No. 27230 (Amendment): R414-303. Coverage Groups

DAR File No.: 27230
Filed: 06/14/2004, 01:25
Received by: NL

 

RULE ANALYSIS

Purpose of the rule or reason for the change:

This rulemaking removes language about the Qualifying Individuals (QI) Group 2 program because Group 2 of the program ended as required by federal statute. It also adds rules as required by H.B. 126, Medicaid Benefits Administration, passed in the 2003 Utah Legislative session, such as: a) requirements for doing eligibility determinations under the "Baby Your Baby" program for pregnant women, the eligibility criteria, and the length of that eligibility period; b) certain requirements and clarifications about the disability determination process, and that a disability reconsideration may be conducted as part of a fair hearing request from the client; c) clarifications about what constitutes a temporary absence, and that absence due to military service does not meet the deprivation of support criteria for Family Medicaid; d) language about Medicaid not being continued when deprivation of support no longer exists has been clarified; e) the requirements for who can evaluate whether an individual is incapacitated has been expanded; and f) a clarification that a child who is 18 but not yet 19 cannot be disqualified from the Newborn Plus Medicaid program (the poverty-related Medicaid for children) because of deemed income or assets from parents. This rulemaking also adds extensions to the QI Group 1 program and to the 12-month Transitional Medicaid program as authorized by Congress under Pub. L. No. 108-89 signed into law on October 1, 2003, and for a further extension of QI-1 as authorized by Congress under Pub. L. No. 108-173 signed into law on December 8, 2003. Other changes: 1) make clarifications about the eligibility for women under the Breast and Cervical Cancer program; 2)add clarifications that the Department of Human Services determines eligibility for Foster Care and Subsidized Adoption Medicaid; 3) add clarifications about income that is excluded under federal laws other than the Social Security Act; and 4) updates, adds, or specifies citations. (DAR NOTE: H.B. 126 is found at UT L 2003 Ch 324, and was effective 05/05/2003.)

 

Summary of the rule or change:

Rules about making disability determinations are changed to clarify: a) when the Department can determine disability; b) how long the Department must follow a Social Security denial of disability; c) requirements for applicants and recipients to cooperate with the disability determination or redetermination process; d) when a person may receive Medicaid eligibility for past months if a denial of disability is later reversed; and e) the process for requesting a reconsideration of a disability decision when the individual has requested a fair hearing. These are required by H.B. 126. Language is modified in Section R414-303-1 to eliminate reference to the QI Group 2 program to extend the QI Group 1 program as required by Pub. L. No. 108-89 passed by Congress and signed into law October 1, 2003, and as required by Pub. L. No. 108-173 passed by Congress and signed into law December 8, 2003. Citations are added to Section R414-303-2 to define some coverage groups required by federal statute. The state has been covering these groups, but the added citation is required by H.B. 126. In Subsection R414-303-4(9), language about temporary absences and deprivation of support has been modified. In Subsection R414-303-4(13), the definition of what qualifies as incapacity has been clarified, and the requirement about who can certify that a person is incapacitated is expanded to include more medical professionals. Language is added in Section R414-303-3 to extend the 12-month transitional Medicaid program as required by Pub. L. No. 108-89 passed by Congress and signed into law October 1, 2003. Language is added in Section R414-303-9 to define criteria for the "Baby Your Baby" program, which includes a presumptive determination of eligibility for pregnant women, who can do a presumptive determination, criteria to be eligible, and when benefits end. Also, language is added to clarify that when a child is 18 years of age, the child cannot be made ineligible for poverty-related Medicaid coverage for children due to deeming parent's income or assets. These are not changes to the coverage provided by the Department, but an addition of this language to rules is required by H.B. 126, Medicaid Benefits Administration, passed by the 2003 Utah Legislature. Sections R414-303-5 and R414-303-6 have language added that states the Department of Human Services is responsible for determining eligibility for foster care and subsidized adoption Medicaid. Language is added to Section R414-303-16 to define a coverage limitation of three months, the initial month plus two additional months, for women diagnosed with a precancerous condition, and that the need for continued treatment of women diagnosed with breast or cervical cancer must be determined at each eligibility review. Coverage under this program ends when the woman is no longer in need of treatment. It also clarifies that a woman who cannot receive coverage until the pre-existing condition period ends is considered not to have insurance coverage until the pre-existing condition period ends. Minor clarifications and some citations have been updated, changed, or added in other parts of the rule.

