Utah Admin. Code R414-303-11 - Presumptive Eligibility for Medicaid

(1) The definitions found in 42 CFR 435.1101, and the provisions for presumptive eligibility found in 42 CFR 435.1103 and 42 CFR 435.1110, apply to this section.

(2) The following definitions also apply to this section:

(a) "covered provider" means a provider whom the Department determines is qualified to determine presumptive eligibility for a pregnant woman, and who meets the criteria defined in Subsection 1920(b)(2) of the Social Security Act. Covered provider also means a hospital that elects to be a qualified entity under a memorandum of agreement with the Department;

(b) "presumptive eligibility" means a period of eligibility for medical services, based on an individual's self-declaration of meeting eligibility criteria.

(3) The Department shall provide coverage to a pregnant woman during a period of presumptive eligibility if a covered provider determines, based on preliminary information, that the woman :

(a) is pregnant;

(b) meets citizenship or alien status criteria as defined in Section R414-302-3;

(c) has household income that does not exceed 139% of the federal poverty guideline applicable to her declared household size; and

(d) is not already covered by Medicaid or the Children's Health Insurance Program (CHIP).

(4) A pregnant woman may only receive medical assistance during one presumptive eligibility period for any single term of pregnancy.

(5) A child born to a woman who is only presumptively eligible at the time of the infant's birth is not eligible for the one year of continued coverage defined in Subsection 1902(e)(4) of the Social Security Act. If the mother applies for Medicaid after the birth and is determined eligible back to the date of the infant's birth, the infant is then eligible for the one year of continued coverage under Subsection 1902(e)(4) of the Social Security Act. If the mother is not eligible, the eligibility agency shall determine whether the infant is eligible under other Medicaid programs.

(6) A child determined presumptively eligible who is under 19 years of age may receive presumptive eligibility only through the end of the month after the presumptive determination date, or until the end of the month in which the child turns 19 years of age, whichever occurs first.

(7) An individual determined presumptively eligible for former foster care children coverage may receive presumptive eligibility only through the end of the month after the presumptive determination date, or until the end of the month in which the individual turns 26 years of age, whichever occurs first.

(8) An individual determined presumptively eligible for adult coverage may receive presumptive eligibility through whichever of the following occurs first:

(a) through the end of the month following the month of the presumptive determination;

(b) through the end of the month in which the individual turns 65 years of age; or

(c) until the eligibility agency makes a determination for ongoing medical assistance.

(9) The Department shall limit the coverage groups for which a hospital may make a presumptive eligibility decision to the groups described in 42 CFR 435.110, 435.116, 435.118, 435.150, and Rule R414-312.

(10) A hospital must enter into a memorandum of agreement with the Department to be a qualified entity and receive training on policy and procedures.

(11) The hospital shall cooperate with the Department for audit and quality control reviews on presumptive eligibility determinations the hospital makes. The Department may terminate the agreement with the hospital if the hospital does not meet standards and quality requirements set by the Department.

(12) A covered provider may not count the following as income:

(a) veteran's administration payments;

(b) child support payments; or

(c) educational grants, loans, scholarships, fellowships, or gifts that a client uses to pay for education.

(13) An individual found presumptively eligible for one of the following coverage groups may only receive one presumptive eligibility period in a calendar year:

(a) parents or caretaker relatives;

(b) children under 19 years of age;

(c) former foster care children;

(d) individuals with breast or cervical cancer; and

(e) adult expansion.

(14) A covered provider shall utilize the Department's electronic portal to make presumptive eligibility determinations. The eligibility agency may only determine regular medical assistance if the provider submits a paper application.

Notes

Utah Admin. Code R414-303-11

Amended by Utah State Bulletin Number 2014-22, effective 11/1/2014 Amended by Utah State Bulletin Number 2019-18, effective 8/29/2019 Amended by Utah State Bulletin Number 2021-07, effective 3/26/2021