Health, Health Care Financing, Coverage and Reimbursement Policy

Rule R414-303

Coverage Groups

Notice of 120-Day (Emergency) Rule

DAR File No.: 37173
Filed: 01/07/2013 03:45:58 PM

RULE ANALYSIS

Purpose of the rule or reason for the change:

The purpose of this change is to extend Medicaid coverage for Transitional Medical Assistance (TMA) and the Qualifying Individual (QI) program in accordance with the American Taxpayer Relief Act of 2012, House Resolution (H.R.) 8.

Summary of the rule or change:

This change extends Medicaid coverage for TMA and the QI program in accordance with the American Taxpayer Relief Act of 2012, H.R. 8. (DAR NOTE: This emergency rule supersedes the emergency rule filed under DAR No. 37120, effective 01/01/2013, and published in the January 15, 2013, issue of the Bulletin.)

Emergency rule reason and justification:

Regular rulemaking procedures would cause an imminent budget reduction because of budget restraints or federal requirements; and place the agency in violation of federal or state law.

Justification: The Department needs to file this emergency rule to extend coverage of TMA and the QI program. Because Congress did not pass legislation to extend these two programs before 01/01/2013, the Department had to file an emergency rule (Rule R414-303, DAR No. 37120, published in the January 15, 2013, issue of the Bulletin) to end coverage for these two programs and avoid being in violation of federal law. With the passage of Sections 621 and 622 of H.R. 8, this emergency rule restores these programs and supersedes the previous emergency rule.

State statutory or constitutional authorization for this rule:

• Section 26-18-3
• Section 26-1-5

This rule or change incorporates by reference the following material:

• Updates Section 1902(a)(10)(E)(i) through (iv) of Title XIX of the Social Security Act, published by Social Security Administration, 11/19/2012

Anticipated cost or savings to:

the state budget:

There is no impact to the state budget because this rule simply continues coverage of TMA and the QI program.

local governments:

There is no impact to local governments because they neither fund Medicaid services nor determine Medicaid eligibility.

small businesses:

There is no impact to small businesses because this rule simply continues coverage of TMA and the QI program.

persons other than small businesses, businesses, or local governmental entities:

There is no impact to Medicaid providers and to Medicaid recipients because this rule simply continues coverage of TMA and the QI program.

Compliance costs for affected persons:

There are no compliance costs to a single Medicaid provider or to a Medicaid recipient because this rule simply continues coverage of TMA and the QI program.

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

Reinstatement of funding under H.R. 8, signed into law on 01/02/2013, allows Medicaid to re-open the eligibility group that had been closed in the prior emergency rule when such funding was not available.

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:

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

This rule is effective on:

01/07/2013

Authorized by:

David Patton, Executive Director

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

R414-303. Coverage Groups.

R414-303-3. Medicaid for Individuals Who Are Aged, Blind or Disabled for Community and Institutional Coverage Groups.

(1) The Department provides Medicaid coverage to individuals as described in 42 CFR 435.120, 435.122, 435.130 through 435.135, 435.137, 435.138, 435.139, 435.211, 435.232, 435.236, 435.301, 435.320, 435.322, 435.324, 435.340, and 435.350, 2011 ed., which are incorporated by reference. The Department provides coverage to individuals as required by 1634(b), (c) and (d), 1902(a)(10)(A)(i)(II), 1902(a)(10)(A)(ii)(X), and 1902(a)(10)(E)(i) through ([iii]iv) of Title XIX of the Social Security Act in effect November 19, 2012, which are incorporated by reference. The Department provides coverage to individuals described in Section 1902(a)(10)(A)(ii)(XIII) of Title XIX of the Social Security Act in effect April 2, 2012, which is incorporated by reference. Coverage under Section 1902(a)(10)(A)(ii)(XIII) is known as the Medicaid Work Incentive Program.

(2) Proof of disability includes a certification of disability from the State Medicaid Disability Office, Supplemental Security Income (SSI) status, or proof that a disabled client is recognized as disabled by the Social Security Administration (SSA).

(3) An individual can request a disability determination from the State Medicaid Disability Office. The Department adopts the disability determination requirements described in 42 CFR 435.541, 2011 ed., and Social Security's disability requirements for the Supplemental Security Income program as described in 20 CFR 416.901 through 416.998, 2011 ed., which are incorporated by reference, to decide if an individual is disabled. The Department notifies the eligibility agency of its disability decision, who then sends a disability decision notice to the client.

