Health, Health Care Financing, Coverage and Reimbursement Policy

Rule R414-308

Application, Eligibility Determinations and Improper Medical Assistance

Notice of Proposed Rule

(Amendment)

DAR File No.: 35441
Filed: 11/15/2011 10:14:59 AM

RULE ANALYSIS

Purpose of the rule or reason for the change:

The purpose of this change is to include provisions that treat certain actions by a recipient as an application for medical assistance, and to not require a recipient to complete a new application form.

Summary of the rule or change:

This change includes provisions that treat certain actions by a recipient as an application for medical assistance when a recipient cannot complete a timely request for verification. It also clarifies the limitations for these circumstances and clarifies agency procedure for eligibility when a recipient reports a change. It also makes other technical changes to the rule text.

State statutory or constitutional authorization for this rule:

• Title 26, Chapter 18

This rule or change incorporates by reference the following material:

• Adds 42 CFR 435.945, 435.948, 435.952, 435.955, and 435.960, published by Government Printing Office, 10/01/2010

Anticipated cost or savings to:

the state budget:

The Department does not anticipate any impact to the state budget because this amendment does not add new services or increase the number of Medicaid eligible individuals.

local governments:

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

small businesses:

There is no impact to small businesses because this amendment does not add new services or increase the number of Medicaid eligible individuals.

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

There is no impact to Medicaid providers and to Medicaid recipients because this amendment does not add new services or increase the number of Medicaid eligible individuals. In addition, it does not impose new costs on Medicaid recipients or reduce Medicaid coverage. It also creates an easier application process for Medicaid recipients.

Compliance costs for affected persons:

There are no compliance costs to a single Medicaid provider or to a Medicaid recipient because this amendment does not add new services or increase the number of Medicaid eligible individuals. In addition, it does not impose new costs on a Medicaid recipient or reduce Medicaid coverage. This change also creates an easier application process for a Medicaid recipient.

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

This rule should simplify application processes for recipients and have no measurable fiscal impact on providers or others.

David Patton, PhD, 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
CANNON HEALTH BLDG
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:

01/03/2012

This rule may become effective on:

01/10/2012

Authorized by:

David Patton, Executive Director

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

R414-308. Application, Eligibility Determinations and Improper Medical Assistance.

R414-308-3. Application and Signature.

(1) An individual may apply for medical assistance by completing and signing any Department-approved application form for [Medicaid, Qualified Medicare Beneficiaries, Specified Low-Income Medicare Beneficiaries, or Qualified Individuals]medical assistance and delivering it to the [Medicaid] eligibility agency. If available, an individual may complete an on-line application for medical assistance and send it electronically to the [Medicaid] eligibility agency.

(a) If an applicant cannot write, the applicant must make his mark on the application form and have at least one witness to the signature.

(b) [For]When completing an on-line application[s], the individual must either send the [Medicaid] eligibility agency an original signature on a printed signature page, or if available on-line, submit an electronic signature that conforms with state law for electronic signatures.

(c) A representative may apply on behalf of an individual. A representative may be a legal guardian, a person holding a power of attorney, a representative payee or other responsible person acting on behalf of the individual. In this case, the [Medicaid] eligibility agency may send notices, requests and forms to both the individual and the individual's representative, or to just the individual's representative.

(d) If the Division of Child and Family Services (DCFS) has custody of a child and the child is placed in foster care, DCFS completes the application. DCFS determines eligibility for the child pursuant to a written agreement with the Department. DCFS also determines eligibility for children placed under a subsidized adoption agreement. The Department does not require an application for Title IV-E eligible children.

(e) An authorized representative may apply for the individual if unusual circumstances or death prevent an individual from applying on his own. The individual must sign the application form if possible. If the individual cannot sign the application, the representative must sign the application. The [Medicaid] eligibility agency may assign someone to act as the authorized representative when the individual requires help to apply and is unable to appoint a representative.

