No. 42628 (Amendment): Section R414-308-3. Application and Signature

(Amendment)

DAR File No.: 42628
Filed: 02/27/2018 11:05:48 AM

RULE ANALYSIS

Purpose of the rule or reason for the change:

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

Summary of the rule or change:

This amendment 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".

Statutory or constitutional authorization for this rule:

• 42 CFR 435.907
• Section 26-1-5
• Section 26-18-3

Anticipated cost or savings to:

the state budget:

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

local governments:

There is no impact to 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, prison, 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]

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:

04/16/2018

This rule may become effective on:

04/23/2018

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, MD, has reviewed and approved this fiscal analysis.

 

 

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

R414-308. Application, Eligibility Determinations and Improper Medical Assistance.

R414-308-3. Application and Signature.

(1) The Department [adopts and incorporates by reference,]shall comply with the requirements in 42 CFR 435.907, [October 1, 2012 ed.,]concerning the application [requirements ]for medical assistance[programs].

(a) The applicant or authorized representative must complete and sign the application under penalty of perjury. If an applicant cannot write, the applicant must make his mark on the application form and have at least one witness to the signature.

(b) A representative may apply on behalf of an individual. A representative may be a legal guardian, a person holding a power of attorney, a representative payee or other responsible person acting on behalf of the individual. In this case, the eligibility agency may send notices, requests and forms to both the individual and the individual's representative, or to just the individual's representative. The eligibility agency may assign someone to act as the authorized representative when the individual requires help to apply and cannot appoint a representative.

(c) If the Division of Child and Family Services (DCFS) has custody of a child and the child is placed in foster care, DCFS completes the application. DCFS determines eligibility for the child pursuant to a written agreement with the Department. DCFS also determines eligibility for children placed under a subsidized adoption agreement. The Department does not require an application for Title IV-E eligible children.

(2) The application date for medical assistance is the date that the eligibility agency receives the application during normal business hours on a week day that does not include Saturday, Sunday or a state holiday except as described below:

(a) When the individual applies through the federally facilitated marketplace (FFM) and the application is transferred from the FFM for a Medicaid eligibility determination, the date of application is the date the individual applies through the FFM.

(b) If the application is delivered to the eligibility agency after the close of business, the date of application is the next business day;

(c) If the applicant delivers the application to an outreach location during normal business hours, the date of application is that business day when outreach staff is available to receive the application. If the applicant delivers the application to an outreach location on a non-business day or after normal business hours, the date of application is the last business day that a staff person from the eligibility agency was available at the outreach location to receive or pick up the application;

(d) When the eligibility agency receives application data transmitted from the Social Security Administration (SSA) pursuant to the requirements of 42 U.S.C. Sec. 1320b-14(c), the eligibility agency shall use the date that the individual submits the application for the low-income subsidy to the SSA as the application date for Medicare cost sharing programs. The application processing period for the transmitted data begins on the date that the eligibility agency receives the transmitted data. The transmitted data meets the signature requirements for applications for Medicare cost sharing programs;

(e) If an application is filed through the "myCase" system, the date of application is the date the application is submitted to the eligibility agency online.

(3) The eligibility agency shall accept a signed application that an applicant sends by facsimile as a valid application.

(4) If an applicant submits an unsigned or incomplete application form to the eligibility agency, the eligibility agency shall notify the applicant that he must sign and complete the application no later than the last day of the application processing period. The eligibility agency shall send a signature page to the applicant and give the applicant at least ten days to sign and return the signature page. When the application is incomplete, the eligibility agency shall notify the applicant of the need to complete the application and offer ways to complete the application.

(a) The date of application for an incomplete or unsigned application form is the date that the eligibility agency receives the application if the agency receives a signed signature page and completed application within the application processing period.

(b) If the eligibility agency does not receive a signed signature page and completed application form within the application processing period, the application is void and the eligibility agency shall send a denial notice to the applicant.

(c) If the eligibility agency receives a signed signature page and completed application within 30 calendar days after the notice of denial date, the date of receipt is the new application date and the provisions of Subsection R414-308-3(2) apply.

