DAR File No. 37549

Health, Health Care Financing, Coverage and Reimbursement Policy

Rule R414-509

Medicaid Autism Waiver Open Enrollment Process

Notice of Proposed Rule

(Amendment)

DAR File No.: 37549
Filed: 04/29/2013 09:57:45 AM

RULE ANALYSIS

Purpose of the rule or reason for the change:

The purpose of this change is to clarify legislative intent to implement the Medicaid Autism Waiver under H.B. 272, 2012 General Session.

Summary of the rule or change:

This amendment clarifies that children who are two years of age through six years of age are eligible to receive Medicaid services under the Autism Waiver if they meet other eligibility requirements. This change, therefore, extends eligibility for the waiver through six years of age. This amendment also makes other clarifications. (DAR NOTE: A corresponding 120-day (emergency) rule that is effective as of 05/01/2013 is under DAR No. 37548 in this issue, May 15, 2013, of the Bulletin.)

State statutory or constitutional authorization for this rule:

• Section 26-18-3
• Section 26-1-5

Anticipated cost or savings to:

the state budget:

There is no impact to the state budget because this amendment neither creates new services nor eliminates current ones. All services are in accordance with legislative intent to allow children who are two years of age through six years of age to become eligible under the Autism Waiver, and are within appropriations approved by the 2012 Legislature.

local governments:

There is no impact to local governments because they neither fund nor provide Medicaid services to Medicaid recipients.

small businesses:

There is no impact to small businesses because this amendment neither creates new services nor eliminates current ones. All services are in accordance with legislative intent to allow children who are two years of age through six years of age to become eligible under the Autism Waiver, and are within appropriations approved by the 2012 Legislature.

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

There is no impact to Medicaid providers and to Medicaid recipients because this amendment neither creates new services nor eliminates current ones. All services are in accordance with legislative intent to allow children who are two years of age through six years of age to become eligible under the Autism Waiver, and are within appropriations approved by the 2012 Legislature.

Compliance costs for affected persons:

There are no compliance costs to a single Medicaid provider or to a Medicaid recipient because this amendment neither creates new services nor eliminates current ones. All services are in accordance with legislative intent to allow children who are two years of age through six years of age to become eligible under the Autism Waiver, and are within appropriations approved by the 2012 Legislature.

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

This change will have no impact on business as it does not change the reimbursement for services.

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:

06/14/2013

This rule may become effective on:

06/21/2013

Authorized by:

David Patton, Executive Director

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

R414-509. Medicaid Autism Waiver Open Enrollment Process.

R414-509-1. Introduction and Authority.

(1) This rule defines the open enrollment process to enroll individuals in the Medicaid Autism Waiver program.

(2) This rule is authorized by Section 26-18-407. Waiver services are optional and provided in accordance with 42 CFR 440.225.

 

R414-509-2. Definitions.

(1) "Attrition" means the act of a waiver recipient leaving the waiver for any reason. Examples include the recipient moving out -of -state or the recipient turning [six]seven years of age.

(2) "Geographical Region" means a county or counties that are identified as belonging to one of the twelve Utah local health department districts.

(3) "Department" means the Department of Health.

(4) "Open enrollment" means the period during which the Department accepts waiver applications.

(5) "Opening" means the availability for an individual to participate in the Medicaid Autism Waiver program.

(6) "Waiver Operating Agency" means the Department of Human Services, which contracts with the Department of Health to implement defined waiver operations.

 

R414-509-3. Open Enrollment Eligibility Requirements.

To participate in the open enrollment process, the individual must meet the following eligibility requirements:

(1) The individual must have a diagnosis of an autism spectrum disorder from a licensed clinician. Diagnosis must be rendered by a clinician who is authorized under the scope of [their]his licensure;

(2) On the final day of the open enrollment period, the individual must:

(a) [have had his or her second birthday]Be at least two years of age;[and]

(b) [b]Be no t older than [five]six years and six months of age; and

(3) [The individual must m]Meet the financial eligibility requirement defined in the Medicaid Autism Waiver program.

 

R414-509-4. Open Enrollment Periods.

The Department will determine when open enrollment periods are held and for what duration based on the availability of funds for the Medicaid Autism Waiver program.

 

R414-509-5. Open Enrollment Procedures.

(1) The Department accepts the following means of application during open enrollment periods:

(a) Online application, with a time and date stamp confirming that the application was received within the open enrollment period;

(b) Facsimile, with a time and date stamp confirming that the application was received within the open enrollment period; and

(c) Mail, with the postmark on applications dated no sooner than the first day of the open enrollment period and no later than the last day of the open enrollment period.

(2) The number of individuals who may enroll in the waiver program during an open enrollment period is based on the availability of funds.

(3) The Department enrolls all individuals who meet the requirements of Section R414-509-3 if the number of applications does not exceed the number of available openings when the open enrollment period ends.

(4) If the number of applications exceeds the number of available waiver openings, then the Department shall:

(a) Compile all applications that it receives during the open enrollment period;

(b) Assign each application a random number;

(c) Create lists of randomly numbered applications by assigned geographical region;

(d) Assure that rural and underserved regions of the state are represented. The Department assigns waiver openings by geographic al regions as follows:

(i) The Department allocates openings to each geographical region based on the percentage of population [of the State's population that]who reside[s] within the geographical region. The Department obtains population information from the most recent United States Census Report;

[ (ii) if insufficient applications are present in a geographic region to fill all existing openings, the Department distributes the remaining waiver openings to an adjacent geographical region;

] (e) The Department [B]begins at the top of the randomized list and match es the number of available geographical openings with the same number of applications;

(i) If a selected applicant does not meet the eligibility criteria described in Section R414-509-3, the Department selects the next application on the randomized list;

(f) The Department [E]enrolls the selected individual[s] into waiver services.

(5) If there are not enough applications to fill all openings within a geographical region, the Department distributes the remaining waiver openings to other geographical regions.

 

R414-509-6. Procedures for Filling Openings Created by Attrition.

Attrition is ongoing in the Medicaid Autism Waiver program because the waiver serves a child only through the end of the month in which the child turns [six]seven years of age.

(1) To fill waiver openings due to attrition outside of open enrollment periods, the Department develops an applicant pool.

(a) The Department determines the number of applicants available in the applicant pool for each geographical region by using the process described in Subsection R414-509-5(4)(d)(i) to determine the number of waiver openings and factoring that number by four;

(b) The Department requires the Waiver Operating Agency to inform the Department of all waiver openings within ten business days;

(c) The Department identifies the geographical region where each opening occurs;

(d) The Department identifies the next randomly numbered application available within that geographical region;

(e) The Department matches the randomly numbered application to the applicant name, and based on the applicant's age, evaluates whether the applicant continues to be eligible for the waiver.

(i) To be eligible for waiver enrollment on the date of identification, the applicant may not exceed [five]six years and six months of age;

(ii) If the applicant is not eligible for waiver enrollment based on Subsection R414-509-6(1)(e)(i), the Department identifies the next randomly numbered application available within the geographical region until the Department can identify an eligible applicant.

(2) If there are not enough applications to fill all openings within a geographical region, the Department distributes the remaining waiver openings to other geographical regions.

([2]3) When the Department determines an open enrollment period is going to occur, it may suspend filling openings that arise through attrition.

 

KEY: Medicaid

Date of Enactment or Last Substantive Amendment: [October 1, 2012]2013

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