Obsolete 0115 - What's New

354 Foster Care Medicaid

354-5 Kinship-Guardianship Medicaid (new section)

-        354 D will be changed to give a brief description of the newly created Medicaid category.

-        354-5 will be created to give a full explanation of the Kinship-Guardianship category.

DHS and DOH have decided, based on the option given by the Social Security Act, to create a separate Medicaid category for those children who are:

-        Not appropriate for adoption,

-        Have been placed with a relative for a long-term placement,

-        Are between the ages of 14 – 18,

-        Will not be in State custody,

-        The new category will be similar to Subsidized Adoption. It will not have an income or asset limit.

-        DHS will open the child on Kinship-Guardianship Medicaid and the program will be maintained in the DHS section of eREP.

-        It will require a new COA.

A pathway needs to be developed similar to the handoff that exists for other children leaving Foster Care. The DHS worker should provide a signed review/application by the individual which will be sent to DWS, in order to open him/her on Child Medicaid until 19, or other appropriate program, such as Disability Medicaid.

229-3 Spouses

Same sex marriage is now legal in the state of Utah.  Customer statement will be accepted regarding marital status and the date of marriage.

314 Medicaid Work Incentive Program

314-1 Income Eligibility for MWI

Clarification that persons who are disabled and have earned income qualify for MWI only if:

·       Countable income is over 100% of FPL for Aged and Disabled poverty group;

·       Countable assets are more than the limit for the Aged and Disabled Poverty Level program; or

·       Both are true. 

If a person (or couple) meets the requirement for the 100% FPL aged and disabled Medicaid group, they are not eligible for MWI. They must be opened under the 100% Poverty Group instead.

If the client's resources fail the 100% poverty group resource test, and the disabled person is working, you can look at the MWI program even if the income is under 100% of poverty.  Then the person can receive the exclusion of a retirement plan or second vehicle used by a spouse or child to go to work.

356 Medicaid Presumptive Eligibility for Children Determined by DHS

The program Presumptive Eligibility for Children determined by DHS will end October 31, 2014.  All policy and procedures related to this program will be obsoleted as of that date.

1008 Certification Periods

1009-3 Adding An Eligible Spouse or Child to An Open UPP Case

Policy in 1008 is being clarified to state that if a client submits an application for Medicaid, and any UPP recipient in the household is found eligible for Medicaid, they must be removed from UPP and moved to Medicaid.  

Policy in section 1009-3 is being clarified to align with policy in the same section and section 1009-5, to state that if someone is added to an open UPP case, a new income determination must be done, and a new review period must be created.

354-3 Former Foster Care Individuals

This section is being amended to include as eligible for the Former Foster Care program, those individuals who age out of the Unaccompanied Refugee Minor Foster Care program. The URM program is administered through the Catholic Community Services which places the children with a foster family and provides case management services for them. DWS determines Medicaid eligibility for these unaccompanied refugee minors, and upon aging out will now ensure that they are approved for the FFC program.

513 Qualified Partnership Insurance Policies

373-3, 373-6, 402 and 403-1

The state has been directed to create a qualified long-term care insurance partnership. A Long Term Care Insurance Partnership is a way for potential Medicaid clients to protect a certain amount of resources from both the Medicaid asset test and from estate recovery by purchasing and receiving benefits from a long term care insurance partnership policy (Qualified Partnership Policy).

These Qualified Partnership policies are insurance plans that help pay for Nursing Home and other long-term care services.  If a client receives a benefit (payments) from a partnership plan, Medicaid will disregard assets, dollar for dollar, from total countable assets the client owns or that are deemed available to the client (such as from a spouse).  In addition to this asset disregard, the disregarded amount is protected from the estate recovery process.

The disregard of assets is available only to aged, blind or disabled nursing home residents and home and community based services waiver recipients who qualify under the special income limit.  The special income limit is when the client's total income does not exceed 300% of the SSI payment rate. 

Individuals who would meet the eligibility criteria for community Medicaid groups do not qualify for this asset disregard.  This includes SSI recipients and SSI Protected Group individuals, aged and disabled individuals meeting the 100% FPL criteria, MWI eligible individuals, and individuals with income above 300% of the SSI rate.

