DAR File No. 27902

Health, Health Care Financing, Coverage and Reimbursement Policy

R414-301

Medicaid General Provisions

NOTICE OF PROPOSED RULE

DAR File No.: 27902
Filed: 05/13/2005, 04:30
Received by: NL

RULE ANALYSIS

Purpose of the rule or reason for the change:

This rulemaking is to add a definition to the list of definitions used in Rules R414-301 through R414-308. It is also needed to correct a reference to a provision in Rule R414-308 which is being changed. Some clarifying language has been added to better explain the interaction between an agency conference and the fair hearing process.

Summary of the rule or change:

This rule adds a definition in Section R414-301-2. It also adds clarifications to the definitions of Qualified Individuals Group 1 (QI-1), Qualified Medicare Beneficiary (QMB), and Specified Low-Income Medicare Beneficiary (SLMB) to say that these are Medicare Cost-Sharing programs rather than Medicaid programs. In Section R414-301-5, the reference to a provision in Rule R414-308 is being corrected because Rule R414-308 is being changed. Also, clarifying language is being added in this section to better explain the interaction between an agency conference and the fair hearing process.

State statutory or constitutional authorization for this rule:

Title 26, Chapter 18

Anticipated cost or savings to:

the state budget:

There are no costs or savings to the state because this just adds a definition, corrects a reference to another rule, and clarifies provisions for agency conferences.

local governments:

There is no impact on local governments because this just adds a definition, corrects a reference to another rule, and clarifies provisions for agency conferences.

other persons:

There are no costs or savings to other persons because this just adds a definition, corrects a reference to another rule, and clarifies provisions for agency conferences.

Compliance costs for affected persons:

There are no compliance costs because this rulemaking just adds a definition, corrects a reference to another rule, and clarifies provisions for agency conferences.

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

It does not appear that this housekeeping change to the rule will have any fiscal impact. A. Richard Melton, Acting Executive Director

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:

Ross Martin at the above address, by phone at 801-538-6592, by FAX at 801-538-6099, or by Internet E-mail at rmartin@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:

07/01/2005

This rule may become effective on:

07/02/2005

Authorized by:

Richard Melton, Deputy Director

RULE TEXT

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

R414-301. Medicaid General Provisions.

R414-301-2. Definitions.

The following definitions apply in rules R414-301 through R414-308:

(1) "Agency" means any local office or outreach location of either the Department of Health or the Department of Workforce Services that accepts and processes applications for Medicaid and Medicare Cost-Sharing programs. In incorporated federal materials, "agency" means the Utah Department of Health.

([1]2) "Applicant" means any person requesting assistance under any of the programs listed in R414-301.

([2]3) "Assistance" means medical assistance under any of the programs listed in R414-301.

([3]4) "CHEC" means Child Health Evaluation and Care.

([4]5) "Client" means an applicant or recipient of any of the programs listed in R414-301.

([5]6) "Department" means the Department of Health.

([6]7) "Director" or "designee" means the director or designee of the Division of Health Care Financing.

([7]8) "Local" office means any community office location of the Department of Workforce Services, the Department of Human Services or the Department of Health where an individual may apply for medical assistance programs.

([8]9) "Outreach location" means any site other than a state office where state workers are located to accept applications for medical assistance programs. Locations include sites such as hospitals, clinics, homeless shelters, etc.

([9]10) "QI-1" means the Qualifying Individuals Group 1 program, a Medicare Cost-Sharing program.

([10]11) "QMB" means Qualified Medicare Beneficiary program, a Medicare Cost-Sharing program.

([11]12) "Recipient" means any individual receiving assistance under any of the programs listed in R414-301-1. It may also be used to mean someone who is receiving other assistance or benefits such as SSI, in which case the text will specify such other type of benefit or assistance.

([12]13) "Reportable change" means any change in circumstances which could affect a client's eligibility for Medicaid, including:

(a) change in the source of income;

(b) change of more than $25 in gross income;

(c) changes in household size;

(d) changes in residence;

(e) gain of a vehicle;

(f) change in resources;

(g) change of more than $25 in total allowable deductions;

(h) changes in marital status, deprivation, or living arrangements;

(i) pregnancy or termination of a pregnancy;

(j) onset of a disabling condition; and

(k) change in health insurance coverage including changes in the cost of coverage.

([13]14) "Resident of a medical institution" means a single client who is a resident of a medical institution from the month after entry into a medical institution until the month prior to discharge from the institution. Death in a medical institution is not considered a discharge from the institution and does not change the client's status as a resident of the medical institution. Married clients are residents of an institution in the month of entry into the institution and in the month they leave the institution.

([14]15) "SLMB" means Specified Low-Income Medicare Beneficiary program, a Medicare Cost-Sharing program.

([15]16) "Spenddown" means an amount of income in excess of the allowable income standard that must be paid in cash to the department or incurred through the medical services not paid by Medicaid, or some combination of these.

([16]17) "Spouse" means any individual who has been married to a client or recipient and has not legally terminated the marriage.

([17]18) "Worker" means a state employee who determines eligibility for Medicaid and Medicare Cost-Sharing programs.

R414-301-5. Complaints and Agency Conferences.

(1) A client may request an agency conference at any time to resolve a problem regarding the client's case. Requests shall be granted at the department's discretion. Clients may have an authorized representative attend the agency conference.

(2) Requesting an agency conference does not prevent a client from also requesting a fair hearing in the event the agency conference does not resolve the client's concerns.

(3) Having an agency conference does not extend the time period in which a client has to request a fair hearing. The client must request a fair hearing within 90 days of the date on the notice with which the client disagrees to assure the right to have a fair hearing if the client is not satisfied with the outcome of the agency conference.

(4) There is no appeal to the decisions made during an agency conference; however, if the client is not satisfied with the results of the agency conference, and makes a timely request for a fair hearing as defined in R414-306-6, the client may proceed with the formal fair hearing process.

(5) The department [must ]provides proper notice as defined in R414-308-[802]5 [of]if there are any additional adverse changes in the client's eligibility that are made as a result of the agency conference. The client then has a right to request a fair hearing based on the new decision letter of an additional adverse action.

KEY: client rights, Medicaid

[September 9, ]200[3]5

Notice of Continuation January 31, 2003

26-18

ADDITIONAL INFORMATION

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For questions regarding the content or application of this rule, please contact Ross Martin at the above address, by phone at 801-538-6592, by FAX at 801-538-6099, or by Internet E-mail at rmartin@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.