DAR File No. 27378

Health, Health Care Financing, Coverage and Reimbursement Policy

R414-303

Coverage Groups

NOTICE OF PROPOSED RULE

DAR File No.: 27378
Filed: 08/30/2004, 05:22
Received by: NL

RULE ANALYSIS

Purpose of the rule or reason for the change:

This rulemaking is needed to change the eligibility criteria for the Family Medicaid program so that a family receiving financial assistance under the Temporary Assistance to Needy Families (TANF) (called the Family Employment Program (FEP) in Utah) will no longer automatically qualify for medical assistance under 1931 Family Medicaid. Families receiving financial assistance will need to meet the same eligibility criteria for 1931 Family Medicaid assistance as families who do not receive financial assistance. It also modifies the income deductions for specified relatives to match those allowed for other Family Medicaid households, including a deduction for the cost of caring for an incapacitated spouse to the because this deduction was missed for specified relatives when it was added for Family Medicaid in a recent change under R414-304. These changes will result in the same eligibility criteria being applied to all households for Family Medicaid.

Summary of the rule or change:

The changes include: 1) in Section R414-303-4, added a new Subsection R414-303-4(1) to state that this section pertains to eligibility for Family Medicaid programs and the other subsections are renumbered accordingly; 2) the old Subsection R414-303-4(2) is removed because these definitions are no longer needed, and the old Subsections R414-303-4(4) and R414-303-4(6) are removed because receipt of a cash payment under FEP or under the FEP Diversion program is no longer an automatic way of receiving eligibility for 1931 Family Medicaid; 3) the new Subsection R414-303-4(3) has been modified to more clearly define the eligibility criteria required for coverage under the 1931 Family Medicaid coverage group. The old R414-303-4(7)(c) is removed as it is not needed in this rule, the requirements for duty of support are covered in Rule R414-302, and the other subsections are renumbered accordingly; 4) in the new Subsection R414-303-4(4)(d), the terms "FEP household" and "FEP" are being removed to comply with the change in policy about eligibility for 1931 Family Medicaid, and the new Subsection R414-303-4(4)(g) is modified to make the income deductions to determine eligibility for a specified relative the same as they are for other Family Medicaid households, including a deduction for the cost of providing care for an incapacitated spouse of the specified relative which was added to a recent rule change in Rule R414-304, but did not get added in this rule at the same time; and 5) in the old Subsection R414-303-5(2), language about FEP or FEP diversion eligible households receiving Transitional Medicaid when their cash assistance ends is being removed. If households receiving cash assistance meet the regular eligibility criteria for 1931 Family Medicaid, they can receive Transitional Medicaid in the same manner as any other 1931 Family Medicaid eligible household. (DAR NOTE: The proposed amendment to Rule R414-304 is under DAR No. 27379 in this issue.)

State statutory or constitutional authorization for this rule:

Title 26, Chapter 18

Anticipated cost or savings to:

the state budget:

A savings of $157,920 of which $113,702 is federal funds and $44,218 is state funds will be realized. This estimate could be less if these individuals can meet a spenddown to become eligible, qualify for a different Medicaid program, or enroll in the Primary Care Network.

local governments:

Local governments are not affected by this rulemaking as this only affects eligibility for individuals.

other persons:

It is difficult to estimate the aggregate costs to the group of about 40 families who may not be able to qualify for Medicaid because of this change. If they have no other medical coverage, their costs would be equal to whatever medical expenses they incur during the year. That total could be anything up to the $157,920 savings the Department anticipates or more.

Compliance costs for affected persons:

It is difficult to estimate the costs individuals (the members of about 40 families) may incur who are not able to qualify for Medicaid because of this change. If they have no other medical coverage, their costs would be equal to whatever medical expenses they incur during the year. Individual costs could be a prorated portion of anything up to the $157,987 savings the Department anticipates or more.

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

These changes are being made at the request of the Department of Workforce Services. This will improve the efficiency and flexibility of their eligibility determination processes. The consequence is that an estimated 40-50 adults that may lose Medicaid eligibility. This will have an impact on these individuals and on their health care provider lasting until these individuals can obtain employer-based health insurance. 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:

10/15/2004

This rule may become effective on:

10/16/2004

Authorized by:

Scott D. Williams, Executive Director

RULE TEXT

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

R414-303. Coverage Groups.

R414-303-4. Family Medicaid and Family Institutional Medicaid Coverage Groups.

(1) This section provides the eligibility criteria for Family Medicaid and Family Institutional Medicaid Coverage groups.

([1]2) The Department [shall] provides Medicaid coverage to individuals who are eligible as described in 42 CFR 435.110, 435.113 through 435.117, 435.119, 435.210 for groups defined under 201(a)(5) and (6), 435.211, 435.217, 435.223, and 435.300 through 435.310, 200[1]3 ed.[, and 45 CFR 233.90, 2001 ed.,] and Title XIX of the Social Security Act [as in effect January 1, 2001,] Sections 1902(e)(1), (4), (5), (6), (7), and 1931(a), (b), and (g) (1931 FM) in effect January 1, 2003, which are incorporated by reference.

[ (2) The following definitions apply to this rule:

(a) "1931 Family Medicaid" (1931 FM) means a medical assistance program that meets the criteria found in Section 1931(a) and (b) of the Social Security Act in effect January 1, 2001 that requires the Department to use the eligibility criteria of the pre-welfare reform Aid to Families With Dependent Children cash assistance program along with any subsequent amendments made by the Department as allowed under Section 1931 of the Act.

(b) "Family Employment Program" (FEP) means a grant program providing financial assistance to eligible families with dependent children. It is also referred to as Temporary Assistance to Needy Families (TANF).

