R414-311. Targeted Adult Medicaid, R414. Health, Health Care Financing, Coverage and Reimbursement Policy, Utah Administrative Code

Utah Administrative Code (Current through November 1, 2019)

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

R414-311-1. Introduction and Authority

Latest version.

(1) This rule is authorized by Sections 26-1-5 and 26-18-3 and allowed under Subsection 1115(f) of the Social Security Act.

(2) This rule establishes eligibility requirements for enrollment under the 1115 Demonstration Waiver for Adults without Dependent Children, also known as the Targeted Adult Medicaid program.

R414-311-2. Definitions

Latest version.

The definitions in Rules R414-1 and R414-301 apply to this rule. In addition, the following definitions apply throughout this rule:

(1) "Chronically Homeless Individual" means an individual who has a substance use disorder, serious mental illness, developmental disability, post-traumatic stress disorder, cognitive impairments resulting from a brain injury, or chronic illness or disability; and

(a) is living or residing for at least 12 months, or on at least four separate occasions that amount to at least 12 months in the last three years, in a place not meant for human habitation, in a safe haven, or in an emergency shelter; or

(b) is living in supportive housing and has previously met the criteria established in Subsection R414-311-2(2)(a).

(2) "Dependent Child" means a child who is under 19 years of age and required to be included in the Targeted Adult Medicaid household size.

(3) "Individual Needing Treatment" means an individual who:

(a) is receiving General Assistance from the Department of Workforce Services and has been diagnosed with a substance use or mental health disorder;

(b) was discharged from the Utah State Hospital and was admitted due to a civil commitment; or

(c) is living or residing for at least 6 months within a 12 month period in a place not meant for human habitation, in a safe haven, or an emergency shelter, and has a substance use or serious mental health disorder.

(4) "Justice Involved Individuals" means an individual who:

(a) has complied with and substantially completed a substance use disorder treatment program while incarcerated in jail or prison; or

(b) was discharged from the Utah State Hospital and was admitted to the civil unit in connection with a criminal charge, or to the forensic unit due to a criminal offense, with which the individual was charged or convicted; or

R414-311-3. General Provisions

Latest version.

(1) The provisions in Rule R414-301 apply to all applicants and enrollees, except that applicants and enrollees are required to report only the following changes in circumstances:

(a) The individual moves out of state; or

(b) The individual enters a public institution or an institution for mental disease.

R414-311-4. General Eligibility Requirements

Latest version.

Unless otherwise stated, the provisions in Rule R414-302 and Section R414-306-4 apply to applicants and enrollees.

(1) The following individuals are not eligible for Targeted Adult Medicaid:

(a) Individuals who do not meet the coverage group criteria of being chronically homeless, justice involved, or needing treatment as defined in Section R414-311-2;

(b) Individuals who have a dependent child under 19 years old; or

(2) An individual must be at least 19 years old and not yet 65 years old to enroll in Targeted Adult Medicaid.

(a) The month in which an individual turns 19 years old is the first month in which the individual may enroll in Targeted Adult Medicaid.

(b) An individual may only enroll in Targeted Adult Medicaid through the month in which the individual turns 65 years old.

(3) The eligibility agency only enrolls applicants during an open enrollment period. The eligibility agency may limit the number it enrolls and may stop enrollment at any time. The open enrollment period may be limited to a coverage group or a subgroup within the coverage group.

(4) The eligibility agency shall waive the open enrollment requirement for the following situations:

(a) The individual who was previously on Targeted Adult Medicaid, and is moving from another Medicaid program back to Targeted Adult Medicaid, is otherwise eligible, and there is no break in coverage between the medical programs;

(b) The individual is no longer eligible for PCN, is otherwise eligible, and there is no break in coverage between the two medical programs; or

(5) A resource test is not required.

R414-311-5. Application, Eligibility Reviews and Improper Medical Assistance

Latest version.

(1) Unless otherwise stated, the provisions of Rule R414-308 apply to applicants and enrollees.

(2) Subject to the provisions of Subsection R414-311-5(3), an individual who is determined eligible shall receive 12 months of coverage that begins with the first month of enrollment.

(3) Coverage for Targeted Adult Medicaid may end before the end of the 12-month certification period if the individual:

(a) turns 65 years old;

(b) moves out of state;

(d) enters a public institution or an institution for mental disease, except as described in Section R414-302-6;

(e) is convicted of fraud; or

(f) leaves the household.

(4) An individual who leaves prison, jail or the Utah State Hospital must submit an application within 60 days of release or discharge.

(5) An enrollee must verify at each review that he meets the criteria of a coverage group as defined in Section R414-311-2. An enrollee who no longer meets criteria of a coverage group is no longer eligible for Targeted Adult Medicaid.

R414-311-6. Household Composition and Income Provisions

Latest version.

(1) The eligibility agency shall use the provisions of Section R414-304-5 to determine household composition and countable income.

(2) Section R414-304-12 applies to the budgeting of income through the Modified Adjusted Gross Income (MAGI) methodology.

(3) For an individual to be eligible to enroll in Targeted Adult Medicaid, the individual must have countable income at or below 5% of the federal poverty level (FPL).