DAR File No. 38818
This rule was published in the September 15, 2014, issue (Vol. 2014, No. 18) of the Utah State Bulletin.
Health, Health Care Financing, Coverage and Reimbursement Policy
Section R414-303-11
Presumptive Pregnant Woman and Child Medicaid
Notice of Proposed Rule
(Amendment)
DAR File No.: 38818
Filed: 08/26/2014 10:16:30 AM
RULE ANALYSIS
Purpose of the rule or reason for the change:
The purpose of this change is to discontinue Medicaid presumptive eligibility due to lack of enrollment.
Summary of the rule or change:
This amendment discontinues Medicaid presumptive eligibility for children who are under 19 years old.
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:
- Removes 78 FR 42303, published by Government Printing Office, 07/15/2013
- Adds 42 CFR 435.1110, published by Government Printing Office, 10/01/2013
- Updates 42 CFR 435.1103, published by Government Printing Office, 10/01/2013
- Adds 42 CFR 435.1101, published by Government Printing Office, 10/01/2013
Anticipated cost or savings to:
the state budget:
Discontinuation of this program results in only negligible savings to the state budget because only a handful of children enroll in the Presumptive Eligibility program each year.
local governments:
There is no impact to local governments because they do not fund or provide Medicaid services to Medicaid recipients.
small businesses:
Small businesses will see little to no financial impact because very few children have been enrolled in Medicaid as presumptively eligible, and a child who could have received presumptive eligibility may still apply for medical assistance. If such child is found eligible for Medicaid, providers will be able to receive payment for services.
persons other than small businesses, businesses, or local governmental entities:
This change will cause little to no financial impact on either providers or individuals because children who could have received presumptive eligibility may still apply for medical assistance, and if found eligible for Medicaid, the child will have coverage for medical expenses, and providers will be able to receive payment for services.
Compliance costs for affected persons:
This change will cause little to no financial impact on any single provider or individual because children who could have received presumptive eligibility may still apply for medical assistance, and if found eligible for Medicaid, the child will have coverage for medical expenses, and providers will be able to receive payment for services.
Comments by the department head on the fiscal impact the rule may have on businesses:
There will be no material impact on business because of the small number of individuals eligible under the program.
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:
HealthHealth 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:
10/15/2014
This rule may become effective on:
11/01/2014
Authorized by:
David Patton, Executive Director
RULE TEXT
R414. Health, Health Care Financing, Coverage and Reimbursement Policy.
R414-303. Coverage Groups.
R414-303-11. Presumptive
Eligibility for[Pregnant Woman and Child] Medicaid.
(1) The Department adopts and incorporates
by reference, the definitions found at 42 CFR 435.1101, and the provisions
found at 42 CFR 435.1103[2],
and 42 CFR 435.1110, October 1, 2013[2] ed., [and also adopts and incorporates by reference 78 FR
42303, ]in relation to
determinations of 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]whom the Department [has ]determine[d]s is qualified to make a determination of presumptive
eligibility for a pregnant woman and [that]who meets the criteria defined in Section 1920(b)(2) of the
Social Security Act. Covered provider also means a hospital that elects to be a
qualified entity under a memorandum of agreement with the
Department;
(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]6) A child determined presumptively eligible
who is under 19 years of age may receive presumptive
eligibility only through the [applicable period]end of the month after the presumptive determination date or
until the end of the month in which the child turns 19, whichever
occurs first.
([9]7)
An individual determined presumptively eligible for former
foster care children coverage may receive presumptive eligibility
only through the end of the month after the presumptive
determination date or until the end of the month in which the
individual turns 26 years old, whichever occurs first.[The Department adopts and incorporates by reference 42 CFR
435.1110, October 1, 2013 ed., which relates to a hospital electing
to be a qualified entity to make presumptive eligibility
decisions.]
([a]8) 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.
(
9[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.
(
10[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.
(11[d]) The
covered provider[eligibility agency] may not count as income the following:
(a) Veteran's Administration (VA) payments
;[.]
(
b[e]) [The eligibility agency may not count as income c]Child support payments; or[.]
(c[f]) [The eligibility agency may not count as income e]Educational grants, loans, scholarships, fellowships, or
gifts that a client uses to pay for education.
(12[g])
An individual found presumptively eligible for one of [T]the following coverage groups may only receive one
presumptive eligibility period in a calendar year:
(a[i]) Parents or caretaker relatives;
(b[ii]) Children under 19 years of age;
(c[iii]) Former foster care children; and
(d[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: [July 1, ]2014
Notice of Continuation: January 23, 2013
Authorizing, and Implemented or Interpreted Law: 26-18-3; 26-1-5
Additional Information
More information about a Notice of Proposed Rule is available online.
The Portable Document Format (PDF) version of the Bulletin is the official version. The PDF version of this issue is available at https://rules.utah.gov/publicat/bull-pdf/2014/b20140915.pdf. The HTML edition of the Bulletin is a convenience copy. Any discrepancy between the PDF version and HTML version is resolved in favor of the PDF version.
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For questions regarding the content or application of this rule, please contact 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. For questions about the rulemaking process, please contact the Division of Administrative Rules.