DAR File No. 43708

Health, Health Care Financing, Coverage and Reimbursement Policy

Rule R414-312

Adult Expansion Medicaid

Notice of 120-Day (Emergency) Rule

DAR File No.: 43708
Filed: 05/07/2019 03:49:35 PM

RULE ANALYSIS

Purpose of the rule or reason for the change:

The purpose of this new rule is to implement provisions of Medicaid expansion set forth in S.B. 96 passed during the 2019 General Session.

Summary of the rule or change:

This rule expands coverage to adults who are 19 through 64 years of age and meet basic Medicaid eligibility criteria.

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: With recent federal approval of the Primary Care Network 1115 Demonstration Waiver, the Department of Health (Department) needs to implement provisions for Medicaid expansion, which began 04/01/2019. These provisions include coverage and eligibility for the Adult Expansion Medicaid Program.

Statutory or constitutional authorization for this rule:

• Section 26-1-5
• Section 26-18-415
• Section 26-18-3

Anticipated cost or savings to:

the state budget:

There is an expected annual cost of $435,800,000 in which up to 90,000 individuals may become eligible for adult Medicaid coverage. This fiscal analysis also applies to the companion filings for Rule R414-303 and Section R414-311-6. (EDITOR'S NOTE: The 120-day (emergency) filing for Rule R414-303 is under Filing No. 43706 and the 120-day (emergency) filing for Section R414-311-6 is under Filing No. 43707 in this issue, June 1, 2019, of the Bulletin.)

local governments:

There is no impact on local governments because they neither fund nor provide services under the Medicaid program. This fiscal analysis also applies to the companion filings for Rule R414-303 and Section R414-311-6.

small businesses:

Small businesses may see a share of revenue up to $435,800,000 with the expansion of adult Medicaid coverage, in which up to 90,000 individuals may become eligible. This fiscal analysis also applies to the companion filings for Rule R414-303 and Section R414-311-6.

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

Medicaid providers may see a share of revenue up to $435,800,000 with the expansion of adult Medicaid coverage, and up to 90,000 individuals will see a share of out-of-pocket savings based on that amount. This fiscal analysis also applies to the companion filings for Rule R414-303 and Section R414-311-6.

Compliance costs for affected persons:

There are no compliance costs because this rule can only result in increased revenue and out-of-pocket savings. This fiscal analysis also applies to the companion filings for Rule R414-303 and Section R414-311-6.

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

Businesses will see a share of revenue through Medicaid expansion to a larger group of adults.

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

This rule is effective on:

05/07/2019

Authorized by:

Joseph Miner, Executive Director

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

R414-312. Adult Expansion Medicaid.

R414-312-1. Introduction and Authority.

(1) This rule is authorized by Sections 26-1-5 and 26-18-3 and allowed under Subsection 1115(f) of the Social Security Act.

(2) This rule establishes eligibility requirements for enrollment under the Primary Care Network 1115 Demonstration Waiver for Adults, also known as the Adult Expansion Medicaid program.

 

R414-312-2. Definitions.

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

 

R414-312-3. General Provisions.

The provisions in Rule R414-301 apply to all applicants and enrollees.

 

R414-312-4. General Eligibility Requirements.

Unless otherwise stated, the provisions in Rule R414-302 and Section R414-306-4 apply to all applicants and enrollees.

(1) The following individuals are not eligible for Adult Expansion Medicaid:

(a) Individuals eligible for any Medicaid program without a spenddown; or

(b) Individuals eligible for or receiving Medicare.

(2) An individual must be at least 19 years old and not yet 65 years old to enroll in Adult Expansion Medicaid.

(a) The month in which an individual turns 19 years old is the first month in which the individual may enroll in Adult Expansion Medicaid.

(b) An individual may only enroll in Adult Expansion Medicaid through the month in which the individual turns 65 years old.

(3) The eligibility agency may only enroll applicants during an open enrollment period. The Department may limit the number it enrolls and may stop enrollment at any time.

(4) The eligibility agency shall waive the open enrollment requirement if the enrollee completes a review within three months of case closure as outlined in Section R414-308-6.

(5) A resource test is not required.

 

R414-312-5. Application, Eligibility Reviews, and Improper Medical Assistance.

The provisions of Rule R414-308 apply to all applicants and enrollees.

 

R414-312-6. Household Composition and Income Provisions.

(1) The eligibility agency shall use the provisions of Section R414-304-5 to determine household composition and countable income.

(2) Section R414-304-12 applies to the budgeting of income through the Modified Adjusted Gross Income (MAGI) methodology.

(3) For an individual to be eligible to enroll in Adult Expansion Medicaid, the individual must have countable income at or below 95% of the federal poverty level (FPL).

 

KEY: Medicaid, adult expansion, eligibility

Date of Enactment or Last Substantive Amendment: May 7, 2019

Authorizing, and Implemented or Interpreted Law: 26-18