Health, Health Care Financing, Coverage and Reimbursement Policy

Rule R414-308

Application, Eligibility Determinations and Improper Medical Assistance

Notice of Proposed Rule

(Amendment)

DAR File No.: 35100
Filed: 08/01/2011 10:47:56 AM

RULE ANALYSIS

Purpose of the rule or reason for the change:

The purpose of this change is to update and clarify periodic eligibility review, change reporting requirements, and procedures that address improper medical coverage for Medicaid recipients.

Summary of the rule or change:

This amendment clarifies the requirements for a Medicaid recipient to complete a periodic review for continued eligibility and specifies the responsibility of the recipient to provide necessary verifications. This amendment also clarifies that the agency cannot stop eligibility while it is making a redetermination decision, and must provide advance notice of an adverse action to comply with federal due process requirements. It further clarifies the eligibility time line for a recipient who must meet a spenddown or pay another type of fee to become eligible for medical assistance. In addition, this amendment clarifies what improper medical coverage is and what a client has to repay for this occurrence. Finally, this amendment clarifies the refund policy for Medicaid recipients.

State statutory or constitutional authorization for this rule:

• Section 26-18-3
• 42 CFR 435.919
• 42 CFR 435.911
• 42 CFR 435.916

This rule or change incorporates by reference the following material:

• Updates 42 CFR 435.911, published by Government Printing Office, 10/01/2010
• Removes 42 CFR 435.912, published by Government Printing Office, 10/01/2006

Anticipated cost or savings to:

the state budget:

The Department does not anticipate any impact to the state budget because Medicaid recipients whose medical assistance ends for failure to complete a review usually complete the review process during the next month and their medical assistance is reinstated.

local governments:

There is no impact to local governments because they do not fund Medicaid services and do not determine Medicaid eligibility.

small businesses:

The Department does not anticipate any impact to small businesses because Medicaid recipients whose medical assistance ends for failure to complete a review usually complete the review process during the next month and their medical assistance is reinstated. In addition, this change does not impose new requirements on small businesses.

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

The Department does not anticipate any impact to Medicaid providers and to Medicaid recipients because recipients whose medical assistance ends for failure to complete a review usually complete the review process during the next month and their medical assistance is reinstated. In addition, this change does not impose new requirements on providers and does not reduce Medicaid coverage for recipients.

Compliance costs for affected persons:

The Department does not anticipate any costs to a single Medicaid provider or to a Medicaid recipient because a recipient whose medical assistance ends for failure to complete a review usually completes the review process during the next month and the recipient's medical assistance is reinstated. In addition, this change does not impose new requirements on a provider and does not reduce Medicaid coverage for a recipient.

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

No costs for business are expected as Medicaid recipients' cost-sharing duties are better clarified by this rule.

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
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:

09/14/2011

This rule may become effective on:

10/01/2011

Authorized by:

David Patton, Executive Director

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

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

R414-308-1. Authority and Purpose.

(1) This rule is authorized by Section 26-18-3.

(2) [This rule establishes]The purpose of this rule is to establish requirements for medical assistance applications, eligibility decisions and reviews, eligibility period, verifications, change reporting, notification and improper medical assistance for the following programs:

(a) Medicaid;

(b) Qualified Medicare Beneficiaries;

(c) Specified Low-Income Medicare Beneficiaries; and

(d) Qualified Individuals.

 

R414-308-2. Definitions.

(1) The definitions in Rules R414-1 and R414-301 apply to this rule.

(2) In addition, the following definitions apply[.]:

(a) "Cost[-]of[-] care" means the amount of income that an institutionalized individual must pay to the medical facility for long-term care services based on the individual's income and allowed deductions.

(b) "Department" means the Utah Department of Health.

(c) "Due date" means the date that a recipient is required to report a change or provide requested verification to the eligibility agency.

