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Utah Administrative Code (Current through November 1, 2019) |
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R414. Health, Health Care Financing, Coverage and Reimbursement Policy |
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R414-307. Eligibility for Home and Community-Based Services Waivers |
| R414-307-1. Introduction and Authority |
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(1) Section 26-18-3 authorizes this rule. It establishes eligibility requirements for Medicaid coverage for home and community-based service waivers. (2) The Department adopts 42 CFR 435.217 and 435.726, 2011 ed., which are incorporated by reference. The Department adopts Title XIX of the Social Security Act, Section 1915(c) in effect April 13, 2012, which is incorporated by reference. |
| R414-307-2. Definitions |
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The definitions found in Rules R 414-1 and R414-301 apply to this rule. |
| R414-307-3. General Requirements for Home and Community-Based Services Waivers |
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(1) The Department shall apply the provisions of Sec. 2404 of Pub. L. No. 111 148, Patient Protection and Affordable Care Act, which refers to applying the provisions of Section 1924 of the Social Security Act to married individuals who are eligible for home and community-based waiver services. (2) To qualify for Medicaid coverage of home and community-based waiver services, an individual must meet: (a) the medical eligibility criteria defined in the State Waiver Implementation Plan adopted in Rule R414-61, which applies to the specific waiver under which the individual is seeking services, as verified by the operating agency case manager; (b) the financial and non-financial eligibility criteria for one of the Medicaid coverage groups selected in the specific waiver implementation plan under which the individual is seeking services; and (c) other requirements defined in this rule that apply to all waiver applicants and recipients, or specific to the waiver for which the individual is seeking eligibility. (3) The provisions found in Rule R414-304 and Rule R414-305 apply to eligibility determinations under a Home and Community-Based Services (HCBS) waiver, except where otherwise stated in this rule. (4) The Department shall limit the number of individuals covered by an HCBS waiver as provided in the adopted waiver implementation plan. (5) The Department adopts and incorporates by reference 42 U.S.C. 1396p(f), in effect February 7, 2016. An individual is ineligible for nursing facility and other long-term care services when an individual has home equity that exceeds the limit set forth in Subsection 1396p(f). (a) The Department sets that limit at the minimum level allowed under Subsection 1396p(f). (b) An individual who has excess home equity and meets eligibility criteria under a community Medicaid eligibility group defined in the Medicaid State Plan may receive Medicaid for services other than long-term care services provided under the plan or the HCBS waiver. (c) An individual who has excess home equity and does not qualify for a community Medicaid eligibility group, is ineligible for Medicaid under both the special income group and the medically needy waiver group. (6) To determine initial eligibility for a Medicaid coverage group under an HCBS waiver, the eligibility agency must receive a completed waiver referral form from the operating agency or designee. An individual who is not eligible for Medicaid must also complete a Medicaid application. (a) The waiver referral form must verify the date the individual meets the level-of-care requirements as defined in the State Waiver Implementation Plan. (b) The following provisions apply for Medicaid eligibility under the HCBS waiver: (i) The eligibility agency must approve a client's eligibility within 60 days of the level-of-care date stated on the waiver referral form for the waiver referral form to remain valid; otherwise the operating agency or designee must submit a new waiver referral form to the eligibility agency to establish a new level-of-care date; (ii) Waiver eligibility cannot begin before the level-of-care date stated on a valid waiver referral form, and; (iii) The eligibility start date must begin within 60 days of the level-of-care date stated on the valid waiver referral form. (c) The Medicaid agency may not pay for waiver services before the start date of the individual's approved comprehensive care plan, which may not be earlier than the date the individual meets: (i) the eligibility criteria for a Medicaid coverage group included in the applicable waiver; and (ii) the level-of-care date verified on a valid waiver referral form. (7) In the event an individual is not approved for Waiver Medicaid services due to Subsection R414-307-3(6), an individual who otherwise meets Medicaid financial and non-financial eligibility criteria for a Non-Waiver Medicaid coverage group may qualify for Medicaid services other than services under an HCBS waiver. (8) If an individual's Medicaid eligibility ends and the individual reapplies for Waiver Medicaid, the Department shall establish a process of obtaining approval from the operating agency or designee in which the individual continues to meet medical criteria for the Waiver. The operating agency or designee approval may establish a new date in which eligibility to receive coverage of waiver services may begin. (9) An individual denied Medicaid coverage for an HCBS waiver may request a fair hearing. (a) The Department conducts hearings on programmatic eligibility for payment of waiver services. (b) The Department of Workforce Services conducts hearings on financial eligibility issues for a Medicaid coverage group. |