 

State statutory or constitutional authorization for this rule:

Section 26-18-3, and Pub. L. No. 108-89 and Pub. L. No. 108-173

 

This rule or change incorporates by reference the following material:

42 CFR 435.115(f),(g) and (h); 42 CFR 435.115(e)(1) and (2), (f), (g), and (h); 42 CFR 435.120, 42 CFR 435.122, 42 CFR 435.130 through 435.135, 42 CFR 435.137, 42 CFR 435.138, 42 CFR 435.139, 42 CFR 435.211, 42 CFR 435.301, 42 CFR 435.320, 42 CFR 435.322, 42 CFR 435.324, 42 CFR 435.340, 42 CFR 435.350 and 42 CFR 435.541, 2001 ed; 42 CFR 435.116(a), 42 CFR 435.301(a) and (b), (1), (i), and (iv); 45 CFR 233.90, 2001 ed; 45 CFR 233.39, 45 CFR 233.90, and 45 CFR 233.100, 2001 ed; 45 CFR 400.90 through 400.107 as modified by the Federal Register (60 FR 33584, published Wednesday, June 28, 1995), and 45 CFR 401, 2001 ed; 20 CFR 416.901 through 1094, 2002 ed; Section 223(d)(4) of the Compilation of the Social Security Laws in effect January 1, 2001; Section 1611(b)(1) of the Social Security Act; Sections 1634(b), (c) and (d), 1902(a)(10)(A)(i)(II); 1902(a)(10)(A)(ii)(X), Sections 1902(a)(10)(E)(i) through (iv)(I), 902(a)(10)(A)(ii)(XIII), Sections 1902(a)(10)(A)(i)(II), 1902(a) (10)(A)(ii)(IX), 1902(a)(10)(A)(ii)(X); Sections 1902(a)(10)(A)(ii)(XVIII), 1925, 1931(a), (b), (c) and (g); Sections 1902(a)(10)(A)(i)(IV), (VI), (VII), 1902(a)(47), 1902(l); Sections 1902(a)(10)(A)(i)(III), 1902(a)(10)(E)(iv)(I) as required by Pub L. 108-89 effective October 1, 2003; Sections 1902(a)(10)(A)(ii)(XVIII), 1902(e)(1), (4), (5), (6), (7) and 1915(c) of Title XIX of the Social Security Act in effect January 1, 2001; Section 1902(a)(47) and 1902(l); Section 1902(l)(1)(D); Section 1902(k) in effect January 1, 1993; Section 1920(b)(2); Sections 1925 and 1931(c)(2); Sections 1925 and 1931(c)(2) as required by Pub L. 108-89 effective October 1, 2003; Section 1931 of the Act; Sections 1931(a) and (b); Sections 1931(a), (b), and (g); Section 1931(c)(1); Section 1933 of Title IX of the Social Security Act; Section Appendix C-4 of the Home and Community Based Waiver for Technology Dependent/Medically Fragile Children implementation plan effective on January 1, 1995 and renewed effective July 1, 2003 through June 30, 2008; DD/MR Home and Community Based Waiver found in R414-303-11; Centers for Disease Control and prevention Breast and Cervical Cancer Early Detection Program established under Title XV of the Public Health Service Act; Health Information Portability and Accountability Act (HIPAA) of Section 2701(c) of the Public Health Service Act

 

Anticipated cost or savings to:

the state budget:

There is no impact to the state budget associated with this rulemaking because it does not add any new programs or benefits.

 

local governments:

There is no budget impact to local governments associated with this rulemaking because this rule only applies to groups that are eligible for Medicaid.

 

other persons:

The group of individuals who are eligible for the QI Group 1 program will continue to save about $35,000 per month on their Medicare Part B premiums.

 

Compliance costs for affected persons:

There are no compliance costs for affected persons because this rulemaking does not set any new requirements or provide any new benefits for Medicaid clients. Furthermore, no benefits are eliminated as a result of this rulemaking.

 

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

Various rule changes are proposed to bring the rule in line with established Medicaid policies on eligibility groups and related eligibility issues. There should be no fiscal impact resulting from these changes. Scott D. Williams MD

 

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 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:

08/02/2004

 

This rule may become effective on:

08/03/2004

 

Authorized by:

Scott D. Williams, Executive Director

 

 

RULE TEXT

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

R414-303. Coverage Groups.

