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.: 35790
Filed: 02/01/2012 05:25:26 PM

RULE ANALYSIS

Purpose of the rule or reason for the change:

The purpose of this change is to define the application requirements and enrollment period for pregnant women and children under the age of 19 who are determined eligible during a presumptive eligibility period.

Summary of the rule or change:

This change defines the application requirements and enrollment period for pregnant women and children under the age of 19 who are determined to be eligible during a presumptive eligibility period. This change also clarifies and simplifies eligibility review requirements.

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:

• Adds 42 CFR 431.206, 431.210, 431.211, 431.213, 431.214, 435.912 and 435.919, 2010 ed., published by Government Printing Office, 10/01/2010

Anticipated cost or savings to:

the state budget:

The Department does not anticipate any impact to the state budget because this change only defines administrative requirements for presumptive eligibility. Any costs or savings associated with providing presumptive eligibility are addressed in a companion rule filing (Rule R414-303). (DAR NOTE: The proposed amendment to Rule R414-303 is under DAR No. 35789 in this issue, February 15, 2012, of the Bulletin.)

local governments:

There is no impact to local governments because they neither determine Medicaid eligibility nor provide Medicaid services.

small businesses:

The Department does not anticipate any impact to small businesses because this change only defines administrative requirements for presumptive eligibility. Any costs or increases in revenue associated with providing presumptive eligibility are addressed in a companion rule filing (Rule R414-303).

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 this change only defines administrative requirements for presumptive eligibility. Any costs, savings, or increases in revenue associated with providing presumptive eligibility are addressed in a companion rule filing (Rule R414-303).

Compliance costs for affected persons:

There are no compliance costs because this change neither imposes new costs on a single Medicaid provider nor reduces coverage for a Medicaid recipient.

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:

Health
Health 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

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

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

R414-308-3. Application and Signature.

(1) An individual may apply for medical assistance by completing and signing any Department-approved application form for medical assistance and delivering it to the eligibility agency. If available, an individual may complete an on-line application for medical assistance and send it electronically to the eligibility agency.

(a) If an applicant cannot write, the applicant must make his mark on the application form and have at least one witness to the signature.

(b) When completing an on-line application, the individual must either send the eligibility agency an original signature on a printed signature page, or if available on-line, submit an electronic signature that conforms with state law for electronic signatures.

(c) A representative may apply on behalf of an individual. A representative may be a legal guardian, a person holding a power of attorney, a representative payee or other responsible person acting on behalf of the individual. In this case, the eligibility agency may send notices, requests and forms to both the individual and the individual's representative, or to just the individual's representative.

(d) If the Division of Child and Family Services (DCFS) has custody of a child and the child is placed in foster care, DCFS completes the application. DCFS determines eligibility for the child pursuant to a written agreement with the Department. DCFS also determines eligibility for children placed under a subsidized adoption agreement. The Department does not require an application for Title IV-E eligible children.

(e) An authorized representative may apply for the individual if unusual circumstances or death prevent an individual from applying on his own. The individual must sign the application form if possible. If the individual cannot sign the application, the representative must sign the application. The eligibility agency may assign someone to act as the authorized representative when the individual requires help to apply and [is unable to]cannot appoint a representative.

(2) The application date is the day that the eligibility agency receives the request or verification from the recipient. The eligibility agency treats the following situations as a new application without requiring a new application form. The effective date of eligibility for these situations depends on the rules for the specific program:

(a) A household with an open medical assistance case asks to add a new household member by contacting the eligibility agency;

(b) The eligibility agency ends medical assistance when the recipient fails to return requested verification, and the recipient provides all requested verification to the eligibility agency before the end of the calendar month that follows the closure date. The eligibility agency waives the open enrollment period requirement during that calendar month for programs subject to open enrollment;

(c) A medical assistance program other than PCN ends due to an incomplete review, and the recipient responds to the review request in the calendar month that follows the closure date. The provisions of Section R414-310-14 apply to recertification for PCN enrollment;

