No. 43332 (New Rule): Rule R414-520. Admission Criteria for Medically Complex Children's Waiver

(New Rule)

DAR File No.: 43332
Filed: 10/30/2018 08:58:46 AM

RULE ANALYSIS

Purpose of the rule or reason for the change:

The purpose of this new rule is to comply with the requirements of H.B. 100 (2018 General Session), which requires the Department of Health (Department) to implement, by rule, entrance criteria to the Medically Complex Children's Waiver.

Summary of the rule or change:

This rule outlines the criteria used by the Department to determine a child's eligibility for the Medically Complex Children's Waiver. Criteria for the waiver includes provisions to determine medical complexity and to evaluate the financial needs of the child and the child's family.

Statutory or constitutional authorization for this rule:

• Section 26-1-5
• Section 26-18-410
• Section 26-18-3

Anticipated cost or savings to:

the state budget:

This rule does not affect the state budget because ongoing costs or revenues associated with waiver eligibility are within previous allocations set forth by the Legislature.

local governments:

This rule does not affect local governments because ongoing costs or revenues associated with waiver eligibility are within previous allocations set forth by the Legislature.

small businesses:

This rule does not affect small businesses because ongoing costs or revenues associated with waiver eligibility are within previous allocations set forth by the Legislature.

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

This rule does not affect Medicaid providers because ongoing costs or revenues associated with waiver eligibility are within previous allocations set forth by the Legislature. Changes in policy may cause some Medicaid members to lose eligibility under the new assessment criteria, but there is no cost-effective data to determine what the financial impact may be.

Compliance costs for affected persons:

There are no compliance costs to a single Medicaid provider. Changes in policy may cause a Medicaid member to lose eligibility under the new assessment criteria, but there is no cost-effective data to determine what the financial impact may be.

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

After conducting a thorough analysis, it was determined that this proposed rule will not result in a fiscal impact to businesses.

Joseph K. Miner, M.D., Executive Director

The full text of this rule may be inspected, during regular business hours, at the Office 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 at the above address, by phone at 801-538-6641, by FAX at 801-538-6099, or by Internet E-mail at [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:

12/17/2018

This rule may become effective on:

12/24/2018

Authorized by:

Joseph Miner, Executive Director

RULE TEXT

Appendix 1: Regulatory Impact Summary Table*

Fiscal Costs

FY 2019

FY 2020

FY 2021

State Government

$0

$0

$0

Local Government

$0

$0

$0

Small Businesses

$0

$0

$0

Non-Small Businesses

$0

$0

$0

Other Person

$0

$0

$0

Total Fiscal Costs:

$0

$0

$0

Fiscal Benefits

State Government

$0

$0

$0

Local Government

$0

$0

$0

Small Businesses

$0

$0

$0

Non-Small Businesses

$0

$0

$0

Other Persons

$0

$0

$0

Total Fiscal Benefits:

$0

$0

$0

Net Fiscal Benefits:

$0

$0

$0

 

*This table only includes fiscal impacts that could be measured. If there are inestimable fiscal impacts, they will not be included in this table. Inestimable impacts for State Government, Local Government, Small Businesses and Other Persons are described in the narrative. Inestimable impacts for Non - Small Businesses are described in Appendix 2.

 

Appendix 2: Regulatory Impact to Non - Small Businesses

This rule does not affect costs or revenue to the 182 Medicaid home and community-based service providers, as fiscal impacts are within previous allocations set forth by the Legislature.

 

 

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

R414-520. Admission Criteria for Medically Complex Children's Waiver.

R414-520-1. Introduction and Authority.

(1) This rule outlines the criteria used to evaluate initial and ongoing eligibility for the Medically Complex Children's Waiver.

(2) This rule is authorized by Section 26-18-3. Waiver services are optional and provided in accordance with 42 CFR 440.225.

 

R414-520-2. Definitions.

(1) "Waiver" means the Medically Complex Children's Waiver.

 

R414-520-3. Eligibility Requirements.

(1) The Department uses the following criteria to determine waiver eligibility:

(a) An assessment of a child's ability to perform age-appropriate activities of daily living and that child's level of independence in the performance of the activity; and

(b) An evaluation to determine whether a child meets nursing facility level of care in accordance with Section R414-502-3.

(2) For a child who meets the criteria in Subsection R414-520-3(1), a point value is attributed to the initial application and annual re-evaluation that includes the following:

(a) Current medical providers;

(b) Condition or diagnosis;

(c) Date of last medical visit;

(d) Documentation of more than three months of dependence on medical devices, treatments, therapies, or subspecialty services to reach a minimum medical score; and

(e) An evaluation of the impact on the parents or guardians who have provided care to the medically complex child during the last 12 months.

 

R414-520-4. Waiver Access.

(1) The Department periodically assesses funding for the waiver to determine the number of children who may be served. It also derives a point value associated with the criteria found in Subsection R414-520-3(2)(d) through (e) to determine which children to enroll. In the event of multiple applications with the same point value, the Department will use the point value derived from Subsection R414-520-3(2)(d) to make its determination. In the event of multiple applications with the same point value derived from Subsection R414-520-3(2)(d), the Department will create a randomized list to determine which children are served.

(2) An applicant who is not admitted to the waiver, or a child who is disenrolled from the waiver, may appeal the decision in accordance with 42 CFR 431, Subpart E.

 

R414-520-5. Service Coverage.

Services and limitations are found in the State Implementation Plan for the Medically Complex Children's Waiver.

 

KEY: Medicaid

Date of Enactment or Last Substantive Amendment: 2018

Authorizing, and Implemented or Interpreted Law: 26-1-5; 26-18-3; 26-18-410

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