(d) "Due process month" means the month that allows time for the recipient to return all verification, and for the eligibility agency to determine eligibility and notify the recipient.

(e) "Eligibility agency" means the Department of Workforce Services (DWS) that determines eligibility for Medicaid under contract with the Department.

(f) "Eligibility review" means a process by which the eligibility agency reviews current information about a recipient's circumstances to determine whether the recipient is still eligible for medical assistance.

(g) "Open enrollment" means a period of time when the eligibility agency accepts applications.[

(b) "Re-certification" means the process of periodically determining that an individual or household continues to be eligible for medical assistance.]

 

R414-308-5. Eligibility Decisions or Withdrawal of an Application.

(1) The eligibility agency shall determine whether[decides] the applicant['s] is [eligibility]eligible within the time limits established in 42 CFR 435.911 , [and 435.912, 2006]2010 ed., which [are]is incorporated by reference. The eligibility agency shall provide proper notice about a recipient's eligibility, changes in eligibility, and the recipient's right to request a fair hearing in accordance with the provisions of 42 CFR 431.206, 431.210, 431.211, 431.213, 431.214, 42 CFR 435.912, and 435.919.

(2) The eligibility agency shall extend[s] the time limit if the applicant asks for more time to provide requested information before the due date. The eligibility agency shall give[s] the applicant at least [10]ten more days after the original due date to provide verifications upon [request of] the applicant 's request. The eligibility agency [can]may allow a longer period of time for the [client]recipient to provide verifications if the agency determines that the delay is due to circumstances beyond the [client]recipient's control[, an emergency, a client illness or a similar cause].

(3) An applicant may withdraw an application for medical assistance any time before the eligibility agency makes an eligibility decision on the application. An individual requesting an assessment of assets for a married couple under [Section 1924 of the Social Security Act,]42 U.S.C. 1396r-5[,] may withdraw the request any time before the eligibility agency [has] complete[d]s the assessment.

 

R414-308-6. Eligibility Period and [Re-Certification]Reviews.

(1) The eligibility period begins on the effective date of eligibility as defined in Section R414-306-4, which may be after the first day of a month, subject to the following requirements.

(a) If a recipient must pay one of the following fees to receive Medicaid, the eligibility agency shall determine eligibility and notify the recipient of the amount owed for coverage. The eligibility agency shall grant eligibility when it receives the required payment, or in the case of a spenddown or cost of care contribution for waivers, the recipient must send proof of incurred medical expenses equal to the payment. The fees a recipient may owe include:

(i) a spenddown of excess income for medically needy Medicaid coverage;

(ii) a Medicaid Work Incentive (MWI) premium;

(iii) an asset copayment for poverty level, pregnant woman coverage; and

(iv) a cost of care contribution for home and community-based waiver services.

(b) A required spenddown, MWI premium, or cost of care contribution is due each month for a recipient to receive Medicaid coverage. A recipient must pay an asset copayment before eligibility is granted for poverty level, pregnant woman coverage.

[ (a) If a client must pay a spenddown, the agency completes the eligibility process and grants eligibility when the agency receives the required payment or proof of incurred medical expenses equal to the required payment for the month or months, including partial months, for which the client wants medical assistance.

(b) If a client must pay a Medicaid Work Incentive premium, the agency completes the eligibility process and grants eligibility when the agency receives the required payment for the month or months, including partial months, for which the client wants medical assistance.

(c) If a client must pay an asset co-payment for prenatal coverage, the agency completes the eligibility process and grants eligibility when the agency receives the required payment for the period of prenatal coverage.

] ([d]c) The [client]recipient must make the payment or provide proof of medical expenses[, if applicable,] within 30 calendar days from the mailing date of the application approval notice , [that tells]which states how much the [client]recipient [the amount] owe[d]s.