This deduction is allowed after the Spousal Asset assessment is completed and is applied to assets attributable to the institutionalized spouse.

The disregard is determined at application.  It does not increase after eligibility is determined.

The eREP system implications for these qualified partnership policies will be to:

1. Identify the partnership plan.

2. Track the benefit received from it.

3. Exclude the amount in #2 (above) from countable resources.

ORS needs to have a way to identify the plan and the exclusion amount for the individual.

Table II-A

The Utility allowances have been updated with current figures.

The Standard Utility Allowance (SUA) was updated from $305 to $311.

The Without Heating Allowance (WOHA) was updated from $220 to $230.

The Telephone Only Allowance was updated from $37 to $45.

Section 900 Questions and Answers- PCN Open Enrollment End Date

PCN open enrollment for adults without dependent children will end September 30, 2014.  Effective October 1, 2014 only adults with dependent children will be approved for PCN.

342-1, 342-2, 342-3 Whose Income Counts for MAGI Household

Recurring cash contributions given to tax dependents by the tax filer when that tax dependent is not the spouse or child of the tax filer are counted as income to the dependent in the full amount when that average is more than $300 per month.  One-time payments or amounts averaging less than $300/month are not counted as income to the dependent.

If the MAGI-based income of such a tax dependent has to count toward the tax filer's household income (because the tax dependent is expected to be required to file a tax return), DO NOT INCLUDE the amount of the cash contribution from the tax filer.

394 Refugee Medical Assistance

394-1 When to Use the RMA Program

900-1 Age Requirements

900-3 Open Enrollment Periods

901 Eligibility For Other Medicaid Programs

909-1 Transitions between PCN and UPP, CHIP and Medicaid

1000-3 UPP Open Enrollment Periods

1001 Eligibility for Other Medicaid Programs

1009-3 Adding an Eligible Spouse or Child to an Open UPP Case

1009-5 Transitions between UPP and CHIP, PCN and Medicaid

RMA will take a priority in the program hierarchy above PCN and UPP. The worker should first look at eligibility under a Medicaid category, and if not eligible, then determine eligibility for RMA. PCN and UPP would be the programs of last resort.

Exception:  If a child is eligible for RMA and UPP, they may receive UPP instead of RMA.

386-2  General Requirements for the New Choices Waiver

386-3 New Choices Waiver Coverage Groups

386-3 Resource NCW Summary of Basic Eligibility Criteria

409-6 Unearned Income Deductions

409-12 Deduction for Dependent Family Members

409-16 New Choices Waiver Post Eligibility Deductions

Policy has been updated and clarified to state that New Choices Waiver Medicaid recipients in the Spenddown Waiver income group have different Spenddown/ Contribution to the Cost of Care calculations for single and married clients.

Single clients are now allowed the following deductions from countable income: the ABD deductions described in policy (409-2), the 100% FPL deduction, Health insurance premiums and Medical expenses.  The remaining amount is the client's spenddown.

Married clients will continue to receive the following deductions from total income (372-1) to determine their Contribution to the Cost of Care.

100% FPL, an Earned Income deduction, Shelter and Utility, Spousal Needs Allowance, Family Needs Allowance, Health Insurance Premiums and certain medical expenses.

721 Eligibility Reviews

721-1 Conducting an Eligibility Review

Workers will complete an ‘ex parte’ review for most non-MAGI programs before involving the client in the review process.   

Determine eligibility using current electronic data sources and case records.

Do not require a signature.

If there are both non-MAGI and MAGI programs on the case, the worker can update the certification period on the MAGI programs at the ex parte review.  The agency must have verified all factors of eligibility without client participation.

If the agency cannot determine eligibility using the current electronic data sources and case records, the agency will send a pre-populated review form and conduct a review following the regular review process.

Programs using the MAGI methodology will still follow the regular review process.

1008-2 Conducting an Eligibility Review

Policy is being clarified to state if a change is reported at review, and the change is in the client’s favor or does not change benefits, the change should be made in the month following the change report month.

This clarification identifies the "Medigap" policies as not being appropriate to refer to the Buyout Unit. They are not cost effective to purchase.

