Utah Admin. Code R414-307-3 - General Requirements for Home and Community-Based Services Waivers
(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
42 U.S.C.
1396p(f).
(b) The department sets that limit at the
minimum level allowed under 42 U.S.C.
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 authorize exceptions to the time frames defined in Subsections
(6)(c)(i) and (6)(c)(iii) due to circumstances beyond the applicant's
control.
(e) 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.
Notes
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
No prior version found.