishing an irrevocable burial contract in accordance with rule 5160:1-3-05.6 of the Administrative Code, or by purchasing any personal items deemed necessary to better the individual's quality of life. After these expenses, DODD and/or OhioMHAS will reimburse their department for funds expended on behalf of the individual and provide documentation of these expenses to the administrative agency

(D) When the individual's responsible party, legal guardian, etc., is not a representative of DODD and/or OhioMHAS, the representative is also afforded the opportunity of increasing assets to the resource limit, establishing an irrevocable burial contract in accordance with rule 5160:1-3-05.6 of the Administrative Code, or purchasing necessary personal items to better the individual's quality of life. Documentation of these expenses shall be provided to the administrative agency. After such expenses, the responsible party, legal guardian, etc., must properly dispose of any excess assets to maintain continued eligibility for medical assistance.

(E) Administrative agency responsibilities. The administrative agency shall:

(1) Notify the responsible party of the options available to appropriately dispose of excess assets. One option is reimbursement to the Ohio department medicaid (ODM) for medicaid expenses. The options of reimbursing ODM, DODD, or OhioMHAS or terminating eligibility for medical assistance and paying privately for the medical expenses remain with the responsible party.

(2) Review necessary documentation for the reimbursement to DODD or OhioMHAS to assure that the individual did, in fact, receive fair market value for the assets.

(a) When the documentation verifies the individual received fair market value, the administrative agency shall accept these expenditures as valid.

(b) Valid expenses and reimbursements to DODD and/or OhioMHAS shall not be considered an improper transfer of assets.

Last updated September 12, 2025 at 12:39 PM

History

Effective: January 1, 2024
Promulgated Under: 111.15

Ohio Adm.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.

(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.

(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.

(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.

(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, 2025). 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, 2025).

(e) Restitution payments under the Aleutian and Pribilof Island Restitution Act, in accordance with 50 U.S.C. 4236 (as in effect October 1, 2025).

(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, 2025).

(l) SSI benefits received under authority of sections 1611 (e)(1)(E) and (G) of the Social Security Act (as in effect October 1, 2025) 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, 2025) 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 temporary assistance for needy families (TANF) funded, in accordance with 42 U.S.C. 604 (as in effect October 1, 2025).

(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, 2025).

(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, 2025):

(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;

(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, 2025).

(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, 2025).

(3) Subtract a personal needs allowance (PNA) of seventy-five 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

(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 (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. The 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.

(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.

(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.

Last updated January 13, 2026 at 2:49 AM

History

Effective: January 1, 2026
Promulgated Under: 111.15

Ohio Adm.Code 5160:1-6-07.1 Medicaid: post-eligibility treatment of income for individuals receiving services through a home and community-based services (HCBS) waiver or the program of all-inclusive care for the elderly (PACE).

(A) This rule describes the process for calculating an individual's post-eligibility treatment of income (PETI), commonly referred to as patient liability or share of cost, when the individual is not living in a medical institution. This rule only applies to an individual who is both eligible for medical assistance under the special income level (SIL) as described in rule 5160:1-6-03.1 of the Administrative Code and who is receiving HCBS waiver or PACE services.

(B) The administrative agency will reduce its payment to the HCBS waiver or PACE providers for services provided to the 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 his or her providers identified by the HCBS waiver or PACE administrative agency.

(D) Providers are to collect the full patient liability amount or up to the cost of care, whichever is less.

(E) Patient liability must be recalculated when there is a change in circumstances that affects the patient liability amount.

(F) 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 (K) of this rule.

(G) Once eligibility has been established, patient liability cannot be increased for past months.

(H) 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.

(I) Providers are required to refund to the individual any overpayments of patient liability paid by the individual, such as when retroactive patient liability adjustments are made.

(J) For purposes of this rule, the following definitions apply:

(1) "Assisted living waiver maintenance needs allowance (ALMNA)" is an amount equal to the current supplemental security income (SSI) federal benefit rate (FBR).

(2) "Special individual maintenance needs allowance (SIMNA)" is sixty-five per cent of the special income level.

(K) 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 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 October 1, 2024). 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).

(e) Restitution payments under the Aleutian and Pribilof Island Restitution Act, in accordance with 50 U.S.C. 4236 (as in effect October 1, 2024).

(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).

(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; and

(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.

(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, 2024).

(l) SSI benefits received under authority of sections 1611(e)(1)(E) and (G) of the Social Security Act (as in effect October 1, 2024) 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 fund for victims of crime.

(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 under 92 Stat. 1515, 42 U.S.C. 3020a 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 programs; 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, 2024).

(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;

(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 October 1, 2024).

(3) Subtract the applicable personal needs allowance (PNA) as follows:

(a) For individuals receiving services under an HCBS waiver, other than the assisted living waiver, the PNA is the SIMNA. When the individual has earned income, subtract up to an additional sixty-five dollars from the earned income.

(b) For individuals receiving services under the assisted living waiver or in an assisted living facility receiving services under the mycare waiver, the PNA is the ALMNA. When the individual has earned income, subtract up to an additional sixty-five dollars from the earned income.

(c) For individuals receiving PACE services and residing in the community, the PNA is the SIMNA. Individuals receiving PACE services and residing in an assisted living facility are considered to be residing in the community.

(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):

(d) The remainder is the ESA.

(iii) Subtract the community spouse's gross monthly income from the lesser of the MMMNA, calculated in paragraph (K)(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.

(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.

(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.

(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.

(i) The service was medically necessary as determined by the administrative agency.

(iii) Unpaid patient liability shall not count as unpaid past medical expenses and shall not be subtracted from the patient liability calculation.

(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 (K)(6)(b) of this rule.

(8) The remainder, rounded down to the nearest dollar, is the individual's monthly patient liability, for a full month of HCBS or PACE services.

(9) The individual's patient liability will be prorated when the individual is enrolled in an HCBS waiver or PACE program for less than a full month. Prorated patient liability amounts are calculated as follows:

(a) Determine the per diem patient liability amount 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.

(c) Multiply the actual number of days of institutionalization by the per diem patient liability amount and round this number down to the nearest dollar. This is the individual's prorated patient liability.

(L) 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.

(M) 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.

Last updated December 6, 2025 at 3:03 PM

History

Effective: June 1, 2025
Promulgated Under: 111.15