DAR File No. 41212
This rule was published in the February 15, 2017, issue (Vol. 2017, No. 4) of the Utah State Bulletin.
Health, Health Care Financing, Coverage and Reimbursement Policy
Section R414-308-7
Change Reporting and Benefit Changes
Notice of Proposed Rule
(Amendment)
DAR File No.: 41212
Filed: 01/26/2017 08:07:44 AM
RULE ANALYSIS
Purpose of the rule or reason for the change:
The purpose of this change is to clarify the effective date of a change for Medicaid recipients.
Summary of the rule or change:
This amendment clarifies that the effective date of a change that is both positive and reported timely is the month of report.
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:
There is no impact to the state budget because this amendment only clarifies effective dates of eligibility based on recipient changes. It neither affects Medicaid services nor provider reimbursement.
local governments:
There is no impact to local governments because they neither fund Medicaid services nor make eligibility determinations for the Medicaid program.
small businesses:
There is no impact to small businesses because this amendment only clarifies effective dates of eligibility based on recipient changes. It neither affects Medicaid services nor provider reimbursement.
persons other than small businesses, businesses, or local governmental entities:
There is no impact to Medicaid providers and to Medicaid recipients because this amendment only clarifies effective dates of eligibility based on recipient changes. It neither affects Medicaid services nor provider reimbursement.
Compliance costs for affected persons:
There is no impact to a single Medicaid provider or to a Medicaid recipient because this amendment only clarifies effective dates of eligibility based on recipient changes. It neither affects Medicaid services nor provider reimbursement.
Comments by the department head on the fiscal impact the rule may have on businesses:
There is no fiscal impact on business because it does not affect the covered services or provider reimbursement.
Joseph K. Miner, MD, Executive Director
The full text of this rule may be inspected, during regular business hours, at the Office of Administrative Rules, or at:
HealthHealth 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 cdevashrayee@utah.gov
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:
03/17/2017
This rule may become effective on:
03/24/2017
Authorized by:
Joseph Miner, Executive Director
RULE TEXT
R414. Health, Health Care Financing, Coverage and Reimbursement Policy.
R414-308. Application, Eligibility Determinations and Improper Medical Assistance.
R414-308-7. Change Reporting and Benefit Changes.
(1) A recipient must report to the
eligibility agency reportable changes [in the recipient's circumstances. Reportable changes
are]as defined in Section R414-301-2
within 10 calendar days of the change.
[(a) The due date for reporting changes is the close of
business ten calendar days after the recipient learns of the
change.
(b) When the change is receipt of income from a new
source, or an increase in income for the recipient, the due date
for reporting the income change is the close of business ten
calendar days after the change.
(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.
(d) The agency shall accept change reports transferred from
other insurance affordability programs.]
(2) The eligibility agency shall:
(a) Act on the reported change; and
(b) Request verification from the recipient if the change cannot
be verified through an electronic interface or other credible
source.[may receive information from credible sources other than
the recipient such as computer income matches and from anonymous
citizen reports. The eligibility agency shall verify information
from other sources that may affect the recipient's eligibility
before using the information to change the recipient's
eligibility for medical assistance. The eligibility agency shall
verify information from citizen reports through other reliable
proofs.]
(3) If [the eligibility agency needs ]verification
is needed[from the recipient], the agency shall send [the recipient ]a written request[. The eligibility agency shall]and give the recipient at least [ten]10 calendar days from the notice date 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.
(4) A recipient must provide change reports, forms or
verifications to the eligibility agency by the close of business on
the due date.]
(a) If the recipient does not provide verification by the due date, the agency shall end eligibility after the month in which proper notice is sent.
(b) If the recipient provides verification by the due date, the agency shall re-determine eligibility.
(c) If the recipient provides verification during the month that follows the effective closure date, the eligibility agency shall treat the date as a new application date without requiring a new application.
(d) If the recipient does not provide verification by the end of the month that follows the effective closure date, the recipient must submit a new application.
(4) If the recipient does not provide verification, or a reported change does not affect all household members, the agency may only take action on those individuals who are affected by the change.
(5) If a due date falls on a non-business day, then the due date shall be the close of the next business day.
(6) If a change has an adverse effect on the recipient, the agency shall change eligibility after the month in which proper notice is sent.
(7) If the agency can verify that a change is timely, the change becomes effective on the first day of the month of report.
(8) If the agency cannot verify that a change is timely, the change becomes effective on the first day of the month in which the agency receives verification.
[(5) If the information about a change causes an increase in
a recipient's benefits and the eligibility agency asks the
recipient for verification, the 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.
(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 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) The eligibility agency shall send a written request
to the recipient for verification if it does not have enough
information to adjust benefits. The recipient has at least ten
days after the date of the request to return
verification.
(i) Upon receiving verification, the eligibility agency
shall adjust benefits to become effective on the first day of the
month after the agency sends proper notice.
(ii) If the recipient does not return verification
timely, the eligibility agency shall discontinue benefits after
the month in which the agency sends proper notice.
(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.]
(9) If a recipient requests to add a new household member, the effective date of the change is the date of request, and the following provisions apply:
(a) The agency does not require a new application; and
(b) The applicant must meet all other eligibility requirements.
(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.
(b) If a recipient fails to report a change timely or return verification or forms by the due date, the recipient must repay all services and benefits paid by the Department for which the recipient is ineligible.
[(11) If a due date falls on a non-business day, the due
date is the close of business on the next business
day.]
KEY: public assistance programs, applications, eligibility, Medicaid
Date of Enactment or Last Substantive Amendment: [December 1, 2014]2017
Notice of Continuation: January 23, 2013
Authorizing, and Implemented or Interpreted Law: 26-18
Additional Information
More information about a Notice of Proposed Rule is available online.
The Portable Document Format (PDF) version of the Bulletin is the official version. The PDF version of this issue is available at https://rules.utah.gov/publicat/bull-pdf/2017/b20170215.pdf. The HTML edition of the Bulletin is a convenience copy. Any discrepancy between the PDF version and HTML version is resolved in favor of the PDF version.
Text to be deleted is struck through and surrounded by brackets ([example]). Text to be added is underlined (example). Older browsers may not depict some or any of these attributes on the screen or when the document is printed.
For questions regarding the content or application of this rule, please contact Craig Devashrayee at the above address, by phone at 801-538-6641, by FAX at 801-538-6099, or by Internet E-mail at cdevashrayee@utah.gov. For questions about the rulemaking process, please contact the Office of Administrative Rules.