File No. 35100
This rule was published in the August 15, 2011, issue (Vol. 2011, No. 16) of the Utah State Bulletin.
Health, Health Care Financing, Coverage and Reimbursement Policy
Application, Eligibility Determinations and Improper Medical Assistance
Notice of Proposed Rule
DAR File No.: 35100
Filed: 08/01/2011 10:47:56 AM
Purpose of the rule or reason for the change:
The purpose of this change is to update and clarify periodic eligibility review, change reporting requirements, and procedures that address improper medical coverage for Medicaid recipients.
Summary of the rule or change:
This amendment clarifies the requirements for a Medicaid recipient to complete a periodic review for continued eligibility and specifies the responsibility of the recipient to provide necessary verifications. This amendment also clarifies that the agency cannot stop eligibility while it is making a redetermination decision, and must provide advance notice of an adverse action to comply with federal due process requirements. It further clarifies the eligibility time line for a recipient who must meet a spenddown or pay another type of fee to become eligible for medical assistance. In addition, this amendment clarifies what improper medical coverage is and what a client has to repay for this occurrence. Finally, this amendment clarifies the refund policy for Medicaid recipients.
State statutory or constitutional authorization for this rule:
- Section 26-18-3
- 42 CFR 435.919
- 42 CFR 435.911
- 42 CFR 435.916
This rule or change incorporates by reference the following material:
- Updates 42 CFR 435.911, published by Government Printing Office, 10/01/2010
- Removes 42 CFR 435.912, published by Government Printing Office, 10/01/2006
Anticipated cost or savings to:
the state budget:
The Department does not anticipate any impact to the state budget because Medicaid recipients whose medical assistance ends for failure to complete a review usually complete the review process during the next month and their medical assistance is reinstated.
There is no impact to local governments because they do not fund Medicaid services and do not determine Medicaid eligibility.
The Department does not anticipate any impact to small businesses because Medicaid recipients whose medical assistance ends for failure to complete a review usually complete the review process during the next month and their medical assistance is reinstated. In addition, this change does not impose new requirements on small businesses.
persons other than small businesses, businesses, or local governmental entities:
The Department does not anticipate any impact to Medicaid providers and to Medicaid recipients because recipients whose medical assistance ends for failure to complete a review usually complete the review process during the next month and their medical assistance is reinstated. In addition, this change does not impose new requirements on providers and does not reduce Medicaid coverage for recipients.
Compliance costs for affected persons:
The Department does not anticipate any costs to a single Medicaid provider or to a Medicaid recipient because a recipient whose medical assistance ends for failure to complete a review usually completes the review process during the next month and the recipient's medical assistance is reinstated. In addition, this change does not impose new requirements on a provider and does not reduce Medicaid coverage for a recipient.
Comments by the department head on the fiscal impact the rule may have on businesses:
No costs for business are expected as Medicaid recipients' cost-sharing duties are better clarified by this rule.
David Patton, PhD, Executive Director
The full text of this rule may be inspected, during regular business hours, at the Division of Administrative Rules, or at:Health
Health Care Financing, Coverage and Reimbursement Policy
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 firstname.lastname@example.org
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:
This rule may become effective on:
David Patton, Executive Director
R414. Health, Health Care Financing, Coverage and Reimbursement Policy.
R414-308. Application, Eligibility Determinations and Improper Medical Assistance.
R414-308-1. Authority and Purpose.
(1) This rule is authorized by 26-18-3.
This rule establishes] requirements for
medical assistance applications, eligibility decisions
, eligibility period, verifications, change
reporting, notification and improper medical assistance for the
(b) Qualified Medicare Beneficiaries;
(c) Specified Low-Income Medicare Beneficiaries; and
(d) Qualified Individuals.
(1) The definitions in R414-1 and R414-301 apply to this rule.
In addition, the following definitions apply[
-]of[ -] care" means the amount of income
an institutionalized individual must pay to the medical
facility for long-term care services based on the individual's
income and allowed deductions.
(b) "Re-certification" means the process of
periodically determining that an individual or household continues
to be eligible for medical assistance.]
R414-308-5. Eligibility Decisions or Withdrawal of an Application.
decides] the applicant[ 's]
[ eligibility] within the time limits established in 42 CFR
[ and 435.912, 2006] ed., which [ are] incorporated by reference.
s] the time limit if the applicant asks for more
time to provide requested information before the due date. The
give[ s] the applicant at least [ 10] more days after the original due date to provide
verifications upon [ request of] the applicant
agency [ can] allow a longer period of time for the [ client] to provide verifications if the
delay is due to circumstances
beyond the [ client]'s control[ , an emergency, a client illness or a similar
(3) An applicant may withdraw an
application for medical assistance any time before the
agency makes an eligibility decision on the
application. An individual requesting an assessment of assets for a
married couple under [
Section 1924 of the Social Security Act,]42 U.S.C.
1396r-5[ ,] may withdraw the request any time before the
agency [ has] complete[ d] the assessment.
