DAR File No. 27216

Health, Health Care Financing, Coverage and Reimbursement Policy

R414-306

Program Benefits

NOTICE OF PROPOSED RULE

DAR File No.: 27216
Filed: 06/01/2004, 04:53
Received by: NL

RULE ANALYSIS

Purpose of the rule or reason for the change:

This amendment is necessary to remove language concerning the Qualifying Individuals Group 2 program because that program ended as required by federal statute. It is also necessary to modify the requirements on medical transportation, make certain clarifications about who can receive medical transportation, clarify when overnight expenses may be paid, and add provisions about the reimbursements for contracted medical transportation providers. It is also necessary to make certain changes to the effective date of eligibility provisions to make it clear that eligibility cannot begin before an individual meets the eligibility criteria. Some citations are also being updated.

Summary of the rule or change:

Section R414-306-2 removes language about the QI-2 program. Section R414-306-4 has the following changes: 1) a clarification that coverage in the retroactive period cannot begin before the individual meets all the eligibility criteria; 2) a modification that eligibility in the month of application will begin on the first day of that month unless the person did not become a state resident until after the first, or the individual was a qualified alien subject to the five-year bar for receipt of Medicaid services and that bar had not expired until some time after the first, or the individual became a qualified alien after the first and is not subject to the five-year bar; 3) a clarification of when a person approved for coverage may request coverage for the retroactive period associated with the approved application; and 4) QI language is referred to as QI-1 instead of QI. Section R414-306-6 has various changes to clarify the medical transportation provisions. These include: 1) a clarification of when non-emergency medical transportation is available; 2) a clarification that individuals who meet the criteria for specialized transportation can receive such services from the Medicaid transportation contractor, and that those who can use public para-transit services must use those services; 3) a limitation in transportation to pick up prescriptions to only when en route to or from a medical appointment; 4) a clarification of some of the provisions and requirements for receiving reimbursement for use of a personal vehicle and for overnight stay costs and a clarification that the amount of reimbursement is limited to the cost to go to the nearest appropriate provider; and 5) an addition of provisions for payments to Medicaid transportation contractors, and the requirements and limitations for using contracted services.

State statutory or constitutional authorization for this rule:

Section 26-18-3 and 42 CFR 435.914

42 CFR 440.240, 441.56, 431.625, 435.914, 431.52, 431.53, 2001 ed.; Subsection 1905(p), Section 1933, Subsection 1902(e)(8), and Subsection 1616(a) through (d) of the Social Security Act, 2001 ed.

Anticipated cost or savings to:

the state budget:

There is a total savings of $372,000 to the state budget; $104,000 is saved in the general fund while $268,000 is saved in federal dollars.

local governments:

There is no budget impact to local governments because only eligibility groups under Medicaid are impacted.

other persons:

There is a total cost of $372,000 to Medicaid recipients as a result of this rulemaking because the retroactive period has been reduced for some eligibility groups.

Compliance costs for affected persons:

The average client that does not receive Medicaid back to the first day of the month will incur an approximate one-time cost of $744.

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

Limiting retroactive eligibility to the day when a person meets eligibility criteria is fiscally appropriate for state funds. Scott D. Williams, MD

The full text of this rule may be inspected, during regular business hours, at the Division of Administrative Rules, or at:

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:

07/15/2004

This rule may become effective on:

07/16/2004

Authorized by:

Scott D. Williams, Executive Director

RULE TEXT

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

R414-306. Program Benefits.

R414-306-1. Medicaid Benefits.

(1) The Department adopts 42 CFR 440.240, 441.56, and 431.625, 1999 ed., which are incorporated by reference.

(2) The Department elects to coordinate Medicaid with Medicare Part B for all Medicaid recipients.

(3) The Department [of Health ]is responsible for defining emergency services which will be paid for by Medicaid for aliens who do not meet citizenship requirements for full Medicaid coverage. Emergency services include medical services given to prevent death or permanent disability. Emergency services do not include prenatal or postpartum services, prolonged medical support, long term care, or organ transplants. Prior authorization is required if the client applies for medical assistance before receiving medical services.

