Health, Health Care Financing, Coverage and Reimbursement Policy

Rule R414-301

Medicaid General Provisions

Notice of Proposed Rule

(Amendment)

DAR File No.: 36872
Filed: 09/27/2012 05:04:44 PM

RULE ANALYSIS

Purpose of the rule or reason for the change:

The purpose of this change is to clarify and update certain provisions within the rule.

Summary of the rule or change:

This amendment removes the list of different categories of Medicaid coverage groups and refers to these categories more generally. It also adds and updates definitions and certain provisions throughout the rule text.

State statutory or constitutional authorization for this rule:

• Section 26-18-3

This rule or change incorporates by reference the following material:

• Adds 42 CFR 431.301 through 42 CFR 431.307, published by Government Printing Office, 10/01/2011

Anticipated cost or savings to:

the state budget:

The Department does not anticipate any impact to the state budget because these changes only clarify and update certain provisions within the rule.

local governments:

There is no impact to local governments because they neither determine Medicaid eligibility nor fund Medicaid programs.

small businesses:

The Department does not anticipate any impact to small businesses because these changes only clarify and update certain provisions within the rule.

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 these changes only clarify and update certain provisions within the rule.

Compliance costs for affected persons:

The Department does not anticipate any impact to a single Medicaid provider or to a Medicaid recipient because these changes only clarify and update certain provisions within the rule.

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

These changes should have no fiscal impact on providers. Updating and simplifying definitions and implementation standards may ease compliance costs.

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:

11/14/2012

This rule may become effective on:

12/01/2012

Authorized by:

David Patton, Executive Director

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

R414-301. Medicaid General Provisions.

R414-301-1. Authority and Purpose.

(1) This rule is established under the authority of Section 26-18-3.

(2) The purpose of this rule is to establish general provisions governing eligibility for medical assistance programs.

(3) The Department of Health may contract with the Department of Workforce Services and the Department of Human Services to do eligibility determinations for one or more [of the] medical assistance programs [listed below]authorized by the Department of Health. The Department of Health is responsible for the administration of [these]medical assistance programs[:] authorized under the Utah Medicaid State Plan, the State Plan for the Utah Children's Health Insurance Program and various waivers under Title XIX of the Social Security Act.

[ (1) Aged Medicaid (AM);

(2) Blind Medicaid (BM);

(3) Disabled Medicaid (DM);

(4) Family Medicaid (FM);

(5) Child Medicaid (CM);

(6) Title IV-E Foster Care Medicaid (FC);

(7) Medicaid for Pregnant Women (PG);

(8) Prenatal Medicaid (PN);

(9) Newborn Medicaid (NB);

(10) Transitional Medicaid (TR);

(11) Refugee Medicaid (RM);

(12) Utah Medical Assistance Program (UMAP);

(13) Qualified Medicare Beneficiary Program (QMB);

(14) Specified Low-Income Medicare Beneficiary Program (SLMB);

(15) Qualifying Individuals, Group 1 Program (QI-1);

(16) Medicaid Work Incentive;

(17) Medicaid Cancer Program;

(18) Primary Care Network Demonstration, which includes the Primary Care Network and the Covered-at-Work Programs.

]

R414-301-2. Definitions.

The definitions in Section 26-18-2 apply in this rule. In addition, the following definitions apply in [r]Rules R414-301 through R414-308:

(1) "Aged" means an individual who is 65 years of age or older.

([1]2) "Agency" means [any local office or outreach location of either ]the Department of Health[ or the Department of Workforce Services that accepts and processes applications for Medicaid and Medicare Cost-Sharing programs. In] as referenced in incorporated federal materials[, "agency" means the Utah Department of Health].

[ (2) "Applicant" means any person requesting assistance under any of the programs listed in R414-301.

(3) "Assistance" means medical assistance under any of the programs listed in R414-301.

] ([4]3) "CHEC" means Child Health Evaluation and Care and is the Utah specific term for the federally mandated program of Early and Periodic Screening, Diagnosis and Treatment (EPSDT) for children under the age of 21.

(4) "Cost-of-care" means the amount of income after allowable deductions an individual must pay for their long-term care services either in a medical institution or for home and community- based waiver services.