([e]d) For ongoing months of eligibility, the [client]recipient has until the close of business [of]on the [10]tenth day of the month after the benefit month to meet the spenddown or the cost of care contribution for waiver services, or to pay the [Medicaid Work incentive]MWI premium. If the [10]tenth day of the month is a non-business day, the [client]recipient has until the close of business on the first business day after the [10]tenth[ to meet the spenddown or pay the premium]. Eligibility begins on the first day of the benefit month once the recipient meets the required payment. If the recipient does not meet the required payment by the due date, the recipient may reapply for retroactive benefits if that month is within the retroactive period of the new application date.

([f]e) [Residents who reside]A recipient who lives in a long-term care facility and [who] owe s a cost[-] of[-] care contribution to the medical facility must pay the medical facility directly. The [resident]recipient may use unpaid past medical bills, or current incurred medical bills other than the charges from the medical facility, to meet some or all of the cost[-] of[-] care contribution subject to the limitations in Section R414-304-9. [The resident must pay any cost-of-care contribution not met with allowable medical bills to the medical facility.] An unpaid cost[-] of[-] care contribution is not allowed as a medical bill to reduce the amount that the [client]recipient owes the facility.

([g]f) Even when the eligibility agency does not close a medical assistance case, [N]no eligibility exists in a month for which the [client]recipient fails to meet a required spenddown ,[ or fails to pay a required Medicaid Work Incentive] MWI premium , or cost of care contribution for home and community-based waiver services.

(g) Eligibility for the [Prenatal]poverty level, pregnant woman program does not exist when the [client]recipient fails to pay a required asset co[-]payment[for the Prenatal program].

(h) Eligibility for a resident of a nursing home continues even when a resident fails to pay the cost of care contribution to the nursing home.

(2) The eligibility period ends on:

(a) the last day of the [re-certification] month in which the eligibility agency determines that the recipient is no longer eligible for medical assistance and sends proper closure notice;

(b) the last day of the month in which the eligibility agency sends proper closure notice when the recipient fails to provide required information or verification to the eligibility agency by the due date;

([b]c) the last day of the month in which the recipient asks the eligibility agency to discontinue eligibility , or if benefits have been issued for the following month, the end of that month;

[ (c) the last day of the month the agency determines the individual is no longer eligible;

] (d) the last day of the month for time-limited programs, in which the time limit ends;

([d]e) [for the Prenatal program,] the last day of the month for the poverty level, pregnant woman program, [that]which is at least 60 days after the date that the pregnancy ends, except that for [Prenatal]poverty-level, pregnant woman coverage for emergency services only, eligibility ends on the last day of the month in which the pregnancy ends; or

([e]f) the date that the individual dies.

[ (3) Recipients must re-certify eligibility for medical assistance at least once every 12 months. The agency may require recipients to re-certify eligibility more frequently when the agency:

(a) receives information about changes in a recipient's circumstances that may affect the recipient's eligibility;

(b) has information about anticipated changes in a recipient's circumstances that may affect eligibility; or

(c) knows the recipient has fluctuating income.

(4) To receive medical assistance without interruption, a recipient must complete the re-certification process by the close of business on the date printed on the re-certification form. The client must also provide verifications by the due date specified by the agency and must continue to meet all eligibility criteria, including meeting a spenddown or paying a Medicaid Work Incentive premium if one is owed.

(a) If the recipient does not complete the re-certification process on time, eligibility ends on the last day of the re-certification month.

(b) If the recipient does not complete the re-certification process on time, but completes the recertification including providing verifications by the close of business on the last business day of the month after the review month, the agency will determine whether the recipient continues to meet all eligibility criteria.

(i) The agency will reinstate benefits effective the beginning of the month after the re-certification month if the recipient continues to meet all eligibility criteria and meets any spenddown or pays the Medicaid Work Incentive premium, if applicable. The client must meet the spenddown or pay the premium no later than the close of business on the 30th day after the date printed on the notice. Otherwise, the recipient remains ineligible for medical assistance.