(4) Workers must inform applicants about the Child Health Evaluation and Care (CHEC) program. By signing the application form the client acknowledges receipt of CHEC program information.

R414-306-2. QMB, SLMB, and QI-1 Benefits.

(1) The [d]Department adopts Subsection 1905(p) and Section 1933 of the Compilation of the Social Security Laws, [1999]2001 ed., U.S. Government Printing Office, Washington, D.C., which is incorporated by reference.

(2) The Department [elects]does not [to ]cover premiums for enrollment with any health insurance plans except for Medicare.[

(3) Benefits covered by the Qualifying Individuals-Group 2 program will be received in the form of a refund check to the individual selected for coverage.]

R414-306-3. QMB and SLMB Date of Entitlement.

The Department adopts Subsection 1902(e)(8) of the Compilation of the Social Security Laws, [1999]2001 ed., U.S. Government Printing Office, Washington, D.C., which is incorporated by reference.

R414-306-4. Effective Date of Eligibility.

(1) The Department adopts 42 CFR 435.914, [2000]2001 ed., which is incorporated by reference.

(2) Eligibility for any Medicaid program, or the SLMB or QI-1 program, shall begin no earlier than the date that is three months before the date of application for benefits. Coverage shall not be effective on the first day of a month if that date is more than three months before the application date. Coverage in the months before the application month cannot begin before the date the applicant met the eligibility criteria.

(a) Institutional Medicaid shall begin on the date that the Department receives verification of nursing home admission from the nursing home, but no earlier than the date that is three months before the date of application for nursing home services.

(b) Eligibility under a Home and Community Based (HCB) Services waiver shall begin on the date the client is determined to meet the level-of-care criteria and home and community based services are scheduled to begin within the month, but no earlier than the date that is three months before the date of application for HCB services.

(c) Eligibility for benefits as a Qualifying Individual-Group 1 can begin no earlier than the date that is three months before the date of application and in no case before January 1, 1998. An individual selected to receive QI-1 benefits in a month of the year is entitled to receive such assistance for the remainder of the calendar year if the individual continues to be a qualifying individual and the program still exists. Receipt of QI-1 benefits in one calendar year does not entitle the individual to continued assistance in any succeeding year.

(3) Eligibility in the application month and on-going months shall begin on the first day of such month, except for

(a) an individual who just moved to Utah, in which case the effective date of eligibility of such individual cannot be earlier than the date that the individual meets the state residency requirement defined in R414-302-2; and

(b) an individual who is a qualified alien subject to the five-year bar on receiving regular Medicaid services, in which case eligibility cannot begin earlier than the date that is five years after the date the person became a qualified alien, or the date the five-year bar ends due to other events defined in statute.

(c) an individual who is a qualified alien not subject to the five-year bar on receiving regular Medicaid services, in which case eligibility cannot begin earlier than the date the individual's qualified alien status began.

([3]4) There is no provision for retroactive QMB assistance.

[(4) Institutional Medicaid shall begin on the date that the Department of Health receives verification of nursing home admission from the nursing home, but no earlier than the date that is three months before the date of application for nursing home services. Coverage shall not be effective on the first day of a month if that date is more than three months before the application date.

(5) Eligibility under a Home and Community Based Services waiver shall begin on the first day of the month in which the client meets the level-of-care criteria and home and community based services begin, but no earlier than the date that is three months before the date of application for waiver Medicaid services. Coverage for waiver Medicaid shall not be effective on the first day of a month if that date is more than three months before the application date.

(6) Eligibility for benefits as a Qualifying Individual can begin no more than the date that is three months before the date of application, and in no case before January 1, 1998. An individual selected to receive QI benefits in a month of the year is entitled to receive such assistance for the remainder of the calendar year if the individual continues to be a qualifying individual. Receipt of benefits as a qualifying individual in one calendar year does not entitle the individual to continued assistance in any succeeding year.](5) After being approved for Medicaid, a client may request retroactive coverage based on the date of the approved application, but only if the client had not previously requested the retroactive coverage, and had either been denied for such time period or had failed to meet a spenddown for such time period. The recipient must provide verifications needed to establish eligibility for the retroactive period being requested.