R414-303-1. [A, B and D Medicaid and A, B and D Institutional Medicaid Coverage Groups]Authority and Purpose.

This rule is authorized by Utah Code Sections 26-1-5 and 26-18-3 and establishes Medicaid eligibility requirements for the following coverage groups:

(1) Aged;

(2) Blind;

(3) Disabled;

(4) Family;

(5) Institutional;

(6) Transitional;

(7) Child;

(8) Refugee;

(9) Prenatal and Newborn;

(10) Pregnant Women;

(11) DD/MR Home and Community Based Services Waiver;

(12) Aging Home and Community Based Services Waiver;

(13) Technologically Dependent Child Waiver/Travis C. Waiver;

(14) Persons with Brain Injury Home and Community Based Services Waiver;

(15) Personal Assistance Waiver for Adults with Physical Disabilities; and

(16) Cancer Program.

 

R414-303-2. Definitions.

The definitions in R414-1 and R414-301 apply to this rule. In addition:

(1) "Medicaid agency" means any one of the state departments that determine eligibility for one or more of the following medical assistance programs: Medicaid, the Primary Care Network, or the Covered-at-Work program.

(2) "Federal poverty guideline" means the U.S. federal poverty measure issued annually by the Department of Health and Human Services that is used to determine financial eligibility for certain means-tested federal programs. Any usage in this rule of the term poverty means the federal poverty guideline.

 

R414-303-3. A, B and D Medicaid and A, B and D Institutional Medicaid Coverage Groups.

(1) The Department [shall ]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, 435.301, 435.320, 435.322, 435.324, 435.340, 435.350 and 435.541, [2000]2001 ed., which are incorporated by reference. The Department [shall ]provides coverage to individuals as described in 20 CFR 416.901 through 416.1094, [2000]2002 ed., which is incorporated by reference. The Department [shall ]provides coverage to individuals as required by [Sections 470 through 479, ]1634(b), (c) and (d), 1902(a)(10)(A)(i)(II), 1902(a)(10)(A)(ii)(X), and 1902(a)(10)(E)(i) through (iv)(I)[ and 1902(e)]of Title XIX of the Social Security Act in effect January 1, [1999]2001, which are incorporated by reference. The Department [shall ]provides coverage to individuals described in Section 1902(a)(10)(A)(ii)(XIII) of Title XIX of the Social Security Act in effect January 1, [1999]2001, which is incorporated by reference. Coverage under Section 1902(a)(10)(A)(ii)(XIII) [shall be referred to]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) If a client has been denied SSI or SSA and claims to have become disabled since the SSI or SSA decision, the State Medicaid Disability Office shall review current medical information to determine if the client is disabled.]

([4]3) [If a client has earned income and claims to be disabled,]An applicant or recipient may request the State Medicaid Disability Office to review medical evidence to determine if the individual is disabled or blind. If the client 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.

(a) If, within the prior 12 months, SSA has determined that the individual is not disabled, the Medicaid 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.

(b) 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.

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

(d) 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.

(a) The individual may provide the Department 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 Department shall notify the individual of its decision upon reconsideration. Thereafter, the individual may choose to pursue or abandon his fair hearing rights.

(5) If the Department denies an individual's Medicaid application because it or SSA has determined that the individual is not disabled and that determination is later reversed on appeal and the individual has otherwise been eligible, the individual's eligibility shall extend back to the application that gave rise to the appeal.

(a) Eligibility cannot begin any earlier than the date of disability onset or the date that is three months before the date of application as defined in R414-306-4(2), 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 Medicaid agency to request the Disability Medicaid coverage.

(c) The individual must provide any verifications the Medicaid agency needs to determine eligibility for past or 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 to receive coverage, the spenddown must be met before Medicaid coverage may be provided for those months.

([5]6) The age requirement for Aged Medicaid is 65 years of age.

([6]7) For children described in Section 1902(a)(10)(A)(i)(II) of the Social Security Act in effect January 1, [1999]2001, the Department shall conduct periodic redeterminations to assure that the child continues to meet the SSI eligibility criteria as required by the section.

([7]8) Coverage for qualifying individuals described in Section 1902(a)(10)(E)(iv)(I) of Title XIX of the Social Security Act in effect January 1, [1999]2001, is limited to the amount of funds allocated under Section 1933 of Title XIX of the Social Security Act in effect January 1, [1999]2001, for a given year, or as subsequently authorized by Congress. Applicants will be denied coverage when the uncommitted allocated funds are insufficient to provide such coverage.

