No. 29174 (New Rule): R414-307. Eligibility for Home and Community-Based Services Waivers

DAR File No.: 29174
Filed: 10/31/2006, 08:23
Received by: NL

RULE ANALYSIS

Purpose of the rule or reason for the change:

This rule is necessary to outline general eligibility requirements for home and community-based services waivers. It also specifies New Choices Waiver eligibility criteria.

Summary of the rule or change:

This proposed new rule outlines general eligibility requirements for home and community-based services waivers, specifies requirements that apply to individuals who qualify for a waiver under the special income group, specifies requirements that apply to individuals who qualify for a waiver under the medically needy waiver group, describes New Choices Waiver eligibility criteria, and states other provisions that apply to all applicants and recipients of home and community-based services waivers.

State statutory or constitutional authorization for this rule:

Sections 26-1-5 and 26-18-3, and 42 CFR 435.217 and 435.726

Anticipated cost or savings to:

the state budget:

There is no budget impact because this rule only specifies eligibility criteria for home and community-based services waivers.

local governments:

There is no budget impact because local governments do not provide home and community-based services.

other persons:

There is no budget impact because this rule only specifies eligibility criteria for home and community-based services waivers.

Compliance costs for affected persons:

There are no compliance costs because this rule only specifies eligibility criteria for home and community-based services waivers.

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

This rule outlines eligibility criteria for home and community-based services and the New Choices Waiver. There should be no fiscal impact on business. David N. Sundwall, MD, 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
CANNON HEALTH BLDG
288 N 1460 W
SALT LAKE CITY UT 84116-3231

Direct questions regarding this rule to:

Craig Devashrayee or Gayle M. Six at the above address, by phone at 801-538-6641 or 801-538-6895, by FAX at 801-538-6099 or 801-538-6952, or by Internet E-mail at [e-mail] or [e-mail]

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:

12/15/2006

This rule may become effective on:

12/23/2006

Authorized by:

David N. Sundwall, Executive Director

RULE TEXT

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

R414-307. Eligibility for Home and Community-Based Services Waivers.

R414-307-1. Introduction and Authority.

Section 26-18-3 authorizes this rule. It establishes general eligibility requirements for home and community based service waivers. It also specifies eligibility criteria that applies to the New Choices Home and the Community-Based Services Waiver.

 

R414-307-2. Definitions.

The definitions found in R414-301 apply to this rule.

 

R414-307-3. General Requirements for Home and Community-Based Services Waivers.

(1) To qualify under a home and community based services waiver, an individual must meet:

(a) the medical eligibility criteria defined in the waiver implementation plan adopted in R414-61 applicable to the specific waiver under which the individual is seeking services, as verified by the referring agency case manager;

(b) the eligibility criteria for one of the Medicaid coverage groups selected for coverage in the specific waiver implementation plan under which the individual is seeking services; and

(c) the non-financial Medicaid criteria defined in R414-302.

(2) An individual must apply for and provide required verifications pursuant to R414-308 relating to the application and verification process.

 

R414-307-4. Special Income Group.

The following requirements apply to individuals who qualify for a Medicaid home and community-based services waiver under the special income group defined in 42 CFR 435.217 because they do not meet community Medicaid rules but would be eligible for Medicaid if they were living in a medical institution:

(1) If the individual's spouse meets the definition of a community spouse, the Department applies the income and resource provisions defined in Section 1924 of the Social Security Act and R414-305-3.

(2) If the individual does not have a spouse, or the individual's spouse does not meet the definition of a community spouse, the Department counts only the individual's resources to determine eligibility. If both members of a married couple who live together apply for waiver services and meet the criteria for the special income group, the Department counts one-half of jointly-held assets as available to each spouse. Each spouse must pass the medically needy resource test for one person.

(3) The Department counts only income determined under the most closely associated cash assistance program to decide if the individual passes the income eligibility test for the special income group. The Department does not count income of the individual's spouse except for actual contributions from the spouse.

(4) If the individual is a minor child, the Department does not count income and resources of the child's parents to decide if the child passes the income and resource tests for the special income group. The Department counts actual contributions from a parent, including court-ordered support payments as income of the child.

(5) The individual's income cannot exceed three times the payment that would be made to an individual with no income under Section 1611(b)(1) of the Social Security Act.

(6) The Department applies the transfer of asset provisions of Section 1917 of the Social Security Act, as amended by Pub. L. 109-171.

(7) The individual's cost-of-care contribution is the income amount remaining after post-eligibility deductions for the applicable waiver. The individual must pay the cost-of-care contribution to the department for Medicaid waiver eligibility.

(8) The Department deducts medical expenses incurred by the individual in accordance with R414-304-9.

(9) The Department determines special income group eligibility for an individual starting the month that waiver services begin. The Department determines eligibility for prior months using the community Medicaid or institutional Medicaid rules applicable to the individual's situation.

 

R414-307-5. Medically Needy Waiver Group.