R414-308-6. Eligibility Period and [
(1) The eligibility period begins on the effective date of eligibility as defined in R414-306-4, which may be after the first day of a month, subject to the following requirements.
(a) If a client must pay a spenddown, the agency completes
the eligibility process and grants eligibility when the agency
receives the required payment or proof of incurred medical expenses
equal to the required payment for the month or months, including
partial months, for which the client wants medical
assistance. (b) If a client must pay a Medicaid Work Incentive
premium, the agency completes the eligibility process and grants
eligibility when the agency receives the required payment for the
month or months, including partial months, for which the client
wants medical assistance.
(c) If a client must pay an asset co-payment for prenatal
coverage, the agency completes the eligibility process and grants
eligibility when the agency receives the required payment for the
period of prenatal coverage.
d]) The [ client] must make the payment or provide proof of medical
expenses[ , if applicable,] within 30 calendar days from the
mailing date of the
[ that tells] the [ client] [ the amount] owe[ d].
e]) For ongoing months of eligibility, the [ client] has until the close of business [ of] the [ 10]th day of the month after the benefit month to meet the
pay the [ Medicaid Work incentive] premium. If the [ 10]th day of the month is a non-business day, the [ client] has until the close of business on the first
business day after the [ 10]th[
to meet the spenddown or pay the premium].
f]) [ Residents who reside] in a long-term care facility and [ who] owe
a cost[ -] of[ -] care contribution to the medical facility must
pay the medical facility directly. The [ resident] may use unpaid past medical bills, or current
incurred medical bills other than the charges from the medical
facility, to meet some or all of the cost[ -] of[ -] care contribution subject to the limitations in
R414-304-9. [ The resident must pay any cost-of-care contribution not met
with allowable medical bills to the medical facility.] An
unpaid cost[ -] of[ -] care contribution is not allowed as a medical
bill to reduce the amount
the [ client] owes the facility.
[ N]o eligibility exists in a month for which the [ client] fails to meet a required spenddown
or fails to pay a required Medicaid Work
Eligibility for the [
Prenatal] program does not exist when
the [ client] fails to pay a required asset co[ -]payment[ for the Prenatal program].
(2) The eligibility period ends on:
(a) the last day of the [
b]) the last day of the month in which the recipient asks the
agency to discontinue eligibility
(c) the last day of the month the agency determines the
individual is no longer eligible;
d]) [ for the Prenatal program,] the last day of the
[ that] is at least 60 days after the date
the pregnancy ends, except that for [ Prenatal] coverage for emergency
services only, eligibility ends
the last day of the month in which the pregnancy ends;
e]) the date
the individual dies.
(3) Recipients must re-certify eligibility for medical
assistance at least once every 12 months. The agency may require
recipients to re-certify eligibility more frequently when the
agency: (a) receives information about changes in a
recipient's circumstances that may affect the recipient's
(b) has information about anticipated changes in a
recipient's circumstances that may affect eligibility;
(c) knows the recipient has fluctuating income.
(4) To receive medical assistance without interruption, a
recipient must complete the re-certification process by the close
of business on the date printed on the re-certification form. The
client must also provide verifications by the due date specified
by the agency and must continue to meet all eligibility criteria,
including meeting a spenddown or paying a Medicaid Work Incentive
premium if one is owed.
(a) If the recipient does not complete the
re-certification process on time, eligibility ends on the last
day of the re-certification month.
(b) If the recipient does not complete the
re-certification process on time, but completes the
recertification including providing verifications by the close of
business on the last business day of the month after the review
month, the agency will determine whether the recipient continues
to meet all eligibility criteria.
(i) The agency will reinstate benefits effective the
beginning of the month after the re-certification month if the
recipient continues to meet all eligibility criteria and meets
any spenddown or pays the Medicaid Work Incentive premium, if
applicable. The client must meet the spenddown or pay the premium
no later than the close of business on the 30th day after the
date printed on the notice. Otherwise, the recipient remains
ineligible for medical assistance.
(ii) If the recipient does not complete the
re-certification process before the close of business of the last
business day of the month following the re-certification month,
eligibility will not be reinstated. The recipient will have to
reapply for medical assistance.
(c) If the recipient does not meet the spenddown or pay
the Medicaid Work Incentive premium on time, then eligibility
ends effective the last day of the re-certification month and the
recipient will have to reapply.
5]) For individuals selected for coverage under the Qualified
Individuals Program, eligibility extends through the end of the
calendar year if the individual continues to meet eligibility
criteria and the program still exists.
R414-308-8. Case Closure and Redetermination.
terminates] medical assistance [ upon] recipient request
or [ if] the agency determines
the recipient is no longer eligible.