Other wording changes update the DOH division to say Medicaid and Health Financing.

342-4 Calculating Income for MAGI-Based Programs

435 Budgeting Income

435-2 Determine a Best Estimate of Income

435-3 Methods of Establishing a Best Estimate

815 Change Reporting

Application or renewal-This change is to correct conflicting information in policy, and to address how income changes during the certification period will affect eligibility for the remainder of the period. Section 435-2 will clarify the budgeting differences between MAGI and non-MAGI groups, and that new income sources require that the worker annualize the income, and adjust the pay periods to account for any delay in receiving the first check. 435 will distinguish between non-MAGI and MAGI-based basic budgeting concepts, and stress that non-MAGI-based coverage groups budget to reflect the income in a specific month, where the MAGI-based groups anticipate an annualized amount over the whole certification period.

Changes- Action on reported income changes during the certification period will depend upon whether or not the change will move an individual from one medical program to another.  The worker will only take action on the reported change, unless the reported change requires the worker to address or verify other factors of eligibility.

If the change, such as a decrease in income, does not affect an individual’s ongoing eligibility, the worker will not change the best estimate.   

A new best estimate will be required on all increase of income.  New income will be annualized of a 12-month period, regardless of how many months are remaining in the certification period. 

342-4- This section has been re-formatted to clarify the two part process in calculating MAGI-based income, prior to applying the "reasonably compatible test", and the 5% disregard.

356-1 Presumptive Medicaid Eligibility For the Baby your Baby Program

356-2 Medicaid Presumptive Eligibility Determined by Qualified Hospitals

Presumptive eligibility can only be approved for a client once in a calendar year.

Pregnant woman PE can only be approved once per pregnancy.

Exempt income types of veteran’s income, educational income and child support are being added to the section.

A client may opt out of applying for ongoing medical assistance when applying for hospital presumptive eligibility.

BYB

The following baby your baby presumptive eligibility policy clarifications will be added July 1, 2014.

Exempt income types of veteran’s income, educational income and child support are being added to the section.

226-2  Assignment to a Health Plan

314-7  MWI Premium

409-16  New Choice Waiver Deductions

415-3  Who Can Receive Medicaid by Spending  Down

415-4 Spenddown with Cash

415-5  Spenddown with Medical Bills

415-8  Applying the Rules for Medical Bills

415-12  Possible Refund of a Cash Spenddown

415-13  Bills That Will Cover Future Months

415-17  Time Limit for Meeting Medicaid Spenddown

603-4 Proof of Eligibility for Medical Assistance

603-5  Medical Card Restriction

641-1 Medical Services in Utah

707  Re-Opening Cases Without a New Application

910  Program Benefits

Clients will no longer receive a monthly Medicaid card.

Policy has been updated to reflect the change on how Medicaid cards are issued.  An individual card, the size of a credit card, will be mailed to each individual who is eligible for certain Medicaid programs.    

As before, individuals eligible for LTC, SLMB, QI and the QDWI programs will not receive a card.

Table II-A Long Term Care Institutional and Waiver

The annual July changes to the table 11-A "Long Term Care Institutional and Waiver" are as follows.

The Spousal Needs Minimum Maintenance Standard has been increased to $1967.00.

The Spousal Needs Allowance Shelter Standard has been increased to $590.00.

Table XIV- Hospitals Authorized to Approve Hospital Presumptive Eligibility (HPE)

Update to Table XIV to include newly approved hospitals including; Blue Mountain, Brigham City, Lakeview, Lone Peak, Mountain View, Ogden Regional,  St. Mark’s, and Timpanogos Regional.

223-1 Resource-Medicare

390-2 Health Coverage and Medicaid Cancer Program Eligibility

903-1 Definitions

903-2  Health Insurance Coverage

903-7  Termination of Health Insurance Coverage

1003-7 Termination of Health Insurance Coverage

The HIP program no longer exists.  HIP language was removed from the Medicaid and CHIP policy manuals.

The language regarding 2011 premiums and the hold harmless provision was removed because it is no longer applicable.