| R414-307-4. Special Income Group |
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The following provisions set forth financial eligibility requirements for the special income group that apply to individuals seeking Medicaid coverage for services under an HCBS waiver as defined in 42 CFR 435.217. (1) If the individual's spouse meets the definition of a community spouse, the eligibility agency shall apply the income and resource provisions defined in Section 1924 of the Social Security Act and Section R414-305-3. (2) If the individual does not have a spouse, or the individual's spouse does not meet the definition of a community spouse, the eligibility agency may only count the individual's resources to determine eligibility. If both members of a married couple who live together apply for waiver services and meet the criteria for the special income group, the eligibility agency shall count one-half of jointly-held assets as available to each spouse. Each spouse must pass the medically needy resource test for one person. (3) The eligibility agency may only count income determined under the most closely associated cash assistance program to decide if the individual passes the income eligibility test for the special income group. The eligibility agency may not count income of the individual's spouse except for actual contributions from the spouse. (4) If the individual is a minor child, the eligibility agency may not count income and resources of the child's parents to decide if the child passes the income and resource tests for the special income group. The eligibility agency shall count actual contributions from a parent, including court-ordered support payments as income of the child. (5) The individual's income cannot exceed three times the payment that would be made to an individual with no income under Subsection 1611(b)(1) of the Social Security Act. (6) The eligibility agency shall apply the transfer of asset provisions of Section 1917 of the Social Security Act. (7) The individual's cost-of-care contribution is determined by deducting from the individual's total income, the post-eligibility allowances for the specific waiver for which the individual qualifies. (8) The eligibility agency shall determine financial eligibility for the special income group for an individual based on the level of care date on a valid waiver referral form as defined in Subsection R414-307-3(2). The eligibility agency shall determine eligibility for prior months using the community Medicaid or institutional Medicaid rules that apply to the individual's situation. |
| R414-307-5. Medically Needy Waiver Group |
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The following sets forth financial eligibility requirements for the medically needy coverage group, and applies to individuals seeking Medicaid coverage for HCBS under the New Choices Waiver or the Individuals with Physical Disabilities Waiver. (1) If an individual's spouse meets the definition of a community spouse, the eligibility agency shall apply the resource provisions defined in Section 1924 of the Social Security Act and Section R414-305-3 and Section R414-305-4. (2) If the individual does not have a spouse or the individual's spouse does not meet the definition of a community spouse, the eligibility agency may only count the individual's resources to determine eligibility. When both members of a married couple who live together apply for waiver services and meet the criteria for the medically needy waiver group, the eligibility agency shall count one-half of jointly-held assets available to each spouse. Each spouse must pass the medically needy resource test for one person. (3) The eligibility agency may only count income of the individual determined under the most closely associated cash assistance program to decide eligibility for the medically needy waiver group. The eligibility agency may not count income of the individual's spouse except for actual contributions from the spouse. (4) If the individual is a minor child, the eligibility agency may only count income and resources of the child and may not count income and resources of the child's parents to decide if the child passes the income and resource tests for the medically needy waiver group. The eligibility agency shall count actual contributions from a parent, including court-ordered support payments as income of the child. (5) The individual's income must exceed three times the payment that would be made to an individual with no income under Subsection 1611(b)(1) of the Social Security Act. (6) To determine eligibility for an individual, the eligibility agency shall apply the income deductions allowed by the community Medicaid category under which the individual qualifies. (a) The eligibility agency shall compare countable income to the applicable medically needy income limit for a one-person household to determine the individual's spenddown. The individual's medical expenses, including the cost of long-term care services, must exceed the spenddown amount. To receive Medicaid eligibility, the individual must meet the monthly spenddown as defined in Subsection R414-304-11(9). (b) The eligibility agency deducts medical expenses incurred by the individual in accordance with Section R414-304-11. (7) The eligibility agency shall determine an individual's financial eligibility for the medically needy waiver group based on the level of care date on a valid waiver referral form as defined in Subsection R414-307-3(2). The eligibility agency shall determine eligibility for prior months using the community Medicaid or institutional Medicaid rules that apply to the individual's situation. |
