Obsolete 0116 - What's New

Added  HPE  providers: 

Moab Regional Hospital (New)(10/01/2015)

Castleview Hospital (Missing)(2/19/2014

Uintah Basin Medical Center (Missing)(2/19/2014)

Corrected existing providers names:

Mountain View Hospital

Ogden Regional Medical Center

Timpanogos Regional Hospital

Removed  Providers:

University Neuropsychiatric Center

New Providers:

Navajo Mountain Community Health Center

Neighborhood Community Health Center

The post-eligibility treatment of income is to be applied only to individuals who qualify under the special income group.

This means that clients who are Home and Community Based Waiver recipients, who are not in the special income group, will not be subject to a Post Eligibility Treatment of Income (PETI).  They will have to meet the financial requirements for the Medicaid Category to which they belong.

The income groups that will be affected by this are the SSI, SSI Protected, 100% FPL, MWI and Spenddown groups.

Currently, only the married clients in these income groups are subject to the PETI rules. 

Adding language to state that with the enrollment group for adults with dependent children, they must have a child under the age of 19. 

Addressed that an unborn may be considered a dependent child if there are no other dependent children in the home.

Addressed an unmarried father of an unborn may be considered for PCN if he is living in the home with the pregnant woman and signs an acknowledgement of paternity form 941.

The various types of VA benefits and the treatment of them are further defined in policy.

Policy defines when how to treat augmented income and when dependents must apply for an apportionment.

Clarification about applying for Medicare Part B benefits.

382  Medically Complex Conditions Waiver

380 Home and Community Based (HCB) Waiver Programs

409-14 Utah Community Supports (UCSW) Deductions

A new HCB waiver was created by House Bill 199.

This waiver will serve a limited number of children (165 at any point in time) under 19 years of age who meet disability criteria according the ADA and have a complex medical condition.

The coverage groups for this waiver are disabled children, MAGI CHILD and Child Medically Needy.

Verification that the individual meets the medical eligibility criteria will be handled through the 927 process for eligibility staff.

811

·        Added a link to policy 1009 to address notification requirements for UPP moving the Medicaid.

1007-2

·        Adding language stating the client must be given 10 day advance notice when decreasing UPP payment or case closure.

1009

·        Added 10*10*10 rule

·        Added language to address reporting requirement of the 10 day advance notice.

·        Added language to address client moving from UPP to Medicaid and the effective date of closure.

1009-4

·        Added language addressing notification requirements.

Added the UPP program landing page with the description of the UPP program, information that individuals must meet the general requirements that apply to Medicaid and CHIP and specific requirements described in this section.  

Changed the statement about the effective date of a change that causes an increase in the UPP payment when verified within 10 days will be effective the month immediately following the change report month.

Adding the list of all BYB providers to the policy manual.

The changes to the Foster Care sections do not reflect a change in policy, but rather a clarification of Foster Care placements and how they pertain to the different methods of making children Medicaid eligible when they are in state custody as well as when they are under some type of guardianship placement.

Change current policy to allow for a youth to receive Foster Care Independent Living Medicaid while continuing in the Utah state foster care system beyond normal foster care Medicaid age. Currently, this category limits the program to those individuals who are "aging out". The statute allows for the possibility that the youth may still be in state custody beyond age 18.

Due to the low number of foster care youth being approved for Medicaid when they age out of foster care, policy will be clarified and enhanced to explain these programs better.

A child who can qualify for Former Foster Care shall be opened on that program without requiring verification needed for other possible coverage groups.

A child whose foster care is ending can be opened on Former Foster Care without requiring a signature page of the application upfront. DHS will refer cases over to be opened. If the youth has signed an application signature page, this will be sent to DWS. If not, give the youth 30 days to provide the signature page. 

Reviews are to be done as ex parte, and since there is no income or asset test, reviews should be approved unless the agency has information that the youth moved out of state, or cannot be located, or is in an ineligible facility.

Discovered the word PACMIS in this policy section.  Updated the reference “PACMIS” with “eREP”.

We have added the following nine counties to the list of those which require Medicaid recipients choose one of the available ACOs to manage the group of authorized medical care and pharmacy providers:

Box Elder

Cache

Rich

Morgan

Summit

Tooele

Wasatch

Iron 

Washington

We have removed outdated information contained in these sections. The DWS work no longer has a requirement to refer clients to the HPR. That is done automatically.

