File No. 33573
This rule was published in the May 15, 2010, issue (Vol. 2010, No. 10) of the Utah State Bulletin.
Health, Health Care Financing, Coverage and Reimbursement Policy
A, B, and D Institutional Medicaid and Family Institutional Medicaid Income Deductions
Notice of Proposed Rule
DAR File No.: 33573
Filed: 04/22/2010 04:34:44 PM
Purpose of the rule or reason for the change:
The purpose of this change is to clarify Medicaid's deduction policy for long-term care services.
Summary of the rule or change:
This amendment clarifies that the restriction against deducting expenses for long-term care services that an individual accrues during a penalty period or due to substantial home equity only applies to the determination of what an individual owes for long-term care contribution.
State statutory or constitutional authorization for this rule:
- Section 26-18-3
Anticipated cost or savings to:
the state budget:
There is no impact to the state budget because this change only clarifies the deduction policy for long-term care services. It neither increases nor decreases services to Medicaid clients.
This change does not impact local governments because they do not fund or provide long-term care services for Medicaid clients.
There is no impact to small businesses because this change only clarifies the deduction policy for long-term care services. It neither increases nor decreases services to Medicaid clients.
persons other than small businesses, businesses, or local governmental entities:
There is no impact to Medicaid providers and Medicaid clients because this change only clarifies the deduction policy for long-term care services. It neither increases nor decreases services.
Compliance costs for affected persons:
There are no compliance costs to a single Medicaid provider or Medicaid client because this change only clarifies the deduction policy for long-term care services. It neither increases nor decreases services.
Comments by the department head on the fiscal impact the rule may have on businesses:
This clarification of the rule to assure that current Medicaid practice is consistent with the rule will not change current fiscal impact on business in this area.
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 firstname.lastname@example.org
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:
This rule may become effective on:
David Sundwall, Executive Director
R414. Health, Health Care Financing, Coverage and Reimbursement Policy.
R414-304. Income and Budgeting.
R414-304-9. A, B, and D Institutional Medicaid and Family Institutional Medicaid Income Deductions.
(1) This section sets forth income deductions for aged, blind, disabled and family institutional Medicaid programs.
(2) The Department applies the financial methodologies required by 42 CFR 435.601 and the deductions defined in 42 CFR 435.725, 435.726, and 435.832, 2005 ed., which are incorporated by reference. The Department applies Subsection 1902(r)(1) and 1924(d) of the Compilation of the Social Security Laws, which are incorporated by reference. Any additional income deductions or limitations are described in this rule.
(3) The following definitions apply to this section:
(a) "Family member" means a son, daughter, parent, or sibling of the client or the client's spouse who lives with the spouse.
(b) "Dependent" means earning less than $2,000 a year, not being claimed as a dependent by any other individual, and receiving more than half of one's annual support from the client or the client's spouse.
(4) Health insurance premiums:
(a) For institutionalized and waiver eligible clients, the Department deducts from income health insurance premiums only for the institutionalized or waiver eligible client and only if paid with the institutionalized or waiver eligible client's funds. Health insurance premiums are deducted in the month due. The payment is not pro-rated. The Department deducts the amount of a health insurance premium for the month it is due if the Department is paying the premium on behalf of the client as authorized by Section 1905(a) of Title XIX of the Social Security Act, except no deduction is allowed for Medicare premiums the Department pays for or reimburses to recipients.
(b) The Department deducts from income the portion of a combined premium, attributable to the institutionalized or waiver-eligible client if the combined premium includes a spouse or dependent family member and is paid from the funds of the institutionalized or waiver eligible client.
(5) The Department deducts medical expenses from income only if the expenses meet all of the following conditions:
(a) the medical service was received by the client;
(b) the unpaid medical bill will not be paid by Medicaid or by a third party;
(c) a paid medical bill can be deducted only through the month it is paid. No portion of any paid bill can be deducted after the month of payment.
T]he Department does not deduct medical or remedial care
expenses that the Department is prohibited from paying because the
expenses are incurred during a penalty period imposed due to a
transfer of assets for less than fair market value. The Department
does not deduct medical or remedial care expenses that the
Department is prohibited from paying under Section 6014 of Pub. L.
109-171 because the equity value of the
individual's home exceeds the limit set by such law. The
Department will not deduct such expenses during the month the
services are received nor for any month after the month services
are received even when such expenses remain unpaid.
(7) The Department does not allow a medical expense as an income deduction more than once.
(8) A medical expense allowed as an income deduction must be for a medically necessary service. The Department of Health decides if services are medically necessary.
