Medicaid Policy

No Previous Policy

The Department of Health and Human Services is the agency that is ultimately responsible for all policy on all medical programs. When a situation arises that is not covered in this policy manual, a designee from the Department of Health and Human Services will decide the policy. Document the decision and who made the decision.

Medicaid Policy

Effective Date: August 1, 2018

Previous Policy

Employees of the Department of Health and Human Services and the Department of Workforce Services are prohibited from advising applicants or recipients to reduce income or terminate employment to qualify for Medicaid. Employees will explain eligibility policy, answer direct questions about the policy, and explain what income deductions are allowed. Employees will also tell applicants or recipients about the Medicaid spenddown program and explain how medical bills may be used to reduce or meet the spenddown amount. (See 400 and 461-5 for rules on medical bills.)

Department employees will identify themselves to applicants and recipients, and treat applicants and recipients with courtesy, dignity and respect.

Keep records which document eligibility, such as:

actions taken in the electronic eligibility system that changes the eligibility;

opening/approving;

closing;

benefit/program changes;

household changes;

evidence changes; and

all circumstances that could affect an individual's eligibility.

See 801-1 for case narration requirements.

Medicaid Policy

Effective Date: June 1, 2025

Previous Policy

To ensure applicants and recipients receive benefits to which they are entitled, Federal and State law specify:

Individuals have the right to receive information about Medicaid, Medicare Cost-Sharing Programs and Utah's Premium Partnership (UPP). See 600 for information about program benefits and services.

Individuals also have the right to receive information about related programs such as: other insurance affordability programs through the FFM, Advance Premium Tax Credits, EPSDT, CHIP, WIC, food stamps, energy assistance, financial assistance, employment planning, child care, skills training, etc. Individuals who are age 19-64 have the right to receive information explaining the benefits and eligibility requirements of the Disability Medicaid program. Case managers and eligibility representatives should explain programs for which they determine eligibility, and offer referrals to appropriate agencies for more information about other related programs. Refer individuals to https://medicaid.utah.gov/additional-information/ for additional information regarding their rights and responsibilities.

Allow individuals to apply or re-apply for medical assistance at any time with one exception: applications for the Utah's Premium Partnership will be accepted only during open enrollment periods. If enrollment has been stopped for the Utah Premium Partnership program, and the individual does not appear to be eligible for another medical program, the worker will send a denial notice saying it is not an open enrollment period and that they can reapply during an open enrollment period. When needed, help individuals complete an application form. Applicants can apply online at https://jobs.utah.gov/mycase/

Applicants may apply for medical assistance programs through the FFM.

Inform individuals in writing, what additional information they need to provide before their eligibility for medical assistance can be determined. Also tell them, in writing, the date by which the information must be provided. The agency will always allow the individual at least 10 days to return information. The written notice must clearly state what is needed and when it is needed.

The eligibility agency cannot close or make a negative change without providing 10-day advance notice. This includes action taken regarding reviews and case changes. See Section 811 for exceptions to the advance notice requirement.

Inform individuals at the time of application, and recipients at the time of review, that information from income match data systems will be used as part of the eligibility determination process. (See section 703 for definition of application)

Inform applicants in writing, when their application is approved.

Provide a written notice to applicants and recipients telling them about actions taken which deny, reduce, terminate, or otherwise change benefits, the effective date of and the reason for such actions. (See section 811 on proper notification.)

That the eligibility agency must: Determine eligibility for medical assistance timely and correctly. Determine amount of member liability timely and correctly. Issue benefits timely and correctly. Fix medical assistance underpayments and overstatements of liability as required by the rules in 825 . The electronic information will be sent to the FFM when Medicaid is closed or denied.

Allow applicants and recipients to request a fair hearing when they disagree with an agency decision. If the issue is simple and straightforward, inform applicants and recipients about the possibility of resolving the dispute through an agency conference.

When the Medicaid Disability Review Office decides an applicant or recipient is not disabled, inform the individual of his right to request a reconsideration of the decision as part of the request for a fair hearing. (See Sections 121 and 125 for rules about agency conferences and fair hearings.)

Do not enter the home of applicants or recipients without their permission. Do not visit an applicant or recipient after working hours without making an appointment.

Keep applicants' and recipients' case record information safeguarded from unauthorized disclosure and use. (See sections 111 , 113 , and 115 for more information.)

Do not discriminate on the basis of race, color, religion, gender, age, national origin, political beliefs or handicapping conditions. (Gender, age, disability and immigration status may affect eligibility for certain programs such as Pregnant Woman Medicaid, Child Medicaid, Aged Medicaid, Disability Medicaid or Refugee Medicaid Assistance. Immigration status also affects whether a recipient can receive full Medicaid services or just emergency services. However, these distinctions do not affect a person's right to apply for assistance or to receive a fair eligibility decision based on the applicable policies. Questions about ethnic background are for statistical purposes only.)

Provide auxiliary aids and services free of charge, in a timely manner, to individuals with disabilities.

Provide language assistance services, free of charge, in a timely manner, to individuals with limited English proficiency.

Medicaid Policy

Previous Policy

To apply for medical assistance, individuals must complete, sign, and date a Medicaid application or the Single Streamlined Application used to apply for all Insurance Affordability programs. The applicant has several choices of how to complete and file an application. (See 703-1 on What is an Application?)

The Medicaid agency will accept applications in the following ways.

Paper Application : Applicants may pick up a paper application at the eligibility agency's local offices, from the Federally Facilitated Marketplace, print one from the agency's website or ask that one be mailed to them. A paper application must be completed, signed, dated and filed at a DWS local office, the Federally Facilitated Marketplace, or an outreach location by delivering it in person, mailing it, or faxing it.

· Telephone Applications : Applicants may ask to apply by telephone. ( 703-1 ) When applying by phone, the agency will take the eligibility information over the phone. The applicant will have the option to complete the application over the phone in one of two ways:

Telephonic signature: The telephonic signature will be documented and stored by the agency. A confirmation receipt documenting the telephonic application will be sent to the applicant via the communication method they have selected, or A copy of the completed telephonic application form can be mailed to the applicant. The applicant must sign and return the signature page in person, by mail or fax no later than the last day of the application processing period.

Online Applications : Applicants may complete an online application through the state agency or complete the Single Streamlined Application through the FFM. When applying online, applicants must complete the online signature. The agency accepts an online signature as a legal signature of the individual applying for Medicaid. The applicant can print a copy of the application, the rights and responsibilities, and other important information provided for their own records.

FFM Account Transfers : Individuals assessed eligible for Medicaid or CHIP by the FFM will have their account transferred to the state agency for a final determination.

Review Form : If an individual or household is currently open for public assistance, a review form may be used as an application for another type of assistance, or for a new household member. The individual must indicate on the form what type of assistance is being requested, who the household wants to cover, and the date of the request. The review form with the request must be delivered to a local agency office. If the individual has not previously signed a Medicaid application and completed appropriate assignment of rights and third party liability information, the agency will send this information to the applicant to complete, sign and return. (See Section 721-1 for updating TPL at reviews.) If the case closed for failure to complete the review process a review form can be used to reapply if received within 3 months of the closure.

Nursing Home/Long-Term Care Addendum : When a recipient enters a nursing home or is referred for home and community based services waiver, the member may be asked to complete a nursing home addendum. New applicants for such services may also need to complete the addendum. Long-term care has different eligibility requirements and additional information is needed to complete an eligibility decision.

An unsigned application is not complete and the agency cannot determine eligibility until it receives the signature. The applicant must return the signed signature page no later than the last day of the application processing period or the agency will deny the application. (See Sec. 703 on filing an application and Sec. 703-2 on how the agency sets the application date.)

If an application is not complete, the agency will contact the applicant and offer ways for the applicant to complete the application. The application must be completed by the end of the application processing period, or the agency will deny the application.

Medicaid Policy

Previous Policy

A. The eligibility agency will use electronic data matching to verify factors of eligibility before asking the individual to provide additional information or documentation. Individuals must verify factors of eligibility when:

the information is not available electronically, or

the electronic data is not reasonably compatible with the client’s statement.

The following rules apply when asking the individual to provide verification.

The agency will give individuals a written request for verifications.

Individuals will have at least 10 days from the date the agency gives or mails a request for verifications to the individual to provide verifications. Individuals must return verifications to the agency by the due date.

Verifications needed to complete an application must be returned no later than the last day of the application period. See Sec. 703-5 for the application processing time period.

If the due date falls on a non-business day, then the individual has until the close of business on the first business day after the due date to return the requested verifications to the agency.

Verifications turned in at an outreach location at a time the outreach office is open are dated as received on that day. If verifications are turned in at an outreach location at a time when the office is closed, the date received is the last day that a staff person was at that location to receive or collect verifications.

Individuals may ask for more time to return verifications. The agency will give the individual at least 10 more days to provide the verifications if the individual asks for more time by the due date. Workers may provide additional extensions of the due date because of circumstances beyond the individual's control such as individual illness, family emergency or similar causes.

If the agency requests more information, the agency will allow at least 10 days for the individual to return the information. The agency will extend the application processing period as needed to give the individual time to return verifications.

Individuals may ask the eligibility worker for help to obtain verifications.

If verifications are not provided on time, the agency will deny the application or close the eligibility review.

If the agency cannot give 10-day notice for an adverse action, it must continue benefits to the following month. See Section 811 for exceptions to the advance notice requirement.

If the individual provides verifications within 30 days after an application has been denied, or within 3 months after the review is closed for failure to provide verification, the date the verifications are received becomes the new application date. The individual does not have to complete a new application form; however, the new application date changes the date retroactive benefits can start.

If the individual returns verifications more than 30 days after the application has been denied, the individual will have to reapply. If a review is closed for not completing the review or not returning verification, see Sec. 721-1 .

Anytime that a due date falls on a Saturday, Sunday or state holiday, the individual has until the close of business on the business day immediately following the due date to turn in verifications or make reported changes.

See Section 721 for more on eligibility reviews. For verifications needed when a change is reported, see Sec. 815

Medicaid Policy

Previous Policy

An applicant or recipient must assign to the Department of Health and Human Services, his or her rights to medical benefits. This includes payments from third parties responsible to pay for medical care, money collected from an insurance policy for services received while on Medicaid, and money collected from anyone liable for the member's medical expenses. See 225 for TPL requirements.

