Health, Health Care Financing, Coverage and Reimbursement Policy

Section R414-303-3

A, B and D Medicaid and A, B and D Institutional Medicaid Coverage Groups

Notice of Proposed Rule

(Amendment)

DAR File No.: 33346
Filed: 01/27/2010 02:19:36 PM

RULE ANALYSIS

Purpose of the rule or reason for the change:

The purpose of this change is to update and correct incorporated materials and to clarify certain eligibility provisions.

Summary of the rule or change:

This change updates and makes corrections to incorporated materials dealing with coverage groups. It also deletes unnecessary incorporated materials. It further clarifies the process used by the Department to determine disability for Medicaid eligibility and updates the incorporated requirements for that process. It also modifies language concerning retroactive coverage to comply with Rule R414-306, and clarifies certain other provisions.

State statutory or constitutional authorization for this rule:

• Section 26-18-3

Anticipated cost or savings to:

the state budget:

The Department does not expect any impact to the state budget because this change neither increases nor decreases coverage for Medicaid clients. It only clarifies certain eligibility provisions and does not affect eligibility criteria.

local governments:

There is no impact to local governments because they do not fund or provide Medicaid services to Medicaid clients.

small businesses:

The Department does not expect any change in revenue to small businesses because this change neither increases nor decreases coverage for Medicaid clients. It only clarifies certain eligibility provisions and does not affect eligibility criteria.

persons other than small businesses, businesses, or local governmental entities:

The Department does not expect any change in revenue to Medicaid providers because this change neither increases nor decreases coverage for Medicaid clients. It only clarifies certain eligibility provisions and does not affect eligibility criteria. Medicaid clients, therefore, will not see additional costs or savings in their Medicaid services.

Compliance costs for affected persons:

The Department does not expect any change in revenue to a single Medicaid provider because this change neither increases nor decreases coverage for a single Medicaid client. It only clarifies certain eligibility provisions and does not affect eligibility criteria. A Medicaid client, therefore, will not see additional costs or savings in his Medicaid services.

Comments by the department head on the fiscal impact the rule may have on businesses:

The proposed rule updates and clarifies language, with no expected changes to current practice. Therefore no expected fiscal impact on business.

David N. Sundwall, MD, Executive Director

The full text of this rule may be inspected, during regular business hours, at the Division of Administrative Rules, or at:

Health
Health Care Financing, Coverage and Reimbursement Policy
288 N 1460 W
SALT LAKE CITY, UT 84116-3231

Direct questions regarding this rule to:

• Craig Devashrayee at the above address, by phone at 801-538-6641, by FAX at 801-538-6099, or by Internet E-mail at [email protected]

Interested persons may present their views on this rule by submitting written comments to the address above no later than 5:00 p.m. on:

03/17/2010

This rule may become effective on:

03/24/2010

Authorized by:

David Sundwall, Executive Director

R414. Health, Health Care Financing, Coverage and Reimbursement Policy.

R414-303. Coverage Groups.

R414-303-3. A, B and D Medicaid and A, B and D Institutional Medicaid Coverage Groups.

(1) The Department provides Medicaid coverage to individuals as described in 42 CFR 435.120, 435.122, 435.130 through 435.135, 435.137, 435.138, 435.139, 435.211, 435.232, 435.236, 435.301, 435.320, 435.322, 435.324, 435.340, and 435.350 , 2009 ed., which are incorporated by reference.[and 435.541, 2001 ed., which are incorporated by reference. The Department provides coverage to individuals as described in 20 CFR 416.901 through 416.1094, 2002 ed., which is incorporated by reference.] The Department provides coverage to individuals as required by 1634(b), (c) and (d), 1902(a)(10)(A)(i)(II), 1902(a)(10)(A)(ii)(X), and 1902(a)(10)(E)(i) through (iv)[(I)] of Title XIX of the Social Security Act in effect January 1, [2001]2009, which are incorporated by reference. The Department provides coverage to individuals described in Section 1902(a)(10)(A)(ii)(XIII) of Title XIX of the Social Security Act in effect January 1, [2001]2009, which is incorporated by reference. Coverage under Section 1902(a)(10)(A)(ii)(XIII) is known as the Medicaid Work Incentive Program.

(2) Proof of disability includes a certification of disability from the State Medicaid Disability Office, Supplemental Security Income (SSI) status, or proof that a disabled client is recognized as disabled by the Social Security Administration (SSA).

(3) An individual can request a disability determination from the State Medicaid Disability Office. The Department adopts the disability determination requirements described in 42 CFR 435.541, 2009 ed., and Social Security's disability requirements for the Supplemental Security Income program as described in 20 CFR 416.901 through 416.998, 416.1015(a) through (e), and 416.1016, 2009 ed., which are incorporated by reference, to decide if an individual is disabled. The Department notifies the Medicaid eligibility agency of its disability decision, who then sends a disability decision notice to the client.

