Health, Health Care Financing, Coverage and Reimbursement Policy

Rule R414-306

Program Benefits

Notice of Proposed Rule

DAR File No.: 32859
Filed: 07/30/2009

RULE ANALYSIS

Purpose of the rule or reason for the change:

The purpose of this change is to clarify eligibility criteria for retroactive Medicaid coverage and to comply with federal requirements.

Summary of the rule or change:

This amendment changes the effective date of Medicaid eligibility to the first day of the month for each month. This change complies with federal requirements to determine the effective date for Medicaid eligibility for the retroactive period.

State statutory or constitutional authorization for this rule:

• Section 26-18-3

Anticipated cost or savings to:

the state budget:

Failure to make this change will cause the state to lose federal financial participation funds. While there may be some minimal costs associated with this change, the Department cannot quantify the cost because it does not have information regarding individual medical expenses for the days before the current effective date of Medicaid eligibility. Nevertheless, the Department does not anticipate large costs because current operations assist individuals to apply in a timelier fashion that allows them to receive coverage for the time period in which they had medical expenses.

local governments:

This change does not impact local governments because they do not determine eligibility nor receive monies collected as spenddowns from Medicaid recipients.

small businesses:

This change does not impact small businesses because they do not determine Medicaid eligibility. Medicaid applicants may see some savings if they delay applying for Medicaid and cannot get coverage for some days in the retroactive period. The Department cannot quantify the savings, however, because it does not have information regarding individual medical expenses for days before the current effective date of Medicaid eligibility.

persons other than business:

This change does not impact small businesses because they do not determine Medicaid eligibility. Medicaid applicants may see some savings if they delay applying for Medicaid and cannot get coverage for some days in the retroactive period. The Department cannot quantify the savings, however, because it does not have information regarding individual medical expenses for days before the current effective date of Medicaid eligibility.

Compliance costs for affected persons:

There are no compliance costs because this change does not require a Medicaid recipient to pay more for Medicaid coverage, and it does not reduce eligibility for Medicaid services.

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

This change is required by federal law and will not have a negative fiscal impact on business.

David N. Sundwall, 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
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:

09/14/2009

This rule may become effective on:

10/01/2009

Authorized by:

David Sundwall, Executive Director

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

R414-306. Program Benefits.

R414-306-3. [QMB and SLMB] Qualified Medicare Beneficiary Date of Entitlement.

(1) [The Department adopts] Eligibility for the Qualified Medicare Beneficiary (QMB) program begins the first day of the month after the month the Medicaid eligibility agency determines that the individual is eligible, in accordance with the requirements of 42 U.S.C. 1396a(e)(8)[Subsection 1902(e)(8) of the Compilation of the Social Security Laws, 2001 ed., U.S. Government Printing Office, Washington, D.C., which is incorporated by reference].

(2) There is no provision for retroactive QMB assistance.

 

R414-306-4. Effective Date of Eligibility.

[(1) The Department adopts 42 CFR 435.914, 2001 ed., which is incorporated by reference.

(2) Eligibility for any Medicaid program, or the SLMB or QI-1 program, shall begin no earlier than the date that is three months before the date of application for benefits. Coverage shall not be effective on the first day of a month if that date is more than three months before the application date. Coverage in the months before the application month cannot begin before the date the applicant met the eligibility criteria.

(a) Institutional Medicaid shall begin on the date that the Department receives verification of nursing home admission from the nursing home, but no earlier than the date that is three months before the date of application for nursing home services.

(b) Eligibility under a Home and Community Based (HCB) Services waiver shall begin on the date the client is determined to meet the level-of-care criteria and home and community based services are scheduled to begin within the month, but no earlier than the date that is three months before the date of application for HCB services.

(c) Eligibility for benefits as a Qualifying Individual-Group 1 can begin no earlier than the date that is three months before the date of application and in no case before January 1, 1998. An individual selected to receive QI-1 benefits in a month of the year is entitled to receive such assistance for the remainder of the calendar year if the individual continues to be a qualifying individual and the program still exists. Receipt of QI-1 benefits in one calendar year does not entitle the individual to continued assistance in any succeeding year.