R414-306-5. Availability of Medical Services.

(1) The Department adopts 42 CFR 431.52, [1999]2001 ed., which is incorporated by reference.

(2) A person may receive medical services from an out-of-state provider if that provider accepts the Utah Medicaid reimbursement rate for the service.

(3) If a medical service requires prior approval for reimbursement in-state, the medical service will require prior approval if received out-of-state.

(4) If a person has a primary care provider, the person shall receive medical services from that provider, or obtain authorization from the primary care provider to receive medical services from another medical provider.

(5) If a person [has]is enrolled in a Medicaid Health [Maintenance Organization]Plan[ as a primary care provider], the person shall receive medical services from a provider within the Medicaid Health [Maintenance Organization]Plan's network, or obtain authorization from the Medicaid Health [Maintenance Organization]Plan or Utah Medicaid to receive medical services from an[other] out-of-network medical provider.

R414-306-6. Medical Transportation.

(1) The Department adopts 42 CFR 431.53, [1999]2001 ed., which is incorporated by reference.

(2) The following applies to all forms of non-emergency medical transportation including services provided by a contracted medical transportation provider and reimbursement for use of personal transportation.

(a) Non-emergency medical transportation is limited to transportation expenses to go to and from [a]the nearest appropriate Medicaid provider to obtain a Medicaid covered service that is medically necessary. If the recipient chooses to travel to a Medicaid provider that is not the nearest appropriate provider, reimbursement of mileage is limited to the distance to go to the nearest appropriate provider. The Department will not cover transportation expenses to go to non-Medicaid providers, or to obtain services not covered by the Medicaid plan.

(b) Non-emergency medical transportation is limited to individuals who are covered under the Traditional Medicaid benefit plan. Individuals covered by the Non-Traditional Medicaid plan, the Primary Care Network, the Covered-At-Work program, and Medicare Cost-Sharing programs are not eligible for non-emergency medical transportation.

([3]c) If transportation is available to a Traditional Medicaid recipient without cost to the recipient, the recipient[s] shall use this transportation. A Traditional Medicaid recipient who needs specialized transportation and who meets the criteria for the Medicaid transportation contractor services found in subsection (13) may receive transportation from the Medicaid transportation contractor.[Other modes of non-emergency medical transportation include bus passes, special bus services, personal transportation reimbursement, taxi service, non-specialized van transportation, and specialized van transportation. Recipients must use the most reasonable and economical mode of transportation available, or transportation shall not be reimbursed.

(a) Prior authorization is required for special bus services, taxi service, non-specialized van transportation, and specialized van transportation.

(b) Taxi service shall not be authorized for recipients who own a licensed vehicle, or who live in a household with a family member who owns a licensed vehicle, unless the recipient verifies that the nature of the recipient's medical condition or disability makes driving inadvisable and there is no household member who can drive the recipient to and from medical appointments. In the case of an urgent medical care need, if the recipient has no other way of getting needed care, Department staff may authorize taxi service when it is a reasonable and safe mode of transportation.]

(d) A Traditional Medicaid recipient who has access to and is able to use public transportation to get to medical appointments may receive a bus pass upon request. The bus pass may be used to pay the fare for an attendant who accompanies a recipient under age 18 or a recipient who has a medical need for an attendant. A recipient who has access to and is capable of using public paratransit services can request authorization to use such transportation. The recipient must follow procedures and meet criteria required by the paratransit provider.

(e) Transportation for picking up prescriptions is not covered unless en route to or from a medical appointment.

(f) The Department will not provide non-emergency medical transportation to nursing home residents because the nursing home must provide the transportation as part of its contracted rate.