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

(6) "Eligibility Agency" means any state office or outreach location of the Department of Workforce Services (DWS) that accepts and processes applications for medical assistance programs under contract with the Department. The Department of Human Services (DHS) is the eligibility agency under contract with the Department to process applications for children in state custody.

(7) "Federal poverty guideline" means the United States (U.S.) federal poverty measure issued annually by the Department and DHS to determine financial eligibility for certain means-tested federal programs.

(8) "Medically needy" means medical assistance coverage under the provisions of 42 CFR 435.301 that uses the Basic Maintenance Standard as the income limit for eligibility.

[ (5) "Client" means an applicant or recipient of any of the programs listed in R414-301.

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

(7) "Director" or "designee" means the director or designee of the Division of Health Care Financing.

(8) "Local" office means any community office location of the Department of Workforce Services, the Department of Human Services or the Department of Health where an individual may apply for medical assistance programs.

] (9) "Outreach location" means any site other than a state office where state workers are located to accept applications for medical assistance programs. Locations include sites such as hospitals, clinics, homeless shelters, etc.

(10) "QI-1" means the Qualifying Individuals Group 1 program, a Medicare Cost-Sharing program.

(11) "QMB" means Qualified Medicare Beneficiary program, a Medicare Cost-Sharing program.

[(12) "Recipient" means any individual receiving assistance under any of the programs listed in R414-301-1. It may also be used to mean someone who is receiving other assistance or benefits such as SSI, in which case the text will specify such other type of benefit or assistance.

] (1[3]2) "Reportable change" means any change in circumstances which could affect a client's eligibility for Medicaid, including:

(a) change in the source of income;

(b) change of more than $25 in gross income;

(c) changes in household size;

(d) changes in residence;

(e) gain of a vehicle;

(f) change in resources;

(g) change of more than $25 in total allowable deductions;

(h) changes in marital status, deprivation, or living arrangements;

(i) pregnancy or termination of a pregnancy;

(j) onset of a disabling condition; and

(k) change in health insurance coverage including changes in the cost of coverage.

(1[4]3) "Resident of a medical institution" means a single [client]individual who is a resident of a medical institution from the month after entry into a medical institution until the month prior to discharge from the institution. Death in a medical institution is not considered a discharge from the institution and does not change the client's status as a resident of the medical institution. Married [clients]individuals are residents of an institution in the month of entry into the institution and in the month they leave the institution.

(1[5]4) "SLMB" means Specified Low-Income Medicare Beneficiary program, a Medicare Cost-Sharing program.

(1[6]5) "Spenddown" means an amount of income in excess of the allowable income standard that must be paid in cash to the [department]eligibility agency or incurred through the medical services not paid by Medicaid or other health insurance coverage, or some combination of these.

(1[7]6) "Spouse" means any individual who has been married to a n [client]applicant or recipient and has not legally terminated the marriage.

(17) "Verification" means the proof needed to decide whether an individual meets the eligibility criteria to be enrolled in the applicable medical assistance program. Verification may include documents in paper format, electronic records from computer match systems, and collateral contacts with third parties who have information needed to determine the eligibility of the individual.

(18) "Worker" means a state employee who determines eligibility for [Medicaid and Medicare Cost-Sharing]medical assistance programs.

 

R414-301-3. Client Rights and Responsibilities.

(1) Anyone may apply or reapply any time for any program. A program subject to periods of closed enrollment will deny applications received during a closed enrollment period.

(2) If someone needs help to apply he may have a friend or family member help, or he may request help from the [local office]eligibility agency or outreach staff.

(3) Workers will identify themselves to clients.

(4) Workers will treat clients[Clients will be treated] with courtesy, dignity and respect.

(5) Workers will ask for verification and information clearly and courteously. Workers shall send a written request for verifications.

(6) If a client must be visited after working hours, the eligibility worker will make an appointment.

(7) Workers will not enter a client's home without the client's permission.

(8) Clients must provide requested verifications within the time limits given. The [Department]eligibility agency may grant additional time to provide information and verifications upon client request.

(9) Clients have a right to be notified about the decision made on an application or other action taken that affects their eligibility for benefits in accordance with the requirements of 42 CFR 431.210, 42 CFR 431.211, 42 CFR 431.213, and 42 CFR 431.214.

