Health, Health Care Financing, Coverage and Reimbursement Policy

Rule R414-509

Medicaid Autism Waiver Open Enrollment Process

Notice of Proposed Rule

(New Rule)

DAR File No.: 36427
Filed: 07/02/2012 12:34:51 PM

RULE ANALYSIS

Purpose of the rule or reason for the change:

The purpose of this rule is to set forth the open enrollment process for the Medicaid autism waiver program, which was created in accordance with H.B. 272 in the 2012 General Session.

Summary of the rule or change:

This new rule sets forth eligibility requirements for open enrollment in the Medicaid autism waiver program. It also clarifies conditions for open enrollment and specifies open enrollment procedures.

State statutory or constitutional authorization for this rule:

• Section 26-1-5
• Section 26-18-407
• Section 26-18-3

Anticipated cost or savings to:

the state budget:

The Department does not anticipate any impact to the state budget because this rule only specifies open enrollment procedures for the autism waiver program. It neither affects waiver services for program recipients nor reimbursement for Medicaid providers.

local governments:

There is no impact to local governments because they neither fund nor provide autism waiver services for Medicaid recipients.

small businesses:

The Department does not anticipate any impact to small businesses because this rule only specifies open enrollment procedures for the autism waiver program. It neither affects waiver services for program recipients nor reimbursement for Medicaid providers.

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

The Department does not anticipate any impact to program recipients and to Medicaid providers because this rule only specifies open enrollment procedures. It neither affects waiver services for recipients nor provider reimbursement.

Compliance costs for affected persons:

The Department does not anticipate any cost to a single program recipient or to a Medicaid provider because this rule only specifies open enrollment procedures. It neither affects waiver services nor provider reimbursement.

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

This program is limited to available appropriations. It will have a positive fiscal impact for businesses that serve children with autism that qualify.

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:

08/14/2012

This rule may become effective on:

09/01/2012

Authorized by:

David Patton, Executive Director

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

R414-509. Medicaid Autism Waiver Open Enrollment Process.

R414-509-1. Introduction and Authority.

(1) This rule defines the open enrollment process to enroll individuals in the Medicaid Autism Waiver program.

(2) This rule is authorized by Section 26-18-407. Waiver services are optional and provided in accordance with 42 CFR 440.225.

 

R414-509-2. Definitions.

(1) "Attrition" means the act of a waiver recipient leaving the waiver for any reason. Examples include the recipient moving out of state or the recipient turning six years of age.

(2) "Geographical Region" means a county or counties that are identified as belonging to one of the twelve Utah local health department districts.

(3) "Department" means the Department of Health.

(4) "Open enrollment" means the period during which the Department accepts waiver applications.

(5) "Opening" means the availability for an individual to participate in the Medicaid Autism Waiver program.

(6) "Waiver Operating Agency" means the Department of Human Services, which contracts with the Department of Health to implement defined waiver operations.

 

R414-509-3. Open Enrollment Eligibility Requirements.

To participate in the open enrollment process, the individual must meet the following eligibility requirements:

(1) The individual must have a diagnosis of an autism spectrum disorder from a licensed clinician. Diagnosis must be rendered by a clinician who is authorized under the scope of their licensure;

(2) On the final day of the open enrollment period, the individual must:

(a) have had his or her second birthday; and

(b) be no older than five years and six months of age; and

(3) The individual must meet the financial eligibility requirement defined in the Medicaid Autism Waiver program.

 

R414-509-4. Open Enrollment Periods.

The Department will determine when open enrollment periods are held and for what duration based on the availability of funds for the Medicaid Autism Waiver program.

 

R414-509-5. Open Enrollment Procedures.

(1) The Department accepts the following means of application during open enrollment periods:

(a) Online application, with a time and date stamp confirming that the application was received within the open enrollment period;

(b) Facsimile, with a time and date stamp confirming that the application was received within the open enrollment period; and

(c) Mail, with the postmark on applications dated no sooner than the first day of the open enrollment period and no later than the last day of the open enrollment period.

(2) The number of individuals who may enroll in the waiver program during an open enrollment period is based on the availability of funds.

(3) The Department enrolls all individuals who meet the requirements of Section R414-509-3 if the number of applications does not exceed the number of available openings when the open enrollment period ends.

(4) If the number of applications exceeds the number of available waiver openings, then the Department shall:

(a) Compile all applications that it receives during the open enrollment period;

(b) Assign each application a random number;

(c) Create lists of randomly numbered applications by assigned geographical region;

(d) Assure that rural and underserved regions of the state are represented. The Department assigns waiver openings by geographic regions as follows:

(i) The Department allocates openings to each geographical region based on the percentage of population of the State's population that resides within the geographical region. The Department obtains population information from the most recent United States Census Report;

(ii) if insufficient applications are present in a geographic region to fill all existing openings, the Department distributes the remaining waiver openings to an adjacent geographical region;

(e) Begin at the top of the randomized list and match the number of available geographical openings with the same number of applications;

(i) If a selected applicant does not meet the eligibility criteria described in Section R414-509-3, the Department selects the next application on the randomized list;

(f) Enroll the selected individuals into waiver services.

 

R414-509-6. Procedures for Filling Openings Created by Attrition.

Attrition is ongoing in the Medicaid Autism Waiver program because the waiver serves a child only through the end of the month in which the child turns six years of age.

(1) To fill waiver openings due to attrition outside of open enrollment periods, the Department develops an applicant pool.

(a) The Department determines the number of applicants available in the applicant pool for each geographical region by using the process described in Subsection R414-509-5(4)(d)(i) to determine the number of waiver openings and factoring that number by four;

(b) The Department requires the Waiver Operating Agency to inform the Department of all waiver openings within ten business days;

(c) The Department identifies the geographical region where each opening occurs;

(d) The Department identifies the next randomly numbered application available within that geographical region;

(e) The Department matches the randomly numbered application to the applicant name, and based on the applicant's age, evaluates whether the applicant continues to be eligible for the waiver.

(i) To be eligible for waiver enrollment on the date of identification, the applicant may not exceed five years and six months of age;

(ii) If the applicant is not eligible for waiver enrollment based on Subsection R414-509-6(1)(e)(i), the Department identifies the next randomly numbered application available within the geographical region until the Department can identify an eligible applicant.

(2) When the Department determines an open enrollment period is going to occur, it may suspend filling openings that arise through attrition.

 

KEY: Medicaid

Date of Enactment or Last Substantive Amendment: 2012

Authorizing, and Implemented or Interpreted Law: 26-1-5; 26-18-3