No. 30133 (Amendment): R414-303. Coverage Groups

DAR File No.: 30133
Filed: 06/26/2007, 10:51
Received by: NL

RULE ANALYSIS

Purpose of the rule or reason for the change:

This amendment is needed to change the resource test for pregnant women, to require verification of a high-risk pregnancy before a client pays a resource payment if the client wants to have the payment waived. It also clarifies that a baby born to a woman who is only presumptively eligible is not eligible for the one year of continued coverage based on the presumptive eligibility.

Summary of the rule or change:

This amendment modifies the resource limit for the prenatal program so that the resource test is now over $5,000 instead of being equal to or greater than $5,000. This change makes the test consistent with how Medicaid applies its other resource tests. This change also clarifies when a pregnant women must document whether she is in a high-risk category before making the payment so that the agency can verify whether the payment may be waived. It incorporates federal statute with an exception that preserves current rule that provides that an infant born to a woman who is only presumptively eligible for Medicaid is not eligible for one year of continued coverage. It also updates the names of the federal waivers in Section R414-303-1. The waivers have not changed, just their names.

State statutory or constitutional authorization for this rule:

Section 26-18-3

This rule or change incorporates by reference the following material:

Section 1902(a)(10)(A)(i)(IV), (VI), (VII); 1902(a)(10)(A)(ii)(IX); 1902(a)(47); 1902(e)(4) and (5); and 1902(l) of the Social Security Act, effective 01/01/2005

Anticipated cost or savings to:

the state budget:

There is no budget impact because this amendment does not add new eligibles and does not reduce Medicaid coverage. The change in the resource limit is only a one cent change and will have a negligible, if any, impact on the number of women who will qualify for Medicaid. The change to Subsection R414-303-11(11) appears to exclude some children from coverage who were previously covered. However, this does not change coverage and is inserted as a necessary exception to the materials incorporated by reference in Subsection R414-303-11(1).

local governments:

There is no budget impact because local governments do not determine Medicaid eligibility and they are not Medicaid clients.

other persons:

There is no impact on other persons because this amendment does not add new eligibles and does not reduce Medicaid coverage. The change in the resource limit is only a one cent change and will have a negligible, if any, impact on the number of women who will qualify for Medicaid. The change to subsection R414-303-11(11) appears to exclude some children from coverage who were previously covered. However, this does not change coverage and is inserted as a necessary exception to the materials incorporated by reference in Subsection R414-303-11(1).

Compliance costs for affected persons:

There is no impact on other affected because this amendment does not add new eligibles and does not reduce Medicaid coverage. The change in the resource limit is only a one cent change and will have a negligible, if any, impact on the number of women who will qualify for Medicaid. The change to subsection R414-303-11(11) appears to exclude some children from coverage who were previously covered. However, this does not change coverage and is inserted as a necessary exception to the materials incorporated by reference in Subsection R414-303-11(1).

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

This rule does not change eligibility or benefits. No fiscal impact on business is expected. 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 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:

08/14/2007

This rule may become effective on:

08/21/2007

Authorized by:

David N. Sundwall, Executive Director

RULE TEXT

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

R414-303. Coverage Groups.

R414-303-1. 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]Community Supports Waiver for 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 Waiver; and

(16) Cancer Program.

 

R414-303-11. 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), 1902(e)(4) and (5) and 1902(l), in effect January 1, [2001]2005, and Title XIX of the Social Security Act, Section 1902(k) in effect January 1, 1993, 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.

(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.

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

(10) At the initial determination of eligibility for Prenatal Medicaid, the agency determines the applicant's countable resources using SSI resource methodologies. [applicants]Applicants for Prenatal Medicaid whose [have $5,000 or more of ]countable resources exceed $5,000[assets, the Department will require the applicant to] must pay four percent of countable resources to the agency to receive[become eligible for] Prenatal Medicaid. [This]The maximum payment amount [shall not exceed]is $3,367. The payment must be met with cash[;]. The applicant cannot use any [incurred ]medical bills [and medical expenses are not allowed ]to meet this payment.

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

(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) of the Social Security Act in effect January 1, [2001]2005.

(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. To obtain this waiver of the resource payment, the woman must provide this information to the agency before the woman pays the resource payment so the agency can determine if she is in a high risk category.

(11) A child born to a woman who is only presumptively eligible at the time of the infant's birth is not eligible for the one year of continued coverage defined in Section 1902(e)(4) of the Social Security Act. The mother can apply for Medicaid after the birth and if determined eligible back to the date of the infant's birth, the infant is then eligible for the one year of continued coverage under Section 1902(e)(4) of the Social Security Act.

([11]12) Children [born after September 30, 1983, ]may qualify for the newborn program through the month in which they turn 19.

([12]13) 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.

 

KEY: income, coverage groups, independent foster care adolescent

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

Notice of Continuation: January 31, 2003

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