DAR File No. 37881

Health, Health Care Financing, Coverage and Reimbursement Policy

Section R414-308-4

Verification of Eligibility and Information Exchange

Notice of Proposed Rule

(Amendment)

DAR File No.: 37881
Filed: 08/01/2013 06:03:26 PM

RULE ANALYSIS

Purpose of the rule or reason for the change:

The purpose of this amendment is to comply with provisions of the Patient Protection and Affordable Care Act, the purpose of this change is to implement the different verification sources for Medicaid eligibility.

Summary of the rule or change:

This amendment defines the requirements for verifying eligibility, and allows for the use of other electronic data sources instead of using the federal data hub. The change sets up the criteria for requesting verification from applicants and recipients.

State statutory or constitutional authorization for this rule:

• Pub. L. No. 111-148
• Section 26-1-5
• Section 26-18-3

This rule or change incorporates by reference the following material:

• Removes 42 CFR 435.945, 435.948, 435.952, 435.955, and 435.960, published by Government Printing Office, 10/01/2010
• Adds 42 CFR 435.945, 42 CFR 435.948, 42 CFR 435.949, 42 CFR 435.952 and 42 CFR 435.956, published by Government Printing Office, 10/01/2012

Anticipated cost or savings to:

the state budget:

Some administrative costs are associated with the implementation of this process. Nevertheless, these costs are minimal and there is no data to determine them at this time.

local governments:

There is no impact to local governments, as they do not make eligibility determinations for Medicaid.

small businesses:

This amendment does not impose any new costs or requirements on small businesses because they do not make eligibility determinations for the Medicaid program.

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

This amendment does not impose any new costs or requirements on Medicaid providers and on Medicaid recipients because it does not affect Medicaid services. These changes are solely about interactions between the Medicaid agency and the federal data hub to implement the eligibility process.

Compliance costs for affected persons:

This amendment does not impose any new costs or requirements on a single Medicaid provider or on a Medicaid recipient because it does not affect Medicaid services. These changes are solely about interactions between the Medicaid agency and the federal data hub to implement the eligibility process.

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

Minimal impact on business. This will allow greater flexibility and efficiency in verifying the client eligibility data.

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:

09/16/2013

This rule may become effective on:

10/01/2013

Authorized by:

David Patton, Executive Director

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

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

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

(1) The Department adopts and incorporates by reference 42 CFR 435.945, 435.948, 435.949, 435.952, and 435.956, October 1, 2012 ed.

(a) The Department may seek approval from the Secretary in accordance with 42 CFR 435.945(k) to use alternative electronic data sources in lieu of using the data available from the federal data hub.

(b) Medical assistance applicants and recipients must provide identifying information that the eligibility agency needs to complete electronic data matches.

(c) The eligibility agency may request verification from applicants and recipients in accordance with the agency's verification plan that is necessary to determine eligibility.

([1]2) Medical assistance applicants and recipients must verify all eligibility factors requested by the eligibility agency to establish or to redetermine eligibility when the information cannot be verified through electronic data matches, or when the electronic data match information is not reasonably compatible with the client provided information.[ 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 shall provide the applicant or recipient a written request of the needed verification.

(b) The applicant or recipient has at least ten calendar days from the date that the eligibility agency gives or sends the verification request 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.

(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.

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

(f) If an applicant or recipient does not provide verification by the due date and does not contact 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.

([2]3) 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]4) 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 require the applicant to provide verification of his citizenship and identity in accordance with 42 U.S.C. 1396a(ee)(1)(B).

(a) The 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 individual fails to provide verification, the eligibility agency shall end eligibility within 30 days after the 90-day period. The eligibility agency 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.

 

KEY: public assistance programs, applications, eligibility, Medicaid

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

Notice of Continuation: January 23, 2013

Authorizing, and Implemented or Interpreted Law: 26-18