Medicaid Policy
Medicaid Policy
Effective Date: January 1, 2025
General Requirements
To be eligible for 12-Month Transitional a family member must meet the following criteria:
Have been eligible for and received PCR (345) in 3 of the 6 months prior to the month in which they lose eligibility for PCR or be a PCR eligible individual described below who meets the 3 of 6 month criteria. The 3 months do not have to be consecutive.
A pregnant woman who has met the criteria for PCR in 3 of the 6 months prior to the month in which she is no longer eligible for PCR Medicaid.
This applies even if she is receiving Pregnant Woman. However, if there are no other children besides the unborn, the 3 months must occur during the 3rd trimester or the post-partum period.
The 12-Month Transitional program requires that a born child be present in the home. The child may be born in the first month of Transitional,
Be an eligible parent not receiving PCR due to being sanctioned for non-cooperation with Medical Support Enforcement.
The parent's dependent child must be receiving Child Medicaid.
The countable income for Child Medicaid must be below the PCR income limit for the required 3 months.
Be a minor parent who is receiving Child Medicaid with her child, but otherwise qualifies for PCR.
Lost PCR eligibility for one of the following reasons:
The earnings of a parent, caretaker relative or pregnant woman cause the countable income to exceed the limit for the PCR Medicaid.
The household loses deprivation because neither parent in a two-parent household is working less than 100 hours per month.
When a spouse or child joins a household with an open PCR program, the agency will consider the new family member to have the same number of months of PCR coverage as the ongoing family members. Example: Jan has been on PCR since May. In July, Jan marries Phil, and he moves into the home. They are both parents of 5 year-old Sam. Phil works full time. Because Jan has 3 of 6 months on PCR and Phil's income makes them ineligible for PCR, Jan and Phil will both go to 12-Month Transitional in August.
Unmarried PCR recipient parents who are living together cannot transition to the same 12-Month Transitional program. If they both had an increase in earned income in the same month, they would each move to their own Transitional program. The children could be included with either parent. See 343 on when a child can be moved to 12-Month Transitional.
The household is eligible for the initial 6 months of coverage. Do not close the 12-Month Transitional Medicaid when the family reports any change in the earned income during the initial 6 months.
The household must meet ALL of the following requirements to remain eligible for the full twelve months:
The household must continue to include an age eligible child;
The household must continue to meet Utah residency requirements;
The household must comply with the income reporting requirements (See below);
A parent must have earnings in each of three months in the 3 report periods or have good cause for no earnings (343-3); and
The parent’s average gross earnings minus the average child care expenses for the second and third report periods must not exceed 185% FPL for the household size. (The child care expenses must be needed so that the parent can go to work.)
There is no asset limit for 12-Month Transitional.
Do not require medical support enforcement or TPL.
There is no deprivation of support requirement during the 12-Month Transitional period.
Loss of eligibility for Adult Expansion due to earnings does not allow an adult to move to 12-Month Transitional.
When to Start 12-Month Transitional Medicaid
The member must receive proper notice when moving from PCR to 12-Month Transitional. Begin 12-Month Transitional coverage on the first day of the month following the loss of PCR coverage for members that meet the requirements outlined in section A1 of this policy.
If the household does not report new employment timely and the 10 day notice requirement causes a household to receive PCR Medicaid for a month or months when it is ineligible, that first ineligible month is the first month of 12-Month Transitional Medicaid. Determine if the household would have met the 3 out of the last 6 month requirement for 12-Month Transitional in the first month it would have been ineligible for PCR Medicaid. Adjust the 12-Month Transitional month count, if needed, to account for any ineligible PCR months due to an untimely report of earnings.
If the household does report the new employment timely, the worker will begin the 12-Month Transitional as soon as possible, following the 10*10*10* requirements. No penalty will be assessed to the member for a month in which her income exceeds the PCR income limit.
Income Reporting Requirement
Households receiving 12-Month Transitional must report income and child care expenses at the end of the first, second and third quarters of the 12-month period.
Do not close 12- Month Transitional between the second or third quarterly report when the family reports a change in income.
If a quarterly report will result in the member losing eligibility for this program see section 343-5.
First Report
A notice is sent to the household in the third month. The notice explains:
A parent must have earnings or good cause for no earnings in the first 3 months.
The household does not have to report if a parent had earnings in all 3 months.
The household must contact you by the 17th of the fourth month if a parent didn’t have earnings in one or more of the first 3 months.
The program remains open if:
The parent does not contact you; or
The parent contacts you and has good cause for no earnings. Document the good cause reason on the case (343-3).
Eligibility for the program ends if:
The member reported that a parent didn’t have earnings in one or more of the first 3 months; and
There wasn’t good cause for no earnings (343-3).
Second Report
An income report is sent in the 6th month. The earnings are required to complete the report. The form itself is not required.
The household must verify all earnings and provide child care expenses for the 4th, 5th and 6th month by the 17th of the 7th month. If the member returns the report after the 17th of the month and before the last day of the report month, it is not considered late. Child care expenses are not required to complete the report (but the lack of these expenses may cause the case to exceed the 185% FPL).
The program remains open if the information is complete and the household meets all of the eligibility requirements for the program.
Eligibility for the program ends if:
The household did not return the second report, provide the information needed, or contact the agency, and the information was not otherwise available;
The parent did not have earnings and did not have good cause* in one or more of the 3 report months; or
The household’s average gross earnings minus the average child care expenses for the 3 months exceeds 185% FPL for the household size.
Third Report
An income report is sent in the 9th month. The earnings are required to complete the report. The form itself is not required.
The household must verify all earnings and provide child care expenses for the 7th, 8th and 9th month by the 17th of the 10th month. If the member returns the report after the 17th of the month and before the last day of the report month it is not considered late. Child care expenses are not required to complete the report (but the lack of these expenses may cause the case to exceed the 185% FPL).
The program remains open if the information is complete and the household meets all of the eligibility requirements for the program.
Eligibility for the program ends if:
The household did not return the third report, provide the information needed, or contact the agency, and the information was not otherwise available;
The parent did not have earnings and did not have good cause in one or more of the 3 report months; or
The household’s average gross earnings minus the average child care expenses for the 3 months exceeds 185% FPL for the household size.
Complete an eligibility review at the end of the 12-Month Transitional period (721).
Before terminating the coverage of members on 12 Month Transitional Medicaid, for any reason, re-determine eligibility for other Medicaid programs for each household member. Move the household members to the appropriate Medicaid program before closing the 12 Month transitional program (827).
All recipients who are losing coverage under this program will need to have all factors of eligibility addressed in order to determine ongoing eligibility. If the member is eligible for another program a new 12-month certification period will be given.
Exception: Recipients who are pregnant or within their postpartum period cannot lose coverage prior to the end of the postpartum period and will continue their coverage on the Pregnant Woman program unless they are found eligible for a better program. The certification period for this member will end at the end of the postpartum period.
A due process month will need to be issued if ongoing eligibility is not determined with sufficient time to give proper notice. See 811-1
343-3 Good Cause For No Earnings
343-4 Good Cause For Late Report
343-5 Changes during the 12-Month Transitional Period
343-6 Reopening a 12 Month Transitional Case