([8]9) 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 Department 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.

([9]10) The Department 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-[2]4. Family Medicaid and Family Institutional Medicaid Coverage Groups.

(1) The Department shall provide Medicaid coverage to individuals who are eligible as described in 42 CFR 435.110, 435.113 through 435.117, 435.119, 435.210 for groups defined under 201(a)(5) and (6), 435.211, 435.217, 435.223, and 435.300 through 435.310, [2000]2001 ed., and 45 CFR 233.90, 2001 ed., and Title XIX of the Social Security Act as in effect January 1, [2000]2001, Sections 1902(e)(1), (4), (5), (6), (7), 1931(a), (b), and (g), which are incorporated by reference.

(2) The following definitions apply to this rule:

(a) "1931 Family Medicaid" (1931 FM) means a medical assistance program that meets the criteria found in Section 1931(a) and (b) of the Social Security Act in effect January 1, [1999]2001 that requires the Department to use the eligibility criteria of the pre-welfare reform Aid to Families With Dependent Children cash assistance program along with any subsequent amendments made by the Department as allowed under Section 1931 of the Act.

(b) "Family Employment Program" (FEP) means a grant program providing financial assistance to eligible families with dependent children. It is also referred to as Temporary Assistance to Needy Families (TANF).

(c) "Diversion" means a one time FEP payment that may equal up to three months of FEP cash assistance.

(3) The Department provides Medicaid coverage to individuals who are 1931 FM qualified, as described in 45 CFR 233.39, 233.90, and 233.100, 2001 ed., which are incorporated by reference.

(4) The Department provides 1931 Family Medicaid coverage to individuals who are qualified for FEP cash assistance.

(5) For unemployed two-parent households, the Department shall not require the primary wage earner to have an employment history.

(6) Households that receive a FEP diversion payment shall have the option to receive 1931 Family Medicaid coverage for three months beginning with the month of application for the diversion payment.

(7) A specified relative, other than the child's parents, may apply for assistance for a child. In addition to other Family Medicaid requirements, all the following rules apply to a Family Medicaid application by a specified relative:

(a) The child must be currently deprived of support because both parents are absent from the home where the child lives.

(b) The child must be currently living with, not just visiting, the specified relative.

(c) The parents' obligation to financially support their child shall be enforced.

(d) The income and resources of the specified relative will not be counted unless the specified relative is also included in the Medicaid coverage group.

(e) If the specified relative is currently included in a FEP household or a 1931 Family Medicaid household, the child shall be included in the FEP or 1931 FM case of the specified relative.

(f) The specified relative may choose to be excluded from the Medicaid coverage group. The ineligible children of the specified relative must be excluded. The specified relative will not be included in the income standard calculation.

(g) The specified relative may choose to exclude any child from the Medicaid coverage group. If a child is excluded from coverage, that child's income and resources will not be used to determine eligibility or spenddown.

(h) If the specified relative is not the parent of a dependent child who meets deprivation of support criteria and elects to be included in the Medicaid coverage group, the following income rules apply:

(i) The monthly gross earned income of the specified relative and spouse shall be counted.

(ii) The unearned income of the relative and the excluded spouse shall be counted.

(iii) For each employed person, $90 will be deducted from the monthly gross income.

(iv) Child care expenses necessary for employment will be deducted for only the specified relative's children. The maximum allowable deduction will be $200.00 per child under age two and $175.00 per child age two and older each month for full-time employment or $160.00 per child under age two and $140.00 per child age two and older each month for part-time employment.

(8) An American Indian child in a boarding school and a child in a school for the deaf and blind are considered temporarily absent from the household.

(9) Temporary absence from the home for purposes of schooling, vacation, [or] medical treatment, military service, or other temporary purpose shall not constitute non-resident status. The following situations do not meet the definition of absence for purposes of determining deprivation of support:

(a) parental absences [which are ]caused solely by reason of employment, schooling, military service, or training;

(b) an absent parent who will return home to live within 30 days from the date of application;

(c) an absent parent is the primary child care provider for the children, and the child care is frequent enough that the children are not deprived of parental support, care, or guidance.

(10) Joint custody situations are evaluated based on the actual circumstances that exist for a dependent child. The same policy is applied in joint custody cases as is applied in other absent parent cases.

