Current through Bulletin 2024-06, March 15, 2024
(1) The department shall apply
Sec.
2404 of
Pub. L. No.
111 148, Patient Protection and Affordable Care
Act, which refers to applying Section 1924 of the Social Security Act to
married individuals who are eligible for home and community-based waiver
services.
(2) To qualify for
Medicaid coverage of home and community-based waiver services, an individual
shall meet:
(a) the medical eligibility
criteria defined in the state waiver implementation plan, which applies to the
specific waiver under which the individual is seeking services, as verified by
the operating agency case manager;
(b) the financial and non-financial
eligibility criteria for one of the Medicaid coverage groups selected in the
specific waiver implementation plan under which the individual is seeking
services; and
(c) other
requirements defined in this rule that apply to waiver applicants and members,
or specific to the waiver for which the individual is seeking
eligibility.
(3) Except
as otherwise stated in this rule, Rules R414-304 and R414-305 apply to
eligibility determinations under an HCBS waiver.
(4) The department shall limit the number of
individuals covered by an HCBS waiver as provided in the specific waiver
implementation plan.
(5)
(a) The department implements the
requirements for liens, adjustments, recoveries, and the transfers of assets
described in 42 U.S.C.
1396p(f). An individual is
ineligible for nursing facility and other long-term care services if an
individual has home equity that exceeds the limit set forth in Subsection
1396p(f).
(b) The department sets
that limit at the minimum level allowed under Subsection 1396p(f).
(c) An individual who has excess home equity
and meets eligibility criteria under a community Medicaid eligibility group
defined in the Utah Medicaid State Plan may receive Medicaid for services other
than long-term care services provided under the plan or the HCBS
waiver.
(d) An individual who has
excess home equity and does not qualify for a community Medicaid eligibility
group, is ineligible for Medicaid under both the special income group and the
medically needy waiver group.
(6)
(a) The
operating agency or designee shall send a completed waiver referral to the
eligibility agency, so the eligibility agency may determine initial eligibility
for a Medicaid coverage group under an HCBS waiver. Additionally, an individual
who is not eligible for Medicaid shall complete a Medicaid
application.
(b) The operating
agency or designee shall verify the form meets the level-of-care requirements
as defined in the state waiver implementation plan.
(c) The following provisions apply for
Medicaid eligibility under the HCBS waiver:
(i) A member shall obtain approval within 60
days of the level-of-care date stated on the waiver referral form for the
waiver referral form to remain valid, otherwise the operating agency or
designee shall submit a new waiver referral form to the eligibility agency to
establish a new level-of-care date;
(ii) waiver eligibility cannot begin before
the level-of-care date stated on a valid waiver referral form; and
(iii) the eligibility start date begins
within 60 days of the level-of-care date stated on the valid waiver referral
form.
(d) The Medicaid
agency may not pay for waiver services before the start date of the
individual's approved comprehensive care plan, which may not be earlier than
the date the individual meets:
(i) the
eligibility criteria for a Medicaid coverage group included in the applicable
waiver; and
(ii) the level-of-care
date verified on a valid waiver referral form.
(7) In the event an individual is not
approved for Waiver Medicaid services due to Subsection (6), an individual who
otherwise meets Medicaid financial and non-financial eligibility criteria for a
Non-Waiver Medicaid coverage group may qualify for Medicaid services other than
services under an HCBS waiver.
(8)
If an individual's Medicaid eligibility ends and the individual reapplies for
Waiver Medicaid, the department shall establish a process of obtaining approval
from the operating agency or designee in which the individual continues to meet
medical criteria for the waiver. The operating agency or designee approval may
establish a new date in which eligibility to receive coverage of waiver
services may begin.
(9)
(a) An individual denied Medicaid coverage
for an HCBS waiver may request a fair hearing.
(b) The department shall conduct hearings on
programmatic eligibility for payment of waiver services.
(c) The Department of Workforce Services
shall conduct hearings on financial eligibility issues for a Medicaid coverage
group.