(2) The application date is the day that the eligibility agency receives the request or verification from the recipient. The eligibility agency treats the following situations as a new application without requiring a new application form. The effective date of eligibility for these situations depends on the rules for the specific program:

(a) A household with an open medical assistance case asks to add a new household member by contacting the eligibility agency;

(b) The eligibility agency ends medical assistance when the recipient fails to return requested verification, and the recipient provides all requested verification to the eligibility agency before the end of the calendar month that follows the closure date. The eligibility agency waives the open enrollment period requirement during that calendar month for programs subject to open enrollment;

(c) A medical assistance program other than PCN ends due to an incomplete review, and the recipient responds to the review request in the calendar month that follows the closure date. The provisions of Section R414-310-14 apply to recertification for PCN enrollment;

(d) Except for PCN and UPP that are subject to open enrollment periods, the eligibility agency denies an application when the applicant fails to provide all requested verification, but provides all requested verification within 30 calendar days of the denial notice date. The new application date is the date that the eligibility agency receives all requested verification and the retroactive period is based on that date. The eligibility agency does not act if it receives verification more than 30 days after it denies the application. The recipient must complete a new application to reapply for medical assistance;

(e) For PCN and UPP applicants, the eligibility agency treats all verification as a new application during an open enrollment period when it receives the verification within 30 days after sending the denial notice. If the eligibility agency stops enrollment, the applicant must wait for an open enrollment period to reapply.

(3) If a medical assistance case closes for one or more calendar months, the recipient must complete a new application form to reapply.

([2]4) The [Medicaid] eligibility agency [will]shall process low-income subsidy application data transmitted from the Social Security Administration in accordance with 42 U.S.C. Sec. 1935(a)(4) as an application for Medicare cost sharing programs. The eligibility agency [will]shall take appropriate steps to gather the required information and verification[s] from the applicant to determine the applicant's eligibility.

(a) Data transmitted from [s]Social [s]Security is not an application for Medicaid.

(b) An [I]individual[s] who want s to apply for Medicaid when contacted for information to process the application for Medicare cost-sharing programs must complete and sign [a Medicaid]a Department-approved application form for medical assistance. The date of application for Medicaid is the date that the [Medicaid] eligibility agency receives the application for Medicaid.

([3]5) [The Medicaid eligibility agency determines the date of application as follows:]The application date for medical assistance is the date that the eligibility agency receives the application during normal business hours on a week day that does not include Saturday, Sunday or a state holiday. The following rules apply in determining the application date:

(a) [The date of application is the date that the Medicaid eligibility agency receives a completed application by the close of normal business hours on a week day that is not a Saturday, Sunday or state holiday.] If the eligibility agency receives an application [is received] after the [normal] close of business[ hours on a weekday that is not a Saturday, Sunday or state holiday], the date of application is the next [weekday that is not a Saturday, Sunday or state holiday]business day[.];

(b) [The Medicaid eligibility agency determines the application date for applications delivered to an outreach location as follows:

(i)] If the applicant delivers the application [is delivered]to an outreach location [at a time when the outreach staff is working at that location]during normal business hours, the date of application is th[e]at business da[te]y when[ the] outreach staff receive[s] the application[.];

(i[i]) If the applicant delivers the application [is delivered] on a non-business day or after normal business hours,[at a time when the outreach office is closed,] the date of application is the [last]next business day that a staff person from the [state Medicaid] eligibility agency [was available to] receive s or pick s up the application[s from that location.];

([c]c) When the [state]eligibility agency receives application data transmitted from [s]Social [s]Security Administration pursuant to the requirements of 42 U.S.C. Sec. 1396u-5(a)(4), the [Medicaid] eligibility agency shall use[s] the date that the individual submit[ted]s for the low-income subsidy application to the Social Security Administration as the application date for Medicare cost sharing programs. The application processing period for the transmitted data begins on the date that the [Medicaid] eligibility agency receives the transmitted data[ from social security]. The transmitted data meets the signature requirements for applications for Medicare cost sharing programs.