(11) The Department imposes no suitable home requirement.

(12) Medicaid assistance is not continued for a temporary period [while the effects of deprivation of support are being overcome.]if deprivation of support no longer exists. If deprivation of support ends due to increased hours of employment of the primary wage earner, the household may qualify for Transitional Medicaid described in R414-303-5.

(13) Full-time employment nullifies a person's claim to incapacity. To claim an incapacity, a parent must meet one of the following criteria:

(a) receive SSI;

(b) be recognized as 100% disabled by the Veteran's Administration, or be determined disabled by the Medicaid Disability Review Office or the Social Security Administration;

(c) provide[ a Medical Report Form 21], either on a Department-approved form or in another written document, completed by [a physician]one of the following licensed medical professionals: medical doctor; doctor of Osteopathy; Advanced Practice Registered Nurse; Physician's Assistant; or a mental health therapist, which includes a [or licensed/certified ]psychologist, Licensed Clinical Social Worker, Certified Social Worker, Marriage and Family Therapist, Professional Counselor, or MD, DO or APRN engaged in the practice of mental health therapy, [which indicates ]that states the incapacity is expected to last at least 30 days. The medical report must also state that the incapacity will substantially reduce the parent's ability to work or care for the child.

 

R414-303-[3]5. 12 Month Transitional Family Medicaid.

(1) The Department complies with Title XIX of the Social Security Act, Sections 1925 and 1931 (c)(2) as in effect January 1, [1999]2001, which are incorporated by reference.

(2) The Department shall consider Medicaid coverage under 12 month Transitional Medicaid for households that lose eligibility for 1931 Family Medicaid, FEP cash assistance, and households that receive 1931 Family Medicaid for three months because they received a FEP Diversion payment.

 

R414-303-[4]6. Four Month Transitional Family Medicaid.

(1) The Department adopts 42 CFR 435.112 and 435.115(f), (g) and (h), [2000]2001 ed., and Title XIX of the Social Security Act, Section 1931(c)(1) in effect January 1, [1999]2001 which are incorporated by reference.

(2) Changes in household composition do not affect eligibility for the four month extension period. New household members may be added to the case only if they meet the AFDC or AFDC two-parent criteria for being included in the household if they were applying in the current month. Newborn babies are considered household members even if they were unborn the month the household became ineligible for Family Medicaid under Section 1931 of the Social Security Act. New members added to the case will lose eligibility when the household loses eligibility. Assistance shall be terminated for household members who leave the household.

 

R414-303-[5]7. Foster Care.

(1) The Department adopts 42 CFR 435.115(e)(2), [2000]2001 ed., which is incorporated by reference.

(2) Eligibility for foster children is not governed by this rule. The Department of Human Services determines eligibility for foster care Medicaid.

 

R414-303-[6]8. Subsidized Adoptions.

(1) The Department adopts 42 CFR 435.115(e)(1), [2000]2001 ed., which is incorporated by reference.

(2) Eligibility for subsidized adoptions is not governed by this rule. The Department of Human Services determines eligibility for subsidized adoption Medicaid.

 

R414-303-[7]9. Child Medicaid.

(1) The Department adopts 42 CFR 435.222 and 435.301 through 435.308, [2000]2001 ed., which are incorporated by reference.

(2) The Department elects to cover all individuals under age 18 who would be eligible for AFDC but do not qualify as dependent children. Individuals who are 18 years old may be covered if they would be eligible for AFDC except for not living with a specified relative or not being deprived of support.

(3) If a child receiving SSI elects to receive Child Medicaid or receives benefits under the Home and Community Based Services Waiver, the child's SSI income shall be counted with other household income.

 

R414-303-[8]10. Refugee Medicaid.

(1) The Department adopts 45 CFR 400.90 through 400.107, 2001 ed., which are modified by the Federal Register 60 FR 33584, published Wednesday, June 28, 1995, and 45 CFR 401, 2001 ed., all of which are incorporated by reference.

(2) Specified relative rules do not apply.

(3) Child support enforcement rules do not apply.

(4) The sponsor's income and resources are not counted. In-kind service or shelter provided by the sponsor is not counted.

(5) Initial settlement payments made to a refugee from a resettlement agency are not counted.

(6) Refugees may qualify for medical assistance for eight months after entry into the United States.

 

R414-303-[9]11. Prenatal and Newborn Medicaid.