(9) The Department deducts only the amount of pre-paid medical expenses that equals the cost of services actually received in the month such expenses are paid. Payments a client makes for medical services in a month before the month the services are actually received cannot be deducted from income.
(10) When a client must meet a spenddown to become eligible for a medically needy program or receive Medicaid under a home and community based care waiver, the client must sign a statement that says:
(a) the agency told the client how spenddown can be met;
(b) the client expects his or her medical expenses to exceed the spenddown amount;
(c) whether the client intends to pay cash or use medical expenses to meet the spenddown; and
(d) that the agency told the client that the Medicaid provider cannot use the provider's funds to pay the client's spenddown and that the provider cannot loan the client money for the client to pay the spenddown.
(11) A client may meet the spenddown by paying the agency the amount with cash or check, or by providing to the agency proof of medical expenses the client owes equal to the spenddown amount.
(a) The client may elect to deduct from countable income unpaid medical expenses for services received in non-Medicaid covered months to meet or reduce the spenddown.
(b) Expenses must meet the criteria for allowable medical expenses.
(c) Expenses cannot be payable by Medicaid or a third party.
(d) For each benefit month, the client may choose to change the method of meeting spenddown by either presenting proof of allowable medical expenses to the agency or by presenting a cash or check payment to the agency equal to the spenddown amount.
(12) The Department cannot accept spenddown payments from a Medicaid provider if the source of the funds is the Medicaid provider's own funds. The Department cannot accept spenddown payments from a client if the funds were loaned to the client by a Medicaid provider.
(13) Institutionalized clients are required to pay all countable income remaining after allowable income deductions to the institution in which they reside as their contribution to the cost of their care.
(14) A client who pays a cash spenddown, or a liability amount to the medical facility in which he resides, may present proof of medical expenses paid during the coverage month and request a refund of spenddown or liability paid up to the amount of bills paid by the client. The following criteria applies:
(a) Expenses for which a refund can be made include medically necessary medical expenses not covered by Medicaid or any third party, co-payments required for prescription drugs covered under a Medicare Part D plan, and co-payments or co-insurance amounts for Medicaid-covered services as required under the State Medicaid Plan.
(b) The expense must be for a service received during the benefit month.
(c) The Department will not refund any portion of any medical expense the client uses to meet a Medicaid spenddown or to reduce the liability owed to the institution because the client assumes responsibility to pay any expenses used to meet a spenddown or reduce a liability.
(d) A refund cannot exceed the actual cash spenddown or liability amount paid by the client.
(e) The Department does not refund spenddown or liability amounts paid by a client based on unpaid medical expenses for services the client receives during the benefit month. The client may present to the agency any unpaid bills for non-Medicaid-covered services that the client receives during the coverage month. The unpaid bills may be used to meet or reduce the spenddown the client owes for a future month of Medicaid coverage to the extent such bills remain unpaid at the beginning of such future month.
(f) The Department reduces a refund by the amount of any unpaid obligation the client owes the Department.
(15) The Department deducts a personal needs allowance for residents of medical institutions equal to $45.
(16) When a doctor verifies that a single person, or a person whose spouse resides in a medical institution is expected to return home within six months of entering a medical institution or nursing home, the Department deducts a personal needs allowance equal to the current Medicaid Income Limit (BMS) for one person, defined in R414-304-11(6), for up to six months to maintain the individual's community residence.
(17) Except for an individual eligible for the Personal Assistance Waiver, an individual receiving assistance under the terms of a Home and Community-Based Services Waiver is eligible to receive a deduction for a non-institutionalized, non-waiver-eligible spouse and dependent family member as if that individual were institutionalized. The Department applies the provisions of Section 1924(d) of the Compilation of Social Security Laws, or the provisions of 42 U.S.C. 435.726 or 435.832 to determine the deduction for a spouse and family members.
(18) A client is not eligible for Medicaid coverage if medical costs are not at least equal to the contribution required towards the cost of care.
(19) Medicaid covered medical costs incurred in a current benefit month cannot be used to meet spenddown when the client is enrolled in a Medicaid Health Plan. Bills for mental health services incurred in a benefit month cannot be used to meet spenddown if Medicaid contracts with a single mental health provider to provide mental health services to all recipients in the client's county of residence. Bills for mental health services received in a retroactive or application month that the client has fully-paid during that time can be used to meet spenddown only if the services were not provided by the Medicaid-contracted, mental health provider.
KEY: financial disclosures, income, budgeting
Date of Enactment or Last Substantive Amendment: [
October 22, 2009]
Notice of Continuation: January 25, 2008
Authorizing, and Implemented or Interpreted Law: 26-18-[
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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 email@example.com.