The following requirements apply to individuals who meet the eligibility criteria for a medically needy coverage group defined in 42 CFR 435.301 that the Department has selected for coverage under the implementation plan for the specific waiver:

(1) If an individual's spouse meets the definition of a community spouse, the Department applies the income and resource provisions defined in Section 1924 of the Social Security Act and R414-305-3.

(2) If the individual does not have a spouse or the individual's spouse does not meet the definition of a community spouse, the Department counts only the individual's resources to determine eligibility. When both members of a married couple who live together apply for waiver services and meet the criteria for the medically needy waiver group, the Department counts one-half of jointly-held assets available to each spouse. Each spouse must pass the medically needy resource test for one person.

(3) The Department counts only income determined under the most closely associated cash assistance program to decide if the individual passes the income eligibility test for the special income group. The Department does not count income of the individual's spouse except for actual contributions from the spouse.

(4) If the individual is a minor child, the Department does not count income and resources of the child's parents to decide if the child passes the income and resource tests for the medically needy waiver group. The Department counts actual contributions from a parent, including court-ordered support payments as income of the child.

(5) The individual's income must exceed three times the payment that would be made to an individual with no income under Section 1611(b)(1) of the Social Security Act.

(6) The Department applies the income deductions allowed by the non-institutional Medicaid category under which the individual qualifies. The Department compares countable income to the applicable medically needy income limit for a one-person household to determine the individual's spenddown. The individual must pay the spenddown to the Department for Medicaid waiver eligibility.

(7) The Department deducts medical expenses incurred by the individual in accordance with R414-304-9.

(8) The Department determines medically needy group eligibility for an individual starting the month that waiver services begin. The Department determines eligibility for prior months using the community Medicaid or institutional Medicaid rules applicable to the individual's situation.

 

R414-307-6. New Choices Waiver Eligibility Criteria.

The following eligibility requirements apply to the New Choices Waiver:

(1) An individual must be age 65 or older, or age 21 through age 64 and disabled as defined in Section 1614(a)(3) of the Social Security Act. For the purpose of this waiver, an individual is 21 years of age beginning the first month after the month of the individual's 21st birthday.

(2) Under post-eligibility income rules defined in Section 1924 of the Social Security Act for individuals with a community spouse, and in 42 CFR 435.726 for individuals without a community spouse, the Department deducts the following amounts from the income of an individual who meets the eligibility criteria for the special income group:

(a) A personal needs allowance equal to 100% of the federal poverty guideline for a household of one.

(b) For individuals with earned income, up to $125 of gross-earned income.

(c) Actual monthly shelter costs not to exceed $300. This deduction includes mortgage, insurance, property taxes, rent, and other shelter expenses.

(d) A deduction for monthly utility costs equal to the standard utility allowance Utah uses under Section 5(e) of the Food Stamp Act of 1977. If the waiver client shares utility expenses with others, the allowance is prorated accordingly.

(e) An allowance for a community spouse and dependent family members living with the community spouse, in accordance with the provisions of Section 1924 of the Social Security Act.

(f) In the case of an individual who does not have a community spouse or whose spouse is also eligible for waiver services, an allowance for dependent family members is equal to one-third of the difference between the minimum monthly spousal needs allowance and the family member's monthly income. If more than one individual contributes income to the dependent family member, the combined income deductions cannot exceed one-third of the difference.

(g) Medical and remedial care expenses incurred by the individual in accordance with R414-304-9.

 

R414-307-7. Other Provisions.

The following provisions apply to all applicants and recipients of home and community based-services waivers:

(1) Applicants and recipients of home and community-based services waivers receive the same rights and have the same responsibilities as all other medical assistance applicants and recipients.

(2) For individuals claiming a disability, the disability provisions of R414-303 apply.

(3) Except where otherwise stated in this rule, the income provisions of R414-304 apply to waiver applicants and recipients.

(4) Except where otherwise stated in this rule, the resource provisions of R414-305 apply to waiver applicants and recipients.

(5) The benefit provisions of R414-306 apply to waiver applicants and recipients.

(6) The provisions found in R414-308 that apply to eligibility determinations, redeterminations, change reporting, and improper medical assistance also apply to waiver applicants and recipients.

(7) The Department limits the number of individuals covered by a home and community based-services waiver as provided in the adopted waiver implementation plan.

(8) The Department does not pay for waiver services when an individual has home equity that exceeds the limit set forth by Pub. L. 109-171.

(a) The state sets that limit at the minimum level allowed under Pub. L. 109-171.

(b) An individual who has excess home equity and meets eligibility criteria under a community Medicaid eligibility group is not disqualified from receiving Medicaid for services other than home and community-based waiver services.

(c) An individual who has excess home equity and does not qualify for a community Medicaid eligibility group, is ineligible for Medicaid under both the special income group and the medically needy waiver group. This is in accordance with institutional deeming rules found in Section 1924 of the Social Security Act.

 

KEY: eligibility, waivers, special income group

Date of Enactment or Last Substantive Amendment: 2006

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