(1) The Department adopts Title XIX of the Social Security Act, Section 1902(a)(10)(A)(i)(IV), (VI), (VII), 1902(a)(47) and 1902(l), in effect January 1, [1999]2001, and Title XIX of the Social Security Act, Section 1902(k) in effect January 1, 1993[, and Section 26-18-3.1], which are incorporated by reference.

(2) The following definitions apply to this section:

(a) "covered provider" means a provider that the Department has determined is qualified to make a determination of presumptive eligibility for a pregnant woman and that meets the criteria defined in Section 1920(b)(2) of the Social Security Act;

(b) "presumptive eligibility" means a period of eligibility for medical services for a pregnant woman based on self-declaration that she meets the eligibility criteria.

(3) The Department provides coverage to pregnant women during a period of presumptive eligibility if a covered provider determines, based on preliminary information, that the woman:

(a) is pregnant;

(b) meets citizenship or alien status criteria as defined in R414-302-1;

(c) has a declared household income that does not exceed 133% of the federal poverty guideline applicable to her declared household size; and

(d) the woman is not covered by CHIP.

(4) No resource test applies to determine presumptive eligibility of a pregnant woman.

(5) A pregnant woman made eligible for a presumptive eligibility period must apply for Medicaid benefits by the last day of the month following the month the presumptive coverage begins.

(6) The presumptive eligibility period shall end on the earlier of:

(a) the day that the Medicaid agency determines whether the woman is eligible for Medicaid based on her application; or

(b) in the case of a woman who does not file a Medicaid application by the last day of the month following the month the woman was determined presumptively eligible, the last day of that following month.

(7) A pregnant woman may receive medical assistance during only one presumptive eligibility period for any single term of pregnancy.

([2]8) The Department elects to impose a resource standard on Newborn Medicaid coverage for children age six to the month in which they turn age 19. The resource standard is the same as other Family Medicaid Categories.

([3]9) The Department elects to provide Prenatal Medicaid coverage to pregnant women whose countable income is equal to or below 133% of poverty.

([4]10) At the initial determination of eligibility for Prenatal Medicaid applicants who have $5,000 or more of assets, the Department will require the applicant to pay four percent of countable resources to become eligible for Prenatal Medicaid. This payment amount shall not exceed $3,367. The payment must be met with cash; incurred medical bills and medical expenses are not allowed to meet this payment.

([5]a) In subsequent months, through the 60 day postpartum period, the Department disregards all excess resources.

([6]b) This resource payment applies only to pregnant women covered under Sections 1902(a)(10)(A)(i)(IV) and 1902(a)(10)(A)(ii)(IX)[(A)] of the Social Security Act in effect January 1, [1999]2001.

([7]c) No resource payment will be required when the Department makes a determination based on information received from a medical professional that social, medical, or other reasons place the pregnant woman in a high risk category.

([8]11) Children born after September 30, 1983, may qualify for the newborn program through the month in which they turn 19.

(12) A child who is 18 but not yet 19 and meets the criteria under 1902(l)(1)(D) cannot be made ineligible for coverage under the Newborn program because of deeming income or assets from a parent, even if the child lives in the parent's home.

 

R414-303-[10]12. [PG]Pregnant Women Medicaid.

(1) The Department adopts 42 CFR 435.116 (a), 435.301 (a) and (b)(1)(i) and (iv),[2000]2001 ed. and Title XIX of the Social Security Act, Section 1902(a)(10)(A)(i)(III) in effect January 1, [1999]2001, which are incorporated by reference.

 

R414-303-[11]13. DD/MR Home and Community Based Services Waiver.

(1) The Department adopts 42 CFR 435.217 and 435.726, [2000]2001 ed., which are incorporated by reference. The Department adopts Title XIX of the Social Security Act, Section 1915(c) in effect January 1, [1999]2001, which is incorporated by reference.

(2) Medicaid Eligibility for Developmentally Disabled Mentally Retarded (DD/MR) Home and Community-Based Services is limited to mentally retarded and developmentally disabled individuals. Eligibility is limited to those referred by the Division of Services to People with Disabilities (DSPD) or any DD/MR worker.

(3) Medicaid eligibility for DD/MR Home and Community-Based Services is limited to individuals who qualify for a regular Medicaid coverage group, except for individuals who only qualify for the Primary Care Network.

(4) A client's resources must be equal to or less than the regular Medicaid resource limit. The spousal impoverishment resource provisions for married, institutionalized individuals in R414-305-3 apply.