1. Upon approval of medical assistance, the member must also give any and all rights to medical support to the State of Utah, and cooperate with the State of Utah in establishing and collecting support payments from an absent parent or spouse. See 227 for more information about Medical Support Enforcement requirements.

2. By signing an application form in either paper or online format, or an addendum to an application, the member is agreeing to the above assignments of rights. A spouse, parent, legal guardian, or personal representative who signs the application or the addendum for a member is making the above assignment of rights for the member.

Medicaid Policy

Previous Policy

Applicants and recipients must report changes within 10 calendar days of the day they learn of the change. Failure to report changes timely may create an eligibility payment error ( 825 ). (For information on how to treat reported changes, see section 815 .)

The date of report is the date the applicant or recipient tells the eligibility agency through an online reporting process, in person, by telephone, by fax or by mail about a change when that report is received by the close of business. The agency will date change reports received after the close of business as received on the next business day. When an applicant or recipient mails information, the business day the agency receives the mailed change report is the date of report.

The change is reported timely when: The agency receives the information by the close of business on the 10th day after the member learns of the change; or If a due date for reporting a change falls on a Saturday, Sunday or state holiday, the member has until the close of business on the next business day to report the change. Change reports delivered to an outreach location at a time when the office is closed will be dated as received on the last business day that an outreach staff person was working at that location. Based on the date the change report is dated as received at an outreach location, timeliness then follows the rules in A. and B. If the agency cannot give 10-day notice for an adverse action, it must continue benefits to the following month. See Section 811 for exceptions to advance notice requirements.

Applicants and recipients must report the following changes within 10 days of when they learn of the change: Change of more than $25 in gross monthly income. (Nursing home and waiver members must report all income changes.) Change in income source (new source, loss of previous source). Receipt of a lump sum from any source, such as Social Security benefits, inheritances, insurance payments, accident or injury awards (insurance or court settlements), etc. Change in assets, such as gaining or losing a vehicle, or opening a bank account. Members on MAGI-based eligibility groups do not have to report asset changes. Change of more than $25 in total allowable deductions. Change in health insurance, such as gaining or losing health insurance, changing to a different health insurance company, premium changes, and changes in the responsibility of a third party to pay medical bills for an applicant or recipient. (Members have 30 days to report these TPL changes.) Change in household size. When a household member experiences a change in pregnancy status. Change in marital status, deprivation, or living arrangements. Change in the type of residence, such as entering or leaving an institution, or a change of address. This includes stays in hospitals or nursing facilities for 30 or more days. Change in non-citizen status.

There are additional reporting requirements for Medicaid programs using MAGI eligibility rules. Applicants and recipients must report changes in: Tax filing status. Number of claimed dependents. Earnings of a child. Student status of a child.

Recipients who provide reports, forms, or verifications by any one of the dates listed below have provided the information on time: When the local office receives the information by 5:00p.m. on the due date; or When the due date is on a Saturday, Sunday or State holiday, the local office receives the information by 5:00p.m. of the first working day after the due date; or When the enrollee faxes in the information and the fax date shows it was faxed by the due date by 5:00p.m. If the agency cannot give 10-day notice for an adverse action, it must continue benefits to the following month. (See Section 811 for exceptions to the advance notice requirements.)

Medicaid Policy

Contact DHHS Policy Specialist for Previous Policy

Medical assistance members are responsible to pay to the state eligibility agency the amount of a medical assistance overpayment or the amount of the understatement of liability as required by the sections 825 , 825-1 , 825-2 , 825-3 , 825-4 , 825-5 , 825-6 , and 825-7 .

Medicaid Policy

Previous Policy

The Department of Workforce Services Internal Audit Division (DWS IAD) conducts reviews of medical assistance cases to determine the accuracy and quality of eligibility decisions made by the eligibility agency, and the accuracy of payments made by DWS IAD.

Applicants and recipients of medical assistance will be asked to cooperate with DWS IAD and the eligibility agency to complete these quality reviews.

1. DWS IAD may contact an applicant or recipient as part of a quality review.

2. The applicant or recipient will be asked to provide complete and accurate information about factors related to the individual's application, medical services received or eligibility.

3. DWS IAD may ask the applicant or recipient to provide verifications of the information being reviewed. The applicant or recipient will be asked to provide any requested information to DWS IAD within 10 days of the request. Do not close the case if the applicant or enrollee does not provide the requested information.

Medicaid Policy

Previous Policy

Applicants and recipients must assume certain responsibilities to receive medical assistance.

Each applicant should receive a copy of the Rights and Responsibilities form. It may be part of the paper or online application or can be accessed at https://medicaid.utah.gov/nondiscrimination-policy/

Applicants and recipients should talk to their eligibility worker if they have any questions about the rights and responsibilities of members. These responsibilities are defined in the sections that follow.

Medicaid Policy

No Previous Policy

Due to the National Voter Registration Act of 1993, anytime an adult applies for medical assistance, the adult must be given the opportunity to register to vote. Ask all adult applicants if they want to register to vote. Explain that their decision will not impact their eligibility for medical assistance. At review time, adult recipients must also be given the opportunity to register to vote.

When applicants or recipients want to register to vote, have them complete form VOT-80. When needed, help applicants or recipients complete the voter registration form. Never discourage applicants or recipients from registering to vote. Also, do not try to influence applicants or recipients to join a particular political party or vote in a certain manner.

When recipients report an address change, they must again be given an opportunity to register to vote. Have recipients complete form VOT-81 when they move, and want to register to vote at their new location.

Give form VPT-PM-82 to applicants or recipients who have questions about the voting process, where to vote, etc. The form is designed to help answer some of these questions.

Medicaid Policy

Contact DHHS Policy Specialist for Previous Policy

Confidential information may only be disclosed and used under limited circumstances. Do not disclose or use confidential information unless it is for one of the purposes described below.

Note: There are special STRIC rules for the disclosure and use of income match data. See sections 115 and 751-3 for specific information.

Administration of the Medicaid Program

Confidential information may be disclosed and used for purposes directly connected with the administration of the Medicaid program. However, only disclose and use the information to the extent necessary to assure valid administration of the program. Purposes directly connected with the administration of the Medicaid program include activities such as:

Establishing eligibility;

Confirming eligibility so the recipient may receive medical services;

Computing the amount of medical excess or nursing home payment;

Assisting with a civil or criminal investigation, or proceeding, that is directly connected with the administration of the Medicaid program.

If a court or law enforcement official asks for confidential information, for a matter not directly connected to the administration of the Medicaid program, the court or law enforcement official is not entitled to the information. If the individual persists in trying to obtain information, have a supervisor explain that Federal and State law prohibits the release of confidential information from a case file.

If a case file is subpoenaed by an outside source, call a Program Specialist immediately. The legal counsel for the Department will ask the court to disallow the information from the case record, citing the Federal Social Security Act and this manual.

Establishing Eligibility for Other Federal or State Programs

Confidential information may be released to governmental agencies, as long as the information is only used to verify and determine eligibility for the following programs: Insurance Affordability programs administered by the Federally Facilitated Marketplace (FFM) , FEP, food stamps, child support enforcement, unemployment compensation, SSA and SSI. Only release confidential information to the extent necessary to assist the agencies in the valid administration of the specific programs listed.

The Department may enter into written agreements with other agencies that permit the release of confidential information to the agencies. Currently the DHHS has agreements with the Department of Health and Human Services, the FFM, and the Department of Workforce Services. The agreement allows for the release of confidential information to the FFM, Department of Health and Human Services and the Department of Workforce Services when the information is to verify and determine eligibility for Medicaid and other assistance.

When governmental agencies request confidential information for purposes not directly related to the administration of one of the programs listed above, please contact a Program Specialist for clarification about whether confidential information may be released to them.

Public Request

The public may view policy manuals and receive non-identifying information about Medicaid recipients. The public is not entitled to information about particular applicants and recipients. This includes people who may demand to see confidential information as a taxpayer.

Do not publish applicant and recipient names.

Do not use applicant and recipient information to distribute commercial information, political information, holiday greetings, general public announcements, etc. The only exception to this is that eligibility workers may distribute material directly related to the health and welfare of applicants and recipients. For example, eligibility workers may distribute information about free medical examinations or services, free vaccinations, information that could protect the health of applicants or recipients, the availability of surplus food, etc.

Permission Granted By Applicants and Recipients

An individual can give written permission to release case record information. A valid permission form must include:

Individual’s name.

Individual’s Social Security number or Medicaid ID number. There is an exception to this requirement if the individual has not provided a Social Security Number, and is not required to do so (i.e., someone who is not applying for benefits for themselves).

Individual’s date of birth.

Name of the person or organization to whom the individual is authorizing the release of information.

The purpose of releasing the information.

The date the release ends. It starts the date it is signed by the individual.

A statement as to how the individual or authorized representative can revoke the authorization.

A statement that explains that there is no obligation to sign the release and that Medicaid eligibility will not be denied if it is not signed.

A statement indicating that the individual understands that once information is released, it may no longer be protected and may be re-disclosed.

The release must be signed and dated by whoever signed the application. If signed by someone other than the individual, describe their authority to sign.

Note : An applicant or recipient CANNOT authorize the release of Income Match Data from the case record. See section 115 for additional information about Income Match Data.

Link to e-Forms. Search for form 114.

Emergency Situations

When an agency, with comparable rules for safeguarding case records, requests information about an applicant or recipient due to an emergency, you may release the information and then get the applicant's or recipient's permission. The Regional Director or his designee decides what constitutes an emergency. Detail the nature of the emergency in eREP.

Note : Income Match Data CANNOT be released due to an emergency. See section 115 for additional information about Income Match Data.

Medicaid Policy

No Previous Policy

All confidential information must be safeguarded from unauthorized disclosure and use. State employees who fail to safeguard confidential information may be subject to both civil and criminal penalties.

Confidential information includes identifying information about applicants and recipients, such as names, addresses, telephone numbers, social security numbers, etc. Second, it includes information used to determine eligibility, such as income, assets, medical reports and data, names of persons obligated to provide financial and medical support, etc. Third, it includes information about benefits and medical services provided to individual recipients.