(ii) If the recipient does not complete the re-certification process before the close of business of the last business day of the month following the re-certification month, eligibility will not be reinstated. The recipient will have to reapply for medical assistance.

(c) If the recipient does not meet the spenddown or pay the Medicaid Work Incentive premium on time, then eligibility ends effective the last day of the re-certification month and the recipient will have to reapply.

] ([5]3) For individuals selected for coverage under the Qualified Individuals Program, eligibility extends through the end of the calendar year if the individual continues to meet eligibility criteria and the program still exists.

(4) The eligibility agency completes a periodic review of a recipient's eligibility for medical assistance in accordance with the requirements of 42 CFR 435.916, at least once every 12 months.

(5) The eligibility agency may complete an eligibility review when it:

(a) has information about anticipated changes in the recipient's circumstances that may affect eligibility;

(b) knows the recipient has fluctuating income;

(c) completes a review for other assistance programs that the recipient receives; or

(d) needs to meet workload demands.

(6) The periodic eligibility review is a review of eligibility factors that may be subject to change. The eligibility agency shall require the review to determine whether a recipient is still eligible for medical assistance. The eligibility agency shall use available, reliable sources to gather information needed to complete the review.

(7) The eligibility agency may ask the recipient to respond to a request to complete the review process during the review month. If the recipient fails to respond to the request, the eligibility agency shall end eligibility after the review month ends. If the recipient responds to the review or reapplies in the month that follows the review month, the eligibility agency shall consider the response to be a new application. The application processing period shall apply for the new request for coverage.

(a) The eligibility agency may ask the recipient for verification to redetermine eligibility.

(b) Upon receiving the verification, the eligibility agency shall redetermine eligibility and notify the recipient. If the recipient fails to return verification within the application processing period or if the recipient is determined to be ineligible, the eligibility agency shall send a denial notice to the recipient.

(c) If the case is closed for one or more calendar months, the recipient must reapply.

(8) If the recipient responds to the request during the review month, the eligibility agency may request verification from the recipient.

(a) The eligibility agency shall send a written request for the necessary verification.

(b) The recipient has at least ten calendar days from the notice date to provide the requested verification to the eligibility agency.

(9) If the recipient responds to the review and provides all verification by the due date within the review month, the eligibility agency shall determine eligibility and notify the recipient of its decision.

(a) If the eligibility agency sends proper notice of an adverse decision in the review month, the agency shall change eligibility for the following month.

(b) If the eligibility agency does not send notice of an adverse change, the agency shall extend eligibility to the following month. This additional month of eligibility is called the due process month. The eligibility agency shall notify the recipient of the adverse decision that becomes effective after the due process month.

(10) If the recipient responds to the review in the review month and the verification due date is in the following month, the eligibility agency shall extend eligibility to the following month. This additional month of eligibility is called the due process month. The recipient must provide all verification by the verification due date.

(a) If the recipient provides all requested verification by the verification due date, the eligibility agency shall determine eligibility and send proper notice of the decision.

(b) If the recipient does not provide all requested verification by the verification due date, the eligibility agency shall end eligibility after the month in which the eligibility agency sends proper notice of the closure.

(c) If the recipient returns all verification after the verification due date and before the effective closure date, the eligibility agency shall treat the date that it receives the verification as a new application date. The agency shall then determine eligibility and send notice to the recipient.

(11) The eligibility agency shall provide ten-day notice of case closure if the recipient is determined ineligible or if the recipient fails to provide all verification by the verification due date.

(12) The eligibility agency may not extend coverage under certain medical assistance programs in accordance with state and federal law. The agency shall notify the recipient before the effective closure date.

(a) If the eligibility agency determines that the recipient qualifies for a different medical assistance program, the agency shall notify the recipient. Otherwise, the agency shall end eligibility after the named time period.

