No. 29469 (Amendment): R414-308. Application, Eligibility Determinations and Improper Medical Assistance

DAR File No.: 29469
Filed: 01/31/2007, 04:38
Received by: NL

RULE ANALYSIS

Purpose of the rule or reason for the change:

This rule is necessary to clarify how the agency determines the application date for medical assistance. It also clarifies the due date for verifications, recertifications, change reports, or other information the agency requests from Medicaid clients.

Summary of the rule or change:

This rule clarifies application date criteria that determine client eligibility. It also clarifies eligibility verification and information exchange requirements, agency responsibilities regarding eligibility decisions, eligibility period and recertification requirements, change reporting requirements, case closure and redetermination requirements, and client rights and responsibilities regarding improper medical coverage.

State statutory or constitutional authorization for this rule:

Title 26, Chapter 18

This rule or change incorporates by reference the following material:

42 CFR 435.911 and 435.912, 2006 ed.

Anticipated cost or savings to:

the state budget:

There may be a minimal savings in state and federal dollars because some Medicaid clients may lose between one and three days of retroactive coverage. The Department has no data to indicate how many Medicaid clients may not meet the new deadlines, but believes that it will be very small because the Medicaid clients will adhere to the slightly changed deadlines rather than lose medical coverage.

local governments:

There is no budget impact because local governments do not determine Medicaid eligibility and are not affected by the deadlines.

other persons:

There may be a cost to Medicaid clients who may lose between one and three days of retroactive coverage. The Department has no data to indicate how many Medicaid clients may not meet the new deadlines, but believes that it will be very small because the Medicaid clients will adhere to the slightly changed deadlines rather than lose medical coverage.

Compliance costs for affected persons:

There may a cost to a single Medicaid client who loses retroactive coverage. There is insufficient data to quantify any dollar amount, but a Medicaid client who loses coverage will be able to reapply at any time.

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

Eligibility for services and deadlines need to be explicit and clear to protect both the taxpayer and the applicant. These rules should not have a negative fiscal impact on business, as it is hoped that Medicaid applicants will comply with the rules. 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:

03/19/2007

This rule may become effective on:

03/27/2007

Authorized by:

David N. Sundwall, Executive Director

RULE TEXT

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.

(2) This rule establishes requirements for medical assistance applications, eligibility decisions, eligibility period, verifications, change reporting, [case records, ]notification and improper medical assistance for the following programs:

(a) Medicaid;

(b) Qualified Medicare Beneficiaries;

(c) Specified Low-Income Medicare Beneficiaries; and

(d) Qualified Individuals.

 

R414-308-3. Application and Signature.

(1) An individual may apply for medical assistance by completing and signing any Department-approved application form for Medicaid, Qualified Medicare Beneficiaries, Specified Low-Income Medicare Beneficiaries, or Qualified Individuals assistance and delivering it to the agency. If available, an individual may complete an on-line application for medical assistance and send it electronically to the agency.

(a) If an applicant cannot write, the applicant must make his mark on the application form and have at least one witness to the signature.

(b) For on-line applications, the individual must either send the agency an original signature on a printed signature page, or if available on-line, submit an electronic signature that conforms with state law for electronic signatures.

(c) A representative may apply on behalf of an individual. A representative may be a legal guardian, a person holding a power of attorney, a representative payee or other responsible person acting on behalf of the individual. In this case, the agency may send notices, requests and forms to both the individual and the individual's representative, or to just the individual's representative.

(d) If the Division of Child and Family Services (DCFS) has custody of a child and the child is placed in foster care, DCFS completes the application. DCFS determines eligibility for the child pursuant to a written agreement with the Department. DCFS also determines eligibility for children placed under a subsidized adoption agreement.

(e) An authorized representative may apply for the individual if unusual circumstances or death prevent an individual from applying on his own. The individual must sign the application form if possible. If the individual cannot sign the application, the representative must sign the application. The agency may assign someone to act as the authorized representative when the individual requires help to apply and is unable to appoint a representative.