[ (d) An applicant must provide the verifications needed to process an application and determine eligibility no later than the close of business on the last day of the application period. If the last day of the application processing period falls on a day of the week when the Medicaid eligibility office is closed, then the applicant has until the close of business on the next day that the Medicaid eligibility agency is open immediately following the last day of the application processing period. An applicant may request more time to provide verifications. The request must be made by the last day of the application processing period.

] ([4]6) The [Medicaid] eligibility agency shall accept[s] a signed application that an applicant sends [sent via]by facsimile as a valid application[ and does not require it to be signed again].

([5]7) If an applicant submits an unsigned[,] or incomplete application form to the [Medicaid] eligibility agency, the [Medicaid] eligibility agency [will]shall notify the applicant that he[or she] must sign and complete the application no later than the last day of the application processing period. The [Medicaid] eligibility agency [will]shall send a signature page to the applicant and give the applicant at least [10]ten days to sign and return the signature page. When the application is incomplete, the [Medicaid] eligibility agency [will]shall notify the applicant of the need to complete the application [through an interview process, by mail, or by coming to an office to complete the form]and offer ways to complete the application.

(a) The date of application for an incomplete or unsigned application form is the date that the eligibility agency receives the application [I]if the [Medicaid eligibility] agency receives a signed signature page [signed by the applicant, and the applicant completes the]and completed application within the application processing period[, the date of application will be the date the Medicaid eligibility agency received the application form that was not complete or signed].

(b) If the [Medicaid] eligibility agency does not receive a signed signature page[, and the applicant does not complete the]and completed application form within the application processing period, the application is void and the [Medicaid] eligibility agency [will]shall send a denial notice to the applicant.[ The previous application date will not be protected.]

(c) [If the Medicaid eligibility agency receives a signed signature page and the completed application after the application processing period but during the 30 calendar days immediately after the denial notice is mailed, the Medicaid eligibility agency will contact the applicant to ask if the applicant wants to reapply for medical assistance. If the applicant wants to reapply, the Medicaid eligibility agency may use the previous application form it received, but the application date will be the date the Medicaid eligibility agency receives both the signed signature page and completed application form according to the same provisions in Subsection R414-308-3(2).]If the eligibility agency receives the signed signature page and completed application within 30 days after the notice of denial date, the date of receipt is the new application date and the provisions of Section R414-308-6 apply.

(d) If the [Medicaid] eligibility agency receives a signed signature page and [the] completed application more than 30 calendar days after it sends the denial notice[ is sent], the applicant [will need to]must reapply by completing and submitting a new application form.[ The original application date is not retained.] The new application date [will be]is the date that the [Medicaid] eligibility agency receives a new application.

 

R414-308-4. Verification of Eligibility and Information Exchange.

(1) Medical assistance applicants and recipients must verify all eligibility factors requested by the eligibility agency to establish or to redetermine eligibility. Medical assistance applicants and recipients must provide identifying information that the eligibility agency needs to meet the requirements of 42 CFR 435.945, 435.948, 435.952, 435.955, and 435.960 , 2010 ed. , which are incorporated by reference.

(a) The eligibility agency [will]shall provide the [client]applicant or recipient a written request of the needed verification.

(b) The [client]applicant or recipient has at least [10]ten calendar days from the date that the eligibility agency gives or [mails]sends the verification request [to the client] to provide verification.

(c) The due date for returning verification, forms or information requested by the eligibility agency is the close of business on the date that the eligibility agency sets as the due date in a written request[to the client, but not less than 10 calendar days from the date such request is given to or mailed to the client].

(d) An applicant or recipient must provide all requested verification before the close of business on the last day of the application period. If the last day of the application processing period is a non-business day, the applicant or recipient has until the close of business on the next business day to return verification.