(g) The Department will not provide non-emergency medical transportation to and from mental health appointments for recipients covered by a prepaid Mental Health Plan because the prepaid Mental Health Plan must provide transportation, as part of its contracted rate, to recipients to obtain covered mental health services.

(h) If medical services are not available in-state, a Traditional Medicaid recipient must receive prior authorization from the Department for the services and the transportation. If the services and the transportation are approved, the Department shall determine, at its discretion, the most cost effective and appropriate transportation, and method of payment for the transportation.

([c]3) [When]If personal transportation is used[,] and it is the most reasonable and economical mode of transportation available, the local office shall reimburse actual mileage at the rate of $0.18 per mile. The Department may deny reimbursement for multiple trips in a day unless the client can demonstrate why multiple trips were necessary. Total reimbursement for mileage must not exceed $150.00 a month per household, unless:

([i]a) an eligibility worker determines that higher reimbursement is necessary because a recipient's medical condition requires frequent travel to a Medicaid provider to obtain Medicaid covered services that are medically necessary; or

([ii]b) an eligibility worker or supervisor determines that higher reimbursement is necessary because a recipient had an unusual medical need in a given month that required frequent or long-distance travel to a Medicaid provider to obtain Medicaid covered services that were medically necessary.

([d]4) The local office supervisor can authorize advance payment for use of personal transportation, overnight stay costs, or both, if the provider verifies the medical appointment, and the client would be unable to obtain the necessary medical services without an advance. The recipient is responsible to repay an advance if the recipient does not provide verification of travel expenses equal to or greater than the amount of funds advanced within 10 days after returning from the scheduled appointment.[

(4) If a State agency or non-profit organization provides transportation, the only reimbursement will be for actual costs or billed charges.]

(5) Transportation reimbursement for use of a personal vehicle may be made to the recipient, to a second party, or to the recipient and second party jointly.

(6) If more than one Traditional Medicaid recipients travel together in a personal vehicle, reimbursement shall be made to only one recipient, or to the driver, and only for the actual miles traveled.[

(7) The Department will not provide non-emergency medical transportation to nursing home residents because the nursing home must provide the transportation as part of its contracted rate.

(8) The Department will not provide non-emergency medical transportation to and from mental health appointments for recipients covered by a prepaid Mental Health Plan because the prepaid Mental Health Plan must provide transportation, as part of its contracted rate, to recipients to obtain covered mental health services.]

([9]7) If medical services are not available locally, a Traditional Medicaid recipient may be reimbursed for transportation to obtain medical services outside of the recipient's local area. If the closest medical provider is out-of-state, a recipient may be reimbursed for transportation to the out-of-state provider if this travel is more cost effective than traveling to an in-state provider. The medical provider's office must verify that the recipient needs to travel outside the local area for medical services, unless:

(a) there are no Medicaid providers in the local area who can provide the services; or

(b) it is the custom in the local area to obtain medical services outside the local area or in neighboring states.[

(10) If medical services are not available in-state, a recipient must receive prior authorization from Department to be reimbursed for transportation to obtain the medical services out-of-state.]

([11]8) A Traditional Medicaid recipient who receives medical treatment outside of the recipient's local area may receive reimbursement for lodging costs when staying overnight, if:

(a) the recipient is obtaining a Medicaid covered service that is medically necessary from the nearest Medicaid provider that can treat the recipient's medical condition; and

(b) the recipient must travel over 100 miles to obtain the medical treatment and would not arrive home before 8:00 p.m. due to the drive time; [or]

(c) the recipient must travel over 100 miles to obtain the medical treatment and would have to leave home before 6:30 a.m. due to drive time to arrive at the scheduled appointment; or

([c]d) the medical treatment requires an overnight stay.

([12]9) The Department shall reimburse actual lodging and food costs or $50.00 per night, whichever is less. Reimbursement for food costs shall be no more than $25 of the $50 overnight reimbursement rate.

(10) If a recipient has a medical need to stay more than two nights to receive medical services, the recipient must obtain approval from the Department before expenses for additional nights can be reimbursed.