(b) If the recipient provides information before the effective closure date that indicates that the recipient may qualify for another medical assistance program, the eligibility agency shall treat the information as a new application. If the recipient contacts the eligibility agency after the effective closure date, the recipient must reapply for benefits.

 

R414-308-8. Case Closure and Redetermination.

(1) The eligibility agency shall [terminates]end medical assistance [upon]when the recipient request s the agency to close his case, when the recipient fails to respond to a request to complete the eligibility review, when the recipient fails to provide all verification needed to determine continued eligibility, or [if]when the agency determines that the recipient is no longer eligible.

(2) [To maintain ongoing eligibility, a recipient must complete the re-certification process as provided in R414-308-6. Failure to complete the re-certification process makes the recipient ineligible.]If a recipient fails to complete the review process in accordance with Section R414-308-6, the eligibility agency shall close the case and notify the recipient.

(3) Before terminating a recipient's medical assistance, the eligibility agency [will]shall [decide if]determine whether the [client]recipient is eligible for any other available medical assistance provided under Medicaid, the Medicare Cost[-] Sharing programs, the Children's Health Insurance Program (CHIP), the Primary Care Network (PCN), and [the]Utah's Premium Partnership for Health Insurance (UPP )[program].

(a) The eligibility agency [does]may not require a recipient to complete a new application[,] to make the redetermination.[but] The agency, however, may request more information from the recipient to [complete the redetermination]determine whether the recipient is eligible for other medical assistance programs. If the recipient does not provide the necessary information by the close of business on the due date, the recipient's medical assistance ends.

(b) When [redetermining]determining eligibility for other programs, the eligibility agency [cannot]may only enroll an individual in a medical assistance program [that is not]during [in] an open enrollment period, [unless]or when that program allows a person who becomes ineligible for Medicaid to enroll during a period when enrollment[s are stopped] is closed.[ An open enrollment period is a time when the agency accepts applications.] Open enrollment applies only to [the Primary Care Network,]the PCN and [the] UPP [P]program s[and the Children's Health Insurance Program].

 

R414-308-9. Improper Medical Coverage.

(1) Improper medical coverage occurs when:

(a) an individual receives medical assistance for which the individual is not eligible. This assistance includes benefits that an individual receives pending a fair hearing or during an undue hardship waiver when the individual fails to take actions required by the eligibility agency;

(b) an individual receives a benefit or service that is not part of the benefit package for which the individual is eligible;

(c) an individual pays too much or too little for medical assistance benefits; or

(d) the Department pays in excess or not enough for medical assistance benefits on behalf of an eligible individual.

([1]2) As [used]applied in this section, services and benefits include all amounts that the Department pays on behalf of the [client]recipient during the period in question and includes :

(a) premiums that the recipient pays [paid] to any Medicaid health plan[s] or managed care plan[s]including any payments for administration costs, Medicare, and private insurance plans;

(b) payments for prepaid mental health services; and

(c) payments made directly to service providers or to the [client]recipient.

[ (2) A client must repay the cost of services and benefits the client receives for which the client is not eligible.

] ([a]3) If the eligibility agency determines that a [client]recipient [was]is ineligible for the services [or]and benefits [received]that he receives, [the client must repay the Department the amount the Department paid for the services or benefits]the recipient must repay to the Department any costs that result from the services and benefits.

(4) The eligibility agency shall reduce [ T]the amount that the [client]recipient must repay [will be reduced] by the amount that the [client paid]recipient pays to the eligibility agency for a Medicaid spenddown , a cost of care contribution, or a [Medicaid Work Incentive]MWI premium for the month.

(5) If a [woman]recipient who [has paid]pays an asset co[-]payment for coverage under Prenatal Medicaid is found to [have been]be ineligible for the entire period of coverage under Prenatal Medicaid, the eligibility agency shall reduce the amount [she]that the recipient must repay [will be reduced] by the amount that[she] the recipient [paid]pays to the agency in the form of the [P]prenatal asset co[-]payment[, if applicable].

