File No. 35789
This rule was published in the February 15, 2012, issue (Vol. 2012, No. 4) of the Utah State Bulletin.
Health, Health Care Financing, Coverage and Reimbursement Policy
Rule R414-303
Coverage Groups
Notice of Proposed Rule
(Amendment)
DAR File No.: 35789
Filed: 02/01/2012 05:14:44 PM
RULE ANALYSIS
Purpose of the rule or reason for the change:
The purpose of this change is to allow the Department to provide medical assistance to a child under the age of 19 during a presumptive eligibility period.
Summary of the rule or change:
This rulemaking allows the state to provide medical assistance to a child under age 19 during a presumptive eligibility period. The presumptive eligibility is determined by a qualified entity that the Department believes is capable of making such decisions. The presumptive eligibility period is based on preliminary information provided by the applicant that the child meets citizenship or qualified alien status, and has household income at or below the applicable percent of the federal poverty guideline for the age of the child.
State statutory or constitutional authorization for this rule:
- Section 26-1-5
- Section 26-18-3
This rule or change incorporates by reference the following material:
- Removes Title XIX of the Social Security Act, Section 1902(k) in effect January 1, 1993, published by Social Security Administration, 01/01/1993
- Updates Title XIX of the Social Security Act, Sections 1902(a)(10)(A)(i)(IV), (VI), (VII), 1902(a)(47) for pregnant women and children under age 19, and Sections 1902(e)(4) and (5) and 1902(l) , published by Social Security Administration, 01/01/2011
Anticipated cost or savings to:
the state budget:
The Department estimates an annual cost to Medicaid of about $21,077 to the General Fund and about $51,579 in federal dollars. This estimate is based on one additional month of Medicaid coverage for about 304 children during the year.
local governments:
There is no impact to local governments as they neither determine Medicaid eligibility nor provide Medicaid services.
small businesses:
The Department estimates an annual increase in revenue to small businesses of about $72,656. This estimate is based on one additional month of coverage for about 34 children during the year.
persons other than small businesses, businesses, or local governmental entities:
The Department estimates an annual increase in revenue to Medicaid providers of about $72,656. This estimate is based on one additional month of coverage for about 34 children during the year. Medicaid recipients will see annual savings during a presumptive eligibility period, but there is no data to estimate how much based on the services they will receive.
Compliance costs for affected persons:
There are no compliance costs because this change only increases revenue to a small business or to a Medicaid provider, and only increases savings to a Medicaid recipient who has coverage during a presumptive eligibility period.
Comments by the department head on the fiscal impact the rule may have on businesses:
This rule change applies to children in foster care and will benefit regulated providers by expediting eligibility for these children and avoiding uncompensated care. The fiscal impact on the State is minimal.
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:
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:
03/16/2012
This rule may become effective on:
04/01/2012
Authorized by:
David Patton, Executive Director
RULE TEXT
R414. Health, Health Care Financing, Coverage and Reimbursement Policy.
R414-303. Coverage Groups.
R414-303-11. [Prenatal]Poverty-Level Pregnant Woman
and [Newborn]Poverty-level Child
Medicaid.
(1) The Department incorporates by
reference Title XIX of the Social Security Act, Section
s 1902(a)(10)(A)(i)(IV), (VI), (VII), 1902(a)(47)
for pregnant women and children under age 19, 1902(e)(4) and
(5) and 1902(l), in effect January 1,
2011[2009, and Title XIX of the Social Security Act, Section
1902(k) in effect January 1, 1993,] which are incorporated
by reference.
(2) The following definitions apply to this section:
(a) "covered provider" means a provider that the Department has determined is qualified to make a determination of presumptive eligibility for a pregnant woman and that meets the criteria defined in Section 1920(b)(2) of the Social Security Act;
(b) "presumptive eligibility"
means a period of eligibility for medical services for a pregnant
woman
, or a child under age 19, based on self-declaration that [she]the pregnant woman, or the child under age 19, meets the
eligibility criteria.
(3) The Department provides coverage to a pregnant woman during a period of presumptive eligibility if a covered provider has verified that she is pregnant and determines, based on preliminary information, that the woman:
(a) meets citizenship or alien status criteria as defined in Section R414-302-1;
(b) has a declared household income that does not exceed 133% of the federal poverty guideline applicable to her declared household size; and
(c) the woman is not covered by CHIP.
(4) No resource test applies to determine presumptive eligibility of a pregnant woman.
[
(5) A pregnant woman made eligible for a presumptive
eligibility period must apply for Medicaid benefits by the last day
of the month following the month the presumptive coverage
begins.
