DAR File No. 39629

Health, Health Care Financing, Coverage and Reimbursement Policy

Rule R414-307

Eligibility for Home and Community-Based Services Waivers

Notice of Proposed Rule

(Amendment)

DAR File No.: 39629
Filed: 08/31/2015 10:16:36 AM

RULE ANALYSIS

Purpose of the rule or reason for the change:

This change is based on guidance from the Centers for Medicare and Medicaid Services (CMS) to clarify post-eligibility treatment of income for individuals who become eligible for the Medically Needy Waiver Group, the New Choices Waiver, and the Home and Community-Based Services (HCBS) Waiver for Individuals with Physical Disabilities. The other purpose is to update the age requirement for Autism Waiver eligibility.

Summary of the rule or change:

This amendment clarifies post-eligibility treatment of income for individuals who become eligible for the New Choices Waiver under the Special Income Group. It also updates the age requirement for Autism Waiver eligibility.

State statutory or constitutional authorization for this rule:

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

Anticipated cost or savings to:

the state budget:

The Department estimates annual savings of $100,000 based on a few individuals who will have to pay more for services under the Medically Needy Waiver Group, the New Choices Waiver, and the HCBS Waiver for Individuals with Physical Disabilities. The update to the Autism Waiver, however, does not affect the state budget because it is within appropriations previously approved for the Autism Waiver program.

local governments:

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

small businesses:

Small businesses may lose a portion of $100,000 in total annual revenue based on a few individuals who will have to pay more for services under the Medically Needy Waiver Group, the New Choices Waiver, and the HCBS Waiver for Individuals with Physical Disabilities. The update to the Autism Waiver, however, does not affect business revenue because it is within appropriations previously approved for the Autism Waiver program.

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

Medicaid providers may lose a portion of $100,000 in total annual revenue based on a few individuals who will have to pay more for services under the Medically Needy Waiver Group, the New Choices Waiver, and the HCBS Waiver for Individuals with Physical Disabilities. Additionally, a few Medicaid recipients may have to pay this aggregate amount in out-of-pocket expenses. The update to the Autism Waiver, however, neither affects providers nor recipients because it is within appropriations previously approved for the Autism Waiver program.

Compliance costs for affected persons:

This amendment requires a few recipients to pay more for services under the Medically Needy Waiver Group, the New Choices Waiver, and the HCBS Waiver for Individuals with Physical Disabilities. The annual out-of-pocket expense to a single Medicaid recipient is about $7,200.

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

The proposed changes may fiscally impact businesses who are medical care providers because they may lose a portion of the estimated $100,000 in annual revenue from program savings based on the few individuals who will pay more for services under the waiver programs.

Joseph K. Miner, 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
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:

10/15/2015

This rule may become effective on:

11/01/2015

Authorized by:

Joseph Miner, Executive Director

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

R414-307. Eligibility for Home and Community-Based Services Waivers.

R414-307-5. Medically Needy Waiver Group.

The following sets forth financial eligibility requirements for the medically needy coverage group, and applies to individuals seeking Medicaid coverage for HCBS under the New Choices Waiver or the Individuals with Physical Disabilities Waiver.

(1) If an individual's spouse meets the definition of a community spouse, the eligibility agency shall apply the resource provisions defined in Section 1924 of the Social Security Act and Section R414-305-3 and Section R414-305-4.

(2) If the individual does not have a spouse or the individual's spouse does not meet the definition of a community spouse, the eligibility agency may only count the individual's resources to determine eligibility. When both members of a married couple who live together apply for waiver services and meet the criteria for the medically needy waiver group, the eligibility agency shall count one-half of jointly-held assets available to each spouse. Each spouse must pass the medically needy resource test for one person.

(3) The eligibility agency may only count income of the individual determined under the most closely associated cash assistance program to decide eligibility for the medically needy waiver group. The eligibility agency may not count income of the individual's spouse except for actual contributions from the spouse.

(4) If the individual is a minor child, the eligibility agency may only count income and resources of the child and may not count income and resources of the child's parents to decide if the child passes the income and resource tests for the medically needy waiver group. The eligibility agency shall count actual contributions from a parent, including court-ordered support payments as income of the child.

(5) The individual's income must exceed three times the payment that would be made to an individual with no income under Subsection 1611(b)(1) of the Social Security Act.

(6) To determine eligibility for an individual[without a community spouse], the eligibility agency shall apply the income deductions allowed by the community Medicaid category under which the individual qualifies.

(a) The eligibility agency shall compare countable income to the applicable medically needy income limit for a one-person household to determine the individual's spenddown. The individual's medical expenses, including the cost of long-term care services, must exceed the spenddown amount.

[(i) If an individual does not have a community spouse, to]To receive Medicaid eligibility, the individual must meet the monthly spenddown as defined[applicable contribution to the cost of care in the same manner as a spenddown as defined] in Subsection R414-304-11(9).

[(ii) An individual who has a community spouse is subject to the post-eligibility provisions of Section 1924 of the Social Security Act. The eligibility agency determines the individual's cost-of-care contribution by deducting from the individual's total income, the post-eligibility allowances defined in the implementation plan of the specific waiver for which the individual qualifies. The individual must meet the applicable contribution to the cost of care in the same manner as a spenddown as defined in Subsection R414-304-11(9).

] (b) The eligibility agency deducts medical expenses incurred by the individual in accordance with Section R414-304-11.

(7) The eligibility agency shall determine an individual's financial eligibility for the medically needy waiver group based on the level of care date on a valid waiver referral form as defined in Subsection R414-307-3(2). The eligibility agency shall determine eligibility for prior months using the community Medicaid or institutional Medicaid rules that apply to the individual's situation.