Medicaid applicants and recipients no longer have to choose a primary health care provider.

The clients who live in required rural counties will be educated by HPRs over the phone.

In the Child Age 0-1 section, we have added that a child born to a woman who received presumptive Medicaid does not qualify for guaranteed coverage until the child turns 1 year old. The woman would have to apply for and be determined eligible for ongoing Medicaid for the birth month to cover the child for the first year.

We removed the paragraph in section C. "Eligibility for Other Programs" which refers to covering Medicaid ineligible children under the CHIP program. This provision was a temporary protection during the transition to the ACA legislation.

Policy sections 240-2 and 386-5 are being removed.

Policy Section 380

At application for the Waiver, the 927 will be valid for 60 days from the “level of care met” date listed on the form.  If eligibility has not been determined within 60 days of that date a new 927 will be needed.

The policy section has also been reformatted and language from 240-2 added to it.

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

The Spousal Needs Minimum Maintenance Standard has been increased to $1992.00.

The Spousal Needs Allowance Shelter Standard has been increased to $598.00.

Other figures may change, this information is based on the figures we have been given.  You will be notified if other figures change.

Updating table to reflect USU Tooele Campus not offering insurance.

Online or distance education students with USU do not have access to insurance.

We replace the TR and QI sections that were removed April 1 and removing any sunset language. Congress made both programs permanent.

 225-1 and 225-2  

Sections state that TPL information that was gathered as part of a failed review should not be requested again at reapplication. We have added a link to Medicaid Section 721-1 for the worker to follow the new review process pertaining to TPL requirements.

 225-3

Clarifies that when completing an ex parte review, the worker will not address updating the TPL information. However, the notice of completion will direct the client to report new TPL information as a change. We removed wording regarding have to deal with TPL at the review, and added a link to Medicaid Section 721-1 where the process is discussed.

303-2 Proof of Blindness or Disability

303-3 When to Establish and Redetermine Blindness or Disability Through the SMDO

Begin gathering medical records for SMDO reviews no earlier than the month the disability review is due. This applies also to someone coming out of a public institution when the SMDO review date is still in the future.

Consider a client disabled until we have determined them to be no longer disabled.

 If a client reapplies within 12 months of when the SMDO review should have taken place and the Medicaid had previously been closed due to a reason other than no longer disabled:

Consider the client disabled

Begin the SMDO review process

341-1 Tax Filer's MAGI Household

341-2 Non-Tax Filer's MAGI Household

Clarifying that children between the ages of 19-23 who are full-time students may be claimed by a parent on the parent's tax return, and therefore included in their parents' Medicaid household. The income of these dependent adult children is counted only if they are expected to be required to file taxes. These dependents may or may not qualify for a Medicaid category.

Adding some examples about household composition.

When parents do not expect to file taxes and their dependent child who meets the age criteria will file a tax return, we will use the non-tax-filer rules to determine the child's MAGI household. Count the parents' income, but the child's income will count only if he's expected to be required to file. (CMS clarification)

An older child or young adult who is living independently, not with parents, may apply on her own. Apply the MAGI Tax-filer or non-tax-filer rules based on the child's expected filing status. Count income of the child. Do not count the parents' income, even if the parents may claim the child as a dependent on their tax return.

Clarified what rules to follow when a child lives with more than 2 parents.

476-1: This section was re-written to be clearer and more concise. In doing so, we stated more clearly that we should not deem income and assets from un-married adults to each other, even if they have children in common. The same is true of NPCRs to children in their care.

476-2: We have added that a child is not included in a non-parent caretaker relative's medically needy case, nor are the income and assets deemed to the child.

585: We have omitted the paragraph which requires that one child be included in the Family Medically Needy program and have his income and assets be deemed to the parent. We added that the program requires that a deprived age eligible child be in the household.

Policy section 585 was incorrectly stating that a married waiver client only has 90 days to transfer excess assets to the spouse or use them.

This is incorrect.  The client has until the next review to transfer them.

Clarify for current recipients that traditional Medicaid benefits and co-pay exemptions begin the month the pregnancy is reported and not the month after report. And to remove the wording regarding verifying the pregnancy.

721 Eligibility Review

721-1  Conducting an Eligibility Review

Section 721 changed to make it clearer and easier to read and was updated to clarify that when completing an ex parte review on non-CHIP programs, you cannot extend out the CHIP certification period, even if you reviewed all factors of eligibility without client participation.

