DAR File No. 41213

Health, Health Care Financing, Coverage and Reimbursement Policy

Section R414-310-13

Change Reporting and Benefit Changes

Notice of Proposed Rule

(Amendment)

DAR File No.: 41213
Filed: 01/26/2017 08:14:31 AM

RULE ANALYSIS

Purpose of the rule or reason for the change:

The purpose of this change is to clarify the process for when a client reports a change in circumstances that affects Primary Care Network (PCN) eligibility.

Summary of the rule or change:

This amendment clarifies how to handle a reported change when the income has already been anticipated in a best estimate.

Statutory or constitutional authorization for this rule:

• Section 26-1-5
• Pub. L. No. 111-148
• Section 26-18-3

Anticipated cost or savings to:

the state budget:

There is no impact to the state budget because this amendment only clarifies procedures for when a client reports changes in circumstances that affect PCN eligibility. It neither affects PCN services nor provider reimbursement.

local governments:

There is no impact to local governments because they neither fund PCN services nor make eligibility determinations for the PCN program.

small businesses:

There is no impact to small businesses because this amendment only clarifies procedures for when a client reports changes in circumstances that affect PCN eligibility. It neither affects PCN services nor provider reimbursement.

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

There is no impact to PCN providers and to PCN recipients because this amendment only clarifies procedures for when a client reports changes in circumstances that affect PCN eligibility. It neither affects PCN services nor provider reimbursement.

Compliance costs for affected persons:

There is no impact to a single PCN provider or to a PCN recipient because this amendment only clarifies procedures for when a client reports changes in circumstances that affect PCN eligibility. It neither affects PCN services nor provider reimbursement.

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

There is no fiscal impact on business because it does not affect the covered services or provider reimbursement.

Joseph K. Miner, MD, Executive Director

The full text of this rule may be inspected, during regular business hours, at the Office 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:

03/17/2017

This rule may become effective on:

03/24/2017

Authorized by:

Joseph Miner, Executive Director

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

R414-310. Medicaid Primary Care Network Demonstration Waiver.

R414-310-13. Change Reporting and Benefit Changes.

(1) Unless otherwise stated, the provisions in Section R414-308-7 apply to the PCN program.[Enrollees are required to report changes defined in Subsection R414-310-3(2) to the eligibility agency.

(a) The eligibility agency shall determine the effect of the change and make the appropriate change in the enrollee's eligibility.

(b) The eligibility agency shall send proper notice of changes in eligibility.

(2) An enrollee who fails to report changes or return verification timely must repay any overpayment of benefits for which the enrollee is not eligible to receive.]

(2) Reportable changes are defined in Subsection R414-310-3(2).

(3) For a decrease in income, the following provisions apply:

(a) If a change is already anticipated in a best estimate of income, the eligibility agency may only re-determine eligibility if the enrollee requests a redetermination of benefits.

(b) If a change is not anticipated, the agency shall re-determine eligibility.

(c) If a change makes the enrollee eligible for Medicaid, the effective date of the change is the first day of the month of report, if the change is verified timely.

(d) If a change is not verified timely, the change is effective on the first day of the month the change is verified.

( 4[3]) If an enrollee requests enrollment for a spouse, the application date for the spouse is the date of the request[.], and the following provisions apply:

(a) [A new application form is not required]The eligibility agency does not require a new application[.];

(b) [The eligibility of the spouse is determined according to]Eligibility is determined in accordance with Section R414-310-11[.];

(c) [The eligibility agency shall determine t]The effective date of enrollment [for the individual]is determined in accordance with Section R414-310-12[.]; and

(d) The applicant must meet [A]all other eligibility requirements[must be met].

[(4) If the eligibility agency requests verification of a reported change and the enrollee fails to return the verification by the due date, the eligibility agency shall end eligibility effective the end of the month in which the agency sends proper notice.]

 

KEY: Medicaid, primary care, demonstration

Date of Enactment or Last Substantive Amendment: [June 28, 2016]2017

Notice of Continuation: June 4, 2012

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