| R414-307-6. New Choices Waiver Eligibility Criteria |
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(1) An individual must be 65 years of age or older, or at least 18 through 64 years of age and disabled to be eligible for the New Choices Waiver, as defined in Subsection 1614(a)(3) of the Social Security Act. In accordance with waiver provisions, the eligibility agency considers an individual to be 18 years of age after the month in which the individual turns 18 years old. (2) A single individual or any married individual with a community spouse, who is eligible under the Special Income Group, may be required to pay a contribution toward the cost of care to receive services under an HCBS waiver. The eligibility agency determines a client's cost-of-care contribution as follows: (a) The eligibility agency counts all of the client's income unless the income is excluded under other federal laws that exclude certain income from being counted to determine eligibility for federally-funded, needs-based medical assistance. (b) The eligibility agency deducts the following amounts from the individual's income: (i) A personal needs allowance equal to 100% of the federal poverty guideline for a household of one; (ii) For individuals with earned income, up to $125 of gross-earned income; (iii) Actual monthly shelter costs not to exceed $300. This deduction includes mortgage, insurance, property taxes, rent, and other shelter expenses; (iv) A deduction for monthly utility costs equal to the standard utility allowance Utah uses under Subsection 5(e) of the Food Stamp Act of 1977. If the waiver client shares utility expenses with others, the allowance is prorated accordingly; (v) In the case of a married individual with a community spouse, an allowance for a community spouse and dependent family members who live with the community spouse, in accordance with the provisions of Section 1924 of the Social Security Act; (vi) When an individual has a dependent family member at home and the provisions of Section 1924 of the Social Security Act do not apply,an allowance for a dependent family member that is equal to one-third of the difference between the minimum monthly spousal needs allowance defined in Section 1924 of the Social Security Act and the family member's monthly income. If more than one individual qualifies for an HCBS waiver or institutional Medicaid coverage, and contributes income to the dependent family member, the combined income deductions of these individuals cannot exceed one-third of the difference between the minimum monthly spousal needs allowance and the family member's monthly income. The eligibility agency shall end this deduction when the dependent family member enters a medical institution; (vii) Medical and remedial care expenses incurred by the individual in accordance with Section R414-304-11. (c) The income deduction to provide an allowance to a spouse or a dependent family member may not exceed the amount the individual actually gives to such spouse or dependent family member. (d) The remaining amount of income after these deductions is the individual's cost-of-care contribution. (3) The individual must pay the cost-of-care contribution to the eligibility agency each month to receive services under an HCBS waiver. |
| R414-307-7. Community Supports Home and Community-Based Services Waiver for Individuals with Intellectual Disabilities and Other Related Conditions |
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(1) Medicaid eligibility for the Community Supports Home and Community-Based Services waiver is limited to individuals with intellectual disabilities and other related conditions. (2) An individual's resources must be equal to or less than the Medicaid resource limit applicable to an institutionalized person. The spousal impoverishment resource provisions for married, institutionalized individuals in Section R414-305-3 apply to a married individual. (3) An eligible individual may be required to pay a contribution toward the cost-of- care to receive home and community-based services. The eligibility agency shall determine an individual's cost-of-care contribution as follows: (a) The eligibility agency shall count all of the individual's income unless such income is excluded under other federal laws that exclude certain income from being counted to determine eligibility for federally-funded, needs-based medical assistance. (b) The eligibility agency shall deduct the following amounts from the individual's income: (i) For an individual with earned income, earned income up to the substantial gainful activity level of earnings defined in Section 223(d)(4) of the Compilation of the Social Security Laws in effect April 4, 2012, to determine