DHHS - Medicaid Policy Manual
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  Medicaid Policy                                                                 

 

348 Adult Expansion

Effective Date: October 1, 2022

 

Previous Policy

 

A.  Introduction and Program Hierarchy

 

The Adult Expansion program is for adults with or without dependent children.  The individual must meet certain financial and non-financial requirements, and be at least 19 and not yet 65 years of age.

 

1.    Individuals are not eligible for the Adult Expansion program if they qualify for the following programs.

·       Parent and Caretaker Relative;

·       Pregnant Woman;

·       Disabled Medicaid for those individuals receiving SSI

·       SSI Protected Groups: Individuals who lost SSI benefits as- Disabled Adult Child (DAC), Pickle Amendment, 1619(b), Disabled Widows or Widowers, or

·       Targeted Adult Medicaid (TAM)

 

2.    An individual who meets the criteria for the Disabled Medicaid without being on SSI and the Adult Expansion program can choose to remain on the Adult Expansion program.

 

3.   Temporary Adult Expansion Coverage

If the agency has all the needed verification for Adult Expansion, but is awaiting verification to determine eligibility for one of the following programs, approve Adult Expansion until the verification is received:

·       TAM.

·       Disabled Medicaid.

 

4.    If individuals submit all requested verification and are determined eligible for the Adult Expansion program, do not put them on:

·      Refugee Medical Assistance; or

·      Medicaid Cancer Program (390-2).  If the individual does not provide the requested verification to determine Adult Expansion eligibility, but meets the criteria for the Medicaid Cancer program, open them up on the Medicaid Cancer program.

5.    If individuals qualify for Adult Expansion and a Medically Needy program, or a Disabled Medicaid program based on criteria other than SSI or SSI Protected Group status, they can choose which of the two programs is most beneficial for them.

·      Approve Adult Expansion first if the individual is eligible for a program with a spenddown, unless the member explicitly told the agency they want to be opened up on the other program.

·      Approve the Disabled Medicaid program first if the member does not have a spenddown unless the member explicitly told the agency they want to be opened on the Adult Expansion program.

·      If an individual selects Medically Needy coverage and fails to meet their spenddown, the member can request the Adult Expansion program effective the month of request and the three retro months, if requested.

·      If they later request the spenddown program for the current or future months, you can approve them for that program.

6.    Individuals who are entitled to or receiving Medicare are not eligible for the Adult Expansion program. Eligibility under Adult Expansion program will end when a recipient becomes entitled to Medicare.

7.    If an individual claims to have medical or mental health issues that may meet the Medically Frail criteria, see 600.

8.    Individuals can move from Adult Expansion to the UPP program when they meet the following criteria:

a.    They have enrolled in ESI,

b.    They lose Adult Expansion Medicaid coverage due to being over income,

c.     Their income is within the UPP income limits and

d.    There is no break in coverage.

 

 

B. General Eligibility Requirements

 

  1. To be eligible for Adult Expansion an individual must:
    1. Be a US citizen or qualified non-citizen (205).
    2. Meet Utah residency requirements (207).
    3. Meet the other non-financial requirements found in section 215 through 234.
    4. Enroll in Employer Sponsored Insurance, or remain enrolled in their current health insurance plan (348-3)
  2. Adult Expansion allows for:
  1. Retroactive coverage (705).
  2. Emergency Medicaid (205-6).
  3. Hospital Presumptive Eligibility (356).
  1. Parents or caretaker relatives with children under the age of 19 in the home will be required to have those children covered under Medicaid, CHIP or Minimum Essential Coverage (MEC)insurance for the adults to be eligible for Adult Expansion.

 

C. Financial Requirements

 

  1. Adult Expansion follows the MAGI methodology for both income and household size (401 & 440-2).
  2. Income must be at or below the income limit for the program.
  3. There is no asset test.