342-1 Income for MAGI Based Programs

342-2 Specific Treatment of Income for MAGI-Based Programs

401-1 Income in Kind

402 What is Not Income

403-1 Examples of Unearned Income

403-7 Educational Assistance

405-1 Sources of Earned Income

Earned in-kind income counts, and unearned in-kind income does not count for MAGI programs.

Personal services such as house cleaning, baby sitting, etc., which are done sporadically, without intent to establish self- employment, and render nominal amounts of money are not considered self-employment income.

Educational loans and Workers’ Compensation are not sources of countable income for MAGI programs.

The Medicaid 405-1 section had an incomplete sentence regarding non-taxable deferred wages for MAGI-based programs. This sentence was completed with a complete thought.

412 Deemed Income From a Spouse for ABD, QM, and QI-1 Programs

412-1 When to Deem Income for ABD, QM, and QI Programs

412-2 When Do We Not Deem Income From a Spouse for ABD, QM, and QI Programs?

413 Deemed Income from a Parent for ABD, QM, and QI Programs

413-2 Parental Deeming Worksheets for ABD, QM, and QI Programs

125-1 Fair Hearing Request

125-3 Benefits Pending a Hearing Decision

Continue CHIP or Medicaid assistance if the client asks for a hearing any time before the effective date of the action or by the close of business on the 10th day after the date the Notice of Decision is received, whichever is later.  The date which the notice is received is considered to be 5 days after the date on the notice, unless the client can show he did not receive the notice within that 5 day period.

If the client can demonstrate that he or she did not receive the Notice of Decision in the mail, mail a new notice of decision and allow the enrollee 15 days from the mailing date of this notice to request the hearing and continued CHIP or Medicaid benefits.

392 TB Positive Group

900-1 Age Requirements

907 Effective Date

Policy is clarified to state that the month in which a customer turns 19 is the first month they may have PCN.

If a customer applies during open enrollment and turns 19 in the application month, the customer may receive Medicaid or CHIP in the month of application and PCN in the month following.

A new application is not required.

All factors of eligibility must be considered when determining eligibility for the individual’s PCN.

900-3 Open Enrollment Periods

903-9 When Other Types of Health Insurance Become Available

909 Changes

909-2 When the PCN/Medicaid Program is Closed for a Full Benefit Month

909-3 Adding an Eligible Spouse to an Open PCN Case

909-4 Removing an Ineligible Person or Closing an Ineligible Case (removed)

909-5 Reopening a PCN Program When a Recipient Has Been Receiving Medicaid (removed)

909-6 When the PCN/Medicaid Program is Closed for a Full Benefit Month (removed)

909-7 When Married Couples Separate During the Certification Period (removed)

PCN recipients will have month to month eligibility.  Changes reported during the review period need to be acted on and may potentially end PCN eligibility.

Spouses may only be added to the PCN benefit during open enrollment periods.  When a new spouse moves in with a PCN recipient, the new spouse’s income will count toward their spouse’s PCN eligibility.

When spouses separate, each spouse will need to have their own PCN case.  All factors of eligibility will be evaluated to determine continuing eligibility for the individuals.

Sections 909-4, 909-5, 909-6, and 909-7 have been removed.

901 Eligibility for Other Medicaid Programs

902 Medical Support Enforcement

903-1 Definitions

903-7 Termination of Health Insurance Coverage

906 Enrollment Fee (Removed)

910-1 Cost Sharing Exemptions

References to the pregnant woman asset copay and the PCN fee were taken out of sections 901,902,906, and 910-1.  The name Utah Health Exchange was changed to Avenue H in Section 903-1.  The formatting was fixed in Section 903-7.

904 Income Standards

904-1 Documenting the Income Determination (renamed)

904-2 Whose Income to Count (removed)

904-3 How to Determine the Household Size (removed)

904-4 Determination of Income Eligibility (removed)

904-5 Documenting the Income Determination (removed)

Table VII

PCN will begin using the MAGI methodology.

Sections 904-2 through 904-5 were removed from the policy manual because PCN will follow Medicaid policy for income and household size determination.

Section 904-1 was renamed.

903-4 Access to Employer Sponsored Insurance

1003-4 Access to Employer-Sponsored Insurance

908 PCN Reviews (renamed section)

908-1 Re-certification for PCN (removed)

Due process policy applies at review.