Information that cannot be identified to particular applicants and recipients is not confidential information. For example, information stating the total number of Medicaid recipients, the total number of children receiving Medicaid, or the total number of elderly individuals receiving Medicaid is not confidential information because no one person can be identified by the general information.

For specific information about releasing case record information TO APPLICANTS AND RECIPIENTS, SEE SECTION 113 .

For specific information about SAFEGUARDING INCOME MATCH DATA, SEE SECTION 115 .

Medicaid Policy

No Previous Policy

At times, when a provider completes a medical report for an applicant or recipient, the provider may not want the person to view the report. Because applicants and recipients are entitled by law to view information used to determine their eligibility, use the following procedures when an applicant or recipient requests to see medical reports contained in the case record.

Determine if the Medical Report is Restricted.

If the report specifies not to show it to the applicant or recipient, go to item 2, below. If a report is marked "Confidential," it may not necessarily mean the provider does not want the applicant or recipient to see it. Ask the provider if the report may be shown to the applicant or recipient and document the provider's response. If the provider says it may be shown to the person, it is not restricted. If the provider states that it cannot be shown to the member, go to item 2, below. If the medical report does not state the provider wants to restrict it from the applicant's or recipient's view and it is not marked "Confidential," but it seems to contain information that could have an adverse impact on the person, follow the procedures below to determine if the information can be released directly to the applicant or recipient.

(1) Call the provider who completed the report to determine if the information can be released directly to the applicant or recipient. Document the provider's response. If the provider states it can be released directly, the report is not restricted. If the provider states that it cannot be released directly, go to item 2, below.

OR

(2) Have an eligibility supervisor review the report and determine if the information can be released directly to the applicant or recipient. The supervisor may choose to discuss the report with the Disability Review Coordinator at the Dept. of Health. If the supervisor states it can be released directly, the report is not restricted. If it cannot be released directly, follow the procedure under item 2 to designate an authorized representative.

Designate an Authorized Representative.

When the provider indicates the report is not to be shown to the applicant or recipient, discuss with the provider that applicants and recipients must have access to medical records used to determine their eligibility. If the provider feels the information may have an adverse impact on the person, tell the provider that we can ask the person to designate an authorized representative to receive the information.

A. If the provider refuses to allow the information to be released to an authorized representative, go to item 3, below.

B. If the provider agrees that the information may be released to an authorized representative, ask the applicant or recipient to designate one. The designation must be done in writing . Because medical reports may be technical, the applicant or recipient may want to chose a physician, social worker, or other professional to receive the information.

(1) Before releasing medical records to an authorized representative, send a notice to the representative explaining the release and responsibility a representative assumes.

(2) After the medical records are released to the authorized representative, send a notice to the applicant or recipient stating the records were sent to the representative.

If the applicant or recipient refuses to designate an authorized representative, ask the provider if the report can be redone so the information may be released directly to the applicant or recipient. If the report cannot be redone, explain to the applicant or recipient that eligibility cannot be determined without the use of the medical information, and that unless the person has access to the information through an authorized representative, we cannot use the information. If the person still refuses to designate a representative, deny or close the case for failure to provide information.

Redo the Report.

If the provider refuses to allow the release of medical information to an authorized representative, ask the provider if the report can be redone so that it could be released to the applicant or recipient, or the person's representative. If the report cannot be redone, go to item 4, below.

Effect of Not Being Able to Use the Medical Report.

If the report cannot be redone AND an authorized representative cannot receive the information, do not use the information for eligibility determinations. Unless the person can obtain a medical report from another provider, this may result in the case being denied or closed for failure to provide information.

Medicaid Policy

No Previous Policy

Applicants and recipients have the right to receive information about their own eligibility and benefits. This right includes viewing and copying information contained in their case record. Although applicants and recipients have the right to information about their own case, the right is not absolute. Some information is of such a nature that it cannot be released to applicants or recipients. Item 2 below discusses what case information cannot be released to applicants and recipients.

What Case Information Can Be Released to Applicants and Recipients

Allow applicants and recipients to view and receive copies of information in their own case record that is not restricted under item 2 below. Authorized representatives may also view and receive a copy of case record information. Have the applicant or recipient sign a statement to allow a representative to receive information when the representative is not named on the case record as an authorized representative.

Do not allow applicants or recipients to remove case records from the eligibility worker's work area. When applicants or recipients want a copy of information from their case record, make the requested copy for them, as long as the information is not restricted under item 2 below. Do not charge the person for the first 10 pages copied. If the person wants more than10 pages copied, charge what it costs your local office to make each additional copy.

Restricted Information that Cannot Be Released to Applicants and Recipients

Some case record information is restricted. Applicants and recipients cannot view or receive copies of any restricted information in their case record. Since applicants and recipients cannot view or receive copies of restricted information, such information cannot be used to deny, reduce, or terminate benefits, or increase a spenddown or MWI premium. Finally, restricted information cannot be used at a fair hearing. See sections 113-1 and 115 .

Medicaid Policy

Previous Policy

IRS Income Match data must NOT be recorded or stored in any place where unauthorized persons may have access to it. Make sure there is NO information in the case that can be identified as IRS data.

To comply with the extra safeguards for IRS data, do not include it in the case record and keep all data which is clearly linked to IRS in locked storage.

NEVER include items in the case record that can form a direct link with the IRS match. Do not refer to IRS in the case record. This includes both notices and the case notes. Use general statements in both. The pre printed request for verification was designed to meet the safeguard rules. If it is completed as designed, it can be filed in the case record. If any extra information is added, it may no longer comply with the rules. Keep case notes entries general. Use "Checked unearned income" or "Cleared Match report." Any information that can be identified specifically as IRS data must be kept in locked storage separate from the case record including the pre-printed request form if it is changes to include any IRS specific information.

The pre-printed request for verification is designed to meet the safeguard rules. When completed as designed, it can be filed in the case record. If extra information is added to the form such as a reference to "Form 1099-R" or "IRS," it may no longer comply with the rules. Such a change would make clear the link between the request and the IRS match. Any information that can be identified specifically as IRS data must be kept in locked storage separate from the case record including the pre-printed request form if it is changed to include any IRS specific information.

Medicaid Policy

Previous Policy

The people listed below have access to income match records:

1. Applicants and recipients may view their own income match records, except for IRS income match records.

2. Employees who work for the SSA.

3. IRS employees who work with tax returns or income match data. This includes those who work with income match safeguards.

4. Employees who administer the following programs in Utah, other states, or with federal agencies.

A. Family Employment Program (FEP)

B. Food Stamps

C. Medicaid

D. Child Support Enforcement (ORS)

E. Social Security (OASDI or SSI)

F. Unemployment Compensation

Note: Quality Control reviews, fair hearings, program outreach and referral activities performed by local office and State office employees, and the pursuit of over payments and estate recovery are aspects of program administration.

Staff who do not work for the programs shown above do NOT have access to Income Match records from SSA, Wage Match or IRS. This includes staff who work exclusively with other Federal programs such as Title XX (Child Care and other) programs.

Even auditors, who can see case records, must have proof of their right to see the IRS income match records. Proof of the right to see IRS data includes being named in the IRS code list of those with access or a letter from IRS. Call the Medicaid Program Specialist, if you have any questions about someone's right to the IRS match data.

Medicaid Policy

Contact DHHS Program Specialist for Previous Policy

Procedure IVES/BEERS Reports - Accessing

Along with certain other governmental agencies, we participate in the Income Eligibility Verification System (IEVS). This allows us to receive computerized income matches from other agencies. The type of income match data we receive includes Wage Match, UC (unemployment compensation), SDX (Supplemental Security Income), BENDEX or BDX (Social Security benefits), BEERS, and IRS (Internal Revenue Service) income match records. Income information received from SSA or the Internal Revenue Service must be safeguarded according to the requirements of the agency that furnished the data.

Safeguard all reports of matched data. This includes printouts, notice and request forms, computer terminal screen displays, and any other items which contain Income Match reports. Restrict access to all income match reports. (Section 115-2 explains the rules on who has access to Income Match information.) Failure to follow these rules can result in a fine of $5,000 and a five year jail term for each offense.

See section 115-1 for specific safeguards of IRS Income Match Records. The income match records are different than IRS Federal Tax Information. (The agency does not receive IRS Federal Tax Information at this time.

See 751-3 for information when to verify income match data.

Medicaid Policy

Effective Date: July 1, 2002

No Previous Policy

Complaints

When an applicant or recipient disagrees with an eligibility decision or has an issue with how services are provided, the person may make a complaint in person, by phone, or in writing. Complaints may be taken at the local office or outreach site, or referred to the eligibility agency's Constituent Services Representative. Complaints must be resolved as quickly as possible. The response to a complaint may be given in person, by telephone, or in writing.

Agency Conferences

An agency conference is a less formal procedure than a fair hearing. Its purpose is to quickly resolve problems that are simple and straightforward.

The agency conference is not mandatory.

The member has the right to proceed with a formal fair hearing regardless of the outcome of the agency conference, as long as the member requests a hearing in a timely manner.

The member may request a fair hearing if the agency takes any new adverse case action as a result of the agency conference.

The member and agency staff, including a supervisor, participate in the agency conference.

Document the results of the agency conference in the case record. Take any appropriate case action.

Medicaid Policy

Previous Policy

Applicant and recipients have the right to ask for a fair hearing in they disagree with the agency's decision about their eligibility for Medicaid benefits or if they disagree with a point in the eligibility process that affected their case.

A. Hearing Requests for Eligibility Decisions

An applicant or recipient must request a hearing in writing or orally within 90 days of the date on the notice with which he disagrees. The applicant or recipient may submit a written, verbal or email request for a fair hearing to the Department of Workforce Services or the Department of Health and Human Services. When the individual contacts either agency and requests a fair hearing, the worker will take the information, document the report and forward the request to the appropriate entity. The individual must make the request by the close of business on the 90th day, or if the 90th day is a non-business day, by the close of business on the first business day following the 90th day. If the agency denies a request to waive a penalty period due to undue hardship, the individual has 90 days from the date on the notice denying the undue hardship to request a fair hearing.