(5) All of the client's income is countable unless excluded under other federal laws that exclude certain income from being counted to determine eligibility for federally-funded, needs-based medical assistance.

(6) To determine countable earned income, the Department will deduct from the individual's earned income an amount equal to the substantial gainful activity level of earnings defined in Section 223(d)(4) of the Compilation of the Social Security Laws in effect January 1, [1999]2001.

(7) The Department shall allow deductions for any health insurance or medical expenses for the waiver eligible client that are paid by the waiver client.

(8) The spousal impoverishment provisions for Institutional Medicaid income apply.

(9) The client obligation for the contribution to care, which may be referred to as a spenddown, will be the amount of income that exceeds the personal needs allowance after allowable deductions. The contribution to care must be paid to the Department.

(10) The Department shall count parental and spousal income only if the client is given a cash contribution from a parent or spouse.

(11) A client who transfers resources for less than fair market value for the purpose of obtaining Medicaid may be ineligible for an indefinite period of time. If the transfer occurred prior to August 11, 1993, the period of ineligibility shall not exceed 30 months.

 

R414-303-[12]14. Aging Home and Community Based Services Waiver.

(1) The Department adopts 42 CFR 435.217 and 435.726, [2000]2001 ed., which are incorporated by reference. The Department adopts Title XIX of the Social Security Act, Section 1915(c) in effect January 1, [1999]2001, which is incorporated by reference.

(2) Medicaid eligibility for Aging Home and Community-Based Services is limited to individuals eligible for Aged Medicaid who could qualify for skilled nursing home care except that the spousal impoverishment resource limits apply. Eligibility is limited to those referred by the Division of Aging or a county aging worker.

(3) A client's resources must be equal to or less than the regular Medicaid resource limit. The spousal impoverishment resource provisions for married, institutionalized individuals in R414-305-3 apply.

(4) All income is counted, unless excluded under other federal laws that exclude certain income from being counted to determine eligibility for federally-funded, needs-based medical assistance. The client's contribution to care, which may be referred to as a spenddown, is determined counting only the client's income less allowable deductions.

(5) The spousal impoverishment provisions for Institutional Medicaid income apply. Income deductions include health insurance premiums, medical expenses, a percentage of shelter costs and an aging waiver personal needs deduction.

(6) A client who transfers resources for less than fair market value for the purpose of obtaining Medicaid may be ineligible for an indefinite period of time. If the transfer occurred prior to August 11, 1993, the period of ineligibility shall not exceed 30 months.

(7) The Department shall count a spouse's income only if the client is given a cash contribution from a spouse.

 

R414-303-[13]15. Technologically Dependent Child Waiver/Travis C. Waiver.

(1) The Department adopts 42 CFR 435.217 and 435.726, [2000]2001 ed., which are incorporated by reference. The Department adopts Title XIX of the Social Security Act, Section 1915(c) in effect January 1, [1999]2001, which is incorporated by reference.

(2) The Department will operate this program statewide with a limited number of available slots.

(3) Eligibility for services under this waiver require that the individual meets the medical criteria established by the Department and the Division in Section Appendix C-4 of the Home and Community Based Waiver for Technology Dependent/Medically Fragile Children implementation plan effective on January 1, 1995 and renewed effective July 1, [1998]2003 through June 30, [2003]2008, which is incorporated by reference.

(4) To be eligible for admission to this waiver, the individual must be under age 21 at the time of admission to the waiver. An individual is considered to be under age 21 until the month after the month in which the twenty first birthday falls.

(5) Once admitted to the waiver, the individual can continue to receive waiver benefits and services as long as the individual continues to meet the medical criteria defined by the Department in R414-303-15(3), non-financial Medicaid eligibility criteria in R414-302, a Medicaid category of coverage defined in R414-303, and the income and resource criteria defined in R414-303-[11]13, except that the earned income deduction is limited to $125.

(6) Income and resource eligibility requirements follow the rules for the DD/MR Home and Community Based Services Waiver found in R414-303-[11.]13, except that the earned income deduction is limited to $125.

 

R414-303-[14]16. Persons with Brain Injury Home and Community Based Services Waiver.

(1) The Department adopts 42 CFR 435.217 and 435.726, [2000]2001 ed., which are incorporated by reference. The Department adopts Title XIX of the Social Security Act, Section 1915(c) in effect January 1, [1999]2001, which is incorporated by reference.