The open enrollment requirement is waived when looking at PCN eligibility during the 3 month review reconsideration period.

1003-7 Termination of Health Insurance Coverage

909-1 Transitions between PCN and UPP, CHIP, and Medicaid (renamed section)

1000-3 UPP Open Enrollment Periods

1008 Certification Periods

1009-3 Adding an Eligible Spouse or Child to an Open UPP Case (renamed)

1009-5 Transitions between UPP, CHIP, PCN, and Medicaid (renamed)

1009-6 When All Programs are Closed for a Full Benefit Month

• Table II - Aged, Blind and Disabled Income Limits and Important Figures
• Table II-A - Long Term Care Institutional Waiver Income Limits
• Table V - Sponsor Deeming
• Table VII - Income Limits for Medical Assistance and Medicare Cost Sharing
• Table VII-A - Medicaid Work Incentive
• Table VII-B - 5% Federal Poverty Level Deduction Amount

125-1 Fair Hearings; 125-2 The Hearing; 125-6 Fair Hearing Decisions

When a client requests a fair hearing as a result of a decision by the State Medicaid Disability Office, the hearing will be conducted by the Office of Formal Hearings at DOH.  Clients will be given the opportunity to have a reconsideration of their disability application as part of the hearing process.  

651 Non-Emergency Medical Transportation

651-1 Exceptions to Eligibility for Non-Emergency Medical Transportation

The state has contracted with a new company to provide Special Transportation Services.  LogistiCare is replacing PickMeUp for these types of services to persons on Traditional Medicaid benefits.  

2013 Policy

2013 Policy has been moved into the Obsolete policy folders.

Obsolete Policy

Obsolete Policy deleted before 2010 has been deleted. Contact Linda Asa if you need the old policy.

347 MAGI-based Medicaid for Children

Removed language about allowing children born to mothers eligible for CHIP to qualify for Child 0-1 without verification. 

Added an explanation that a child who was eligible in December 2013 and then loses Medicaid eligibility at the first review in 2014 will be eligible to receive CHIP for 1 year if the income is under 200% FPL.  This applies even if the child has other health insurance.  At the end of the one year of CHIP coverage, the child must meet all of the CHIP criteria to receive any continuation of CHIP.

354, 354-3 Former Foster Care Individuals; 354-4 Foster Care Independent Living

Persons eligible for Foster Care Independent Living may be moved to the Former Foster Care Individual program at review or when they turn 21 as long as they had Utah Medicaid when they aged out of Foster Care.  

356 Medicaid Presumptive Eligibility for Children Determined by DHS

356-1 Presumptive Medicaid Eligibility for the Baby Your Baby Program

Baby Your Baby:

• Clients no longer have a time limit to request a Baby Your Baby extension.  Extensions may be granted as long as an application for ongoing Medicaid filed during the Baby Your Baby eligibility period remains pending.

• TPL information is not required; however a referral to ORS will be made (by Med Ops Worker at DOH) if TPL information is received.

• Educational income and child support are not countable sources of income.

• Who to include in the household has also changed.

• Clarified in policy that a client may not have received a denial for Medicaid, CHIP, UPP or PCN unless circumstances have changed.  This is done today.

PE Kids:

• Educational income and child support are not countable sources of income.

• A client may not have received a denial for Medicaid, CHIP,  and UPP unless circumstances have changed.

• A client must not be eligible for Medicaid with a spenddown.

• TPL information is optional.

Hospital Presumptive Eligibility:

• Specific eligibility requirements for each program type were added to policy.

• A client may not have received a denial for Medicaid, CHIP, UPP or PCN unless circumstances have changed.

• A client must not be eligible for Medicaid with a spenddown.

721 Eligibility Review

721-1 Conducting an Eligibility Review

UPP 1008-1, 1008-2

• For Medicaid, when completing a review for Jan., Feb., and March 2014 medical benefits, if an individual fails eligibility for a MAGI-based Medicaid program using the MAGI methodology, apply the 2013 rules to the program and if eligible, re-certify the program through March 2014.  Re-determine eligibility for April 2014 using the MAGI methodology.