Recipients receive continued medical benefits pending a hearing decision if they request a fair hearing before the effective date of the action or within 10 calendar days of the receipt of the notice, whichever is longer. The notice is considered to be received 5 days from the date on the notice, unless the recipient can show they did not receive the notice within the 5 day period ( 125-3 ).

The individual must repay any benefits received pending the hearing decision if the hearing decision upholds the agency action ( 125-3 ).

An individual has the right to refuse continued benefits pending a hearing decision.

The eligibility agency cannot hold hearings concerning the spousal resource assessment until the institutionalized person applies for Medicaid.

When a recipient requests a hearing to increase the spousal resource allocation for a community spouse of an institutionalized spouse, the "income first" rule applies to the hearing decision ( 573-2 ).

An individual, an individual’s spouse, a parent of a minor child or an authorized representative may request a hearing.

Hearing Requests for Decisions by the State Medicaid Disability Office

When the State Medicaid Disability Office (SMDO) decides a person is not disabled, the individual may request a fair hearing. Hearings based on decisions of the SMDO are with the Office of Formal Hearings at the Department of Health and Human Services. The individual may also ask for a reconsideration of the disability decision as part of the fair hearing request. Reconsideration is a good idea when the individual has new medical evidence that was not available for the original claim. If the SMDO re-affirms the original decision, the individual may continue with the fair hearing.

When the eligibility agency denies or stops medical assistance because of a denial of disability from Social Security (SSA), the Medicaid agency cannot conduct a hearing based solely on the SSA decision. The individual can only appeal SSA’s denial of disability through the Social Security office. See 125-3 for policy on continued benefits. The individual may request a hearing when there is new medical evidence not considered for the SSA decision ( 303-3 ).

Medicaid Policy

Previous Policy

1. The Department of Workforce Services, as the eligibility agency, handles all medical assistance hearings except hearings for foster care, subsidized adoption or disability claims determined by the State Medicaid Disability Office (SMDO).

2. The Office of Formal Hearings at the Department of Health and Human Services (DHHS) conducts all hearings concerning Medicaid eligibility for foster care, subsidized adoption and disability claims determined by the SMDO.

3. An expedited hearing is processed in 7 days and can only be granted if the individual can verify that the standard time for a hearing (90 days) could jeopardize their life, or ability to reach, maintain, or return their health to maximum function ( 125-4 ).

4. The Hearings Office must notify the individual and the local office of the time, date, place, and reason for the hearing. The agency must mail the notice at least seven days before the hearing. However, if all parties agree, the hearings officer may hold the hearing sooner. The Hearing Officer may choose to schedule pre-hearing meetings as a way to clarify the issue, arrange for the exchange of documents and identify witnesses.

5. The Hearings Office generally schedules hearings as phone hearings. The individual can ask for an in-person hearing by contacting the Administrative Law Judge before the date of the scheduled hearing.

6. For hearings held in person, all parties meet at the same place for the hearing.

7. For a hearing held by telephone, the Hearing Officer remains in the office and conducts the hearing via telephone conference call to other locations where the parties involved in the hearing are located.

8. The ALJ, eligibility agency or individual can request a postponement of the hearing. The postponement cannot exceed a total of 30 days.

a. The request for the postponement must be made before the scheduled hearing.

b. The request must be made orally or in writing to the ALJ assigned to hear the case.

c. The party requesting the postponement must show a reasonable reason for the request.

d. The agency must hold the rescheduled hearing within 30 days of the original hearing date.

9. The individual may have a representative, including legal counsel.

10. The eligibility agency may have legal counsel.

11. No party to the hearing can discuss the issues pertinent to the hearing with the Hearing Officer without all interested parties either being present or subsequently informed of the content of the discussion.

12. Fair Hearings are not open to the public. Only the following individuals may attend:

o The Hearing Officer.

o Representatives, legal counsel and witnesses from the Department of Health and Human Services and Department of Workforce Services.

o A transcriber, as determined by the Hearing Officer.

o The applicant or individual, friends or relatives of the individual’s choice, and a designated representative for the individual as space permits.

13. Cancelling a Hearing.

a. The applicant or individual must notify the DWS Office of Adjudication and Appeals or the DHHS Office of Formal Hearings if they want to cancel the hearing and not proceed with the appeal.

b. The ALJ issues a decision dismissing the appeal.

c. This decision has the effect of upholding the eligibility agency’s original action.

d. The customer has 30 days to reinstate the appeal by filing a written request for reinstatement to the Division of Adjudication.

14. Failure to Appear for a Fair Hearing.

o If either party fails to appear at the hearing in person, by telephone or through a representative, the ALJ issues a decision based on the available evidence.

15. Reopening a Fair Hearing.

a. If either party fails to participate in the hearing, but the agency has not issued a decision, the party may request the hearing be reopened.

b. If the agency has issued a decision, either party that failed to participate personally may request the decision be set aside and a new hearing scheduled.

i. The request must be in writing and mailed, faxed or delivered to the Division of Adjudication within 10 days of the issuance of the decision.

ii. Individuals who request the hearing be reopened more than 10 days after the issuance of the decision must show good cause for not making the request within the allotted time limit.

iii. A request made by the eligibility agency more than 10 days after the decision will not be granted.

16. Good Cause to Reopen a Fair Hearing.

a. Failure to report as instructed at the time and place of the scheduled hearing is the equivalent of failing to participate, even if the party reports at another time or place.

b. Good cause for failing to participate in a hearing does not include such things as:

o Failure to read and follow instructions on the notice of the hearing.

o Failure to arrange for personal circumstances such as transportation or child care.

o Failure to arrange for receipt or distribution of mail.

o Failure to delegate responsibility for participation in the hearing,

o Forgetfulness.

Medicaid Policy

Previous Policy

When a recipient asks for a fair hearing, the recipient may be eligible to receive medical benefits while the hearing is pending. Applicants cannot receive medical benefits during the hearing process. Continue benefits for a recipient in the following two instances. Continue the medical assistance if the member asks for a hearing any time before the effective date of the action or by the close of business on the 10th day from the date the Notice of Decision was received by the member. (The notice is considered to be received 5 days from the date on the notice.) (See Sec. 811 for advance notice requirements.) If the 10th day after the notice was mailed is a non-business day, then continue the medical assistance if the member makes the request no later than the first business day following the 10th day. At the hearing or pre-hearing conference, the Hearing Officer will determine what the actual issues are. If the Hearing Officer finds the only reason for the hearing is because of Federal or State policy or law and discontinues the fair hearing process, stop the medical assistance. Otherwise, continue the medical assistance until you get the hearing decision. When Social Security determines an individual is not disabled or blind, or finds the individual no longer meets disability or blindness criteria, continue medical assistance ONLY IF the member was receiving Disabled or Blind Medicaid before the agency receives the SSA denial, and the member files the SSA appeal timely and notifies the Medicaid worker of the appeal. The computer match record for SSI benefits may show the member has filed an appeal and that is effective verification, too. If the member was applying for disability benefits other than SSI, ask for verification from the Social Security agency of the appeal status. If the member has an attorney helping with the SSA appeal, the lawyer can verify the appeal status. Benefits may continue throughout the administrative appeal process with SSA. If SSA's final decision upholds the decision that the person is not blind or disabled, stop the continued Medicaid benefits giving proper notice. The member must repay the continued Medicaid benefits. ( 825-2.1 # 3). If Disabled or Blind Medicaid was not approved before we receive an SSA denial, the applicant cannot receive benefits pending the SSA appeal. (See 125-3 , #1)

Member's Requirement to Repay Continued Benefits ( 825-2.1 # 3) The recipient must repay benefits if the hearing decision goes against the recipient. The agency must tell the member of the requirement to repay benefits pending the hearing decision. Repayment is required even if the recipient does not use any medical or mental health services while the hearing is pending. This is also the case if a recipient receives continued benefits pending an appeal to Social Security about a disability decision, and the appeal goes against the member. This information is part of the hearing request form. ( 825-2.1 # 3) Repayment of benefits includes all expenses paid by the Medicaid agency on behalf of the recipient including: premiums and fees for a Medicaid Health Plan, the contracted mental health provider serving Medicaid recipients in a given area, Medicare or other health insurance, medical transportation and all fee-for-service expenses.

How to Handle Case Changes Before the Hearing Decision When a new change happens during the continued benefits time, adjust the medical assistance, holding constant whatever item is the subject of the hearing. Notify the recipient of the effect of the change. If the new change causes the individual to be ineligible for medical assistance, stop the continued benefits giving proper notice. The individual has the right to ask for a new hearing on the new change and may receive continued benefits if the criteria under 125-3 are met.

Appeals Recipients who were receiving benefits pending the hearing decision are not entitled to continued benefits during an appeal to District Court. Recipients are not entitled to continued benefits during a court appeal of a Social Security denial, i.e.: they have exhausted SSA's administrative appeal process. When the hearing decision upholds the agency's decision or the SSA appeal decision upholds SSA's original denial, stop assistance at that time.

When to Stop Assistance Pending the Hearing Decision A recipient who meets the criteria to receive benefits pending the hearing decision may choose not to receive continued benefits. Do not provide benefits pending the hearing decision if the recipient says he or she does not want benefits while the hearing process or SSA appeal goes on. The recipient can mark the box on the hearing request form or make the request by telephone or in person to say he does not want continued benefits. Note the request and the date on the case narrative, discontinue assistance and send a notice confirming the recipient’s decision. If a recipient who initially declined the continued benefits later says he wants to receive benefits while the hearing is still in process, confirm that the hearing is still pending. Reopen the case from that point forward. Document the request. Do not open prior months. Once a hearing decision has been made, follow that decision. If the Hearing Officer states, in writing, that the only reason for the hearing is because of Federal or State policy or law and decides not to hold a hearing, stop the medical assistance at that time. (The Hearing Officer decides what the issues are at the hearing or pre-hearing conference.) Otherwise, provide the medical assistance until a hearing decision is received. If the recipient's whereabouts are unknown, stop the continued benefits and send notice to the last known address. Reopen the case without requiring a new application if the recipient contacts the office within 30 days after the closure, still wants to receive benefits pending the hearing decision, and the hearing decision is still pending. If the recipient contacts the office more than 30 days after the case is closed, reopen the case only from that point forward if the hearing is still pending. If another change makes the recipient ineligible, stop the continued benefits. Send appropriate notice of the closure. (See 125-3 #3 above) Do not provide continued benefits during an appeal to District Court. (See sec. 125-6 )

Medicaid Policy

1. All hearings will be conducted informally and in a way to protect the rights of the parties. The hearing may be recorded.