To maintain ongoing eligibility, a recipient must complete
the re-certification process as provided in R414-308-6. Failure to
complete the re-certification process makes the recipient
(3) Before terminating a recipient's
medical assistance, the
will] [ decide if] the [ client] is eligible for any other available medical
assistance provided under Medicaid, the Medicare Cost[ -] Sharing programs, the Children's Health
, the Primary Care Network
and [ the]
does] not require a recipient to complete a new application[ ,]
may request more information from the
recipient to [ complete the redetermination] for other
medical assistance programs. If the recipient does not provide the
necessary information by the close of business on the due date, the
recipient's medical assistance ends.
(b) When [
redetermining] eligibility for other programs, the
agency [ cannot] enroll an individual in a medical assistance
program [ that is not] [ in] an open enrollment period, [ unless] that program allows a person who becomes ineligible
for Medicaid to enroll during a period when enrollment[ s are stopped]
An open enrollment period is a time when the agency accepts
applications.] Open enrollment applies only to [ the Primary Care Network,] [ the] UPP [ P]rogram
[ and the Children's Health Insurance
R414-308-9. Improper Medical Coverage.
1]) As [ used] in this section, services and benefits include all
the Department pays on behalf of the [ client] during the period in question and includes
paid] to any Medicaid health plan[ s] or managed care plan[ s], Medicare,
and private insurance plans;
payments for prepaid mental health services; and
payments made directly to service providers or to the [
(2) A client must repay the cost of services and benefits
the client receives for which the client is not
a]) If the
a [ client] [ was] ineligible for the services [ or] benefits [ received], [ the client must repay the Department the amount the
Department paid for the services or benefits].
the [ client] must repay [ will be reduced] by the amount
the [ client paid] the
agency for a Medicaid spenddown
or a [ Medicaid Work Incentive] premium for the month.
If a [
woman] who [ has paid] an asset co[ -]payment for coverage under Prenatal Medicaid is
found to [ have been] ineligible for the entire period of coverage under
Prenatal Medicaid, the
amount [ she] must repay [ will be reduced] by the amount
[ paid] the agency in the form of the [ P]renatal asset co[ -]payment[ , if applicable].
b]) If the [ client] is eligible but the overpayment [ was] because the spenddown, the [ Medicaid Work Incentive] premium, the asset co[ -]payment for prenatal services, or the cost[ -] of[ -] care contribution [ was] incorrect, the [ client] must repay the difference between the correct
the [ client should have paid and]
[ what] the [ client actually] paid.
3]) A [ client] may request a refund from the Department [ for any month in which] the [ client] believes that
-]payment for prenatal services, or cost[ -] of [ -]care contribution
the [ client paid] to receive medical assistance is less than
what the Department [ paid] for medical services and benefits for the [ client,] or
(b) the amount
client paid] in the form of a spenddown, a [ Medicaid Work Incentive] premium, a cost[ -] of[ -]care contribution for long-term care services,
or an asset co[ -]payment for prenatal services [ was more than it should have been].
4]) Upon receiving the request[
for a refund], the Department [ will] determine [ if the client is owed] a refund.
(a) In the case of an incorrect
calculation of a spenddown, [
Medicare Work Incentive] premium, cost[ -] of[ -]care contribution
or asset co[ -]payment for [ prenatal] services, the refundable
amount is the difference between the incorrect amount
the [ client paid] the Department for medical assistance and
the correct amount that the [ client] should [ have paid], less the amount
the [ client] owes
the Department for any other past due, unpaid claims.
n the case when] the spenddown, asset co[ -]payment for [ prenatal] services
or a cost[ -] of[ -]care contribution for long-term care exceeds
medical expenditures, the refundable amount is the difference
between the correct spenddown, asset co[ -]payment
or cost[ -] of[ -] care contribution
the [ client paid] for medical assistance and the [ actual] amount
the Department [ paid] on behalf of the [ client] for services and benefits, less the amount
the [ client] owes
the Department for any other past due, unpaid claims. The
issue[ s] the refund only after the 12-month time[ -] period that medical providers have to submit
claims for payment.
(c) The [
agency does] not issue a cash refund for any portion of a
spenddown or cost[ -] of[ -]care contribution that [ was] met with medical bills.
5]) A [ client] who pays a premium for the [ Medicaid Work Incentive] program [ cannot] receive a refund even [ if] the
services [ paid by the Department] are less than the premium
the [ client] pays
6]) If the cost[ -] of[ -]care contribution
a [ client] pays a medical facility is more than the Medicaid
daily rate for the number of days
the [ client was] in the medical facility, the [ client can] request a refund from the medical facility.
The Department [ will] refund the amount
owe[ d] the [ client] only [ if] the medical facility [ has sent] the excess cost[ -]of[ -] care contribution to the Department.
7]) If the sponsor of an alien does not provide correct
information, the alien and the alien's sponsor are jointly
liable for any overpayment of benefits. The Department
recover[ s] the overpayment from both the alien and the
KEY: public assistance programs, application , eligibility, Medicaid
Date of Enactment or Last Substantive Amendment: [
November 1, 2010]
Notice of Continuation: January 31, 2008
Authorizing, and Implemented or Interpreted Law: 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 email@example.com. For questions about the rulemaking process, please contact the Division of Administrative Rules.