DAR File No. 38044

Health, Health Care Financing, Coverage and Reimbursement Policy

Rule R414-302

Eligibility Requirements

Notice of Proposed Rule

(Amendment)

DAR File No.: 38044
Filed: 10/07/2013 03:15:31 PM

RULE ANALYSIS

Purpose of the rule or reason for the change:

The purpose of this change is to comply with provisions of the Patient Protection and Affordable Care Act (ACA).

Summary of the rule or change:

This amendment implements a new requirement to verify citizenship and alienage through an electronic system before requiring verification from the client. It also adds deprivation of support requirements for Medicaid programs, and updates criteria to comply with ACA provisions on social security numbers, third party liability, and the assignment of rights. It further implements financial requirements for Modified Adjusted Group Income (MAGI)-based Medicaid groups.

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 42 CFR 435.602(a), published by Government Printing Office, 10/01/2012
• Updates 42 CFR 433.138(b), published by Government Printing Office, 10/01/2012
• Adds 42 CFR 435.4, published by Government Printing Office, 10/01/2012
• Updates 42 CFR 610, published by Government Printing Office, 10/01/2012
• Updates Subsection 1902(b) of the Compilation of the Social Security Laws, published by Social Security Administration, 05/08/2013
• Adds 42 CFR 949 and 952, published by Government Printing Office, 10/01/2012
• Updates 1915(b) of the Compilation of the Social Security Laws, published by Social Security Administration, 09/09/2013
• Updates Definitions in 42 CFR 435.1010 , published by Government Printing Office, 10/01/2012
• Updates 42 CFR 433.145 through 433.148, published by Government Printing Office, 10/01/2012
• Removes 45 CFR 233.106, published by Government Printing Office, 10/01/1997
• Updates 42 CFR 435.1009, published by Government Printing Office, 10/01/2012
• Updates 42 CFR 435.910, published by Government Printing Office, 10/01/2012
• Updates 42 CFR 435.608, published by Government Printing Office, 10/01/2012
• Updates 42 CFR 435.403, published by Government Printing Office, 10/01/2012
• Updates Section 1137 of the Compilation of the Social Security Laws, published by Social Security Administration, 05/08/2013
• Updates 42 CFR 435.406, published by Government Printing Office, 10/01/2012

Anticipated cost or savings to:

the state budget:

There are no anticipated costs or savings to the state budget because these changes are primarily administrative modifications, statutory updates, and definition changes.

local governments:

There is no impact to local governments because they do not determine Medicaid eligibility for Medicaid recipients.

small businesses:

This amendment does not impose any new costs or requirements on small businesses because they do not make eligibility determinations for the Medicaid program. In addition, this amendment does not affect business revenue because the conversion process to MAGI methodology does not systematically increase or decrease Medicaid eligibility.

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

This amendment does not impose any new costs or requirements on Medicaid providers and on Medicaid recipients because it does not affect Medicaid services. In addition, this amendment does not affect provider revenue because the conversion process to MAGI methodology does not systematically increase or decrease Medicaid eligibility.

Compliance costs for affected persons:

This amendment does not impose any new costs or requirements on a single Medicaid provider or on a Medicaid recipient because it does not affect Medicaid services. In addition, this amendment does not affect provider revenue because the conversion process to MAGI methodology does not systematically increase or decrease Medicaid eligibility.

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

The rule will have no impact on business.

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:

12/02/2013

This rule may become effective on:

01/01/2014

Authorized by:

David Patton, Executive Director

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

R414-302. Eligibility Requirements.

R414-302-1. Authority and Purpose.

This rule is authorized by Section 26-1-5 and Section 26-18-3 and establishes eligibility requirements for Medicaid and the Medicare Cost Sharing programs.

 

R414-302-2. Definitions.

The definitions in Rules R414-1 and R414-301 apply to this rule.

 

R414-302-[1]3. Citizenship and Alienage.

(1) The Department incorporates by reference 42 CFR 435.406 [2008]October 1, 2012 ed., which requires applicants and recipients to be United States (U.S. ) citizens or qualified aliens and to provide verification of their U.S. citizenship or lawful alien status.

(2) The definitions in R414-1 and R414-301 apply to this rule.

(3) The Department shall decide if a public or private organization no longer exists or is unable to meet an alien's needs. The Department shall base the decision on the evidence submitted to support the claim. The documentation submitted by the alien must be sufficient to prove the claim.

(4) One adult household member must declare the citizenship status of all household members who will receive Medicaid.[ The client must provide verification of citizenship and identity as described in 42 CFR 435.407.]

(5) A qualified alien, as defined in 8 U.S.C. 1641 who was residing in the [United States]U.S. [prior to]before August 22, 1996, may receive full Medicaid, Qualified Medicare Beneficiaries (QMB ), Specified Low-Income Medicare Beneficiaries (SLMB ), or Qualifying Individuals (QI) services.