2. The ALJ considers all issues relevant to the hearing and bases the decision on the relevant evidence and policies.

3. All parties may testify, present evidence, and comment on the issues.

4. All testimony of the parties and witnesses will be given under oath or affirmation.

5. The ALJ will direct the order of testimony and rule on the admissibility of evidence.

6. The ALJ may accept oral or written evidence of any nature, whether or not conforming to the legal rules of evidence, including hearsay, and determine its relevance to the issues.

7. Each party to a hearing receives an adequate opportunity to be heard and to present any pertinent evidence that helps prove the party's position. Each party can know about and rebut by cross-examination or otherwise any evidence submitted.

8. Official records of the eligibility agency, including reports submitted in connection with any program administered by the agency or other State agency may be included in the record.

9. The parties, with the consent of the ALJ, may stipulate to the facts involved. The ALJ may decide the issues on the basis of such facts or may set the matter for hearing and take such further evidence as deemed necessary to determine the issues.

10. The ALJ makes a decision based solely on the testimony and evidence presented at the hearing.

11. Unless the applicant or individual requests a continuance, the ALJ issues a decision within 60 days of the date on which the individual requests the hearing.

12. An individual may request an expedited fair hearing (a decision issued to the individual within 7 business days of request) if they can verify that waiting the standard time for a hearing (90 days) could jeopardize their life, or ability to reach, maintain or regain maximum function.

· These circumstances must be justified with sufficient documentation and should be entered into the case record.

· If requested documentation is not received within 7 days, the request will be denied and treated as a standard fair hearing request (90-day decision).

· A decision of whether an expedited hearing will be granted will be made based on the evidence submitted. Additional information may be required to demonstrate the urgent need on a case-by-case basis.

· If the expedited hearing request is denied, the initial request will be treated as a standard fair hearing. The individual will be notified of the denial for an expedited fair hearing and allowed to request continued benefits during the appeal.

· If the Request is approved, the individual will be contacted to set up an expedited hearing.

· After the hearing, the department will issue a determination within 7 business days after receiving the initial request.

13. A decision of the ALJ which results in a reversal of the eligibility agency becomes final 30 days after the decision unless the Department of Health and Human Services chooses to conduct an Agency Review. (See 125-6 )

A. The DWS hearing decision may be made final in less than 30 days upon agreement of all parties.

B. The Medicaid eligibility agency will take case action within 10 calendar days from the date the decision becomes final.

14. The ALJ may take evidence after the hearing. If more facts are found in the process, the ALJ may reopen the hearing.

Medicaid Policy

Previous Policy

1. The Department of Workforce Services (DWS) Division of Adjudications must issue a written decision to all parties involved in the hearing. The Office of Formal Hearings at the Department of Health and Human Services (DHHS) will issue the written decision if the hearing was the result of a decision by the State Medicaid Disability Office (SMDO). (Sec. 125-1 )

2. Send copies of the decision to the DWS Fair Hearing Team. This group is responsible to forward the decision to the individual, the individual’s authorized representative and selected representatives of the DWS and possibly DHHS for review.

3. What Must Be Included in the Decision

a. A description of the evidence that was presented.

b. Findings of facts based on the evidence. The decision must be based on more than just hearsay evidence.

c. Conclusions of laws and rules upon which the decision was based.

d. Statement of the reason for the decision.

e. Statement of action the agency must take, if any.

f. Right to request an Agency Review from the DWS Division of Adjudications and how to make the request.

g. Citations of statutes, regulations, and eligibility criteria.

4. Agency Review

a. DHHS, as the Single-State Medicaid Agency, is a party to all fair hearings concerning eligibility for medical assistance programs. The DWS Division of Adjudications conducts appeals and DHHS has the right to conduct an Agency Review of medical assistance hearing decisions rendered by the DWS Division of Adjudications or the Office of Formal Hearings.

b. The applicant or recipient may appeal the hearing decision to DWS. The request for agency review must be made in writing within 30 days of the mailing date of the hearing decision.

c. The DWS hearing decision becomes final 30 days after the decision is sent unless DHHS will conduct an Agency Review. The DWS Division of Adjudications will conduct an Agency Review when the applicant or individual appeals the hearing decision, or if DHHS disagrees with a DWS decision, they will conduct an agency review.

d. The DWS hearing decision may be made final in less than 30 days upon agreement of all parties.

e. DHHS notifies DWS Division of Adjudications it will conduct an Agency Review. The hearing decision is suspended until DWS Division of Adjudications issues a final Decision and Order on an Agency Review.

f. A Decision and Order on an Agency Review from DHHS is reviewed a second time by the DWS Division of Adjudications, and is either agreed upon and corrected, or rejected by the DWS Division of Adjudications who’s decision is then final.

g. Within 30 days of the date the Decision and Order on an Agency Review was issued, the applicant or individual may file a petition for judicial review with the District Court. Failure to appeal a hearing decision to DWS Division of Adjudications negates this right to a judicial appeal.

h. Individuals are not entitled to continued benefits pending judicial review by the District Court.

i. The eligibility agency must take case action within 10 calendar days of the date the decision becomes final if the decision reverses or modifies the eligibility agency's decision.

Medicaid Policy

Contact DHHS Policy Specialist for Previous Policy

Records of hearing requests are kept by the agency that conducted the hearing. The agency also keeps records about the content of the hearing and the hearing decision. The records are safeguarded according to the rules specified in sections 111 and 113 .

The public may request and view summaries of hearing decisions which do not identify specific applicants and recipients. The agency will make summaries available upon request.

Medicaid Policy

Applicants and recipients have a legal right to ask for a fair hearing any time they disagree with an agency action taken on their case.

Applicants and recipients should file the fair hearing with the agency that took the action on their case that they disagree with.

Medicaid Policy

Effective Date: June 1, 2025

Previous Policy

This section of the policy manual contains the basic non-financial eligibility rules for Aged, Blind, and Disabled Medicaid, the Qualified Medicare Beneficiaries (QMB) Program, the Specified Low-Income Medicare Beneficiaries (SLMB) Program, the Qualifying Individuals (QI) Program, the Qualified Disabled Working Individual (QDWI) program and the Family Medicaid programs. These basic, non-financial rules apply to all types of medical assistance, unless this manual specifically states otherwise.

This section also describes other types of benefits for which a person may qualify. An applicant or recipient may be required to apply for Medicare Part B to be eligible for Medicaid.

Medicaid Policy

Previous Policy

Effective July 1, 2006, Medicaid applicants and recipients must document U.S. Citizenship and identity for household members applying for or receiving Medicaid. See 205 and Table IV

An individual is a U.S. citizen if any of the following criteria are met:

Birth in the United States. U.S. citizenship is automatic for individuals born in any of the 50 states, the District of Columbia, Puerto Rico, Guam, the U.S. Virgin Islands, the Northern Mariana Islands. EXCEPTION: Children born in the U.S. to foreign sovereigns or diplomatic officers are not U.S. citizens because they are not subject to the jurisdiction of the United States. It should be noted that for Medicaid purposes, there is not a distinction between U.S. Citizenship and Naturalized citizens.

Naturalization and non-citizen U.S. Nationals. Citizenship may be granted to an individual who was not born in the U.S. or one of its territories if that individual satisfies the legal requirements for naturalization, or the individual is a non-citizen U.S. National from American Samoa or the Swain’s islands. It should be noted that for Medicaid purposes, there is not a distinction between U.S. Citizenship and Naturalized citizens.

Born outside of the U.S. to a U.S. Citizen Parent. If a child is born outside of the United States to a person who is a United States citizen at the time the child is born and citizenship has been claimed, the child is also considered a U.S. citizen for Medicaid purposes.

Automatic Citizenship.

Children, biological or adopted, born in a foreign country automatically become U.S. Citizens when they meet all of the following criteria at the same time on or after February 27, 2001.

At least one parent (biological or adoptive, but not a step-parent) is a U.S. Citizen either by birth or naturalization. The parent may become naturalized after the birth or adoption of a foreign born child; and

The child is under age 18. If an individual has turned 18 before February 27, 2001, or if the child turns 18 before a parent becomes a U.S. citizen, automatic citizenship does not apply; and

The child lives in the United States pursuant to a lawful admission for permanent residence and resides in the legal and physical custody of a U.S. Citizen parent. Permanent resident status could have been granted before, on or after February 27, 2001. The child must be residing with the U.S. Citizen parent on or after February 27, 2001; and

For an adopted child born outside the U.S., the adoption has been finalized either in the country from which the child is being adopted or in the United States. The adoption can take place in another country or in the U.S., and finalization may occur before, on or after February 27, 2001.

Summary: To receive automatic citizenship, the child must be the adopted or biological child of the U.S. Citizen parent, have permanent resident status in the U.S., be residing with a U.S. citizen parent and still be under age 18, on or after February 27, 2001.

When is Automatic Citizenship Effective?

The effective date for automatic citizenship cannot be earlier than February 27, 2001. The effective date is the date when all the criteria are true at the same time on or after February 27, 2001. Once the individual has met this citizenship criteria, a change in circumstances does not affect citizenship status.

Proof of Citizenship.

These children will receive proof of citizenship only upon application to USCIS (formerly known as INS).

If the child does not have a Certificate of Citizenship or U.S. passport, one parent must certify on form N-6006 that the child satisfies the criteria for automatic citizenship, and

Provide documentation of the parent's citizenship, and alternative documentation for the child that establishes that the child meets these requirements. Such documents need to show the child's place of birth (a birth certificate or other medical record), adoption records showing the relationship to the parent and proof of finalization either in the foreign country or the U.S., and USCIS residency status documents.

Medicaid Policy

Effective Date: December 5, 2017

Previous Policy

o A child who does not meet the non-citizen status requirements in 205-2 , but is lawfully present in the United States may be eligible for Medicaid and CHIP. These children must meet all other eligibility factors such as state residency, age (up to 19), income and assets.

o Some of these children will not have an SSN ( 221-3 ).

o Do not impose a 5 year bar to children who are lawfully present.

o Do not deem a sponsor’s income and assets when determining eligibility.

o Verify lawfully present status at application and review.