(6) The presumptive eligibility period shall end on the
earlier of:
(a) the day that the Medicaid agency determines whether
the woman is eligible for Medicaid based on her application;
or
(b) in the case of a woman who does not file a Medicaid
application by the last day of the month following the month the
woman was determined presumptively eligible, the last day of that
following month.
] ([7]5) A pregnant woman may receive medical assistance during
only one presumptive eligibility period for any single term of
pregnancy.
(6) The Department provides medical assistance in accordance with Section 1920A of the Social Security Act to children under age 19 during a period of presumptive eligibility if a Medicaid eligibility worker with the Department of Human Services has determined, based on preliminary information, that:
(a) the child meets citizenship or alien status criteria as defined in Section R414-302-1;
(b) for a child under age 6, the declared household income does not exceed 133% of the federal poverty guideline applicable to the declared household size;
(c) for a child age 6 through 18, the declared household income does not exceed 100% of the federal poverty guideline applicable to the declared household size; and
(d) the child is not already covered on Medicaid or CHIP.
(7) No resource test applies to determine presumptive eligibility of a child.
(8) A child may receive medical assistance during only one period of presumptive eligibility in any six-month period.
([8]9) The Department elects to impose a resource standard on [Newborn]poverty-level child Medicaid coverage for children age six
to the month in which they turn age 19. The resource standard is
the same as other Family Medicaid Categories.
([9]10) The Department elects to provide [Prenatal] Medicaid coverage to pregnant women
whose countable income is equal to or below 133% of poverty.
([10]11) At the initial determination of eligibility for [Prenatal]Poverty-level Pregnant Woman Medicaid, the
eligibility agency determines the applicant's countable
resources using SSI resource methodologies. Applicants for [Prenatal]Poverty-level Pregnant Woman Medicaid whose countable
resources exceed $5,000 must pay four percent of countable
resources to the agency to receive [Prenatal]Poverty-level Pregnant Woman Medicaid. The maximum payment
amount is $3,367. The payment must be met with cash. The applicant
cannot use any medical bills to meet this payment.
(a) In subsequent months, through the 60 day postpartum period, the Department disregards all excess resources.
(b) This resource payment applies only to
pregnant women covered under Sections 1902(a)(10)(A)(i)(IV) and
1902(a)(10)(A)(ii)(IX) of the Social Security Act in effect January
1, [2009]2011.
(c) No resource payment will be required when the Department makes a determination based on information received from a medical professional that social, medical, or other reasons place the pregnant woman in a high risk category. To obtain this waiver of the resource payment, the woman must provide this information to the eligibility agency before the woman pays the resource payment so the agency can determine if she is in a high risk category.
([11]12) A child born to a woman who is only presumptively
eligible at the time of the infant's birth is not eligible for
the one year of continued coverage defined in Section 1902(e)(4) of
the Social Security Act. The mother can apply for Medicaid after
the birth and if determined eligible back to the date of the
infant's birth, the infant is then eligible for the one year of
continued coverage under Section 1902(e)(4) of the Social Security
Act. If the mother is not eligible, the Department determines if
the infant is eligible under other Medicaid programs.
([12]13) The Department provides Medicaid coverage to an infant
until the infant turns one-year old when born to a woman eligible
for Utah Medicaid on the date of the delivery of the infant,
in compliance with Sec. 113(b)(1), Children's Health
Insurance Program Reauthorization Act, Pub. L. No. 111 3. [without regard to whether the]
The infant
does not have to remain[s] in the birth mother's home [or whether]and the birth mother [would]does not have to continue to be eligible for Medicaid[, in compliance with Sec. 113(b)(1), Children's Health
Insurance Program Reauthorization Act, Pub. L. No. 111 3].
The infant must continue to be a Utah resident to receive
coverage.
([13]14) Children who meet the criteria under the Social Security
Act, Section 1902(l)(1)(D) may qualify for the [newborn]poverty-level child program through the month in which they
turn 19.
A child determined presumptively eligible may receive
presumptive eligibility only through the applicable period or until
the end of the month in which the child turns 19, whichever occurs
first. The
eligibility agency deems the parent's income and
resources to the 18-year old to determine eligibility when the
18-year old lives in the parent's home. An 18-year old who does
not live with a parent may apply on his own, in which case the
agency does not deem income or resources from the parent.
KEY: income, coverage groups, independent foster care adolescent
Date of Enactment or Last Substantive Amendment: [January 27, 2011]2012
Notice of Continuation: January 25, 2008
Authorizing, and Implemented or Interpreted Law: 26-18-3; 26-1-5
Additional Information
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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 cdevashrayee@utah.gov.