(d) Except for PCN and UPP that are subject to open enrollment periods, the eligibility agency denies an application when the applicant fails to provide all requested verification, but provides all requested verification within 30 calendar days of the denial notice date. The new application date is the date that the eligibility agency receives all requested verification and the retroactive period is based on that date. The eligibility agency does not act if it receives verification more than 30 calendar days after it denies the application. The recipient must complete a new application to reapply for medical assistance;

(e) For PCN and UPP applicants, the eligibility agency denies an application when the applicant fails to provide all requested verification, but provides all requested verification within 30 calendar days of the denial notice date and the eligibility agency has not stopped the open enrollment period. If the eligibility agency has stopped enrollment,[treats all verification as a new application during an open enrollment period when it receives the verification within 30 days after sending the denial notice. If the eligibility agency stops enrollment,] the applicant must wait for an open enrollment period to reapply.

(3) If a medical assistance case closes for one or more calendar months, the recipient must complete a new application form to reapply.

(4) A child under the age of 19, or a pregnant woman who is eligible for a presumptive eligibility period, must file an application for medical assistance with the eligibility agency in accordance with the requirements of Sections 1920 and 1920A of the Social Security Act.

([4]5) The eligibility agency shall process low-income subsidy application data transmitted from the Social Security Administration (SSA) in accordance with 42 U.S.C. Sec. 1935(a)(4) as an application for Medicare cost sharing programs. The eligibility agency shall take appropriate steps to gather the required information and verification from the applicant to determine the applicant's eligibility.

(a) Data transmitted from [Social Security]SSA is not an application for Medicaid.

(b) An individual who wants to apply for Medicaid when contacted for information to process the application for Medicare cost-sharing programs must complete and sign a Department-approved application form for medical assistance. The date of application for Medicaid is the date that the eligibility agency receives the application for Medicaid.

([5]6) The application date for medical assistance is the date that the eligibility agency receives the application during normal business hours on a week day that does not include Saturday, Sunday or a state holiday. The following rules apply in determining the application date:

(a) If the eligibility agency receives an application after the close of business, the date of application is the next business day;

(b) If the applicant delivers the application to an outreach location during normal business hours, the date of application is that business day when outreach staff receive s the application;

(i) If the applicant delivers the application on a non-business day or after normal business hours, the date of application is the [next]last business day that a staff person from the eligibility agency was available at the outreach location to receive[s] or pick[s] up the application;

(c) When the eligibility agency receives application data transmitted from [Social Security Administration]SSA pursuant to the requirements of 42 U.S.C. Sec. 1396u-5(a)(4), the eligibility agency shall use the date that the individual submits the application for the low-income subsidy [application] to the [Social Security Administration]SSA as the application date for Medicare cost sharing programs. The application processing period for the transmitted data begins on the date that the eligibility agency receives the transmitted data. The transmitted data meets the signature requirements for applications for Medicare cost sharing programs.

([6]7) The eligibility agency shall accept a signed application that an applicant sends by facsimile as a valid application.

([7]8) If an applicant submits an unsigned or incomplete application form to the eligibility agency, the eligibility agency shall notify the applicant that he must sign and complete the application no later than the last day of the application processing period. The eligibility agency shall send a signature page to the applicant and give the applicant at least ten days to sign and return the signature page. When the application is incomplete, the eligibility agency shall notify the applicant of the need to complete the application and offer ways to complete the application.

(a) The date of application for an incomplete or unsigned application form is the date that the eligibility agency receives the application if the agency receives a signed signature page and completed application within the application processing period.

(b) If the eligibility agency does not receive a signed signature page and completed application form within the application processing period, the application is void and the eligibility agency shall send a denial notice to the applicant.

(c) If the eligibility agency receives [the]a signed signature page and completed application within 30 calendar days after the notice of denial date, the date of receipt is the new application date and the provisions of Section R414-308-6 apply.

(d) If the eligibility agency receives a signed signature page and completed application more than 30 calendar days after it sends the denial notice, the applicant must reapply by completing and submitting a new application form. The new application date is [the date that]when the eligibility agency receives a new application.