([3]a) [An applicant or recipient may request the State Medicaid Disability Office to review medical evidence to determine if the individual is disabled or blind.] If [the client]an individual has earned income, the State Medicaid Disability Office shall review medical information to determine if the client is disabled without regard to whether the earned income exceeds the Substantial Gainful Activity level defined by the Social Security Administration.

([a]b) If, within the prior 12 months, SSA has determined that the individual is not disabled, the Medicaid agency must follow SSA's decision. If the individual is appealing SSA's denial of disability, the State Medicaid Disability Office must follow SSA's decision throughout the appeal process, including the final SSA decision.

([b]c) If, within the prior 12 months, SSA has determined an individual is not disabled but the individual claims to have become disabled since the SSA decision, the State Medicaid Disability Office shall review current medical information to determine if the client is disabled.

([c]d) Clients must provide the required medical evidence and cooperate in obtaining any necessary evaluations to establish disability.

([d]e) Recipients must cooperate in completing continuing disability reviews as required by the State Medicaid Disability Office unless they have a current approval of disability from SSA. Medicaid eligibility as a disabled individual will end if the individual fails to cooperate in a continuing disability review.

(4) If an individual denied disability status by the Medicaid Disability Review Office requests a fair hearing, the Disability Review Office may reconsider its determination as part of fair hearing process. The individual must request the hearing within the time limit defined in Section R414-301-6.

(a) The individual may provide the [Department]Medicaid eligibility agency additional medical evidence for the reconsideration.

(b) The reconsideration may take place before the date the fair hearing is scheduled to take place.

(c) The [Department shall notify]Medicaid eligibility agency notifies the individual of [its decision upon] the reconsideration decision. Thereafter, the individual may choose to pursue or abandon [his]the fair hearing[ rights].

(5) If the [Department]Medicaid eligibility agency denies an individual's Medicaid application because [it]the Medicaid Disability Review Office or SSA has determined that the individual is not disabled and that determination is later reversed on appeal , the Medicaid eligibility agency determines the individual's eligibility back to the application that gave rise to the appeal. The individual must meet all other eligibility criteria for such past months.[ and the individual has otherwise been eligible, the individual's eligibility shall extend back to the application that gave rise to the appeal.]

(a) Eligibility cannot begin any earlier than the [date]month of disability onset or [the date that is] three months before the [date]month of application subject to the requirements [as] defined in Section R414-306-4[(2)], whichever is later.

(b) If the individual is not receiving medical assistance at the time a successful appeal decision is made, the individual must contact the Medicaid eligibility agency to request the Disability Medicaid coverage.

(c) The individual must provide any verifications the Medicaid agency needs to determine eligibility for past [or]and current months for which the individual is requesting medical assistance.

(d) If an individual is determined eligible for past or current months, but must pay a spenddown or Medicaid Work Incentive (MWI) premium for one or more months to receive coverage, the spenddown or MWI premium must be met before Medicaid coverage may be provided for those months.

(6) The age requirement for Aged Medicaid is 65 years of age.

(7) For children described in Section 1902(a)(10)(A)(i)(II) of the Social Security Act in effect January 1, 200[1]9, the Department shall conduct periodic redeterminations to assure that the child continues to meet the SSI eligibility criteria as required by [the]such section.

(8) Coverage for qualifying individuals described in Section 1902(a)(10)(E)(iv)[(I)] of Title XIX of the Social Security Act in effect January 1, [2001]2009, is limited to the amount of funds allocated under Section 1933 of Title XIX of the Social Security Act in effect January 1, [2001]2009, for a given year, or as subsequently authorized by Congress. The Medicaid eligibility agency will deny coverage to applicants[Applicants will be denied coverage] when the uncommitted allocated funds are insufficient to provide such coverage.

(9) To determine eligibility under Section 1902(a)(10)(A)(ii)(XIII), if the countable income of the individual and the individual's family does not exceed 250% of the federal poverty guideline for the applicable family size, the Department shall disregard an amount of earned and unearned income of the individual, the individual's spouse, and a minor individual's parents that equals the difference between the total income and the Supplemental Security Income maximum benefit rate payable.

(10) The Department shall require individuals eligible under Section 1902(a)(10)(A)(ii)(XIII) to apply for cost-effective health insurance that is available to them.

 

KEY: income, coverage groups, independent foster care adolescent

Date of Enactment or Last Substantive Amendment: [September 1, 2009]2010

Notice of Continuation: January 25, 2008

Authorizing, and Implemented or Interpreted Law: 26-18-3; 26-1-5