DAR File No. 38465

Health, Health Care Financing, Coverage and Reimbursement Policy

Rule R414-303

Coverage Groups

Notice of Proposed Rule

(Amendment)

DAR File No.: 38465
Filed: 04/28/2014 09:54:52 AM

RULE ANALYSIS

Purpose of the rule or reason for the change:

The purpose of this change is to specify when coverage ends for the 12-Month Transitional Medicaid (TR) program in accordance with Pub. L. No. 113-93, and to clarify eligibility requirements for the Hospital Presumptive Eligibility program.

Summary of the rule or change:

This amendment specifies when coverage ends for the TR program. It also complies with a mandate from the Centers for Medicare and Medicaid Services (CMS) on hospital presumptive eligibility, which clarifies uncountable income and limits the frequency in which an individual may receive coverage. This amendment also updates incorporations by reference and makes other technical changes.

State statutory or constitutional authorization for this rule:

• Pub. L. No. 113-93
• Section 26-1-5
• Section 26-18-3

This rule or change incorporates by reference the following material:

• Adds 42 CFR 435.1110, published by Government Printing Office, 10/01/2013

Anticipated cost or savings to:

the state budget:

There is no impact to the state budget because this amendment only clarifies eligibility requirements and specifies duration of coverage.

local governments:

There is no impact to local governments because they do not fund or provide Medicaid services to Medicaid recipients.

small businesses:

There is no impact to small businesses because this amendment only clarifies eligibility requirements and specifies duration of coverage.

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

There is no impact to Medicaid providers and to Medicaid recipients because this amendment only clarifies eligibility requirements and specifies duration of coverage.

Compliance costs for affected persons:

There is no impact to a single Medicaid provider or to a Medicaid recipient because this amendment only clarifies eligibility requirements and specifies duration of coverage.

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

No impact on business as it merely conforms the rules to new legal requirements.

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:

06/16/2014

This rule may become effective on:

07/01/2014

Authorized by:

David Patton, Executive Director

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

R414-303. Coverage Groups.

R414-303-6. 12-Month Transitional Medicaid.

(1) The Department adopts and incorporates by reference Title XIX of the Social Security Act Section 1925 in effect January 1, 2013, to provide 12 months of extended medical assistance when the parent or caretaker relative is eligible and enrolled in Medicaid as defined in 42 CFR 435.110, and loses eligibility as described in Section 1931(c)(2) of the Social Security Act.

(a) A pregnant woman who is eligible and enrolled in Medicaid as defined in 42 CFR 435.116, and who meets the income limit defined in 42 CFR 435.110 for three of the prior six months, is eligible to receive 12-month Transitional Medicaid.

(b) Children who live with the parent are eligible to receive Transitional Medicaid.

(2) Pub. L. No. 113 93 requires the Transitional Medicaid program to end after March 31, 2015.

 

R414-303-11. Presumptive Pregnant Woman and Child Medicaid.

(1) The Department adopts and incorporates by reference 42 CFR 435.1102, October 1, 2012 ed., and also adopts and incorporates by reference 78 FR 42303, in relation to presumptive eligibility for pregnant women and children under 19 years of age.

(2) The following definitions apply to this section:

(a) "covered provider" means a provider that the Department has determined is qualified to make a determination of presumptive eligibility for a pregnant woman and that meets the criteria defined in Section 1920(b)(2) of the Social Security Act;

(b) "presumptive eligibility" means a period of eligibility for medical services based on self-declaration that the individual meets the eligibility criteria.

(3) The Department provides coverage to a pregnant woman during a period of presumptive eligibility if a covered provider determines, based on preliminary information, that the woman states she:

(a) is pregnant;

(b) meets citizenship or alien status criteria as defined in Section R414-302-3;

(c) has household income that does not exceed 139% of the federal poverty guideline applicable to her declared household size; and

(d) is not already covered by Medicaid or CHIP.

(4) A pregnant woman may only receive medical assistance during one presumptive eligibility period for any single term of pregnancy.

(5) A child born to a woman who is only presumptively eligible at the time of the infant's birth is not eligible for the one year of continued coverage defined in Section 1902(e)(4) of the Social Security Act. If the mother applies for Utah Medicaid after the birth and is determined eligible back to the date of the infant's birth, the infant is then eligible for the one year of continued coverage under Section 1902(e)(4) of the Social Security Act. If the mother is not eligible, the eligibility agency shall determine whether the infant is eligible under other Medicaid programs.

(6) The Department provides medical assistance to children under the age of 19 during a period of presumptive eligibility if a Medicaid eligibility worker with the Department of Human Services has determined, based on preliminary information, that:

(a) the child meets citizenship or alien status criteria as defined in Section R414-302-3;

(b) for a child under age 6, the declared household income does not exceed 139% of the federal poverty guideline applicable to the declared household size;

(c) for a child six through 18 years of age, the declared household income does not exceed 133% of the federal poverty guideline applicable to the declared household size; and

(d) the child is not already covered under Medicaid or CHIP.

(7) A child may receive medical assistance during only one period of presumptive eligibility in any six-month period.

(8) A child determined presumptively eligible may receive presumptive eligibility only through the applicable period or until the end of the month in which the child turns 19, whichever occurs first.

(9) The Department adopts and incorporates by reference 42 CFR 435.1110, October 1, 2013 ed.[78 FR 42303], which relates to a hospital electing to be a qualified entity to make presumptive eligibility decisions.

(a) The Department shall limit the coverage groups for which a hospital may make a presumptive eligibility decision to the groups defined in Section 1920 (pregnant women, former foster care children, parents or caretaker relatives), Section 1920A (children under 19 years of age) and 1920 B (breast and cervical cancer patients but only Centers for Disease Control provider hospitals can do presumptive eligibility for this group) of the Social Security Act, January 1, 2013.

(b) A hospital must enter into a memorandum of agreement with the Department to be a qualified entity and receive training on policy and procedures.

(c) The hospital shall cooperate with the Department for audit and quality control reviews on presumptive eligibility determinations the hospital makes. The Department may terminate the agreement with the hospital if the hospital does not meet standards and quality requirements set by the Department.

(d) The eligibility agency may not count as income Veteran's Administration (VA) payments.

(e) The eligibility agency may not count as income child support payments.

(f) The eligibility agency may not count as income educational grants, loans, scholarships, fellowships, or gifts that a client uses to pay for education.

(g) The following coverage groups may only receive one presumptive eligibility period in a calendar year:

(i) Parents or caretaker relatives;

(ii) Children under 19 years of age;

(iii) Former foster care children; and

(iv) Individuals with breast or cervical cancer.

(h) The pregnant woman coverage group is limited to one presumptive eligibility period per pregnancy.

 

KEY: MAGI-based, coverage groups, former foster care youth, presumptive eligibility

Date of Enactment or Last Substantive Amendment: [January 1, ]2014

Notice of Continuation: January 23, 2013

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