 

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

(1) The eligibility agency shall determine whether the applicant is eligible within the time limits established in 42 CFR 435.911, 2010 ed., which 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, 2010 ed., which are incorporated by reference; and 42 CFR 435.912[,] and 435.919 , 2010 ed., which are incorporated by reference.

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

(3) If an individual who is determined presumptively eligible files an application for medical assistance in accordance with the requirements of Sections 1920 and 1920A of the Social Security Act, the eligibility agency shall continue presumptive eligibility until it makes an eligibility decision based on that application. The filing of additional applications by the individual does not extend the presumptive eligibility period.

([3]4) 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 42 U.S.C. 1396r-5 may withdraw the request any time before the eligibility agency completes the assessment.

 

R414-308-6. Eligibility Period and 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, when the recipient [must] send s 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.

(c) The recipient must make the payment or provide proof of medical expenses within 30 calendar days from the mailing date of the application approval notice, which states how much the recipient owes.

(d) For ongoing months of eligibility, the recipient has until the close of business on the 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 MWI premium. If the tenth day of the month is a non-business day, the recipient has until the close of business on the first business day after the tenth. 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.

(e) A recipient who lives in a long-term care facility and owes a cost of care contribution to the medical facility must pay the medical facility directly. The 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. An unpaid cost of care contribution is not allowed as a medical bill to reduce the amount that the recipient owes the facility.

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

(g) Eligibility for the poverty level, pregnant woman program does not exist when the recipient fails to pay a required asset copayment.

(h) The [E]eligibility agency shall continue eligibility for a resident of a nursing home [continues] even when a n eligible resident fails to pay the nursing home the cost of care contribution[ to the nursing home]. The resident, however, must continue to meet all other eligibility requirements .

(2) The eligibility period ends on:

(a) the last day of the 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;

(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;

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

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

(f) the date that the individual dies.

(3) A presumptive eligibility period begins on the day that the qualified entity determines an individual to be presumptively eligible. The presumptive eligibility period shall end on the earlier of:

(a) the day that the eligibility agency makes an eligibility decision for medical assistance based on the individual's application when that application is filed in accordance with the requirements of Sections 1920 and 1920A of the Social Security Act; or

(b) in the case of an individual who does not file an application in accordance with the requirements of Sections 1920 and 1920A of the Social Security Act, the last day of the month that follows the month in which the individual becomes presumptively eligible.

([3]4) For an individual[s] selected for coverage under the Qualified Individuals Program, the eligibility agency shall extend[s] eligibility through the end of the calendar year if the individual continues to meet eligibility criteria and the program still exists.

([4]5) The eligibility agency shall complete[s] 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. The eligibility agency shall review factors that are subject to change to determine if the recipient continues to be eligible for medical assistance.

([5]6) The eligibility agency may complete an eligibility review more frequently 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]7) [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. The eligibility agency may complete an eligibility review without requiring the recipient to provide additional information.

([7]8) 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]effective at the end of the review month [ends]and send proper notice to the recipient. 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.

(i) If the recipient becomes eligible based on this reapplication, the recipient's eligibility becomes effective the first day of the month after the closure date.

(ii) 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) The eligibility agency may not continue eligibility while it makes a new eligibility determination.

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

([8]9) 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]10) 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 proper notice of an adverse change for the following month, the agency shall extend eligibility to the following month. This additional month of eligibility is called the due process month. Upon completing an eligibility determination, [T]the eligibility agency shall [notify the recipient]send proper notice of the effective date of any adverse decision[ that becomes effective after the due process month].

([10]11) 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]effective the end of 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]12) 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]13) 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]when the permitted time period for such program expires.

(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.

 

KEY: public assistance programs, applications, eligibility, Medicaid

Date of Enactment or Last Substantive Amendment: [October 1, 2011]2012

Notice of Continuation: January 31, 2008

Authorizing, and Implemented or Interpreted Law: 26-18