Updated 721-1 to clarify any changes at an ex parte review that moves an individual from one medical program to another will require the regular review process.  There are two exceptions:

Moving from one cost-sharing program to another.

Moving from ABD without a spenddown to ABD with a spenddown, or vice versa.

Updated formatting and table references to section 371-3.

The table references referred to Table II and should be Table II-A.

There was formatting that lead to some confusion about requesting a hardship.  Corrected the formatting.

The eligibility agency may deny an LIS application for being over assets without requesting additional verification from the applicant if:

• The stated assets on the LIS application are well over the asset limit for Cost-Sharing programs;

• The agency does not have other information in an existing case that conflicts with the client's statement of assets;

• The agency uses a reasonable approach in determining assets are far enough above the limit that additional verification is unlikely to result in eligibility, meaning that if assets are close to the limit, the agency should request additional verification from the applicant; and

• The agency will send a notice denying eligibility based on being over the asset limit.

• The worker will need to document clearly the reason for their actions in the case notes.

Policy is currently correct when it states that we count the retirement funds of any “eligible” family member for ABD and LTC.  An “eligible” family member is either a spouse of the client, a parent of a minor client, or a spouse of a parent of a minor client, who is also Aged, Blind, or Disabled, whether or not that family member is on or is applying for Medicaid.

However, we will be adding a sentence to clarify that retirement funds of any “ineligible” family members are not countable for ABD and LTC.  An “ineligible” spouse, parent or spouse of a parent is someone who is not Aged, Blind or Disabled.

342-3 Whose Income Counts for MAGI Household?

This section has been updated with the 2014 figures for:

• Earnings of when an individual would be "expected to be required" to file taxes.

• The income limit of when a tax filer can no longer claim a dependent, when the person is not a spouse or qualifying child of the tax filer.

345 MAGI Based PCR

343-1 4 Month Extended Medicaid

343-2 12-Month Transitional Medicaid

343-5 Changes During the 12-Month Period

There are several changes affecting Parent/ Caretaker Relative eligibility:

• Unmarried parents will not be on the same program for PCR, 4 Month or 12 Month Transitional. One child in common can qualify each parent for PCR. For Transitional, if one parent's income increases, that parent will go to Transitional. The other would remain on PCR, if still eligible.

• A child does not go on the Extended or Transitional Medicaid with a non-parent caretaker relative. This is because the non-parent caretaker's income does not count for the child's Medicaid eligibility.

• If the father of an unborn child lives in the home and has acknowledged paternity on form 941, the unborn child could qualify as the dependent child for both parents in the 3rd Trimester. The parents do not have to be married.  Do not deem income to each other.

345 MAGI Based PCR

To qualify a parent or caretaker relative for PCR Medicaid, there must be "a dependent, deprived child" living in the household who meets the age limit. However, that child does not have to be "eligible" for Medicaid. The child could be an ineligible alien and the parent is a qualified alien.

224 Strikers

345-2 Deprivation of Support

350-2 Deprivation of Support

224 We've deleted the concept of PWE as stated in this section.

350-2 will be replaced with a statement to follow the deprivation rules found in 345-2, which the MAGI-Based PCR program uses.

350-2 B 4, said "good cause to refuse work, quit work or reduce hours of employment," but this does not appear in 345-2. ACA does not require an individual to be employed, maintain or continue work to be eligible for Medicaid. This policy does not need to be retained.

345-2

• Under the new ACA policy, the primary wage earner concept has become obsolete. Now, when two or more parents are present in the household, only one of them has to be unemployed or employed less than 100 hours per month for the children to be deprived of support.

• We also updated the policy to treat children as deprived of support when a parent is convicted of a crime, living at home, and sentenced to perform community service or unpaid public work.

• We limited the deprivation due to incapacity to those individuals determined to be incapacitated by the Social Security Administration, the State Medicaid Disability Office or the Veterans Administration. Any other claimed disability is nullified by the individual working 100 hours per month.

• We made other wording changes to clarify and better organize the section. 

345-3 Caretaker Relatives for MAGI

350 Medically Needy Programs for Families

350-4 Household Size for Family Medically Needy

350-6 Family Medically Needy Elig. For a Child

350-7 Medically Needy Medicaid for Non-Parent

353 Medically Needy Child

Policy has been changed to allow a non-parent caretaker relative to take primary responsibility for a child even when that child's parent resides in the home. The child must still be deprived of support. The situation will not be common, but the worker should take the non-parent caretaker relative's statement when the situation occurs.