([d]e) The eligibility agency shall allow the [client additional]applicant or recipient more time to provide verification if [the client]he requests [additional]more time by the due date. The eligibility agency shall set a new due date based on what the [client]applicant or recipient needs to do to obtain the verification and whether [the client]he shows a good faith effort to obtain the verification.

([e]f) If a n [client has not provided]applicant or recipient does not provide [required] verification by the due date[,] and [has]does not contact[ed] the eligibility agency to ask for more time to provide verification, the eligibility agency shall deny the application[,] or review, or end eligibility.

(g) If a due date falls on a non-business day, the due date is the close of business on the next business day.

[ (f) If the eligibility agency receives all necessary verification during the 30 days after denying an application for lack of verification, the date the eligibility agency receives all the verification is the new application date. If the eligibility agency receives verification more than 30 days after the application has been denied, the client will need to reapply for medical assistance.

] (2) The eligibility agency must receive verification of an individual's income, both unearned and earned. To be eligible under the Medicaid Work Incentive program, the eligibility agency may require proof such as paycheck stubs showing deductions of FICA tax, self-employment tax filing documents, or for newly self-employed individuals who have not filed tax forms yet, a written business plan and verification of gross receipts and business expenses, to verify that the income is earned income.

(3) If an applicant's citizenship and identity do not match through the Social Security electronic match process and the eligibility agency cannot resolve this inconsistency, the eligibility agency shall [request]require the applicant to provide verification of his citizenship and identity in accordance with 42 U.S.C. 1396a(ee)(1)(B).

(a) The [applicant]individual must provide verification to resolve the inconsistency or provide original documentation to verify his citizenship and identity within 90 days of the request.

(b) The eligibility agency shall continue to provide medical assistance during the 90-day period if the individual meets all other eligibility criteria.

(c) If the [applicant]individual fails to provide verification, the eligibility agency shall end[s]eligibility within 30 days after the 90-day period. The eligibility agency [can]may not extend or repeat the verification period.

(d) An individual who provides false information to receive medical assistance is subject to investigation of Medicaid fraud and penalties as outlined in 42 CFR 455.13 through 455.23.

 

R414-308-7. Change Reporting and Benefit Changes.

(1) A [client]recipient must report to the eligibility agency reportable changes in the [client's]recipient's circumstances. Reportable changes are defined in Section R414-301-2.

(a) The due date for reporting changes is the close of business ten calendar days[on the 10th calendar day] after the [client]recipient learns of the change.

(b) When the change is receipt of income from a new source, or an increase in income [the client receives]for the recipient, the due date for reporting the income change is the close of business [on the day that is] ten calendar days after [the date] the [client receives such] change.[income.]

(c) The date of report is the date that the recipient reports the change to the eligibility agency during normal business hours, or the date that the eligibility agency receives the information from another source.

[ (c) The due date for providing verifications of changes is the close of business on the date the agency sets as the due date in a written notice to the client.

] (2) The eligibility agency may receive information from credible sources other than the [client]recipient such as computer income matches[,] and from anonymous citizen reports. [If the]The eligibility agency [receives]shall verify information from other sources [other than the client] that may affect the [client's]recipient's eligibility[, the agency will verify the information as needed depending on the source of information] before using the information to change the [client's]recipient's eligibility for medical assistance. The eligibility agency shall verify [I]information from citizen reports [must always be verified by]through other reliable proofs.

[ (3) The date of report is the date the client reports the change to the agency by the close of business on a business day by phone, by mail, by fax transmission or in person, or the date the agency receives the information from another source.

] ([4]3) If the eligibility agency needs verification from the recipient,[ of the reported change from the client, the agency requests it in writing and provides] the agency shall send the recipient a written request. The eligibility agency shall give the recipient at least ten calendar days from the notice date[for the client] to respond. The due date for providing verification of changes is the close of business on the date that the eligibility agency sets as the due date in a written notice to the recipient.

([5]4) A [client]recipient [who]must provide[s] change reports, forms or verifications to the eligibility agency by the close of business on the due date[has provided the information on time].