(c) "Diversion" means a one time FEP payment that may equal up to three months of FEP cash assistance.

(3) The Department provides Medicaid coverage to individuals who are 1931 FM qualified, as described in 45 CFR 233.39, 233.90, and 233.100, 2001 ed., which are incorporated by reference.

(4) The Department provides 1931 Family Medicaid coverage to individuals who are qualified for FEP cash assistance.

] ([5]3) For unemployed two-parent households, the Department [shall]does not require the primary wage earner to have an employment history.

[ (6) Households that receive a FEP diversion payment shall have the option to receive 1931 Family Medicaid coverage for three months beginning with the month of application for the diversion payment.

] ([7]4) A specified relative, as that term is used in the provisions incorporated into this section, other than the child's parents, may apply for assistance for a child. In addition to other Family Medicaid requirements, all the following [rules apply]applies to a Family Medicaid application by a specified relative:

(a) The child must be currently deprived of support because both parents are absent from the home where the child lives.

(b) The child must be currently living with, not just visiting, the specified relative.

[ (c) The parents' obligation to financially support their child shall be enforced.

] ([d]c) The income and resources of the specified relative [will not be]are not counted unless the specified relative is also included in the Medicaid coverage group.

([e]d) If the specified relative is currently included in [a FEP household or ]a 1931 Family Medicaid household, the child [shall]must be included in the [FEP or ]1931 FM [case of]eligibility determination for the specified relative.

([f]e) The specified relative may choose to be excluded from the Medicaid coverage group. [T]If the specified relative chooses to be excluded from the Medicaid coverage group, the ineligible children of the specified relative must be excluded[. T] and the specified relative [will]is not [be ]included in the income standard calculation.

([g]f) The specified relative may choose to exclude any child from the Medicaid coverage group. If a child is excluded from coverage, that child's income and resources [will not be]are not used to determine eligibility or spenddown.

([h]g) If the specified relative is not the parent of a dependent child who meets deprivation of support criteria and elects to be included in the Medicaid coverage group, the following income [rules]provisions apply:

(i) The monthly gross earned income of the specified relative and spouse [shall be]is counted.

[ (ii) The unearned income of the relative and the excluded spouse shall be counted.

] (ii[i]) [For each employed person, ]$90 will be deducted from the monthly gross earned income for each employed person.

(iii) The $30 and 1/3 disregard is allowed from earned income for each employed person, as described in R414-304-6(4).

(iv) Child care expenses and the cost of providing care for an incapacitated spouse necessary for employment [will be]are deducted for only the specified relative's children, spouse, or both. The maximum allowable deduction will be $200.00 per child under age two, and $175.00 per child age two and older or incapacitated spouse each month for full-time employment. For part-time employment, the maximum deduction is[ or] $160.00 per child under age two, and $140.00 per child age two and older or incapacitated spouse each month[ for part-time employment].

(v) Unearned income of the specified relative and the excluded spouse that is not excluded income is counted.

(vi) Total countable earned and unearned income is divided by the number of family members living in the specified relative‛s household.

([8]5) An American Indian child in a boarding school and a child in a school for the deaf and blind are considered temporarily absent from the household.

([9]6) Temporary absence from the home for purposes of schooling, vacation, medical treatment, military service, or other temporary purpose shall not constitute non-resident status. The following situations do not meet the definition of absence for purposes of determining deprivation of support:

(a) parental absences caused solely by reason of employment, schooling, military service, or training;

(b) an absent parent who will return home to live within 30 days from the date of application;

(c) an absent parent is the primary child care provider for the children, and the child care is frequent enough that the children are not deprived of parental support, care, or guidance.

([10]7) Joint custody situations are evaluated based on the actual circumstances that exist for a dependent child. The same policy is applied in joint custody cases as is applied in other absent parent cases.

([11]8) The Department imposes no suitable home requirement.

([12]9) Medicaid assistance is not continued for a temporary period if deprivation of support no longer exists. If deprivation of support ends due to increased hours of employment of the primary wage earner, the household may qualify for Transitional Medicaid described in R414-303-5.

([13]10) Full-time employment nullifies a person's claim to incapacity. To claim an incapacity, a parent must meet one of the following criteria:

(a) receive SSI;

(b) be recognized as 100% disabled by the Veteran's Administration, or be determined disabled by the Medicaid Disability Review Office or the Social Security Administration;

(c) provide, either on a Department-approved form or in another written document, completed by one of the following licensed medical professionals: medical doctor; doctor of Osteopathy; Advanced Practice Registered Nurse; Physician's Assistant; or a mental health therapist, which includes a psychologist, Licensed Clinical Social Worker, Certified Social Worker, Marriage and Family Therapist, Professional Counselor, or MD, DO or APRN engaged in the practice of mental health therapy, that states the incapacity is expected to last at least 30 days. The medical report must also state that the incapacity will substantially reduce the parent's ability to work or care for the child.

R414-303-5. 12 Month Transitional Family Medicaid.

[(1) The Department complies with Title XIX of the Social Security Act, Sections 1925 and 1931 (c)(2) as in effect January 1, 2001, which are incorporated by reference.

(2) The Department shall consider Medicaid coverage under 12 month Transitional Medicaid for households that lose eligibility for 1931 Family Medicaid, FEP cash assistance, and households that receive 1931 Family Medicaid for three months because they received a FEP Diversion payment.]The Department covers households that lose eligibility for 1931 Family Medicaid, in accordance with the provisions of Title XIX of the Social Security Act, Sections 1925 and 1931 (c)(2).

KEY: income, coverage groups

2004

Notice of Continuation January 31, 2003

26-18-3

26-1-5

ADDITIONAL INFORMATION

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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.