countable earned income. (ii) A personal needs allowance for the individual equal to 100% of the federal poverty level for one person. (iii) In the case of a married individual with a community spouse, a deduction for a community spouse and dependent family members living with the community spouse in accordance with the provisions of Section 1924 of the Social Security Act. (iv) In the case of an individual who does not have a community spouse or whose spouse is also eligible for institutional or waiver services, an allowance for a dependent family member that is equal to one-third of the difference between the minimum monthly spousal needs allowance defined in Section 1924 of the Social Security Act and the family member's monthly income. If more than one individual who qualifies for a Medicaid home and community-based waiver or institutional Medicaid coverage contributes income to the dependent family member, the combined income deductions of such individuals cannot exceed one-third of the difference between the minimum monthly spousal needs allowance and the family member's monthly income. (v) Health insurance premiums for the waiver-eligible recipient paid by the recipient, or medical expenses incurred by the recipient in accordance with Section R414-304-11. (c) The income deduction to provide an allowance to a spouse or a dependent family member cannot exceed the amount the individual actually gives to such spouse or dependent family member. (d) The remaining amount of income after such deductions is the individual's cost-of-care contribution. (4) The individual must pay the contribution to cost-of-care to the eligibility agency each month to receive home and community-based services. (5) The eligibility agency shall count parental and spousal income only if the individual receives a cash contribution from a parent or spouse. (6) The provisions of Section R414-305-9 concerning transfers of assets apply to individuals seeking eligibility or receiving benefits under this home and community-based services waiver. |
| R414-307-8. Home and Community-Based Services Waiver for Individuals Age 65 and Older |
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(1) Medicaid eligibility for Home and Community-Based Services for individuals 65 years of age and older is limited to individuals eligible for Aged Medicaid who could qualify for skilled nursing home care. (2) A client's resources must be equal to or less than the Medicaid resource limit applicable to an institutionalized person. The spousal impoverishment resource provisions for married, institutionalized individuals in Section R414-305-3 apply to a married individual. (3) An eligible client may be required to pay a contribution toward the cost-of-care to receive home and community-based services. The eligibility agency shall determine a client's cost-of-care contribution as follows: (a) The eligibility agency shall count all income unless such income is excluded under other federal laws that exclude certain income from being counted to determine eligibility for federally-funded, needs-based medical assistance. The eligibility agency shall count a spouse's income only if the client receives a cash contribution from a spouse. (b) The eligibility agency shall deduct the following amounts from the individual's income: (i) A personal needs allowance for the individual equal to 100% of the federal poverty level for one person; (ii) For individuals with earned income, up to $125 of gross-earned income; (iii) Actual monthly shelter costs not to exceed $300. This deduction includes mortgage, insurance, property taxes, rent, and other shelter expenses; (iv) A deduction for monthly utility costs equal to the standard utility allowance Utah uses under Section 5(e) of the Food Stamp Act of 1977. If the waiver client shares utility expenses with others, the allowance is prorated accordingly; (v) In the case of a married individual with a community spouse, a deduction for a community spouse and dependent family members who live with the community spouse in accordance with the provisions of Section 1924 of the Social Security Act; (vi) In the case of an individual who does not have a community spouse or whose spouse is also eligible for institutional or waiver services, an allowance for a dependent family member that is equal to one-third of the difference between the minimum monthly spousal needs allowance defined in Section 1924 of the Social Security Act and the family member's monthly income. If more than one individual who qualifies for a Medicaid home and community-based waiver or institutional Medicaid coverage contributes income to the dependent family member, the combined income deductions of such individuals cannot exceed one-third of the difference between the minimum monthly spousal needs allowance and the family member's monthly income; (vii) Health insurance premiums for the waiver-eligible recipient paid by the recipient, or medical expenses incurred by the recipient in accordance with Section R414-304-11. (c) The income deduction to provide an allowance to a spouse or a dependent family member cannot exceed the amount the individual actually gives to such spouse or dependent family member. (d) The remaining amount of income after such deductions is the individual's cost-of-care contribution. (4) The individual must pay the contribution to cost-of-care to the eligibility agency each month to receive home and community-based services. (5) The provisions of Section R414-305-9 concerning transfers of assets apply to individuals seeking eligibility or receiving benefits under this home and community-based services waiver. |