A. A child will be considered lawfully present if he or she is:

1. A qualified non-citizen as defined in section 205-2 who is subject to the 5 year bar but has not met the 5 year requirement;

2. A non-citizen in nonimmigrant status who has not violated the terms of the status under which he or she was admitted or to which he or she has changed after admission;

3. A non-citizen who has been paroled into the United States pursuant to section 212(d)(5) of the Immigration and Nationality Act (INA) (8 U.S.C. §1182(d)(5)) for less than 1 year, except for a non-citizen paroled for prosecution, for deferred inspection or pending removal proceedings;

4. A non-citizen who belongs to one of the following classes:

o N on-citizens currently in temporary resident status pursuant to section 210 or 245A of the INA (8 U.S.C. §§1160 or 1255a, respectively);

o N on-citizens currently under Temporary Protected Status (TPS) pursuant to section 244 of the INA (8 U.S.C. §1254a), and pending applicants for TPS who have been granted employment authorization;

o N on-citizens who have been granted employment authorization under 8 CFR 274a.12(c)(9), (10), (16), (18), (20), (22), or (24);

o Family Unity beneficiaries pursuant to section 301 of Pub. L. 101-649, as amended;

o N on-citizens currently under Deferred Enforced Departure (DED) pursuant to a decision made by the President;

o N on-citizens currently in deferred action status; or

o N on-citizens whose visa petition has been approved and who have a pending application for adjustment of status;

5. A pending applicant for asylum under section 208(a) of the INA (8 U.S.C. § 1158) or for withholding of removal under section 241(b)(3) of the INA (8 U.S.C. § 1231) or under the Convention Against Torture who has been granted employment authorization, and such an applicant under the age of 14 who has had an application pending for at least 180 days;

6. A non-citizen who has been granted withholding of removal under the Convention Against Torture;

7. A child who has a pending application for Special Immigrant Juvenile status as described in section 101(a)(27)(J) of the INA (8 U.S.C. § 1101(a)(27)(J));

8. A non-citizen who is lawfully present in the Commonwealth of the Northern Mariana Islands under 48 U.S.C. § 1806(e); or

9. A non-citizen who is lawfully present in American Samoa under the immigration laws of American Samoa.

Medicaid Policy

Previous Policy

A qualified non-citizen is a non-citizen who is lawfully admitted for permanent residence under various sections of the Immigration and Nationality Act (INA). Some qualified non-citizens cannot receive full service Medicaid, but may receive coverage only for emergency services for five years from the date they obtained qualified non-citizen status. After determining that a non-citizen is a qualified non-citizen, it is necessary to determine if the non-citizen is subject to the five-year bar. (See #B.) If a child is a qualified non-citizen but has not met the 5 year bar, see if the child meets the criteria in section 205-2.1 .

A. Qualified Non-Citizens

1. A non-citizen who is lawfully admitted for permanent residence under the Immigration and Nationality Act. This includes Amerasian immigrants. Proof is an Immigration and Naturalization Service (INS) Form I-151 or I-551 or INS Form I-94 with class codes AM1, AM2, or AM3.

2. A non-citizen who is admitted as a refugee under section 207 of the INA. Proof is an INS Form I-94.

3. Iraqi and Afghan immigrants who enter as Lawful Permanent residents may receive Special Immigrant status (either before or after they enter the country.) The law allows these Iraqi and Afghan Special Immigrants to be treated as refugees after their date of entry or the date they are granted this Special Immigrant status. See #3 below for the policy governing these immigrants.

4. A non-citizen who is granted conditional entry under section 203(a)(7) of the INA as in effect prior to April 1, 1980. Proof is an INS Form I-94 stamped "Refugee - Conditional Entry."

5. A non-citizen who is granted asylum under section 208 of the INA. Proof is an INS Form I-94 and a letter establishing this status.

6. A non-citizen who is paroled into the United States under section 212(d)(5) of the INA for a period of at least 1 year. Proof is an I-94 stating that he has been paroled under Section 212(d)(5) of the INA or stamped "Cuban/Haitian Entrant (Status Pending) Reviewable January 15, 1981."

7. A non-citizen whose deportation is being withheld under section 243(h) of the INA (status granted prior to September 30, 1996), or under section 241(b)(3) after September 30, 1996. Proof is an order from an immigration judge showing that deportation has been withheld. If deportation is being withheld under another section of the INA, the person is not a qualified non-citizen.

8. A non-citizen who is granted status as a Cuban and Haitian entrant (as defined in section 501(e) of the Refugee Education Assistance Act of 1980).

9. A non-citizen who is admitted as an Amerasian immigrant (these individuals may enter as refugees or lawful permanent residents.)

10. An American Indian born in Canada who is at least one-half American Indian. They are considered lawful permanent residents, but will not have INS documents. A statement from the tribe is acceptable verification. They are not subject to the five-year bar for eligibility.

11. Battered non-citizens, who meet the conditions set forth in §431(c) of PRWORA, as added by §501 of the Illegal Immigration Reform and Immigrant Responsibility Act of 1996, P.L. 104-208 (IIRIRA), and amended by §5571 of the Balanced Budget Act of 1997, P.L. 105-33 (BBA), and §1508 of the Violence against Women Act of 2000, P.L. 106-386. Section 431(c) of PRWORA, as amended, is codified at 8 USC 1641(c).

12. Victims of a severe form of trafficking, in accordance with §107(b)(1) of the Trafficking Victims Protection Act of 2000, P.L. 106-386.

13. A citizen of the Freely Associated (COFA) States of: The Federated States of Micronesia, the Republic of the Marshall Islands, and the Republic of Palau.

B. Application of the 5-Year Bar

Some qualified non-citizens are barred from receiving Medicaid, QMB, SLMB or QI for five years from the date they obtain qualified non-citizen status. The 5-year bar applies only to immigrants who enter the country on or after August 22, 1996. Non-citizens who do not meet one of the following exemptions can receive Medicaid only for emergency services until after the 5-year bar. At the end of the 5-year bar, lawful permanent residents can receive full Medicaid.

1. Exceptions to the 5-Year Bar

Resident non-citizens who have been granted certain non-citizen statuses or meet certain conditions can be eligible for Medicaid, QMB, SLMB or QI and are not subject to the five-year bar regardless of their entry date. They must meet the eligibility requirement for Medicaid or the Medicare Cost-Sharing programs. Resident non-citizens not subject to the 5-year bar include:

a. A non-citizen who is admitted as a refugee under section 207 of the Immigration and Nationality Act (INA).

b. A non-citizen who is granted asylum under section 208 of the INA.

c. A non-citizen whose deportation has been withheld under section 243(h) of the INA (prior to September 30, 1996) or under section 241(b)(3) of the INA (after September 30, 1996).

d. A non-citizen granted status as a Cuban and Haitian entrant as defined in section 501(e) of the Refugee Education Assistance Act of 1980.

e. A non-citizen admitted as an Amerasian immigrant.

f. An American Indian born in Canada who is at least one-half American Indian.

g. A qualified non-citizen who is a veteran with an honorable discharge from the Armed Forces of the United States. The spouse and unemancipated dependent children of the veteran may also qualify if they too are qualified non-citizens and are considered to be household members. The spouse of a deceased veteran who has not remarried may also qualify if he or she is a qualified non-citizen.

h. A qualified non-citizen who is on active duty in the Armed Forces of the United States. A person on active duty for training does not qualify under this category. The spouse and unemancipated dependent children of the person on active duty may also qualify if they are qualified non-citizens and are considered to be household members.

i. Hmong and other Highland Lao tribal peoples who have been lawfully admitted to the United States for permanent residence, and who fought on behalf of the United States during the Vietnam conflict are considered Veterans and therefore are not subject to the five-year bar on eligibility.

j. Victims of a severe form of trafficking, in accordance with §107(b)(1) of the Trafficking Victims Protection Act of 2000, P.L. 106-386.

k. Beginning December 19, 2009, Iraqi and Afghan Special Immigrants admitted to the United States for permanent residence, regardless if they received the status before December 19, 2009.

l. Legal permanent residents who first entered the country under one of the exempt categories above and who later converted to LPR status.

m. A citizen of the Freely Associated (COFA) States of: The Federated States of Micronesia, the Republic of the Marshall Islands, and the Republic of Palau.

2. Entry Prior to August 22, 1996

a. All qualified non-citizens can be eligible for Medicaid, QMB, SLMB, or QI without meeting the 5-year bar, when they meet all other eligibility criteria and entered the United States before August 22, 1996 as a qualified non-citizen. The U.S. residency does not have to be continuous.

b. If they entered before August 22, 1996 without a qualified non-citizen status and later received a qualified non-citizen status, and have continuously resided in the U.S., they are exempt from the 5-year bar.

c. If they entered before August 22, 1996 without a qualified non-citizen status and have not continuously resided in the U.S., the 5-year bar begins with the month they receive their qualified non-citizen status, unless they meet one of the exceptions.

d. To decide if the 5-year bar applies, the date of entry may be a date other than the date on the individual's INS non-citizen registration card.

e. To decide if a person entered the United States before August 22, 1996, it does not matter if the immigrant entered the U.S. legally or illegally, or whether a legal entrant maintained a legal status with INS for the whole time they have resided in the U.S.

f. To decide if a person has resided in the U.S. continuously, any single absence of more than 30 days or multiple absences totaling more than 90 days is considered to interrupt the continuous residence.

g. The applicant's qualified non-citizen status must be valid at the time of application.

3. Entry after August 22, 1996

Immigrants who entered the country on or after August 22, 1996 and who do not meet one of the exceptions listed above, are subject to the 5-year bar.

a. Use the actual date of entry only to determine if the 5-year bar applies. This may or may not be the date on the person's INS Alien registration card.

b. Once you have determined that the 5-year bar applies, the non-citizen is not eligible for full Medicaid services for five years from the date that he or she obtained qualified non-citizen status. This will be the date on the immigrant's INS Alien registration card, which may be different from the actual date of entry.

c. Qualified non-citizens who are subject to the 5-year bar can only qualify for emergency Medicaid services for five years from the date they obtained qualified non-citizen status. (See section 205-6 .)