(2) The Department will operate this program statewide [initially] with a limited number of available slots.

(3) Eligibility for services under this waiver requires that the individual has medical needs resulting from a brain injury. This means that the individual must be in need of skilled nursing or rehabilitation services as a result of the damage sustained because of the brain injury. A medical need determination will be established through the Department of Human Services, Division of Services for People with Disabilities.

(4) To qualify for services under this waiver, the individual must be 18 years old or older. The person is considered to be 18 in the month in which the 18th birthday falls.

(5) All other eligibility requirements follow the rules for the Aging Home and Community Based Services Waiver found in R414-303-[12]14.

(6) The spousal impoverishment provisions for Institutional Medicaid income apply, with one exception: An individual who has a dependent family member living in the home is allowed a deduction for a dependent family member even if the individual is not married or is not living with the spouse.

 

R414-303-[15]17. Personal Assistance Waiver for Adults with Physical Disabilities.

(1) The Department adopts 42 CFR 435.726 and 435.217, [2000]2001 ed., which are incorporated by reference. The Department adopts Title XIX of the Social Security Act, Section 1915(c) in effect January 1, [1999]2001, which is incorporated by reference.

(2) The Department operates this program statewide with a limited number of slots, and eligibility for this waiver [shall be]is limited to individuals 18 years of age and over.

(3) The individual must meet non-financial criteria for Aged, Blind, or Disabled Medicaid.

(4) A client must qualify for a nursing home level of care. Eligibility is limited to those referred by the Division of Services to People with Disabilities and determined medically eligible by the Bureau of Medicare/Medicaid Program Certification and Resident Assessment.

(5) A client's resources must be equal to or less than $2000. The spousal impoverishment resource provisions for married, institutionalized clients in R414-305-3 apply to this rule.

(6) Countable income is determined using income rules of Aged, Blind, or Disabled Institutional Medicaid. All income is counted, unless excluded under other federal laws that exclude certain income from being counted to determine eligibility for federally-funded, needs-based medical assistance. After determining countable income, eligibility is determined counting only the gross income of the client.

(7) The client's income can not exceed three times the SSI benefit amount payable under Section 1611(b)(1) of the Social Security Act, except that individuals with income over this amount can spenddown to the Medicaid Basic Maintenance Standard for a household of one.

(8) Transfer of resource provisions described in R414-305-6 apply to this rule.

 

R414-303-[16]18. Medicaid Cancer Program.

(1) The Department shall provide coverage to individuals described in 1902(a)(10)(A)(ii)(XVIII) of the Social Security Act in effect January 1, [1999]2001, as amended by Pub. L. No. 106-354 effective October 24, 2000[.], which is incorporated by reference. This coverage shall be referred to as the Medicaid Cancer Program.

([1]2) Medicaid eligibility for services under this program will be provided to women who have been screened for breast or cervical cancer under the Centers for Disease Control and prevention Breast and Cervical Cancer Early Detection Program established under Title XV of the Public Health Service Act and are in need of treatment.

([2]3) A woman who is covered for treatment of breast or cervical cancer under a group health plan or other health insurance coverage defined by the Health [Insurance]Information Portability and Accountability Act (HIPAA) of Section 2701 (c) of the Public Health Service Act, is not eligible for coverage under the program. If the woman has insurance coverage but is subject to a pre-existing condition period that prevents her from receiving treatment for her breast or cervical cancer or precancerous condition, she is considered to not have other health insurance coverage until the pre-existing condition period ends at which time her eligibility for the program ends.

([3]4) A woman who is eligible for Medicaid under any mandatory categorically needy eligibility group, or any optional categorically needy or medically needy program that does not require a spenddown or a premium, is not eligible for coverage under the program.

([4]5) A woman must be under 65 years of age to enroll in the program.

(6) Coverage for the treatment of precancerous conditions is limited to two calendar months after the month benefits are made effective.

(7) Coverage for a woman with breast or cervical cancer under 1902(a)(10)(A)(ii)(XVIII) ends when she is no longer in need of treatment for breast or cervical cancer. At each eligibility review, eligibility workers determine whether an eligible woman is still in need of treatment based on the woman's doctor's statement or report.

 

KEY: income, coverage groups[*]

[July 2, 2002]2004

Notice of Continuation January 31, 2003

26-18-3

26-1-5