A child who is medically needy should be opened on Child Medically Needy as they do not have to be living with any specific person, nor be deprived of support to qualify for coverage.

The change in 353 clarifies that a child will never be on Family Medically Needy with a specified relative. Also, the child will not be sanctioned for failure of an adult to complete Medical Support Enforcement.

386-3 New Choices Waiver Coverage Groups

Medicaid Policy section 386-3(B)(2)(b)(ii)  says not to use the health insurance deduction found in 409-1 and the next line says to use the deductions found in 409-16.  409-16 includes the deduction in 409-1.

This language has been clarified to remove the circular reference.

The deduction in 409-1 is to be used in determining the clients contribution to the cost of care.

554 Annuities

554-1 Treatment of Annuities

Medicaid policy on annuities did not have language describing the “right to cancel” time frame.

Policy was updated to include the “right to cancel” time frame for the annuitant.

Once the annuitant receives the final contract from the issuing entity (the company that will make the annuity payments), the annuitant has a “right to cancel” time frame.  During that time frame, the annuitant can cancel the policy and receive a refund.

641-2  Out of State Medical Services

Monthly Medicaid cards are no longer issued.  The policy still had references to the old monthly card.

Table II Aged, Blind and Disabled Figures

Table II-A Long Term Care Institutional and Waiver Figures

Table V - Sponsor Deeming

Table VII - Income Limits

Table VII-A Medicaid Work Incentive

Table VII-B 5% FPL Deduction Amount

Updates

512-2.4 Trust Accounting Review

721 Eligibility Review

721-1 Conducting an Eligibility Review

908 PCN Reviews

1008-1 Eligibility Review

MAGI-based programs are being added to the ex parte review process based on federal regulation requirements.  Non-MAGI-based programs started the ex parte review process in September 2014.  

Workers will complete an ex parte review by initially checking all available electronic resources to determine eligibility before involving the client.

If the client remains eligible, workers approve the review and notify the client.

TPL verification will be done post eligibility via the approval notice

The 116M for CHIP and PCN programs will be done post eligibility

UPP cases will not be reviewed as ex parte

If eligibility can’t be approved with electronic sources, a pre-populated review form will be sent to the client to complete.

Added new exception to CHIP policy explaining when an enrollee may lose eligibility before the end of the 12 month certification period.

Added clarification that a yearly accounting review needs to be completed for special needs and pooled trusts.  The yearly trust review should align with the yearly case review.  Reviews of other types of trusts should be completed when questionable.

Table VII

904  Income Standards

415-2 Who is eligible without a spenddown

330 Protected Medicaid Groups For Former SSI Recipients

334 Protected Medicaid Group for a Child SSI Recipient

334-1 Income and Asset Requirements for a Protected Medicaid

334-2 Changes that may affect Protected Medicaid SSI Child

334-3 Disability Review Requirements for Protected Medicaid SSI Child

413 Deemed Income From A Parent For ABD And Medicare Cost Sharing Programs

We are removing sections 334, 334-1, 334-2, and 343-3 from policy because children who could have qualified for this coverage will all exceed the age requirements after 2014.  References to K-Kids were removed from sections 330.  References to K-Kids were removed and minor wording changes were made to section 413.

Self-employed individuals no longer have to provide receipts to verify business expenses. They may provide ledgers if they do not have current tax forms or if the ledgers are more representative of anticipated expenses.  Tax forms can also be used if they are representative of anticipated expenses.  Receipts would be needed if the person does not keep other types of records of expenses.

The MAGI programs allow self-employed individuals to deduct such as expenses as SEP, SIMPLE and Qualified Plans.

The standard mileage rate was updated to 56 cents per mile.

Table II-Aged, Blind, and Disabled Figures

Table II-A-Long Term Care Figures

Table VII- Income Limits for Medical Assistance & Medicare Cost-Sharing Programs

Table IX- Phone numbers

Table XI-Pickle Reduction Figures

The annual COLA increase for Social Security benefits causes income amounts to change. Various related figures change as a result.

The Spousal Impoverishment Resource and Income amounts change due to the annual increase.

Table IX was updated to reflect that Tiffany Cruz is now the CUP policy specialist.

900 Questions and Answers

PCN open enrollment for parents and caretaker relatives ended December 31, 2014