4. N on-citizens Who Are Receiving SSI Benefits

a. Certain non-citizens who were receiving SSI benefits on August 22, 1996 and who are still getting SSI benefits, continue to qualify for Medicaid even if they cannot prove that they are qualified non-citizens.

b. Qualified non-citizens residing in the U.S. before August 22, 1996, who later become disabled, may be eligible for SSI benefits without having to meet additional requirements that SSI requires. See Section 223-3 for more information about "grand-fathered" non-citizens and SSI eligibility. This section also describes the additional requirements that qualified non-citizens must meet to be eligible for SSI benefits.

C. Iraqi and Afghan Special Immigrants

Federal laws allow Lawful Permanent resident immigrants from Iraq and Afghanistan who are granted a Special Immigrant (SIV) status to receive the same types of benefits that refugees can receive. The special status applies to the individual and their dependent family members who either enter at the same time, or follow later.

1. Workers must always consider eligibility for other Medicaid programs or Chip before Refugee Medical Assistance. If the Iraqi or Afghan Special Immigrant household qualifies for other Medicaid programs or CHIP, there are no time limits to eligibility, aside from the normal program rules.

2. If the Iraqi or Afghan Special Immigrant household is not eligible for other Medicaid programs or CHIP, they may receive Refugee Medical Assistance for up to 8 months from the month they enter the United States.

3. If an Iraqi or Afghan Special Immigrant household loses eligibility under a regular Medicaid program or Chip before the end of the 8 months, convert the household to Refugee Medical Assistance for the balance of the 8 months.

4. Iraqi and Afghan Special Immigrants are LPR's, not refugees. They are treated as qualified non-citizens and no longer be subject to the 5-year bar. It does not matter if they received the Special Immigrant status before December 19, 2009.

5. An infant born to a woman who is eligible for Medicaid on the date of birth is a U.S. citizen and eligible for the one year of continued coverage.

D. Afghan Parolees

1. In addition to the Special Immigrant Visa (SIV) holders mentioned in C., other Afghan evacuees will receive the Special Immigrant (SI/SQ) Parolee or the Humanitarian (non-SI/SQ) Parolee status. Like the SIV holders, those individuals with either parolee status will be eligible for full Medicaid benefits if they meet all other eligibility factors.

2. Workers must always consider eligibility for other Medicaid programs or Chip before Refugee Medical Assistance. If the Iraqi or Afghan Special Immigrant household qualifies for other Medicaid programs or CHIP, there are no time limits to eligibility, aside from the normal program rules.

3. If the parolee is not eligible for other Medicaid programs or CHIP, they may receive Refugee Medical Assistance for up to 8 months from the month they enter the United States.

4. If a parolee household loses eligibility under a regular Medicaid program or Chip before the end of the 8 months, convert the household to Refugee Medical Assistance for the balance of the 8 months.

E. Ukrainian Nationals

Ukrainians who have been displaced by Russia’s February 24, 2022 invasion and fled Ukraine may be eligible for Medicaid based on their immigration status. These individuals may be granted a range of lawful non-citizen statuses, including parole, temporary protected status (TPS), immigrant and nonimmigrant visas, and refugee or asylee. A Ukrainian national may be eligible for Refugee or Emergency Medicaid if they are not eligible for any other Medicaid.

1. Parolees:

· Ukrainian nationals who enter the United States as parolees on or between February 24, 2022 and September 30, 2023 are eligible for Medicaid, without a five-year waiting period, if they meet all other eligibility requirements.

· Ukrainian nationals who are paroled into the U.S. after September 30, 2023, or are the spouse or child of a parolee described above, or who is the parent, legal guardian, or primary caregiver of a parolee described above who is determined to be an unaccompanied child may also be eligible for Medicaid if they meet all other eligibility requirements.

2. Temporary Protected Status (TPS)

· Ukrainians granted TPS, and Ukrainians who have pending applications for TPS and who have been granted employment authorization are not considered “qualified non-citizens” for purposes of Medicaid, and thus are not eligible for Medicaid, unless they are:

i. a child under age 21, or

ii. a pregnant individual.

· The TPS designation is effective April 19, 2022, and will remain in effect for 18 months, through October 19, 2023.

Medicaid Policy

Previous Policy

When a non-citizen who is required to have a sponsor applies for entry, or a change in status, on or after December 19, 1997, their sponsor must sign a legally enforceable Affidavit of Support, Form I-864, with INS.

When the sponsor has signed an I-864, income from the non-citizen's sponsor must be deemed to the non-citizen when determining eligibility for non-MAGI Medicaid groups such as the aged, blind or disabled, medically needy, etc. Do not deem sponsor's income when determining eligibility under one of the MAGI-based eligibility groups unless the sponsor is someone whose MAGI-based income must be counted according to the MAGI rules. Do count actual cash contributions the sponsor gives to the non-citizen. See sec. 440 for MAGI-based income rules. Do not deem a sponsor's income to lawfully present children defined in 205-2.1 eligible for MAGI and non-MAGI programs.

Sponsored non-citizens should know that they were required to have a sponsor, even though they may not have a copy of the Affidavit of Support form.

Iraqi and Afghan Special Immigrants are not required to have sponsors, so sponsor deeming does not apply at any time.

Sponsor deeming only applies when the sponsor is an individual.

Do not deem the income or resources of a sponsoring agency or corporation.

See Section 425-2 for policy on deeming the sponsor's income for non-MAGI-based eligibility groups.

Medicaid Policy

Previous Policy

MAGI-Based Medicaid

For the MAGI-based programs there is no sponsor deeming ( 205-4 ). Follow the MAGI household composition rules in 401 to determine household size and the income rules in 440 .

For emergency Medicaid for a MAGI-based household, determine the household size and income in the same manner as you do for a non-emergency MAGI-based household, but do not include any citizen or qualified non-citizen in the emergency coverage.

Family Related Non-MAGI-Based Medicaid

Non-Emergency Medicaid Cases

If the individual is not eligible under a MAGI-based group, but could be eligible under a Family-related medically needy group, follow the rules for the program type for which you are determining eligibility. Sponsor deeming may apply.

Do not include any ineligible non-citizen family member in the coverage for regular (non-emergency) family related Medicaid programs. 2 . Emergency Medicaid Cases

Follow the income deeming and household size rules for the program type for which you are determining eligibility.

Do not deem income from a non-citizen's sponsor who is not a spouse or parent living with the non-citizen on an Emergency Medicaid program. Do count any cash contributions that the sponsor gives to the non-citizen.

Do not include any U.S, citizen or eligible qualified non-citizen family member in the coverage for an Emergency Medicaid program.

Aged, Blind and Disabled Medicaid

Deeming from an Ineligible Spouse

For community Aged, Blind, and Disabled Medicaid, QMB, SLMB and QI programs, income and resources of a spouse who does not meet citizenship requirements must be deemed to the eligible spouse. Regular deeming rules apply, including deductions for dependent children living with the parents, even if those children do not meet citizenship requirements. See 410 for spouse to spouse deeming rules.

Sponsor income may be deemed for non-emergency Medicaid.

Do not deem sponsor income for emergency Medicaid.

For an institutional or waiver case, an assessment of assets is required even if the spouse of the qualified non-citizen member does not meet the citizenship or qualified non-citizen requirements. Income and assets of the spouse do not count after eligibility has been established. See Nursing Home policy on determining income and assets of an institutional or waiver eligible spouse.

Sponsor deeming may apply

Institutional and waiver cases do not allow emergency coverage, so sponsor deeming is not an issue.

Deeming from an Ineligible Parent

Income and assets of parents of a disabled or blind child must be deemed to the child even if the parents do not meet the citizenship requirements. If the child is a non-citizen, sponsor deeming may apply.

If a child receives SSI, the assets, but not the income, of parents must be deemed to the child, even if the parents do not meet the citizenship requirements. There is no sponsor deeming to an SSI recipient non-citizen child.

For an institutionalized child, parents' income and assets must be deemed in the month of entry and the month of discharge, even if the parents do not meet the citizenship requirements. See 412 for exception for newborn babies. If the child is a non-citizen, sponsor deeming may apply.

Do not deem sponsor income for emergency Medicaid for a blind or disabled non-citizen child.

Medicaid Policy

Previous Policy

A. Definition

Emergency Medicaid is not a separate type of Medicaid. Emergency Medicaid is temporary coverage only for emergency services to individuals who meet all the requirements for a Medicaid program but are not U.S. citizens and do not meet the eligible qualified non-citizen or lawfully present child ( 205-2.1 ) status requirements for full Medicaid coverage. It is not an ongoing Medicaid program. See section 205-1 and 205-2 . It is available to both MAGI-based groups and non-MAGI-based groups.

B. Who May Be Eligible?

Any non-citizen who does not meet the non-citizen status requirements for full Medicaid coverage may be eligible for Emergency Medicaid. See section 205 . This includes:

1. Undocumented non-citizens.

2. non-citizens who are in the country legally but are not qualified non-citizens as described in section 205-2 , No. 1.

3. Qualified non-citizens who are barred from full Medicaid coverage for 5 years as described in section 205-2 .

4. Deferred Action for Childhood Arrivals (DACA) individuals.

C. Eligibility Requirements

1. State Residency

To qualify for Medicaid for emergency services, the applicant has to be a resident of Utah. See Sec. 207 for residency requirements.

2. Verification of Citizenship or non-citizen Status

If an individual says that he or she does not meet U.S. citizenship or qualified non-citizen status, accept the client's statement. The individual must sign the application, which certifies that the questions about citizenship/non-citizen status were answered correctly.

3. Social Security Number

An undocumented non-citizen does not have to provide a Social Security number nor apply to receive one.

4. Program eligibility

The individual must meet the eligibility requirements for a Medicaid program. For example, eligibility for Disabled Medicaid requires that the individual meets disability requirements. The Disability Review Committee can decide if the person is disabled. Emergency Services are not available under the 4-month Extended Medicaid, 12-Month Transitional Medicaid, Targeted Adult Medicaid, Nursing Home, HCB Waivers, QMB, SLMB, or QI programs. Use MAGI-based methodologies for MAGI groups, and non-MAGI-based methodologies for non-MAGI groups. The only difference is that the individual does not have to meet the citizenship/non-citizen status requirements.