(3) Eligibility in the application month and on-going months shall begin on the first day of such month, except for

(a) an individual who just moved to Utah, in which case the effective date of eligibility of such individual cannot be earlier than the date that the individual meets the state residency requirement defined in R414-302-2; and

(b) an individual who is a qualified alien subject to the five-year bar on receiving regular Medicaid services, in which case eligibility cannot begin earlier than the date that is five years after the date the person became a qualified alien, or the date the five-year bar ends due to other events defined in statute.

(c) an individual who is a qualified alien not subject to the five-year bar on receiving regular Medicaid services, in which case eligibility cannot begin earlier than the date the individual's qualified alien status began.

(4) There is no provision for retroactive QMB assistance.

(5) After being approved for Medicaid, a client may request retroactive coverage based on the date of the approved application, but only if the client had not previously requested the retroactive coverage, and had either been denied for such time period or had failed to meet a spenddown for such time period. The recipient must provide verifications needed to establish eligibility for the retroactive period being requested.] (1) Subject to the exceptions in Subsection R414-306-4(3), eligibility for any Medicaid program, and for the Specified Low-income Medicare Beneficiary (SLMB) or Qualified Individual (QI) programs begins the first day of the application month if the individual is determined to meet the eligibility criteria for that month.

(2) An applicant for Medicaid, SLMB or QI benefits may request medical coverage for the retroactive period. The retroactive period is the three months immediately preceding the month of application.

(a) An applicant may request coverage for one or more months of the retroactive period.

(b) Subject to the exceptions in Subsection R414-306-4(3), eligibility for retroactive medical coverage begins no earlier than the first day of the month that is three months before the application month.

(c) The applicant must receive medical services during the retroactive period and be determined eligible for the month he receives services.

(3) To determine the date eligibility for medical assistance may begin for any month, the following requirements apply:

(a) Eligibility of an individual cannot begin any earlier than the date the individual meets the state residency requirement defined in Section R414-302-2;

(b) Eligibility of a qualified alien subject to the five-year bar on receiving regular Medicaid services cannot begin earlier than the date that is five years after the date the person became a qualified alien, or the date the five-year bar ends due to other events defined in statute;

(c) Eligibility of a qualified alien not subject to the five-year bar on receiving regular Medicaid services can begin no earlier than the date the individual meets qualified alien status.

(4) If an applicant is not eligible for the application month, but requests retroactive coverage, the agency will determine eligibility for the retroactive period based on the date of that application.

(5) The agency may use the same application to determine eligibility for the month following the month of application if the applicant is determined ineligible for both the retroactive period and the application month. In this case, the application date changes to the date eligibility begins. The retroactive period associated with the application changes to the three months preceding the new application date.

(6) Medicaid eligibility for certain services begins when the individual meets the following criteria:

(a) Eligibility for coverage of institutional services cannot begin before the date that the individual has been admitted to a medical institution and meets the level of care criteria for admission. The medical institution must provide the required admission verification to the Department within the time limits set by the Department in Rule R414-501. Medicaid eligibility for institutional services does not begin earlier than the first day of the month that is three months before the month of application for Medicaid coverage of institutional services.

(b) Eligibility for coverage of home and community-based services under a Medicaid waiver cannot begin before the first day of the month the client is determined by the case management agency to meet the level of care criteria and home and community-based services are scheduled to begin within the month. The case management agency must verify that the individual meets the level of care criteria for waiver services. Medicaid eligibility for waiver services does not begin earlier than the first day of the month that is three months before the month of application for Medicaid coverage of waiver services.

(7) An individual determined eligible for QI benefits in a calendar year is eligible to receive those benefits throughout the remainder of the calendar year, if the individual continues to meet the eligibility criteria and the program still exists. Receipt of QI benefits in one calendar year does not entitle the individual to QI benefits in any succeeding year.

(8) After being approved for Medicaid, a client may later request coverage for the retroactive period associated with the approved application if the following criteria are met:

(a) The client did not request retroactive coverage at the time of application; and

(b) The agency did not make a decision about eligibility for medical assistance for that retroactive period; and

(c) The client states that he received medical services and provides verification of his eligibility for the retroactive period.

(9) A client cannot request coverage for the retroactive period associated with a denied application. The client, however, may reapply and a new retroactive coverage period is considered based on the new application date.

 

KEY: effective date, program benefits, medical transportation

Date of Enactment or Last Substantive Amendment: [July 19, 2004] 2009

Notice of Continuation: January 25, 2008

Authorizing, and Implemented or Interpreted Law: 26-18