No. 37121 (Emergency Rule): Rule R414-306. Program Benefits and Date of Eligibility

DAR File No.: 37121
Filed: 12/28/2012 08:45:56 AM

RULE ANALYSIS

Purpose of the rule or reason for the change:

The purpose of this emergency rule is to make technical changes to the rule to end medical assistance coverage for the Qualifying Individuals program.

Summary of the rule or change:

This change removes language about the benefits and coverage period for individuals eligible for the Qualifying Individuals program, which is due to sunset under federal statute after 12/31/2012. (DAR NOTE: With the passage of Section 621 of H.R. 8, American Taxpayer Relief Act of 2012, signed on 01/02/2013, another emergency rule was filed under DAR No. 37174 that restores this program as of 01/07/2013, and supersedes this emergency rule. The emergency rule under DAR No. 37174 will be published in the February 1, 2013, issue of the Bulletin.)

Emergency rule reason and justification:

Regular rulemaking procedures would cause an imminent budget reduction because of budget restraints or federal requirements; and place the agency in violation of federal or state law.

Justification: Federal authority to provide medical assistance for Qualifying Individuals ends after 12/31/2012. There will be no federal funds to provide medical assistance to anyone under this coverage group. The Qualifying Individuals program is 100% federal match dollars. (See DAR NOTE under the summary above.)

State statutory or constitutional authorization for this rule:

• Section 26-18-3
• Section 26-1-5

Anticipated cost or savings to:

the state budget:

The state cost for the number of enrolled persons in the Qualifying Individuals group is about $201,513 per month if the Department were to continue coverage after the federal sunset date. This cost, however, is considered in the companion filing for Rule R414-303, which actually removes coverage for this group.

local governments:

This change does not create costs for local governments because they do not determine Medicaid eligibility.

small businesses:

This change will not cost small businesses anything because the Qualifying Individuals program only pays the Medicare Part B premium. It does not provide any other benefits.

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

This change creates a cost of about $201,513 for individuals who will lose medical benefits as a result of this change.

Compliance costs for affected persons:

An individual who loses eligibility for the Qualifying Individuals program will incur a cost of $104.90 a month to pay the Medicare Part B premium.

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

Lack of federal funding as of 01/01/2013 necessitates termination of this Medicaid eligibility group. Fiscal impact on businesses that serve Medicaid clients that qualify through this program is unavoidable.

David Patton, PhD, 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]

This rule is effective on:

01/01/2013

Authorized by:

David Patton, Executive Director

RULE TEXT

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

R414-306. Program Benefits and Date of Eligibility.

R414-306-2. QMB[,] and SLMB[, and QI] Benefits.

(1) The Department must provide the services outlined under 42 U.S.C. 1396d(p) and 42 U.S.C. 1396u-3 for Qualified Medicare Beneficiaries.

(2) The Department provides the benefits outlined under 42 U.S.C. 1396d(p)(3)(ii) for Specified Low-Income Medicare Beneficiaries[ and Qualifying Individuals. Benefits for Qualifying Individuals are subject to the provisions of 42 U.S.C. 1396u-3].

(3) The Department does not cover premiums for enrollment with any health insurance plans except for Medicare.

 

R414-306-4. Effective Date of Eligibility.

(1) Subject to the exceptions in Subsection R414-306-4(3), eligibility for any Medicaid program, and for the Specified Low-income Medicare Beneficiary (SLMB)[ or Qualified Individual (QI)] programs begins the first day of the application month if the individual is determined to meet the eligibility criteria for that month.

(2) An applicant for Medicaid[,] or SLMB [or QI ]benefits may request medical coverage for the retroactive period. The retroactive period is the three months immediately preceding the month of application.

(a) An applicant may request coverage for one or more months of the retroactive period.

(b) Subject to the exceptions in Subsection R414-306-4(3), eligibility for retroactive medical coverage begins no earlier than the first day of the month that is three months before the application month.

(c) The applicant must receive medical services during the retroactive period and be determined eligible for the month he receives services.

(3) To determine the date eligibility for medical assistance may begin for any month, the following requirements apply:

(a) Eligibility of an individual cannot begin any earlier than the date the individual meets the state residency requirement defined in Section R414-302-2;

(b) Eligibility of a qualified alien subject to the five-year bar on receiving regular Medicaid services cannot begin earlier than the date that is five years after the date the person became a qualified alien, or the date the five-year bar ends due to other events defined in statute;

(c) Eligibility of a qualified alien not subject to the five-year bar on receiving regular Medicaid services can begin no earlier than the date the individual meets qualified alien status.

(d) An individual who is ineligible for Medicaid while residing in a public institution or an Institution for Mental Disease (IMD) may become eligible on the date the individual is no longer a resident of either one of these institutions. If an individual is under the age of 22 and is a resident of an IMD, the individual remains a resident of the IMD until he is unconditionally released.

(4) If an applicant is not eligible for the application month, but requests retroactive coverage, the agency will determine eligibility for the retroactive period based on the date of that application.

(5) The agency may use the same application to determine eligibility for the month following the month of application if the applicant is determined ineligible for both the retroactive period and the application month. In this case, the application date changes to the date eligibility begins. The retroactive period associated with the application changes to the three months preceding the new application date.

(6) Medicaid eligibility for certain services begins when the individual meets the following criteria:

(a) Eligibility for coverage of institutional services cannot begin before the date that the individual has been admitted to a medical institution and meets the level of care criteria for admission. The medical institution must provide the required admission verification to the Department within the time limits set by the Department in Rule R414-501. Medicaid eligibility for institutional services does not begin earlier than the first day of the month that is three months before the month of application for Medicaid coverage of institutional services.

(b) Eligibility for coverage of home and community-based services under a Medicaid waiver cannot begin before the first day of the month the client is determined by the case management agency to meet the level of care criteria and home and community-based services are scheduled to begin within the month. The case management agency must verify that the individual meets the level of care criteria for waiver services. Medicaid eligibility for waiver services does not begin earlier than the first day of the month that is three months before the month of application for Medicaid coverage of waiver services.

[(7) An individual determined eligible for QI benefits in a calendar year is eligible to receive those benefits throughout the remainder of the calendar year, if the individual continues to meet the eligibility criteria and the program still exists. Receipt of QI benefits in one calendar year does not entitle the individual to QI benefits in any succeeding year.

] ([8]7) After being approved for Medicaid, a client may later request coverage for the retroactive period associated with the approved application if the following criteria are met:

(a) The client did not request retroactive coverage at the time of application; and

(b) The agency did not make a decision about eligibility for medical assistance for that retroactive period; and

(c) The client states that he received medical services and provides verification of his eligibility for the retroactive period.

([9]8) A client cannot request coverage for the retroactive period associated with a denied application. The client, however, may reapply and a new retroactive coverage period is considered based on the new application date.

 

KEY: effective date, program benefits, medical transportation

Date of Enactment or Last Substantive Amendment: January 1, 2013

Notice of Continuation: January 25, 2008

Authorizing, and Implemented or Interpreted Law: 26-18

 

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