DAR File No. 37120

Health, Health Care Financing, Coverage and Reimbursement Policy

Rule R414-303

Coverage Groups

Notice of 120-Day (Emergency) Rule

DAR File No.: 37120
Filed: 12/28/2012 08:28:11 AM

RULE ANALYSIS

Purpose of the rule or reason for the change:

The purpose of this change is to end coverage for the Qualifying Individuals (QI) program and for the 12-month Transitional Medicaid program.

Summary of the rule or change:

This change removes coverage for the QI program and for the 12-month Transitional Medicaid program, both of which are due to sunset under federal statute after 12/31/2012. (DAR NOTE: With the passage of Sections 621 and 622 of H.R. 8, American Taxpayer Relief Act of 2012, signed on 01/02/2013, another emergency rule was filed under DAR No. 37173 that restores these programs as of 01/07/2013, and supersedes this emergency rule. The emergency rule under DAR No. 37173 will be published in the February 1, 2013, issue of the Bulletin.)

Emergency rule reason and justification:

Regular rulemaking procedures would cause an imminent budget reduction because of budget restraints or federal requirements; and place the agency in violation of federal or state law.

Justification: Federal authority to provide medical assistance under both of these coverage groups ends after 12/31/2012. There will be no federal funds to provide medical assistance to anyone under these two coverage groups. The Qualifying Individuals program is 100% federal match dollars, while the 12-month Transitional Medicaid program is at the regular federal match rate of about 70% federal funds, and 30% state funds. (See DAR NOTE under the summary above.)

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:

• Updates Section 1931(c)(1) and Section 1931(c)(2) of Title XIX of the Social Security Act, published by Social Security Administration, 11/19/2012
• Updates 42 CFR 435.112 and 435.115(f), (g) and (h), published by Government Printing Office, 10/01/2011
• Updates Sections 1634(b), (c) and (d), 1902(a)(10)(A)(i)(II), 1902(a)(10)(A)(ii)(X), 1902(a)(10)(E)(i) through (iii) of Title XIX of the Social Security Act, published by Social Security Administration, 11/19/2012

Anticipated cost or savings to:

the state budget:

The state cost for the number of enrolled persons in these two programs would be about $1,286,013 per month if the Department were to continue coverage after the federal sunset date.

local governments:

This change does not create costs for local governments because they do not provide Medicaid services.

small businesses:

This change could create a cost for some medical providers who could lose some revenue because they would not be able to provide services to individuals who previously had Medicaid coverage.

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

This change creates a cost of about $1,286,013 for individuals who will lose their medical benefits as a result of this change.

Compliance costs for affected persons:

An individual who loses eligibility for the Qualifying Individuals program will incur a cost of $104.90 a month to pay the Medicare Part B premium. An individual losing eligibility for the 12-month Transitional Medicaid program could incur medical costs of any amount because the individual will not have Medicaid coverage. Some individuals losing coverage under the 12-month Transitional Medicaid program may qualify for a different Medicaid program, such as Child Medicaid or the Children's Health Insurance Program, and still have medical assistance.

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

Lack of federal funding as of 01/01/2013 necessitates termination of this Medicaid eligibility group. Fiscal impact on businesses that serve Medicaid clients that qualify through this program is unavoidable.

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

This rule is effective on:

01/01/2013

Authorized by:

David Patton, Executive Director

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

R414-303. Coverage Groups.

R414-303-3. Medicaid for Individuals Who Are Aged, Blind or Disabled for Community and Institutional Coverage Groups.

(1) The Department provides Medicaid coverage to individuals as described in 42 CFR 435.120, 435.122, 435.130 through 435.135, 435.137, 435.138, 435.139, 435.211, 435.232, 435.236, 435.301, 435.320, 435.322, 435.324, 435.340, and 435.350, 2011 ed., which are incorporated by reference. The Department provides coverage to individuals as required by 1634(b), (c) and (d), 1902(a)(10)(A)(i)(II), 1902(a)(10)(A)(ii)(X), and 1902(a)(10)(E)(i) through ([iv]iii) of Title XIX of the Social Security Act in effect [April 2]November 19, 2012, which are incorporated by reference. The Department provides coverage to individuals described in Section 1902(a)(10)(A)(ii)(XIII) of Title XIX of the Social Security Act in effect April 2, 2012, which is incorporated by reference. Coverage under Section 1902(a)(10)(A)(ii)(XIII) is known as the Medicaid Work Incentive Program.

(2) Proof of disability includes a certification of disability from the State Medicaid Disability Office, Supplemental Security Income (SSI) status, or proof that a disabled client is recognized as disabled by the Social Security Administration (SSA).

(3) An individual can request a disability determination from the State Medicaid Disability Office. The Department adopts the disability determination requirements described in 42 CFR 435.541, 2011 ed., and Social Security's disability requirements for the Supplemental Security Income program as described in 20 CFR 416.901 through 416.998, 2011 ed., which are incorporated by reference, to decide if an individual is disabled. The Department notifies the eligibility agency of its disability decision, who then sends a disability decision notice to the client.