([6]5)[(a)] If [the reported information]the information about a change causes an increase in a [client's]recipient's benefits and the eligibility agency [requests]asks the recipient for verification, the [increase in benefits is effective the first day of the month following:]eligibility agency shall increase benefits as follows:

(a) An increase in benefits is effective on the first day of the month after the change report month if the recipient returns all verification within ten calendar days of the request date or by the end of the change report month, if longer;

(b) An increase in benefits is effective on the first day of the month after the date that the eligibility agency receives all verification if the recipient does not return verification by the due date, but returns verification in the calendar month that follows the report month.

[ (i) the date of the report if the agency receives verifications within ten days of the request; or

(ii) the date the verifications are received if verifications are received more than ten days after the date of the request.

(b) The agency cannot increase benefits if the agency does not receive requested verifications.

] (6) If the reported information causes an increase in a recipient's benefits and the eligibility agency does not request verification, the increase in benefits is effective on the first day of the month that follows the change report month.

[ (7) If the reported information causes a decrease in the client's benefits, the agency makes changes as follows:

(a) If the agency has sufficient information to adjust benefits, the change is effective the first day of the month after the month in which the agency sends proper notice of the decrease, regardless of whether verifications have been received.

] (7) If a change adversely affects the recipient's eligibility for benefits, the eligibility agency shall change the effective date of eligibility to the first day of the month after the month in which it sends proper notice of the change.

(a) The eligibility agency shall change the effective date if it has enough information to adjust benefits, regardless of whether the recipient returns verification.

(b) [If t]The eligibility agency shall send a written request to the recipient for verification if it does not have [sufficient]enough information to adjust benefits[, the agency requests verifications from the client]. The [due date is]recipient has at least [10]ten days [from]after the date of the request to return verification.

(i) Upon receiving [the] verification[s], the eligibility agency shall adjust[s] benefits to become effective on the first day of the month [following the month in which the agency can]after the agency send s proper notice.

(ii) If the recipient does not return[the] verification[s are not returned on] time ly, the eligibility agency shall discontinue[s] benefits [for the affected individuals effective the end of]after the month in which [the agency can]the agency send s proper notice.

[ (8) Any time the agency requests verifications to determine or redetermine eligibility for an individual or a household, the agency may discontinue benefits if all required factors of eligibility are not verified by the due date. If a change does not affect all household members and verifications are not provided, the agency discontinues benefits only for the individual or individuals affected by the change.

] (8) If the recipient returns all requested verification related to a change report in the month that follows the effective closure date, the eligibility agency shall treat the date of receipt as an application date and may not require the recipient to complete a new application form. The eligibility agency shall review the verification to determine whether the recipient is still eligible and notify the recipient of its decision. The eligibility agency may not change the review date unless it updates all factors of eligibility.

(9) If the eligibility agency cannot determine the effect of a change without verification from the recipient, the agency shall discontinue benefits if it does not receive the requested verification by the due date. If a change does not affect all household members and the recipient does not return verification, the eligibility agency shall discontinue benefits only for those individuals affected by the change.

(10) An overpayment may occur if the recipient does not report changes timely, or if the recipient does not return verification by the verification due date.

(a) The eligibility agency shall determine whether an overpayment has occurred based on when the agency could have made the change if the recipient had reported the change on time or returned verification by the due date.

([9]b) If a [client]recipient fails to [timely] report a change timely or return verification[s] or forms by the due date, the [client]recipient must repay all services and benefits paid by the Department for which the [client was]recipient is ineligible.

([10]11) If a due date falls on a non-business day, the due date [will be]is the close of business on the [first]next business day[ immediately after the due date].

 

KEY: public assistance programs, applications, eligibility, Medicaid

Date of Enactment or Last Substantive Amendment: [October 1, 2011]2012

Notice of Continuation: January 31, 2008

Authorizing, and Implemented or Interpreted Law: 26-18