(a) If an individual has earned income, the State Medicaid Disability Office shall review medical information to determine if the client is disabled without regard to whether the earned income exceeds the Substantial Gainful Activity level defined by the Social Security Administration.

(b) If, within the prior 12 months, SSA has determined that the individual is not disabled, the eligibility agency must follow SSA's decision. If the individual is appealing SSA's denial of disability, the State Medicaid Disability Office must follow SSA's decision throughout the appeal process, including the final SSA decision.

(c) If, within the prior 12 months, SSA has determined an individual is not disabled but the individual claims to have become disabled since the SSA decision, the State Medicaid Disability Office shall review current medical information to determine if the client is disabled.

(d) Clients must provide the required medical evidence and cooperate in obtaining any necessary evaluations to establish disability.

(e) Recipients must cooperate in completing continuing disability reviews as required by the State Medicaid Disability Office unless they have a current approval of disability from SSA. Medicaid eligibility as a disabled individual will end if the individual fails to cooperate in a continuing disability review.

(4) If an individual denied disability status by the Medicaid Disability Review Office requests a fair hearing, the Disability Review Office may reconsider its determination as part of fair hearing process. The individual must request the hearing within the time limit defined in Section R414-301-6.

(a) The individual may provide the eligibility agency additional medical evidence for the reconsideration.

(b) The reconsideration may take place before the date the fair hearing is scheduled to take place.

(c) The eligibility agency notifies the individual of the reconsideration decision. Thereafter, the individual may choose to pursue or abandon the fair hearing.

(5) If the eligibility agency denies an individual's Medicaid application because the Medicaid Disability Review Office or SSA has determined that the individual is not disabled and that determination is later reversed on appeal, the eligibility agency determines the individual's eligibility back to the application that gave rise to the appeal. The individual must meet all other eligibility criteria for such past months.

(a) Eligibility cannot begin any earlier than the month of disability onset or three months before the month of application subject to the requirements defined in Section R414-306-4, whichever is later.

(b) If the individual is not receiving medical assistance at the time a successful appeal decision is made, the individual must contact the eligibility agency to request the Disability Medicaid coverage.

(c) The individual must provide any verifications the eligibility agency needs to determine eligibility for past and current months for which the individual is requesting medical assistance.

(d) If an individual is determined eligible for past or current months, but must pay a spenddown or Medicaid Work Incentive (MWI) premium for one or more months to receive coverage, the spenddown or MWI premium must be met before Medicaid coverage may be provided for those months.

(6) The age requirement for Aged Medicaid is 65 years of age.

(7) For children described in Section 1902(a)(10)(A)(i)(II) of the Social Security Act in effect April 4, 2012, the agency shall conduct periodic redeterminations to assure that the child continues to meet the SSI eligibility criteria as required by such section.

(8) Coverage for qualifying individuals described in Section 1902(a)(10)(E)(iv) of Title XIX of the Social Security Act in effect November 19, 2012, is limited to the amount of funds allocated under Section 1933 of Title XIX of the Social Security Act in effect November 19, 2012, for a given year, or as subsequently authorized by Congress under the American Taxpayer Relief Act, House Resolution 8, signed into law on January 2, 2013. The eligibility agency shall deny coverage to applicants when the uncommitted allocated funds are insufficient to provide such coverage.

( 9[8]) To determine eligibility under Section 1902(a)(10)(A)(ii)(XIII), if the countable income of the individual and the individual's family does not exceed 250% of the federal poverty guideline for the applicable family size, the agency shall disregard an amount of earned and unearned income of the individual, the individual's spouse, and a minor individual's parents that equals the difference between the total income and the Supplemental Security Income maximum benefit rate payable.

( 10[9]) The agency shall require individuals eligible under Section 1902(a)(10)(A)(ii)(XIII) to apply for cost-effective health insurance that is available to them.

R414-303-5. 12 Month Transitional Family Medicaid[Reserved].

The agency provides transitional Medicaid coverage in accordance with the provisions of Title XIX of the Social Security Act Section 1925 for households that lose eligibility for 1931 Family Medicaid as described in 1931(c)(2).

KEY: income, coverage groups, independent foster care adolescent

Date of Enactment or Last Substantive Amendment: January 7, 2013

Notice of Continuation: January 25, 2008

Authorizing, and Implemented or Interpreted Law: 26-18-3; 26-1-5