No. 42489 (Emergency Rule): Rule R414-311. Targeted Adult Medicaid

DAR File No.: 42489
Filed: 01/19/2018 10:08:32 AM

RULE ANALYSIS

Purpose of the rule or reason for the change:

The purpose of this emergency rule is to comply with the provisions of H.B. 437 passed during the 2016 General Session, which requires the Department of Health (Department) to expand Medicaid coverage for adults without dependent children.

Summary of the rule or change:

This rule change expands coverage for a new eligibility group of adults without dependent children. These individuals are required to meet basic Medicaid eligibility criteria, and to meet specific criteria for one of the three following Targeted Adult Medicaid groups: "Chronically Homeless"; "Involved in the Justice System"; or "Needing Substance Use or Mental Health Treatment".

Emergency rule reason and justification:

Regular rulemaking procedures would cause an imminent peril to the public health, safety, or welfare.

Justification: This new coverage group specifically targets the homeless population who need substance use disorder treatment for the opioid epidemic. This rule, therefore, is needed to protect the homeless from the harmful effects of this epidemic.

Statutory or constitutional authorization for this rule:

• Section 26-1-5
• Subsection 1115(f) of the Social Security Act
• Section 26-18-3

Anticipated cost or savings to:

the state budget:

There is an annual cost of about $26,800,000 in state funds and about $63,000,000 in federal funds as a result of this amendment.

local governments:

There is no impact on local governments because they do not fund specific programs for the Medicaid adult population.

small businesses:

Small businesses in the fields of social services, mental health, and addiction recovery may see a portion of annual revenue that totals $100,000,000 based on member eligibility and participation in the Needing Substance Use or Mental Health Treatment group.

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

The Utah Hospital Association will incur an annual cost of about $10,200,000 to share in the implementation of these new programs. On the other hand, Medicaid providers in the fields of social services, mental health, and addiction recovery may see a portion of annual revenue that totals $100,000,000 based on member eligibility and participation in the Needing Substance Use or Mental Health Treatment group. As more individuals become eligible for the Chronically Homeless coverage group, homeless shelters will see a decrease in operating costs. Likewise, the public will see a decrease in taxes needed to support jails, prisons, and the court system as more individuals become eligible for the Involved in the Justice System coverage group. All of the aforementioned groups will see a portion of $100,000,000 in out-of-pocket savings as they are able to access these new services.

Compliance costs for affected persons:

There are no compliance costs because an individual business or provider will only see potential revenue, and an individual who qualifies for one of the coverage groups will only see out-of-pocket savings.

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

Businesses in the fields of social services, mental health, and addiction recovery will see a portion of annual revenue that totals $100,000,000 based on member eligibility and participation in the Needing Substance Use or Mental Health Treatment group.

Joseph K. Miner, MD, 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]

This rule is effective on:

01/19/2018

Authorized by:

Joseph Miner, Executive Director

RULE TEXT

Appendix 1: Regulatory Impact Summary Table*

Fiscal Costs

FY 2018

FY 2019

FY 2020

State Government

$100,000,000

$100,000,000

$100,000,000

Local Government

$0

$0

$0

Small Businesses

$0

$0

$0

Non-Small Businesses

$0

$0

$0

Other Person

$10,200,000

$10,200,000

$10,200,000

Total Fiscal Costs:

$110,200,000

$110,200,000

$110,200,000

Fiscal Benefits

State Government

$0

$0

$0

Local Government

$0

$0

$0

Small Businesses

A portion of $100,000,000

A portion of 100,000,000

A portion of 100,000,000

Non-Small Businesses

A portion of $100,000,000

A portion of 100,000,000

A portion of 100,000,000

Other Persons

A portion of $100,000,000

A portion of 100,000,000

A portion of 100,000,000

Total Fiscal Benefits:

$100,000,000

$100,000,000

$100,000,000

Net Fiscal Benefits:

Portions of $100,000,000

Portions of 100,000,000

Portions of 100,000,000

 

*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 above. Inestimable impacts for Non-Small Businesses are described below.

 

Appendix 2: Regulatory Impact to Non-Small Businesses

The Utah Hospital Association will incur an annual cost of about $10,200,000 to share in the implementation of these new programs. On the other hand, about 2,500 Medicaid providers in the fields of social services, mental health, and addiction recovery may see a portion of annual revenue that totals $100,000,000 based on member eligibility and participation in the Needing Substance Use or Mental Health Treatment group. As more individuals become eligible for the Chronically Homeless coverage group, all 24 of Utah's homeless shelters will see a decrease in operating costs. Likewise, the public will see a decrease in taxes needed to support jails, prison, and the court system as more individuals become eligible for the Involved in the Justice System coverage group. Medicaid members who qualify for the aforementioned programs will share a portion of $100,000,000 in out-of-pocket savings as they are able to access new services.

 

The Executive Director of the Department of Health, Joseph K. Miner, M.D., has reviewed and approved this fiscal analysis.

 

 

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

R414-311. Targeted Adult Medicaid.

R414-311-1. Introduction and Authority.

(1) This rule is authorized by Sections 26-1-5 and 26-18-3 and allowed under Subsection 1115(f) of the Social Security Act.