(6) A qualified alien, as defined in 8 U.S.C. 1641 newly admitted into the [United States]U.S. on or after August 22, 1996, may receive full Medicaid, QMB, SLMB, or [Qualifying Individuals (]QI[)] services after five years have passed from the person's date of entry into the [United States]U.S.

(7) The Department accepts as verification of citizenship documents from federally recognized Indian tribes evidencing membership or enrollment in such tribe including those with international borders as required under Section 2[2]11(b)(1) of the Children's Health Insurance Program Reauthorization Act of 2009, Pub. L. No. 111 3, or as prescribed by the Secretary.

(8) The Department provides reasonable opportunity for applicants or clients to present satisfactory documentation of citizenship as required under Section 2[2]11(b)(2) of the Children's Health Insurance Program Reauthorization Act of 2009, Pub. L. No. 111 3.

(9) The Department considers that an infant born to a mother who is eligible for Medicaid at the time of [such]the infant's birth has provided satisfactory evidence of citizenship. The Department does not require further verification of citizenship for [such]the infant as required under Section 2[2]11(b)(3) of the Children's Health Insurance Program Reauthorization Act of 2009, Pub. L. No. 111 3.

(10) The Department [may implement an electronic match system with the Social Security Administration to verify citizenship or nationality, and the identity of an applicant for medical assistance. The electronic match system shall meet the requirements of Section 211(a) of the Children's Health Insurance Program Reauthorization Act of 2009, Pub. L. No. 111 3.]adopts and incorporates by reference 42 CFR 435.949 and 42 CFR 435.952, October 1, 2012 ed.

(a) The Department shall verify citizenship and immigration status requirements through the Federal Data Services Hub or through other electronic match systems approved by the Secretary.

(b) If the Department cannot verify citizenship or immigration status through an electronic match system or the electronic data is not reasonably compatible with the client statement, the client must provide verification of citizenship and identity as described in 42 CFR 435.407.

 

R414-302-[2]4. Utah Residence.

(1) The Department adopts and incorporates by reference 42 CFR 435.403, [1997]October 1, 2012 ed.[, which is incorporated by reference.] The Department also adopts and incorporates by reference Subsection 1902(b) of the Compilation of the Social Security Laws, in effect [January 1, 1998]May 8, 2013[, which is incorporated by reference].

(2) The Department considers an individual who establishes state residency to be a resident of the state during periods of temporary absence, if the individual intends to return to the state when the purpose for the temporary absence ends.

 

R414-302-[3]5. [Reserved.]Deprivation of Supports.

[Reserved.](1) The Department adopts and incorporates by reference the definition of "dependent child" found in 42 CFR 435.4, October 1, 2012 ed.

(2) A child who lives with two parents is deprived of support if at least one parent is working less than 100 hours a month.

(3) A child is not considered deprived of support if any of the following situations is true:

(a) The parent is absent because of military service;

(b) The parent is absent for employment, schooling, training or another temporary purpose;

(c) The parent will return to live in the home within 30 days from the date of the application;

(d) The parent is the primary child care provider and care is frequent enough that the child is not deprived of support, care and guidance.

(4) A parent is incapacitated if the parent meets one of the following criteria:

(a) The parent receives SSI;

(b) The parent is recognized as 100% disabled by the Veteran's Administration;

(c) The parent is determined disabled by the State Medicaid Disability Office or the Social Security Administration;

(d) The parent provides written documentation completed by a medical professional engaged in the practice of mental health therapy, which states that the parent is incapacitated and the incapacity is expected to last at least 30 days. The medical report must also state that the incapacity substantially reduces the parent's ability to work or care for the child. Full-time employment, however, nullifies the parent's claim of incapacity. The written documentation must be completed by one of the following medical professionals:

(i) Medical Doctor (MD);

(ii) Doctor of Osteopathy (DO);

(iii) Advanced Practice Registered Nurse (APRN);

(iv) Physician Assistant; or

(v) Mental Health Therapist who is either a psychologist, licensed clinical social worker, certified social worker, marriage and family therapist, professional counselor, MD, DO, or APRN.

 

R414-302-[4]6. Residents of Institutions.

(1) The Department provides Medicaid coverage to individuals who are residents of institutions subject to the limitations related to residents of public institutions, patients in an institution for mental diseases who do not meet the age criteria, and patients in an institution for tuberculosis as defined in 42 CFR 435.1009, October 1, 20[09]12 ed., which is incorporated by reference. The Department also adopts and incorporates by reference the definitions in 42 CFR 435.1010, 20[09]12 ed.

(2) The Department does not consider persons under the age of 18 to be residents of an institution if they are living temporarily in the institution while arrangements are being made for other placement.

(3) The Department does not consider an individual who resides in a temporary shelter for a limited period of time as a resident of an institution.