| R414-307-9. Home and Community Based Services Waiver for Technology Dependent/Medically Fragile Individuals |
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(1) 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 21st birthday falls. (2) 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 the Technology Dependent waiver implementation plan, non-financial Medicaid eligibility criteria in Rule R414-302, and a Medicaid category of coverage defined in the waiver implementation plan. (3) All other eligibility requirements follow the rules for the Community Supports Home and Community-Based Services Waiver found in Section R414-307-7, except for Subsection R414-307-7(1). |
| R414-307-10. Home and Community-Based Services Waiver for Individuals with Acquired Brain Injury |
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(1) To qualify for services under this waiver, the individual must be at least 18 years of age. The person is considered to be 18 years of age in the month in which the 18th birthday falls. (2) All other eligibility requirements follow the rules for the Home and Community-Based Services Waiver for Aged Individuals found in Section R414-307-8, except for Subsection R414-307-8(1). |
| R414-307-11. Home and Community-Based Services Waiver for Individuals with Physical Disabilities |
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(1) To qualify for the waiver for individuals with physical disabilities, the individual must meet non-financial criteria for Aged, Blind, or Disabled Medicaid. (2) A client's resources must be equal to or less than $2000. The spousal impoverishment resource provisions for married, institutionalized clients in Section R414-305-3 apply to this rule. (3) Countable income is determined using income rules of Aged, Blind, or Disabled Institutional Medicaid. The eligibility agency counts all income unless the income is excluded under other federal laws that exclude certain income from being counted to determine eligibility for federally-funded, needs-based medical assistance. Eligibility is determined counting only the gross income of the client. (4) The eligibility agency counts a spouse's income only if the client receives a cash contribution from a spouse. (5) An individual whose income does not exceed 300% of the federal benefit rate may be required to pay a cost-of-care contribution. The following provisions apply to the determination of cost-of-care contribution. (a) The eligibility agency counts all of the client's income except income that is excluded under other federal laws from being counted to determine eligibility for federally-funded, needs-based medical assistance. (b) The eligibility agency deducts the maximum allowance available, which is a personal needs allowance equal to 300% of the federal benefit rate payable under Section 1611(b)(1) of the Social Security Act for an individual with no income. No other deductions from income are allowed. (6) An individual whose income exceeds three times the federal benefit rate payable under Section 1611(b)(1) of the Social Security Act may pay a spenddown to become eligible. To determine the spenddown amount, the income rules and medically needy income standard for non-institutionalized aged, blind or disabled individuals in Rule R414-304 apply except that income is not deemed from the client's spouse. (7) The provisions of Section R414-305-9 concerning transfers of assets apply to individuals seeking eligibility or receiving benefits under this home and community-based services waiver. |
| R414-307-12. Home and Community-Based Services Waiver for Individuals with Autism |
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(1) An individual must be at least two years of age and under seven years of age to be eligible for the Medicaid Autism Waiver. (a) The eligibility agency shall treat an individual as being under seven years of age through the month in which the individual turns seven years old. (b) The agency shall end waiver eligibility after the month in which the individual turns seven years old. (2) This waiver complies with the provisions of the Community Supports Home and Community-Based Services Waiver and all other eligibility requirements found in Section R414-307-7, except for the requirement of Subsection R414-307-7(1). |
| R414-307-13. Home and Community-Based Services Waiver for Medically Complex Children |
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(1) An individual must be under 19 years of age to be eligible for the HCBS Waiver for Medically Complex Children. (a) The eligibility agency shall treat an individual as being under 19 years of age through the month in which the individual turns 19 years old. (b) The agency shall end waiver eligibility after the month in which the individual turns 19 years old. (2) The agency shall determine whether an individual meets the disability criteria described in Section R414-303-3. (3) This waiver is in accordance with the provisions of the Community Supports Home and Community-Based Services waiver and all other eligibility requirements found in Section R414-307-7, except for the requirement of Subsection R414-307-7(1). |