([13]11) If a recipient has a medical need for a companion or attendant when traveling outside of the recipient's local area, and the recipient is not staying in a medical facility, lodging costs for the companion or attendant may be reimbursed according to the rate specified in subsection ([12]9). The reimbursement may also include salary if the attendant is not a member of the recipient's family, but not for standby time. One parent or guardian may qualify as an attendant if the parent or guardian must receive medical instructions to meet the recipient's needs, or the recipient is a minor child.

([14]12) Reimbursements for personal transportation shall not be made for trips made more than 12 months before the month the client requests reimbursement, with one exception. If a client is granted coverage for months more than one year prior to the eligibility decision, the client may request reimbursement and provide verification for personal transportation costs incurred during those months. In this case, the client must make the request and provide verification within three months after receiving the eligibility decision.

(13) Reimbursement for fee-for-service providers:

(a) Payments for Medical transportation are based on the established fee schedule unless a lower amount is billed. The amount billed cannot exceed usual and customary charges to private pay patients.

(b) Fees are established using the methodology as described in the State Plan, Attachment 4.19-B Section R, Transportation.

(14) Medical Transportation under a Section 1915(b) waiver using a transportation contractor:

(a) Non-emergency medical transportation will be provided by a contracted transportation provider. The contractor provides non-emergency medical transportation services statewide, either as the primary provider or through a subcontractor. Transportation service under the waiver do not include bus passes and paratransit services by a public carrier, such as Flextrans.

(b) Prior authorization is required for all transportation services provided through the contractor.

(c) If the medical service is not available within the state, or the nearest Medicaid provider is outside the state, medical transportation to services outside of Utah is covered up to 120 ground travel miles one-way outside of the Utah border. The ride must originate or end within Utah borders. Non-emergency transportation originating and ending outside of Utah is not covered.

(d) A recipient is not eligible for non-emergency medical transportation services if the recipient owns a licensed vehicle or lives in a residence with a family member who owns a licensed vehicle, unless a physician verifies that the nature of the recipient's medical condition or disability makes driving inadvisable and there is no family member physically able to drive the recipient to and from medical appointments.

(e) A recipient is not eligible for non-emergency medical transportation services if public transportation is available in the recipient's area, unless the public transportation is inappropriate for the recipient's medical or mental condition as certified by a physician.

(f) A recipient is not eligible for non-emergency medical transportation services if parartransit services such as Flextrans are available in the recipient's area, unless the recipient's medical condition requires door to door services due to physical inability to get from the curb or parking lot to the medical provider's facility. This inability must be certified by a physician. To be eligible for transportation under the waiver, the recipient must receive a denial of services letter from Flextrans or other paratransit services.

(g) Transportation for urgent care services is provided under the provisions of items (d), (e) and (f) above and will be provided within 24 hours of request. Urgent care is defined as non-emergency medical care which is considered by the prudent lay person as medically safe to wait for medical attention within the next 24 hours.

R414-306-7. State Supplemental Payments for Institutionalized SSI Recipients.

(1) The Department adopts Subsection 1616(a) through (d) of the Compilation of the Social Security Laws, [1993]2001 ed., U.S. Government Printing Office, Washington, D.C., which is incorporated by reference.

(2) A State Supplemental payment equal to $15 shall be paid to a resident of a medical institution who receives a Supplemental Security Income (SSI) payment.

(3) Recipients must be eligible for Medicaid benefits to receive the State Supplemental payment.

(4) Recipients are eligible to receive the $15 State Supplemental payment beginning with the first month that their SSI assistance is reduced to $30 a month because they stay in an institution and they are eligible for Medicaid.

(5) The State Supplemental payment terminates effective the month the recipient no longer meets the eligibility criteria for receiving such supplemental payment.

KEY: program benefits, medical transportation

[November 1, 2001]2004

Notice of Continuation January 31, 2003

26-18

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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 (801-538-3764). Please Note: The Division of Administrative Rules is NOT able to answer questions about the content or application of these administrative rules.