(4) The Department considers ineligible residents of institutions for mental disease (IMD) who are ages 21 through 64 as non-residents while on conditional or convalescent leave from the institution. A resident of an IMD who is under 21 years of age, or is under 22 years of age and enters an IMD before reaching 21 years of age, is considered to be a resident while on conditional or convalescent leave from the institution.

(5) For individuals under 22 years of age who become residents of an IMD before reaching 21 years of age, the Department limits Medicaid eligibility to individuals residing in the Utah State Hospital.

 

R414-302-[5]7. Social Security Numbers.

(1) The Department adopts and incorporates by reference 42 CFR 435.910, [1997]October 1, 2012 ed., which requires the social security number (SSN) of each applicant or beneficiary, specifies the exceptions to requiring the SSN, and specifies agency verification responsibilities.[which is incorporated by reference.] The Department adopts Section 1137 of the Compilation of the Social Security Laws, in effect [January 1, 1998]May 8, 2013, which is incorporated by reference.

(2) [Clients must provide their correct Social Security Number (SSN).

(a) The Department requires clients to provide their correct SSN or a proof of application for a SSN at the time of application for Medicaid.

(b) The Department requires clients who do not know their SSN or provide a SSN that is questionable to provide proof of application for a SSN upon application for Medicaid.

(c)] Acceptable proof of [application for] an SSN is an electronic match, a [S]social [S]security [C]card, or an official document from the Social Security Administration, which identifies the correct number . Acceptable proof of an application for an SSN is [or] a [S]social [S]security receipt [form 5028, 2880, or 2853]that confirms the individual has applied for an SSN.

([d]3) The Department requires a new proof of application for a n SSN at each recertification if the SSN has not previously been provided[ previously].

(4) The Department may assign a unique Medicaid identification number to an applicant or beneficiary who meets one of the exceptions to the requirement to provide an SSN.

 

R414-302-[6]8. Application for Other Possible Benefits.

(1) The Department adopts and incorporates by reference 42 CFR 435.608, October 1, 2012 ed., which requires applicants for and recipients of medical assistance to apply for and take all reasonable steps to receive other possible benefits[ as required by 42 CFR 435.608, 2004 ed., which is incorporated by reference].

(2) The Department may not require an applicant for or recipient of medical assistance to apply for an income benefit if the applicant's or recipient's income is not counted for the purpose of determining eligibility for medical assistance for either that individual or any other household member.

([2]3) Individuals who may be eligible for Medicare Part B benefits must apply for Medicare Part B and, if eligible, become enrolled in Medicare Part B to be eligible for Medicaid. The state pays the applicable monthly premium and cost-sharing expenses for Medicare Part B for individuals who are eligible for both Medicaid and Medicare Part B.

 

R414-302-[7]9. Third Party Liability.

(1) The Department adopts and incorporates by reference 42 CFR 433.138(b) , October 1, 2012 ed., on the collection of health insurance information.[and 435.610, 1997 ed., and] The Department also adopts and incorporates by reference Section 1915(b) of the Compilation of the Social Security Laws, in effect [January 1, 1998,]September 9, 2013[which are incorporated by reference].

(2) The Department requires clients to report any changes in third party liability information within 30 days.

(3) The Department considers a client [non]uncooperative if the client knowingly withholds third party liability information without good cause.

(4) The Department shall decide whether employer provided group health insurance would be cost effective for the state to purchase as a benefit of Medicaid.

(5) The Department requires clients residing in selected communities to be enrolled in a Health Maintenance Organization as their primary care provider. The Department shall enroll clients who do not make a selection in a Health Maintenance Organization that the Department selects. The Department shall notify clients of the Health Maintenance Organization that they will be enrolled in and allowed ten days to contact the Department with a different selection. If the client fails to notify the Department to make a different selection within ten days, the enrollment shall become effective for the next benefit month.

 

R414-302-[8]10.  Assignment of Rights and Medical Support Enforcement.

The Department adopts and incorporates by reference 42 CFR 433.145 through 433.148, [1997]and 435.610, October 1, 2012 ed., which spell out the assignment of rights to the state to collect from liable third parties and to cooperate in establishing paternity and medical support[which is incorporated by reference].

 

R414-302-[9]11. [Relationship Determination ]Financial Responsibility[for Family Medicaid].

(1) The Department adopts and incorporates by reference 42 CFR 435.602(a), [1997]October 1, 2012 ed., on the financial responsibility of family members[which is incorporated by reference].

(2) The Department shall apply the requirements of 42 CFR 435.603 for all individuals eligible for coverage groups subject to the Modified Adjusted Gross Income (MAGI) methodology.

 

[R414-302-10. Strikers - Family Medicaid.

The Department adopts 45 CFR 233.106, 1997 ed., which is incorporated by reference.]

 

KEY: [public assistance programs]state residency, [application]citizenship, [eligibility]third party liability, Medicaid

Date of Enactment or Last Substantive Amendment: [July 1, 2010]2013

Notice of Continuation: January 23, 2013

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