(d) If the eligibility agency receives a signed signature page and completed application more than 30 calendar days after it sends the denial notice, the applicant must reapply by completing and submitting a new application form. The new application date is determined in accordance with this rule.

(5) The eligibility agency treats the following situations as a new application without requiring a new application form. The application date is the day that the eligibility agency receives the request or verification from the recipient. The effective date of eligibility for these situations depends on the rules for the specific program:

(a) A household with an open medical assistance case asks to add a new household member by contacting the eligibility agency;

(b) The eligibility agency ends medical assistance when the recipient fails to return requested verification, and the recipient provides all requested verification to the eligibility agency before the end of the calendar month that follows the closure date. The eligibility agency waives the requirement for the open enrollment period during that calendar month for programs subject to open enrollment;

(c) A medical assistance program other than PCN ends due to an incomplete review, and the recipient responds to the review request within the three calendar months that follow the closure date. The provisions of Section R414-310-14 apply to recertification for PCN enrollment;

(d) Except for PCN, Targeted Adult Medicaid and UPP that are subject to open enrollment periods, the eligibility agency denies an application when the applicant fails to provide all requested verification, but provides all requested verification within 30 calendar days of the denial notice date. The new application date is the date that the eligibility agency receives all requested verification and the retroactive period is based on that date. The eligibility agency does not act if it receives verification more than 30 calendar days after it denies the application. The recipient must complete a new application to reapply for medical assistance;

(e) For PCN, Targeted Adult Medicaid and UPP applicants, the eligibility agency denies an application when the applicant fails to provide all requested verification, but provides all requested verification within 30 calendar days of the denial notice date and the eligibility agency has not stopped the open enrollment period. If the eligibility agency has stopped enrollment, the applicant must wait for an open enrollment period to reapply.

[(6) The eligibility agency shall use the 2013 eligibility criteria in effect from October 1, 2013, through December 31, 2013, when considering applications that it receives during that time period. The agency may also use the three-month retroactive period.]

([7]6) For an individual who applies for and is found ineligible for Medicaid from October 1, 2013, and December 31, 2013, the eligibility agency shall redetermine eligibility under the policies that become effective January 1, 2014, using the modified adjusted gross income (MAGI)-based methodology without requiring a new application.

(a) Medicaid eligibility may begin no earlier than January 1, 2014, for an individual who becomes eligible using the MAGI-based methodology;

(b) For applications received on or after January 1, 2014, the eligibility agency shall apply the MAGI-based methodology first to determine Medicaid eligibility.

(c) The eligibility agency shall determine eligibility for other Medicaid programs that do not use MAGI-based methodology if the individual meets the categorical requirements of these programs, which may include a medically needy eligibility group for individuals found ineligible using the MAGI-based methodology.

([8]7) If a medical assistance case closes for one or more calendar months, the recipient must complete a new application form to reapply, except as defined in Subsection R414-308-6(7).

([9]8) An individual determined eligible for a presumptive eligibility period must file an application for medical assistance with the eligibility agency in accordance with the requirements of Sections 1920, 1920A and 1920B of the Social Security Act.

([10]9) The eligibility agency shall process low-income subsidy application data transmitted from SSA in accordance with 42 U.S.C. Sec. 1320b-14(c) as an application for Medicare cost sharing programs. The eligibility agency shall take appropriate steps to gather the required information and verification from the applicant to determine the applicant's eligibility.

(a) Data transmitted from SSA is not an application for Medicaid.

(b) An individual who wants to apply for Medicaid when contacted for information to process the application for Medicare cost sharing programs must complete and sign a Department-approved application form for medical assistance. The date of application for Medicaid is the date that the eligibility agency receives the application for Medicaid.

 

KEY: public assistance programs, applications, eligibility, Medicaid

Date of Enactment or Last Substantive Amendment: [March 28, 2017]2018

Notice of Continuation: January 8, 2018

Authorizing, and Implemented or Interpreted Law: 26-18

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