 

R414-307-6. New Choices Waiver Eligibility Criteria.

(1) [To qualify for the New Choices Waiver, a]An individual must be 65 years of age or older, or at least 18 through 64 years of age and disabled to be eligible for the New Choices Waiver, as defined in Subsection 1614(a)(3) of the Social Security Act. [For the purpose of]In accordance with [this ]waiver provisions, the eligibility agency considers an individual [is]to be 18 years of age [beginning the first month ]after the month [of]in which the individual['s] turns 18[th birthday]years old.

(2) A single individual [eligible under the special income group, ]or any married individual with a community spouse, who is eligible under the Special Income Group, may be required to pay a contribution toward the cost of care to receive services under an HCBS waiver. The eligibility agency determines a client's cost-of-care contribution as follows:

(a) The eligibility agency counts all of the client's income unless the income is excluded under other federal laws that exclude certain income from being counted to determine eligibility for federally-funded, needs-based medical assistance.

(b) The eligibility agency deducts the following amounts from the individual's income:

(i) A personal needs allowance equal to 100% of the federal poverty guideline for a household of one;

(ii) For individuals with earned income, up to $125 of gross-earned income;

(iii) Actual monthly shelter costs not to exceed $300. This deduction includes mortgage, insurance, property taxes, rent, and other shelter expenses;

(iv) A deduction for monthly utility costs equal to the standard utility allowance Utah uses under Subsection 5(e) of the Food Stamp Act of 1977. If the waiver client shares utility expenses with others, the allowance is prorated accordingly;

(v) In the case of a married individual with a community spouse, an allowance for a community spouse and dependent family members who live with the community spouse, in accordance with the provisions of Section 1924 of the Social Security Act;

(vi) When an individual has a dependent family member at home and the provisions of Section 1924 of the Social Security Act do not apply,an allowance for a dependent family member that is equal to one-third of the difference between the minimum monthly spousal needs allowance defined in Section 1924 of the Social Security Act and the family member's monthly income. If more than one individual qualifies for an HCBS waiver or institutional Medicaid coverage, and contributes income to the dependent family member, the combined income deductions of these individuals cannot exceed one-third of the difference between the minimum monthly spousal needs allowance and the family member's monthly income. The eligibility agency shall end this deduction when the dependent family member enters a medical institution;

(vii) Medical and remedial care expenses incurred by the individual in accordance with Section R414-304-11.

(c) The income deduction to provide an allowance to a spouse or a dependent family member may not exceed the amount the individual actually gives to such spouse or dependent family member.

(d) The remaining amount of income after these deductions is the individual's cost-of-care contribution.

(3) The individual must pay the cost-of-care contribution to the eligibility agency each month to receive services under an HCBS waiver.

 

R414-307-11. Home and Community-Based Services Waiver for Individuals with Physical Disabilities.

(1) To qualify for the waiver for individuals with physical disabilities, the individual must meet non-financial criteria for Aged, Blind, or Disabled Medicaid.

(2) A client's resources must be equal to or less than $2000. The spousal impoverishment resource provisions for married, institutionalized clients in Section R414-305-3 apply to this rule.

(3) Countable income is determined using income rules of Aged, Blind, or Disabled Institutional Medicaid. The eligibility agency counts all income unless the income is excluded under other federal laws that exclude certain income from being counted to determine eligibility for federally-funded, needs-based medical assistance. Eligibility is determined counting only the gross income of the client.

(4) The eligibility agency counts a spouse's income only if the client receives a cash contribution from a spouse.

(5) An individual whose income does not exceed 300% of the federal benefit rate[, or any married individual with a community spouse] may be required to pay a cost-of-care contribution. The following provisions apply to the determination of cost-of-care contribution.

(a) The eligibility agency counts all of the client's income except income that is excluded under other federal laws from being counted to determine eligibility for federally-funded, needs-based medical assistance.

(b) The eligibility agency deducts the maximum allowance available, which is a personal needs allowance equal to 300% of the federal benefit rate payable under Section 1611(b)(1) of the Social Security Act for an individual with no income. No other deductions from income are allowed.

(6) An individual [who does not have a community spouse and ]whose income exceeds three times the federal benefit rate payable under Section 1611(b)(1) of the Social Security Act may pay a spenddown to become eligible. To determine the spenddown amount, the income rules and medically needy income standard for non-institutionalized aged, blind or disabled individuals in Rule R414-304 apply except that income is not deemed from the client's spouse.

(7) The provisions of Section R414-305-9 concerning transfers of assets apply to individuals seeking eligibility or receiving benefits under this home and community-based services waiver.

 

R414-307-12. Home and Community-Based Services Waiver for Individuals with Autism.

[(1) To qualify for the waiver for individuals with autism, the child must be at least two years of age and under six years of age. The last month a child can be eligible for this waiver is the month in which the child turns six years of age.

(2) All other eligibility requirements follow the rules of the Community Supports Home and Community-Based Services Waiver found in Section R414-307-7 except for Subsection R414-307-7(1).

] (1) An individual must be at least two years of age and under seven years of age to be eligible for the Medicaid Autism Waiver .

(a) The eligibility agency shall treat an individual as being under seven years of age through the month in which the individual turns seven years old.

(b) The agency shall end waiver eligibility after the month in which the individual turns seven years old.

(2) This waiver complies with the provisions of the Community Supports Home and Community-Based Services Waiver and all other eligibility requirements found in Section R414-307-7, except for the requirement of Subsection R414-307-7(1).

 

KEY: eligibility, waivers, special income group

Date of Enactment or Last Substantive Amendment: [ July 1, ]2015

Notice of Continuation: April 17, 2012

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