No. 32747 (Amendment): R414-303-11. Prenatal and Newborn Medicaid

DAR File No.: 32747
Filed: 06/24/2009, 02:06
Received by: NL

RULE ANALYSIS

Purpose of the rule or reason for the change:

The purpose of this change is to implement the requirements of The Children's Health Insurance Program Reauthorization Act, and to modify this rule to comply with The American Recovery and Reinvestment Act of 2009 (ARRA).

Summary of the rule or change:

This change adds a provision that requires states to provide one year of Medicaid coverage to infants born to a mother who is eligible for Medicaid at the time of birth, regardless of whether the infant remains in the mother's home. In addition, this change states that the Department cannot remove an 18-year old from the Medicaid case of the parent and other children when the 18-year old lives with the parent, and the Department must count parents' income to determine the 18-year old's eligibility for poverty level Medicaid. (DAR NOTE: A corresponding 120-day (emergency) rule that is effective as of 07/01/2009 is under DAR No. 32746 in this issue, July 15, 2009, of the Bulletin.)

State statutory or constitutional authorization for this rule:

Section 26-18-3

This rule or change incorporates by reference the following material:

Title XIX of The Social Security Act, Sections 1902(a)(10)(A)(i)(IV), (VI),(VII), 1902(a)(47), 1902(e)(4)and(5), and 1902(I), in effect January 1, 2009

Anticipated cost or savings to:

the state budget:

These changes could result in some infants who are placed for adoption receiving up to five months of additional coverage. The change in coverage for 18-year olds must be made or the Department could lose up to $68,263,000 in enhanced federal matching funds under ARRA.

local governments:

This change does not impact local governments because they do not determine Medicaid eligibility or provide Medicaid services.

small businesses and persons other than businesses:

There may be a nominal savings to some families with infants who are eligible to receive additional months of Medicaid coverage. Nevertheless, there is insufficient data to determine that savings. In addition, this change could also result in a cost for 18-year olds who may lose coverage and have to pay for medical care. However, there is insufficient data to determine that cost.

Compliance costs for affected persons:

This change could result in a savings to a family with an eligible infant because the infant may receive additional months of Medicaid coverage. However, there is insufficient data to determine that savings. In addition, this change could also result in a cost for an 18-year old who may lose coverage and have to pay for medical care. Once again, there is insufficient data to determine that cost.

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

This rule change implements changes in federal law and will not have a fiscal impact on business. 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:

Kimi McNutt at the above address, by phone at 801-538-6381, 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:

08/14/2009

This rule may become effective on:

08/21/2009

Authorized by:

David N. Sundwall, Executive Director

RULE TEXT

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

R414-303. Coverage Groups.

R414-303-11. Prenatal and Newborn Medicaid.

(1) The Department [adopts]incorporates by reference 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, 200[5]9, 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 for Prenatal Medicaid whose countable resources exceed $5,000 must pay four percent of countable resources to the agency to receive Prenatal Medicaid. The maximum payment amount is $3,367. The payment must be met with cash. The applicant cannot use any medical bills 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, 200[5]9.

(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. If the mother is not eligible, the Department determines if the infant is eligible under other Medicaid programs.

(12) The Department provides Medicaid coverage to an infant until the infant turns one-year old when born to a woman eligible for Utah Medicaid on the date of the delivery of the infant, without regard to whether the infant remains in the birth mother's home or whether the birth mother would continue to be eligible for Medicaid, in compliance with Sec. 113(b)(1), Children's Health Insurance Program Reauthorization Act, Pub. L. No. 111 3. The infant must continue to be a Utah resident to receive coverage.

(1[2]3) Children who meet the criteria under the Social Security Act, Section 1902(l)(1)(D) may qualify for the newborn program through the month in which they turn 19. The agency deems the parent's income and resources to the 18-year old to determine eligibility when the 18-year old lives in the parent's home. An 18-year old who does not live with a parent may apply on his own, in which case the agency does not deem income or resources from the parent.[

(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: [November 21, 2007]2009

Notice of Continuation: January 25, 2008

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