(10) Clients may look at most information about their case.

(11) Anyone may look at the policy manuals located at any [department local office]eligibility agency office or online. Policy manuals are not available for review at outreach locations or call centers.

(12) Applicants and recipients may request a fair hearing if they disagree with the eligibility agency's decision.

(1[2]3) The [client]recipient must repay any understated liability. The [client]recipient is responsible for repayments due to ineligibility including benefits received pending a fair hearing decision. In addition to payments made directly to medical providers, benefits include Medicare or other health insurance premiums, premium payments made in the [client]recipient's behalf to Medicaid [H]health [P]plans and mental health providers even if the [client]recipient does not receive a direct medical service from these entities.

(1[3]4) The client must report a reportable change as defined in Subsection R414-301-2(1[2]1) to the [local office]eligibility agency within ten days of the day the change becomes known.

 

R414-301-4. Safeguarding Information.

(1) The [d]Department adopts 42 CFR 431[(F)].301 through 42 CFR 431.307, [2001]2011 ed., which is incorporated by reference. The [d]Department requires compliance with Section[s] 63G-2-101 through Section 63G-2-310.

(2) Workers shall safeguard all information about specific clients.

(3) There are no provisions for taxpayers to see any information from client records.

(4) The director or designee shall decide if a situation is an emergency warranting release of information to someone other than the client. The information may be released only to an agency with comparable rules for safeguarding records. The information released cannot include information obtained through an income match system.

 

R414-301-5. Complaints and Agency Conferences.

(1) A client may request an agency conference with the eligibility staff or supervisor at the [Medicaid ]eligibility agency at any time to resolve a problem regarding the client's case. Requests shall be granted at the [Medicaid ]eligibility agency's discretion. Clients may have an authorized representative or a friend attend the agency conference.

(2) Requesting an agency conference does not prevent a client from also requesting a fair hearing in the event the agency conference does not resolve the client's concerns.

(3) Having an agency conference does not extend the time period in which a client has to request a fair hearing. The client must request a fair hearing according to the provisions in Section R414-301-6, to assure the right to a hearing.

(4) There is no appeal to the decisions made during an agency conference; however, if the client is not satisfied with the results of the agency conference, and makes a timely request for a fair hearing as defined in Section R414-301-6, the client may proceed with the fair hearing process.

(5) The [Medicaid ]eligibility agency shall provide[s] proper notice if the agency makes any additional adverse changes in the client's eligibility as a result of the agency conference. The client then has a right to request a fair hearing based on the new adverse action.

 

R414-301-6. Hearings.

(1) The [Department]eligibility agency shall provide[s] a fair hearing process for applicants and [clients]recipients in accordance with the requirements of 42 CFR 431.220 through 42 CFR 431.246. The [Department]eligibility agency shall compl[ies]y with Title 63G, Chapter 4.

(2) An applicant or [client]recipient must request a hearing in writing or orally at the [Medicaid] eligibility agency. The request must be made within 90 calendar days of the date of the notice of agency action with which the applicant or [client]recipient disagrees. The request need only include a statement that the applicant or [client]recipient wants to present his [or her ]case.

(3) Hearings are conducted only at the request of a client or spouse; a minor client's parent; or a guardian or representative of the client.

(4) A [client]recipient who requests a fair hearing shall receive continued medical assistance benefits pending a hearing decision if the [client]recipient requests a hearing before the effective date of the action or within ten calendar days of the mailing date of the notice of agency action.

(5) The [client]recipient must repay the continued benefits that he receives pending the hearing decision if the hearing decision upholds the agency action.

(a) A [client has the right to not accept]recipient may decline the continued benefits that the Department offers pending a hearing decision by notifying the eligibility agency.

(b) Benefits that the [client]recipient must repay include premiums for Medicare or other health insurance, premiums and fees to managed care and contracted mental health services entities, fee-for-service benefits on behalf of the individual, and medical travel fees or reimbursement to or on behalf of the individual.

(6) The [Medicaid] eligibility agency must receive a request for a hearing by the close of business on a business day that is before or on the due date. If the due date is a non-business day, then the [Medicaid] eligibility agency must receive the request by the close of business on the first business day immediately following the due date.

