Utah Administrative Code

The Utah Administrative Code is the body of all effective administrative rules as compiled and organized by the Division of Administrative Rules (see Subsection 63G-3-102(5); see also Sections 63G-3-701 and 702).

NOTE: For a list of rules that have been made effective since April 1, 2019, please see the codification segue page.

NOTE TO RULEFILING AGENCIES: Use the RTF version for submitting rule changes.


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

Rule R414-520. Admission Criteria for Medically Complex Children's Waiver.

As in effect on April 1, 2019

Table of Contents

R414-520-1. Introduction and Authority.

(1) This rule outlines the criteria used to evaluate initial and ongoing eligibility for the Medically Complex Children's Waiver.

(2) This rule is authorized by Section 26-18-3. Waiver services are optional and provided in accordance with 42 CFR 440.225.

R414-520-2. Definitions.

(1) "Waiver" means the Medically Complex Children's Waiver.

R414-520-3. Eligibility Requirements.

(1) The Department uses the following criteria to determine waiver eligibility:

(a) An assessment of a child's ability to perform age-appropriate activities of daily living and that child's level of independence in the performance of the activity; and

(b) An evaluation to determine whether a child meets nursing facility level of care in accordance with Section R414-502-3.

(2) For a child who meets the criteria in Subsection R414-520-3(1), a point value is attributed to the initial application and annual re-evaluation that includes the following:

(a) Current medical providers;

(b) Condition or diagnosis;

(c) Date of last medical visit;

(d) Documentation of more than three months of dependence on medical devices, treatments, therapies, or subspecialty services to reach a minimum medical score; and

(e) An evaluation of the impact on the parents or guardians who have provided care to the medically complex child during the last 12 months.

R414-520-4. Waiver Access.

(1) The Department periodically assesses funding for the waiver to determine the number of children who may be served. It also derives a point value associated with the criteria found in Subsection R414-520-3(2)(d) through (e) to determine which children to enroll. In the event of multiple applications with the same point value, the Department will use the point value derived from Subsection R414-520-3(2)(d) to make its determination. In the event of multiple applications with the same point value derived from Subsection R414-520-3(2)(d), the Department will create a randomized list to determine which children are served.

(2) An applicant who is not admitted to the waiver, or a child who is disenrolled from the waiver, may appeal the decision in accordance with 42 CFR 431, Subpart E.

R414-520-5. Service Coverage.

Services and limitations are found in the State Implementation Plan for the Medically Complex Children's Waiver.

KEY

Medicaid

Date of Enactment or Last Substantive Amendment

January 4, 2019

Authorizing, Implemented, or Interpreted Law

26-1-5; 26-18-3; 26-18-410


Additional Information

Contact

For questions regarding the content or application of rules under Title R414, please contact the promulgating agency (Health, Health Care Financing, Coverage and Reimbursement Policy). A list of agencies with links to their homepages is available at http://www.utah.gov/government/agencylist.html or from http://www.rules.utah.gov/contact/agencycontacts.htm.