(2) The date of application [will be decided]is determined as follows:

(a) The application date is the date the agency receives a completed, signed application at a local office by 5:00 p.m. on a business day.[is the application date when the application is delivered to a local office.] This applies to paper applications delivered in person or by mail, paper applications sent via facsimile transmission, and electronic applications sent via the Internet.

(b) [The date postmarked on the envelope is the application date if a completed, signed application is mailed to the agency.]If a local office receives an application after 5:00 p.m. of a business day, the date of application is the next business day.

(c) The application date for applications delivered to an outreach location is as follows:

(i) If the application is delivered at a time when the outreach staff is working at that location, the date of application is the date the outreach staff receives the application.

(ii) If the application is delivered at a time when the outreach office is closed, including being closed for weekends or holidays, the date of application is the last business day that a staff person from the state agency was available to receive or pick up applications from that location.

(d) The due date for verifications needed to complete an application and determine eligibility is 5:00 p.m. on the last day of the application period.

([c]3) [The date the agency receives the completed, signed application via facsimile transfer is the application day. ]The agency accepts [the]a signed application sent via facsimile as a valid application and does not require it to be signed again.

([3]4) If an applicant submits an unsigned, completed application form to the agency, the agency will notify the applicant that he or she must sign the application [must be signed ]within 30 days of the application date. The agency will send a signature page to the applicant within 10 days for the client to sign and return.

(a) If the agency receives a signature page signed by the applicant within 30 days of receiving the completed application, the original application date [is the date the agency received the unsigned, completed application form]is retained.

(b) If the agency does not receive a signed signature page within 30 days of when it received the completed application, the application is void and the agency will send a denial notice to the applicant. The previous application date will not be protected.

(c) If the agency receives a signed signature page during the 30 days immediately after the denial notice is mailed, the agency will contact the applicant to ask if the applicant wants to reapply for medical assistance. If the applicant wants to reapply, the agency may use the previous completed application form, but the application date will be the date the agency received the signed signature page according to the same provisions in R414-308-3(2).

(d) If the agency receives a signed signature page more than 30 days after the denial notice is sent, the applicant will need to reapply. The original application date is not retained.

(5) If an application is not complete, but it is signed by the applicant, the eligibility worker will ask the applicant to complete the application. If the client completes the application within 30 days of the date the agency received the application, the agency will determine eligibility based on the original application date. If the client does not complete the application within 30 days, the original application date is not retained and the agency denies the application.

 

R414-308-4. Verification of Eligibility and Information Exchange.

(1) Medical assistance applicants and recipients must verify all eligibility factors requested by the agency to establish or to redetermine eligibility. Medical assistance applicants and recipients must provide identifying information that the agency needs to meet the requirements of 42 CFR 435.945, 435.948, 435.952, 435.955, and 435.960.

(a) The agency will provide the client a written request of the needed verifications.

(b) The [agency must give the client]client has at least 10 calendar days from the date [of ]the agency gives or mails the verification request[s the verifications] to the client to provide verifications.

(c) The due date for returning verifications, forms or information requested by the agency is 5:00 p.m. on the date the agency sets as the due date in a written request to the client, but not less than 10 calendar days from the date such request is given to or mailed to the client.

([c]d) The agency allows additional time to provide verifications if the client [may ]requests additional time [to provide verifications]by the due date. The agency will set a new due date that is at least 10 days from the date the client asks for more time to provide the verifications, forms or information.

([d]e) If [an applicant]a client has not provided required verifications by the [end of the application period or by the end of the re-certification month]due date, and has not contacted the agency to [request additional]ask for more time to provide verifications, the agency denies the application, [or the ]re-certification, or ends eligibility.

(f) If the agency receives all necessary verifications during the 30 days after denying an application for lack of verifications, the date the agency receives all the verifications is the new application date. If the agency receives verifications more than 30 days after the application has been denied, the client will need to reapply for medical assistance.