(7) [The Department of Workforce Services (]DWS[)] conducts fair hearings for all medical assistance cases except those concerning eligibility for foster care or subsidized adoption Medicaid. The Department [of Health (DOH)] conducts hearings for foster care or subsidized adoption Medicaid cases.

(8) DWS conducts informal, evidentiary hearings in accordance with Section[s] R986-100-124 through Section R986-100-134, except for the provisions in Subsection[s] [R986-100-124(1) and] R986-100-128(17) and Subsection R986-100-134(5). Instead, the provisions in Subsection R414-301-6(16) concerning the time frame to comply with the DWS decision, and Subsection R414-301-6 (17)(c) concerning continued assistance during a superior agency review conducted by the Department apply respectively.[ In addition, DWS complies with all the hearing requirements of Rule R986-100.]

(9) [DOH]The Department conducts informal hearings concerning eligibility for foster care or subsidized adoption Medicaid in accordance with Rule R414-1. Pursuant to Section 63G-4-402, within 30 days of the date [DOH]the Department issues the hearing decision, the applicant or [client]recipient may file a petition for judicial review with the district court.

(10) DWS [shall]may not conduct a hearing contesting resource assessment until an institutionalized individual has applied for Medicaid.

(11) An applicant or [client]recipient may designate a person or professional organization to assist in the hearing or act as his representative. An applicant or [client]recipient may have a friend or family member attend the hearing for assistance.

(12) The applicant, [client]recipient or representative can arrange to review case information before the scheduled hearing.

(13) At least one employee from the [Medicaid] eligibility agency must attend the hearing. Other employees of the [Medicaid] eligibility agency, other state agencies and legal representatives for the [Medicaid] eligibility agency may attend as needed.

(14) The DWS [Office]Division of Adjudication[s] and Appeals shall mail a written hearing decision to the parties involved in the hearing. The decision shall include the decision, a summary of the facts and the policies or regulations supporting the decision.

(a) The DWS decision shall include information about the right to request a superior agency review from [DOH]the Department and how to make that request.

(b) The applicant or [client]recipient may appeal the DWS decision to [DOH]the Department pursuant to Section R410-14-1[7]8. The request for agency review must be made in writing and delivered to either DWS or the Department within 30 days of the mailing date of the decision.

(15) [DOH]The Department, as the single state Medicaid agency, is a party to all fair hearings concerning eligibility for medical assistance programs. [DOH]The Department conducts appeals and has the right to conduct a superior agency review of medical assistance hearing decisions rendered by DWS.

(16) The DWS hearing decision becomes final 30 days after the decision is sent unless [DOH]the Department conducts a superior agency review. [DOH conducts a superior agency review when the applicant or client appeals the DWS decision or upon its own accord if it disagrees with the DWS decision.] The DWS hearing decision may be made final in less than 30 days upon agreement of all parties.

(17) The Department conducts a superior agency review when the applicant or recipient appeals the DWS decision or upon its own accord if it disagrees with the DWS decision.

(a) [DOH]The Department notifies DWS whenever it conducts a superior agency review.

(b) The DWS hearing decision is suspended until [DOH]the Department issues a final decision and order on agency review.

(c) A recipient receiving continued benefits continues to be eligible for continued benefits pending the superior agency review decision.

(18) The superior agency review is an informal proceeding and shall be conducted in accordance with Section 63G-4-301.

(19) A [DOH]Department decision and order on agency review becomes final upon issuance.

(20) The [Medicaid] eligibility agency takes case action within ten calendar days of the date the decision becomes final.

(21) Pursuant to Section 63G-4-402, within 30 days of the date the decision and order on agency review is issued, the applicant or [client]recipient may file a petition for judicial review with the district court. Failure to appeal a DWS hearing decision to [DOH]the Department negates this right to a judicial appeal.

(22) [Clients]Recipients are not entitled to continued benefits pending judicial review by the district court.

 

KEY: client rights, hearings, Medicaid

Date of Enactment or Last Substantive Amendment: [October 22, 2009]2012

Notice of Continuation: January 31, 2008

Authorizing, and Implemented or Interpreted Law: 26-18