Utah Admin. Code R414-308-6 - Eligibility Period and Reviews

(1)

(a) The eligibility period begins on the effective date of eligibility as defined in Section R414-306-4, which may be after the first day of a month, subject to the following requirements.

(b) If a member must pay one of the following fees to receive Medicaid, the eligibility agency shall determine eligibility and notify the member of the amount owed for coverage. The eligibility agency shall grant eligibility if it receives the required payment, or in the case of a spenddown or cost-of-care contribution for waivers, if the member sends proof of incurred medical expenses equal to the payment. The fees a member may owe include:

(i) a spenddown of excess income for medically needy Medicaid coverage;

(ii) a Medicaid Work Incentive (MWI) premium; or

(iii) a cost-of-care contribution for home and community-based waiver services.

(2) A required spenddown, MWI premium, or cost-of-care contribution is due each month for a member to receive Medicaid coverage. A pregnant member or member in their postpartum period is only required to meet the spenddown once and remains eligible through the remainder of the postpartum period.

(3) The member must make the payment or provide proof of medical expenses within 30 calendar days from the mailing date of the application approval notice, which states how much the member owes.

(4) For ongoing months of eligibility, the member has until the close of business on the tenth day of the month after the benefit month to meet the spenddown or the cost-of-care contribution for waiver services, or to pay the MWI premium. If the tenth day of the month is a non-business day, the member has until the close of business on the first business day after the tenth. Eligibility begins on the first day of the benefit month once the member meets the required payment. If the member does not meet the required payment by the due date, the member may reapply for retroactive benefits if that month is within the retroactive period of the new application date.

(5) A member who lives in a long-term care facility and owes a cost-of-care contribution to the medical facility must pay the medical facility directly. The member may use unpaid past medical bills or current incurred medical bills other than the charges from the medical facility to meet some or all of the cost-of-care contribution subject to the limitations in Section R414-304-9. An unpaid cost-of-care contribution is not allowed as a medical bill to reduce the amount that the member owes the facility.

(6) Even if the eligibility agency does not close a medical assistance case, no eligibility exists in a month in which the member fails to meet a required spenddown, MWI premium, or cost-of-care contribution for home and community-based waiver services.

(7) The eligibility agency shall continue eligibility for a resident of a nursing home even if an eligible resident fails to pay the nursing home the cost-of-care contribution. The resident, however, must continue to meet all other eligibility requirements.

(8) The eligibility period ends on:

(a) the last day of the month in which the eligibility agency determines that the member is no longer eligible for medical assistance and sends proper closure notice;

(b) the last day of the month in which the eligibility agency sends proper closure notice if the member fails to provide required information or verification to the eligibility agency by the due date;

(c) the last day of the month in which the member asks the eligibility agency to discontinue eligibility, or if benefits have been issued for the following month, the end of that month;

(d) for time-limited programs, the last day of the month in which the time limit ends;

(e) for the pregnant woman program, the last day of the month which is at least 12 months after the date the pregnancy ends, except that for pregnant woman coverage for emergency services only, eligibility ends on the last day of the month in which the pregnancy ends;

(f) for children under 19 years of age, the earlier of:

(i) the end of the 12-month period beginning on the date the member is determined eligible;

(ii) the date the member reaches 19 years of age;

(iii) the date the member ceases to be a state resident; or

(iv) the date the member loses lawful permanent residence status as defined in Subsection R414-302-3(2); or

(g) the date the member dies.

(9) A presumptive eligibility period begins on the day the qualified entity determines an individual to be presumptively eligible. The presumptive eligibility period shall end on the earlier of:

(a) the day the eligibility agency makes an eligibility decision for medical assistance based on the individual's application if that application is filed in accordance with the requirements of Sections 1920 and 1920A of the Social Security Act; or

(b) in the case of an individual who does not file an application in accordance with Sections 1920 and 1920A of the Social Security Act, the last day of the month that follows the month in which the individual becomes presumptively eligible.

(10) For an individual selected for coverage under the Qualified Individuals program, the eligibility agency shall extend eligibility through the end of the calendar year if the individual continues to meet eligibility criteria and the program still exists.

(11) The eligibility agency shall complete a periodic review of a member's eligibility for medical assistance in accordance with 42 CFR 435.916 (2024). The department elects to conduct reviews for non-MAGI-based coverage groups in accordance with 42 CFR 435.916(a)(3) if eligibility cannot be renewed in accordance with 42 CFR 435.916(a)(2). The eligibility agency shall review factors that are subject to change to determine if the member continues to be eligible for medical assistance.

(12) For non-MAGI-based coverage groups, the eligibility agency may complete an eligibility review more frequently if it:

(a) has information about anticipated changes in the member's circumstances that may affect eligibility;

(b) knows the member has fluctuating income;

(c) completes a review for other assistance programs that the member receives; or

(d) needs to meet workload demands.

(13) If a member fails to respond to a request for information to complete the review, the eligibility agency shall end eligibility effective at the end of the review month and send proper notice to the member.

(a) If the member responds to the review or reapplies within three calendar months of the review closure date, the eligibility agency shall consider the response to be a new application without requiring the member to reapply. The application processing period shall apply for the new request for coverage.

(b) If the member becomes eligible based on this reapplication, the member's eligibility becomes effective the first day of the month after the closure date if verification is provided timely. If the member fails to return verification timely or if the member is determined to be ineligible, the eligibility agency shall send a denial notice to the member.

(c) The eligibility agency may not continue eligibility while it makes a new eligibility determination.

(14) If the eligibility agency sends proper notice of an adverse decision in the review month, the agency shall change eligibility for the following month.

(15) If the eligibility agency does not send proper notice of an adverse change for the following month, the agency shall extend eligibility to the following month. Upon completing an eligibility determination, the eligibility agency shall send proper notice of the effective date of any adverse decision.

(16) If the member responds to the review in the review month and the verification due date is in the following month, the eligibility agency shall extend eligibility to the following month. The member must provide verification by the verification due date.

(a) If the member provides requested verification by the verification due date, the eligibility agency shall determine eligibility and send proper notice of the decision.

(b) If the member does not provide requested verification by the verification due date, the eligibility agency shall end eligibility effective the end of the month in which the eligibility agency sends proper notice of the closure.

(c) If the member returns verification after the verification due date and before the effective closure date, the eligibility agency shall treat the date that it receives the verification as a new application date. The agency shall then determine eligibility and send notice to the member.

(17) The eligibility agency shall provide ten-day notice of case closure if the member is determined ineligible or if the member fails to provide verification by the verification due date.

(18) The eligibility agency may not extend coverage under certain medical assistance programs in accordance with state and federal law. The agency shall notify the member before the effective closure date.

(a) If the eligibility agency determines that the member qualifies for a different medical assistance program, the agency shall notify the member. Otherwise, the agency shall end eligibility when the permitted time period for the program expires.

(b) If the member provides information before the effective closure date that indicates the member may qualify for another medical assistance program, the eligibility agency shall treat the information as a new application. If the member contacts the eligibility agency after the effective closure date, the member must reapply for benefits.

Notes

Utah Admin. Code R414-308-6

Amended by Utah State Bulletin Number 2014-24, effective 12/1/2014 Amended by Utah State Bulletin Number 2024-21, effective 10/28/2024