(2) The agency must receive verification of an individual's income, both unearned and earned. To be eligible under Section 1902(a)(10)(A)(ii)(XIII), the Medicaid Work Incentive program, the agency may require proof such as paycheck stubs showing deductions of FICA tax; self-employment tax filing documents; or for newly self-employed individuals who have not filed tax forms yet, a written business plan and verification of gross receipts and business expenses, to verify that the income is earned income.[

(3) The agency denies eligibility or discontinues benefits if an applicant or recipient does not provide required verifications. In the case of a change report that would increase benefits, the agency does not increase benefits if the client does not provide required verifications.]

 

R414-308-5. Eligibility Decisions or Withdrawal of an Application.

(1) The agency [shall ]decides the applicant's eligibility within the time limits established in 42 CFR 435.911 and 435.912, [2004]2006 ed., which are incorporated by reference.

(2) The agency [may ]extends the time limit if the applicant asks for more time to provide requested information before the due date. The agency gives the applicant at least 10 more days after the original due date to provide verifications upon request of the applicant. The 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 cause.

(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 completed the assessment.

 

R414-308-6. Eligibility Period and Re-Certification.

(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 days from the mailing date of the notice that tells the client the amount owed.

(e) For ongoing months of eligibility, the client has until [the]5:00 p.m. of the 10th day of the month after the benefit month to meet the spenddown or pay the Medicaid Work incentive premium. If the 10th day of the month is a weekend or holiday, the client has until 5:00 p.m. on the first business day after the 10th 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.

(g) No eligibility exists in a month for which the client fails to meet a required spenddown or fails to pay a required Medicaid Work Incentive premium. 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 re-certification month;

(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 month 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; or

(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 eligibility;

(b) has information about anticipated changes in a recipient's circumstances that may affect eligibility; or

(c) knows the recipient has fluctuating income.

(4) To receive medical assistance without interruption, a recipient must complete the re-certification process by [the]5:00 p.m. 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 [if one is owed, ]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 [it]the recertification including providing verifications by [the]5:00 p.m. on the last business day [end ]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, within 30 days. Otherwise, the recipient remains ineligible for medical assistance.

(ii) If the recipient does not complete the re-certification process before [the]5:00 p.m. of the last business day [end ]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.

 

R414-308-7. Change Reporting and Benefit Changes.

(1) A client must report to the agency reportable changes in the client's circumstances. Reportable changes are defined in R414-301-2. [A client must report:]

(a) The due date for reporting changes is 5:00 p.m. on the 10th calendar day after the client learns of the change.

(b) When the change is receipt of income from a new source, or an increase in income the client receives, the due date for reporting the income change is 5:00 p.m. on the day that is ten calendar days after the date the client receives such income.

(c) The due date for providing verifications of changes is 5:00 p.m. on the date the agency sets as the due date in a written notice to the client.

[ (a) a reportable change within ten calendar days of the day the client learns of the change;

(b) income from a new source within ten calendar days of the date the client receives money from that new source; and

(c) an increase in income within ten days of the date the client receives the increased amount of income.

] (2) The agency may receive information from credible sources other than the client such as computer income matches, and from anonymous citizen reports. If the agency receives information from sources other than the client that may affect the client's eligibility, the agency will verify the information as needed depending on the source of information before using the information to change the client's eligibility for medical assistance. Information from citizen reports must always be verified by other reliable proofs.

(3) The date of report is the date the client reports the change to the agency by 5:00 p.m. on a business day by phone, by mail, by fax transmission or in person, or the date the agency receives the information from another source.[ If a change is reported by mail, the agency uses the date of the postmark to decide if the report was made on time.]

(4) If the agency needs verification of the reported change from the client, the agency requests it in writing and provides at least ten calendar days for the client to respond.

(5) A client who provides change reports, forms or verifications by 5:00 p.m. on the due date has provided the information on time.