([b]6) If the [client]recipient is eligible but the overpayment [was]is because the spenddown, the [Medicaid Work Incentive]MWI premium, the asset co[-]payment for prenatal services, or the cost[-] of[-] care contribution [was]is incorrect, the [client]recipient must repay the difference between the correct amount that the [client should have paid and] recipient should pay and the amount that [what] the [client actually]recipient has paid.

(7) If the eligibility agency determines that the recipient is ineligible due to having resources that exceed the resource limit, the recipient must pay the lesser of the cost of services or benefits that the recipient receives, or the difference between the recipient's countable resources and the resource limit for each month resources exceed the limit.

([3]8) A [client]recipient may request a refund from the Department [for any month in which]if the [client]recipient believes that :

(a) the monthly spenddown, the asset co[-]payment for prenatal services, or cost[-] of [-]care contribution that the [client paid]recipient pays to receive medical assistance is less than what the Department [paid]pays for medical services and benefits for the [client,]recipient; or

(b) the amount that the [client paid]recipient pays in the form of a spenddown, a [Medicaid Work Incentive]MWI premium, a cost[-] of[-]care contribution for long-term care services, or an asset co[-]payment for prenatal services [was more than it should have been]exceeds the payment requirement.

([4]9) Upon receiving the request[ for a refund], the Department [will]shall determine [if the client is owed]whether it owes the recipient a refund.

(a) In the case of an incorrect calculation of a spenddown, [Medicare Work Incentive]MWI premium, cost[-] of[-]care contribution , or asset co[-]payment for [prenatal]poverty level, pregnant woman services, the refundable amount is the difference between the incorrect amount that the [client paid]recipient pays to the Department for medical assistance and the correct amount that the [client]recipient should [have paid]pay, less the amount that the [client]recipient owes to the Department for any other past due, unpaid claims.

(b) I f[n the case when] the spenddown, asset co[-]payment for [prenatal]poverty level, pregnant woman services , or a cost[-] of[-]care contribution for long-term care exceeds medical expenditures, the refundable amount is the difference between the correct spenddown, asset co[-]payment , or cost[-] of[-] care contribution that the [client paid]recipient pays for medical assistance and the [actual] amount that the Department [paid]pays on behalf of the [client]recipient for services and benefits, less the amount that the [client]recipient owes to the Department for any other past due, unpaid claims. The Department shall issue[s] the refund only after the 12-month time[-] period that medical providers have to submit claims for payment.

(c) The [agency does]Department may not issue a cash refund for any portion of a spenddown or cost[-] of[-]care contribution that [was]is met with medical bills. Nevertheless, the Department may pay additional covered medical bills used to meet the spenddown or cost of care contribution equal to the amount of refund that the Department owes the recipient, or apply the bill amount toward a future spenddown or cost of care contribution.

([5]10) A [client]recipient who pays a premium for the [Medicaid Work Incentive]MWI program [cannot]may not receive a refund even [if]when the Department pays for services [paid by the Department]that are less than the premium that the [client]recipient pays for MWI.

([6]11) If the cost[-] of[-]care contribution that a [client]recipient pays a medical facility is more than the Medicaid daily rate for the number of days that the [client was]recipient is in the medical facility, the [client can]recipient may request a refund from the medical facility. The Department [will]shall refund the amount that it owe[d]s the [client]recipient only [if]when the medical facility [has sent]sends the excess cost[-]of[-] care contribution to the Department.

([7]12) If the sponsor of an alien does not provide correct information, the alien and the alien's sponsor are jointly liable for any overpayment of benefits. The Department shall recover[s] the overpayment from both the alien and the sponsor.

 

KEY: public assistance programs, applications , eligibility, Medicaid

Date of Enactment or Last Substantive Amendment: [November 1, 2010]2011

Notice of Continuation: January 31, 2008

Authorizing, and Implemented or Interpreted Law: 26-18