• Reviews in 2014 for both MAGI-based and non-MAGI-based coverage groups and for all CHIP cases will require client participation.  The review policies have been modified to explain this.  Sometime, during 2014, we intend to start ex parte reviews for non-MAGI-based Medicaid groups, which do not require clients to participate in the review.  For now though, all reviews will require the client to respond to the review.

• If a child is eligible for Medicaid in December 2013, and could be eligible for CHIP except for the fact that the child has other health insurance, we must provide one year of CHIP coverage for the child even though the child has health insurance.

815 Changes

815-5 Income Changes

UPP 1009  Change Reports

• For MAGI-based Medicaid groups, if an individual who is eligible in December 2013 reports a change in income before the individual's scheduled review, gather information needed to make a MAGI determination.  If the person continues to be eligible for the same program, continue eligibility until the next review.  However, if the person's eligibility is adversely affected by the change, use the 2013 rules to determine if the individual is still eligible under those rules.  If not, close the case, and see if the person qualifies for any other program.

PCN 904 Income Standards

PCN 906 Enrollment Fee

• There will no longer be a PCN enrollment fee.

• The income limit is changing to 100% of the FPL.

UPP 1003-7 Termination of Health Insurance Coverage

New exceptions to the 90 days sanction period for voluntarily terminating health insurance have been added to CHIP and UPP policy. 

• The premium paid that includes the CHIP child/UPP individual exceeds 5% of the total household income.

• The cost of the premium and deductible that includes the CHIP child/UPP individual exceeds 9.5% of the total household income.

• Individuals are determined eligible for APTC’s through the FFM because employer sponsored insurance is determined unaffordable.

• The CHIP child/UPP individual has special healthcare needs.

• Coverage was lost due to the death or divorce of a CHIP parent or UPP individual.

Added examples regarding involuntary termination of coverage:

• An employer stopped offering coverage under an employer- sponsored health insurance plan.

• A change in employment, including involuntary separation, results in the loss of employer-sponsored insurance

The yearly SSI  and Medicare related figures have been updated by the Social Security Administration, Medicare and CMS.

The tables II, IIA, VII and XI have been updated with this information.

The Social Security figures that have changed for January, 2014 are:

1. The SSI maximum monthly payments have increased to $721.00 for single individuals and $1082.00 for a couple.
2. The SSI maximum monthly payments with PMV factored in by the Social Security Administration have increased to $480.67 for single individuals and $721.34 for a couple.
3. The 300% of the SSI figure has been updated to $2163.00.
4. The SSI Break even point was updated to $1527.00.
5. The Presumed Maximum Value's (PMV) have been updated to $260.33 for an individual and $380.66 for a couple.
6. The Substantial Gainful Activity Limit (SGA) for a disabled individual has increased to $1070.00.
7. The Substantial Gainful Activity Limit (SGA) for a blind individual has increased to $1,800.00.
8. The earning required for a covered quarter for Social Security and Medicare has updated to $1200.00.
9. The maximum allocation and deductions for a spouse have increased to $360.50.
10. The maximum allocation and deductions for a non-disabled child have increased to $360.50.
11. The Allocation for Parents (ABD deeming) have increased to $721.00 for 1 parent in the home and $1082.00 for two parents in the home.
12. The earned income deduction for a disabled student child and an ineligible student child have increased to $1750.00 maximum per month and $7060.00 per calendar year maximum.

The Medicare figures that have changed for January, 2014 are:

1. The Medicare Costing Program asset limits have increased to $7160.00 for an individual and $10,750.00 for a couple.
2. The Medicare part A deductible has increased to $1216.00.
3. The Skilled Nursing Home figures have increased $152.00 per day.
4. The part D low income subsidy has decreased to $39.02.

The Long Term Care Community Spouse and Maximum home equity figures that have changed for January, 2014 are:

1. The Maximum Spousal Needs Standard has increased to $2,931.00.
2. The minimum Community Spouse resource standard has increased to $23,448.00.
3. The maximum Community Spouse resource standard has increased to $117,240.00.
4. The Maximum Home Equity Limit has increased to $543,000.00.

The Pickle rate increase for 2014 was .015% and the table was adjusted accordingly.