[ (a) The due date is:

(i) for a change report, ten calendar days after the date the client learns of the change or ten calendar days after the client receives an increase in income or income from a new source; or

(ii) for verifications or forms, the date by which the agency tells the client the verifications or forms must be returned, but no earlier than ten calendar days after the agency mails the request to the client.

(b) If the due date falls on a Saturday, Sunday or state holiday, the report is timely if received before 5 p.m. of the first business day after the due date.

(c) If the information is mailed to the agency, the report is timely if the day of the postmark on the envelope matches or is prior to the due date.

(d) If the information is sent via facsimile transmission, the report is timely when the date of the fax transmission matches or is before the due date.

] (6)(a) If the reported information causes an increase in a client's benefits and the agency requests verification, the increase in benefits is effective the first day of the month following:

(i) the date of the report if the agency receives verifications within ten days of the request; or

(ii) the date the verifications are received if verifications are received more than ten days after the date of the request.

(b) The agency cannot increase benefits if the agency does not receive requested verifications.

(7) If the reported information causes a decrease in the client's benefits, the agency makes changes as follows:

(a) If the agency has sufficient information to adjust benefits, the change is effective the first day of the month after the month in which the agency sends proper notice of the decrease, regardless of whether verifications have been received.

(b) If the agency does not have sufficient information to adjust benefits, the agency requests verifications from the client. The due date is at least 10 days from the date of the request.

[ (i) The client has ten calendar days to return verifications.

] (i[i]) Upon receiving the verifications, the agency adjusts benefits effective the first day of the month following the month in which the agency can send proper notice.

(ii[i]) If the verifications are not returned on time, the agency [may ]discontinues benefits for the affected individuals effective the [first]end of the month in which the agency can send proper notice.

(8) Any time the agency requests verifications to determine or redetermine eligibility for an individual or a household, the agency may discontinue benefits if all required factors of eligibility are not verified by the due date. If a change does not affect all household members and verifications are not provided, the agency discontinues benefits only for the individual or individuals affected by the change.

(9) If a client fails to timely report a change or return verifications or forms by the due date, the client must repay all services and benefits paid by the Department for which the client was ineligible.

(10) If a due date falls on a weekend or holiday, the due date will be 5:00 p.m. on the first business day immediately after the due date.

([10]11) Notwithstanding the provisions of subsections (6) and (7), changes affecting an institutionalized client's eligibility are effective as of the date of the change.

 

R414-308-8. Case Closure and Redetermination.

(1) The agency terminates medical assistance upon recipient request or if the agency determines the recipient is no longer eligible.

(2) 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 ineligible.

([2]3) Before terminating a recipient's medical assistance, the agency will decide if the client is eligible for any other available medical assistance provided under Medicaid, the Medicare Cost-Sharing programs, the Primary Care Network and the [Covered-at-Work]UPP program. Children will be referred to the Children's Health Insurance Program when applicable.

(a) The agency does not require a recipient to complete a new application, but 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, 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 enrollments are stopped. An open enrollment period is a time when the agency accepts applications. Open enrollment applies only to the Primary Care Network, the [Covered-at-Work ]UPP Program and the Children's Health Insurance Program.

 

R414-308-9. Improper Medical Coverage.

(1) As used in this section, services and benefits include all amounts the Department pays on behalf of the client during the period in question and includes premiums paid to any Medicaid health plans or managed care plans, Medicare, and private insurance plans; payments for prepaid mental health services; and payments made directly to service providers or to the client.

(2) A client must repay the cost of services and benefits the client receives for which the client is not eligible.

(a) If the agency determines 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 amount 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 she paid the agency in the form of the Prenatal 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 amount 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

(a) the spenddown, asset co-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 the 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.

(b) In 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 Department issues 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 owed 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 recovers the overpayment from both the alien and the sponsor.

 

KEY: public assistance programs, [records]application, eligibility, Medicaid

Date of Enactment or Last Substantive Amendment: [November 1, 2005]2007

Notice of Continuation: January 31, 2003

Authorizing, and Implemented or Interpreted Law: 26-18