(a) If an individual has earned income, the State Medicaid Disability Office shall review medical information to determine if the client is disabled without regard to whether the earned income exceeds the Substantial Gainful Activity level defined by the Social Security Administration.

(b) If, within the prior 12 months, SSA has determined that the individual is not disabled, the eligibility agency must follow SSA's decision. If the individual is appealing SSA's denial of disability, the State Medicaid Disability Office must follow SSA's decision throughout the appeal process, including the final SSA decision.

(c) If, within the prior 12 months, SSA has determined an individual is not disabled but the individual claims to have become disabled since the SSA decision, the State Medicaid Disability Office shall review current medical information to determine if the client is disabled.

(d) Clients must provide the required medical evidence and cooperate in obtaining any necessary evaluations to establish disability.

(e) Recipients must cooperate in completing continuing disability reviews as required by the State Medicaid Disability Office unless they have a current approval of disability from SSA. Medicaid eligibility as a disabled individual will end if the individual fails to cooperate in a continuing disability review.

(4) If an individual denied disability status by the Medicaid Disability Review Office requests a fair hearing, the Disability Review Office may reconsider its determination as part of fair hearing process. The individual must request the hearing within the time limit defined in Section R414-301-6.

(a) The individual may provide the eligibility agency additional medical evidence for the reconsideration.

(b) The reconsideration may take place before the date the fair hearing is scheduled to take place.

(c) The eligibility agency notifies the individual of the reconsideration decision. Thereafter, the individual may choose to pursue or abandon the fair hearing.

(5) If the eligibility agency denies an individual's Medicaid application because the Medicaid Disability Review Office or SSA has determined that the individual is not disabled and that determination is later reversed on appeal, the eligibility agency determines the individual's eligibility back to the application that gave rise to the appeal. The individual must meet all other eligibility criteria for such past months.

(a) Eligibility cannot begin any earlier than the month of disability onset or three months before the month of application subject to the requirements defined in Section R414-306-4, whichever is later.

(b) If the individual is not receiving medical assistance at the time a successful appeal decision is made, the individual must contact the eligibility agency to request the Disability Medicaid coverage.

(c) The individual must provide any verifications the eligibility agency needs to determine eligibility for past and current months for which the individual is requesting medical assistance.

(d) If an individual is determined eligible for past or current months, but must pay a spenddown or Medicaid Work Incentive (MWI) premium for one or more months to receive coverage, the spenddown or MWI premium must be met before Medicaid coverage may be provided for those months.

(6) The age requirement for Aged Medicaid is 65 years of age.

(7) For children described in Section 1902(a)(10)(A)(i)(II) of the Social Security Act in effect April 4, 2012, the [Department]agency shall conduct periodic redeterminations to assure that the child continues to meet the SSI eligibility criteria as required by such section.

[(8) Coverage for qualifying individuals described in Section 1902(a)(10)(E)(iv) of Title XIX of the Social Security Act in effect April 4, 2012, is limited to the amount of funds allocated under Section 1933 of Title XIX of the Social Security Act in effect April 4, 2012, for a given year, or as subsequently authorized by Congress. The eligibility agency will deny coverage to applicants when the uncommitted allocated funds are insufficient to provide such coverage.

] ([9]8) To determine eligibility under Section 1902(a)(10)(A)(ii)(XIII), if the countable income of the individual and the individual's family does not exceed 250% of the federal poverty guideline for the applicable family size, the [Department]agency shall disregard an amount of earned and unearned income of the individual, the individual's spouse, and a minor individual's parents that equals the difference between the total income and the Supplemental Security Income maximum benefit rate payable.

([10]9) The [Department]agency shall require individuals eligible under Section 1902(a)(10)(A)(ii)(XIII) to apply for cost-effective health insurance that is available to them.

 

R414-303-5. [12 Month Transitional Family Medicaid.]Reserved.

[ The Department covers households that lose eligibility for 1931 Family Medicaid, in accordance with the provisions of Title XIX of the Social Security Act, Sections 1925 and 1931 (c)(2).

]

R414-303-6. Four Month Transitional Family Medicaid.

(1) The Department adopts 42 CFR 435.112 and 435.115(f), (g) and (h), [2001]2011 ed., and Title XIX of the Social Security Act, Section 1931(c)(1) and Section 1931(c)(2) in effect [January 1, 2001]November 19, 2012 which are incorporated by reference.

(2) Changes in household composition do not affect eligibility for the four month extension period. New household members may be added to the case only if they meet the AFDC or AFDC two-parent criteria for being included in the household if they were applying in the current month. Newborn babies are considered household members even if they were unborn the month the household became ineligible for Family Medicaid under Section 1931 of the Social Security Act. New members added to the case will lose eligibility when the household loses eligibility. Assistance shall be terminated for household members who leave the household.

 

KEY: income, coverage groups, independent foster care adolescent

Date of Enactment or Last Substantive Amendment: January 1, 2013

Notice of Continuation: January 25, 2008

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