(2) This rule establishes eligibility requirements for enrollment under the 1115 Demonstration Waiver for Adults without Dependent Children, also known as the Targeted Adult Medicaid program.

 

R414-311-2. Definitions

The definitions in Rules R414-1 and R414-301 apply to this rule. In addition, the following definitions apply throughout this rule:

(1) "Chronically Homeless Individual" means an individual who has a substance use disorder, serious mental illness, developmental disability, post-traumatic stress disorder, cognitive impairments resulting from a brain injury, or chronic illness or disability; and

(a) is living or residing for at least 12 months, or on at least four separate occasions that amount to at least 12 months in the last three years, in a place not meant for human habitation, in a safe haven, or in an emergency shelter; or

(b) is living in supportive housing and has previously met the criteria established in Subsection R414-311-2(2)(a).

(2) "Dependent Child" means a child who is under 19 years of age and required to be included in the Targeted Adult Medicaid household size.

(3) "Individual Needing Treatment" means an individual who:

(a) is receiving General Assistance from the Department of Workforce Services and has been diagnosed with a substance use or mental health disorder;

(b) was discharged from the Utah State Hospital and was admitted due to a civil commitment; or

(c) is living or residing for at least 6 months within a 12 month period in a place not meant for human habitation, in a safe haven, or an emergency shelter, and has a substance use or serious mental health disorder.

(4) "Justice Involved Individuals" means an individual who:

(a) has complied with and substantially completed a substance use disorder treatment program while incarcerated in jail or prison; or

(b) was discharged from the Utah State Hospital and was admitted to the civil unit in connection with a criminal charge, or to the forensic unit due to a criminal offense, with which the individual was charged or convicted; or

(c) is involved with a drug or mental health court.

 

R414-311-3. General Provisions.

(1) The provisions in Rule R414-301 apply to all applicants and enrollees, except that applicants and enrollees are required to report only the following changes in circumstances:

(a) The individual moves out of state; or

(b) The individual enters a public institution or an institution for mental disease.

 

R414-311-4. General Eligibility Requirements.

Unless otherwise stated, the provisions in Rule R414-302 and Section R414-306-4 apply to applicants and enrollees.

(1) The following individuals are not eligible for Targeted Adult Medicaid:

(a) Individuals who do not meet the coverage group criteria of being chronically homeless, justice involved, or needing treatment as defined in Section R414-311-2;

(b) Individuals who have a dependent child under 19 years old; and

(c) Individuals eligible for another Medicaid program.

(2) A member shall be at least 19 years old, but shall be younger than 65 years old to enroll in Targeted Adult Medicaid.

(a) The month in which an individual turns 19 years old is the first month in which the member may enroll in Targeted Adult Medicaid.

(b) A member may only enroll in Targeted Adult Medicaid through the month in which the member turns 65 years old.

(3) The eligibility agency only enrolls applicants during an open enrollment period. The eligibility agency may limit the number it enrolls and may stop enrollment at any time. The open enrollment period may be limited to a coverage group or a subgroup within the coverage group.

(4) The eligibility agency shall waive the open enrollment requirement for the following situations:

(a) The individual who was previously on Targeted Adult Medicaid, and is moving from another Medicaid program back to Targeted Adult Medicaid, is otherwise eligible, and there is no break in coverage between the medical programs;

(b) The individual is no longer eligible for PCN, is otherwise eligible, and there is no break in coverage between the two medical programs; or

(c) The enrollee completes a review within three months of case closure as outlined in Section R414-308-6.

(5) A resource test is not required.

 

R414-311-5. Application, Eligibility Reviews and Improper Medical Assistance.

(1) Unless otherwise stated, the provisions of Rule R414-308 apply to applicants and enrollees.

(2) Subject to the provisions of Subsection R414-311-5(3), an individual who is determined eligible shall receive 12 months of coverage that begins with the first month of enrollment.

(3) Coverage for Targeted Adult Medicaid may end before the end of the 12-month certification period if the individual:

(a) turns 65 years old;

(b) moves out of state;

(c) becomes eligible for another Medicaid program;

(d) enters a public institution or an institution for mental disease, except as described in Section R414-302-6;

(e) is convicted of fraud; or

(f) leaves the household.

(4) An individual who leaves prison, jail or the Utah State Hospital must submit an application within 60 days of release or discharge.

(5) An enrollee must verify at each review that he meets the criteria of a coverage group as defined in Section R414-311-2. An enrollee who no longer meets criteria of a coverage group is no longer eligible for Targeted Adult Medicaid.

 

R414-311-6. Household Composition and Income Provisions.

(1) The eligibility agency shall use the provisions of Section R414-304-5 to determine household composition and countable income.

(2) Section R414-304-12 applies to the budgeting of income through the Modified Adjusted Gross Income (MAGI) methodology.

(3) For an individual to be eligible to enroll in Targeted Adult Medicaid, the individual must have zero countable income.

 

KEY: Medicaid, Targeted Adult Medicaid, eligibility

Date of Enactment or Last Substantive Amendment: January 19, 2018

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

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