D. Receipt of Emergency Medical Services

Except for coverage for a pregnant member, Emergency Medicaid coverage will be for retroactive months or the application month. This is because emergency services are unplanned events.

1. To be eligible for Emergency Medicaid, the individual must indicate that he or she received medical services in the application month or retro period which the individual believes were for a serious enough situation that it was an emergency.

o The eligibility worker does not need to determine if the services will be covered by Emergency Medicaid.

2. A pregnant individual may apply in the month before the expected due date because labor and delivery of the baby is considered an emergency service.

o Keep the case open until the end of the month the pregnancy ends.

o If the member owes a spenddown, she will usually only meet it for the month of delivery and may choose to use medical bills to meet the spenddown.

3. Other types of medical services that an individual needs are not emergency services if the services are or can be scheduled in the future.

o Emergency Medicaid does not cover long-term nursing home or HCB waiver services.

o It is not for routine care, scheduled services, or treatment of chronic conditions. For dialysis treatments, see E.4. below.

4. All claims for Emergency Medicaid cases are reviewed by Medicaid Operations to determine if the service meets the criteria for emergency services.

o Tell individuals that receipt of Emergency Medicaid is not a guarantee that any or all services will be paid by Medicaid.

5. Do not deny emergency Medicaid eligibility because you suspect the services the applicant received do not qualify as emergency services.

o If the individual says they received medical services for a serious or emergency situation, determine eligibility for Medicaid.

E. Other Considerations

1. Pregnant Woman Medicaid . Pregnant individuals who qualify for Pregnant Woman Emergency Medicaid may be eligible for emergency services at any time during their pregnancy if they have an emergency need.

o If the emergency need occurs two or more months before the expected month of delivery, close the case at the end of that month, unless the emergency situation spanned into the next month.

o The pregnant individual can reapply and have a new eligibility decision made one month before the due date, or if a subsequent emergency occurs.

o Coverage for the delivery can begin in the month before the month of the expected date of delivery. The emergency need will be labor and delivery. Keep the case open until after the delivery. If the delivery date is at the end of one month, and the member is still in the hospital on the first of the next month, continue coverage into that next month.

o The unborn (single or multiple unborn children) will be counted in the member's household size. Once the infant is born, open the child on MAGI Child Under One Medicaid because the child is a U.S. citizen and cannot be open under an emergency program. The newborn automatically qualifies for Child 0-1 coverage until the child turns age 1. See sec. 347 .

o 12-Month Coverage . A pregnant member who received Emergency Medicaid in the month of the birth does NOT qualify for coverage during the 12 month postpartum period. However, if the individual experiences a new emergency during the postpartum period, she could reapply to address that issue.

2. Family Coverage (Parent/Caretaker Relative or Medically Needy Family) - If a parent has had an emergency medical need and requests Emergency Medicaid coverage, they must have a dependent child in the home per policy found at 345 , 345-1 , 345-2 . The child does not also have to claim having had an emergency medical need for the parent to get coverage. The entire family may be approved for a family program when only one family member had the emergency need. The child may or may not meet citizenship or non-citizen status requirements.

3. Spenddown . Spenddown is allowed if the applicant qualifies for a category of Medicaid that allows Spenddown. This includes the Medically Needy Pregnant Woman program. (See Section 441-3 ) If an applicant qualifies for Emergency Medicaid and has a spenddown, it will usually be in the applicant’s best interest to use incurred medical bills (See Section 461-5 ) to satisfy the spenddown requirement. This is because in most cases the applicant cannot be assured that the medical service meets Medicaid’s emergency criteria. It is possible that the service will not be paid (one service that always meets emergency criteria is labor and delivery for pregnant women.)

4. Duration of Coverage . An applicant can receive Emergency Medicaid for each retroactive month and the application month if the applicant says that he or she has received emergency services in such months.

Emergency Medicaid is not an on-going medical program. Close the case at the end of the application month, except in the following circumstances:

· Pregnant women: Open the case only for the retro or application month during which the member received medical services.

· Individuals with renal failure requiring dialysis: These individuals will remain open until their next scheduled review, provided they continue to meet all eligibility requirements.

Do not continue the coverage into the month after the application month unless you know that the member received medical services near the end of the application month and into the following month. In that case, close the case at the end of the month after the application month.

Do not leave the case open for future months. If the member has another emergency situation in a future month, the member can reapply in that month or within the 90 days after receiving the emergency services.

The approval and closure notices should tell members that they may reapply whenever they have received emergency services for which they want Medicaid coverage.

If a member is eligible for Medicare and workers leave the emergency Medicaid case open, the state will continue paying the Medicare premiums creating an overpayment for the member. Do Not Leave Emergency Medicaid open like an ongoing case .

If the member's condition has resulted in multiple emergency episodes within a 12 month period, the agency may contact DHHS to request the program remain open until the next review, provided they continue to meet all eligibility requirements.

5. Retroactive Period Coverage .

o Follow the rules in Section 705 to decide what the retroactive period is based on the application date.

o See Sec. 703-2 to decide the application date.

o If a spenddown is owed for retroactive coverage, review Section 461-8 to decide how to apply medical bills the applicant may have incurred before or during the retroactive period.

o Close the emergency Medicaid case at the end of either the retroactive period or the end of the application month.

Medicaid Policy

Previous Policy

A. Eligibility Requirement for Full Medicaid

Individuals eligible to receive full Medicaid services and QMB, SLMB or QI include the following. All others may only receive emergency Medicaid services, described in Section 205-6 .

1. U. S. citizens. See Section 205-1 .

2. Qualified non-citizens. See Section 205-2 .

3. SSI recipients living in the U.S. on August 22, 1996 and meeting the criteria for one of the grand-fathered SSI recipient non-citizen groups. See Section 329 .

4. Lawfully present children as described in section 205-2.1 .

B. Proof of Citizenship, Qualified Non-Citizen and Identity

1. U.S. Citizens must document their Citizenship and Identity. Determine first if the individual meets a citizenship exemption. (See below and Table IV ) Verify citizenship and identity electronically through electronic data sources before asking for verification from the customer. A positive match with SCHIP satisfies verification of citizenship and identity. If an electronic interface runs before determining an exemption, document in the case file which exemption the individual meets.

2. Applicants : Do not delay or deny benefits when an individual declares to be a US Citizen or US National or qualified non-citizen, and there is no evidence that contradicts their claim.

If otherwise eligible, provide Medicaid coverage and give the member reasonable time to provide the documentation.

a. “Reasonable time” is defined as (at least) 95 days from the date verification is requested. A member needs to either provide the documentation by the end of the time-frame given, or provide proof they are working to obtain the documentation. Give more time to members who show a good faith effort to provide the documentation.

b. If the member has been given reasonable time and does not provide the documentation or proof they are working on obtaining it, remove the member from the Medicaid coverage with proper notice.

3. Citizenship/Identity Documentation Exemptions

The following individuals are EXEMPT and do not have to meet the Cit/ID documentation requirement. If the individual loses an exempt status they must meet the Cit/ID requirement at their next scheduled review.

o SSI recipients and those in an SSI Protected group

o SS-DI recipients

o Medicare recipients

o Children in receipt of Title IV-B or Title IV-E Subsidized Adoption Assistance

o Children in receipt of Title IV-B or Title IV-E Foster Care Payments

o Qualifying non-citizens

o Members only eligible for Emergency Medicaid

o Household members who are not receiving Medicaid benefits

4. Children who received Child 0-1 eligibility

When a child receives Child 0-1 coverage, the child's citizenship and identity are verified and no additional verification is required at any time.

a. Make a collateral contact with the applicable State Medicaid agency to verify the claim that the child received Child 0-1 coverage.

b. Once the agency has verification of the child's eligibility under the Child 0-1 eligibility, the child never has to provide Cit/ID documentation again.

C. Documentation Requirements

1. States must obtain satisfactory documentary evidence of an applicant’s or recipient’s, citizenship and identity. Verify citizenship/identification and non-citizen status through electronic data sources first before requesting any documents from the customer.

o Table IV in Medicaid policy (Charts 1 and 2) outlines acceptable Citizenship documentation.

o Chart 3 on Table IV describes the acceptable sources of identity documentation.

o States are allowed to match with the State Children's Health Insurance Program - Internet (SCHIP-I) via the Social Security Administration (SSA) interface. A match satisfies the citizenship and identity requirement. See #3 below for additional information.

o States are allowed to match with the State Vital Statistics to obtain birth verification.

o When a member born in Utah does not have an original birth certificate, do an electronic search for birth years that have been computerized. For years that have not been computerized, they are to submit a Form 125 to Utah State Vital Records to obtain verification that a birth record is on file with the state.

o State Verification and Exchange System (SVES)

a. SCHIP verifies information regarding the person's claim of US citizenship or nationality.

i. The member's name, SSN and date of birth compares with data in the SSA Master File of SSN Holders (Numident).

ii. The interface is in real time.

iii. Two responses are possible: Y for positive, or N for no match with SSA records.

b. A positive response satisfies the Citizenship and Identity requirement. See Table IV , Chart 1.

i. The data submitted is consistent with SSA records.

ii. No additional information is required from the member.

c. A no inconsistency or no match response indicates the data submitted to SSA does not match. (IE, misspelled name, incorrect SSN, incorrect DOB or incorrect citizenship declaration.)

i. The agency first makes a reasonable effort to identify and resolve the cause of the inconsistency. For example, typographical or other clerical error.

ii. When an inconsistency is identified and corrected, resubmit the request.

iii. When an inconsistency is not found by the agency, OR if the second request result is the same, the member has 95 days to provide proper citizenship documentation.

o The 95 days starts with the date the member receives the notice.

o Medicaid benefits remain open during the 95 day verification period.

o If the case closes for any reason during the 95 day verification period, the 95 days continues to run.

o Once the 95 day verification period has expired, it cannot be extended or repeated.

iv. If proper citizenship documentation has not been provided by the end of the 95 day verification period, remove the individual from coverage at the end of the month for which 10-day notice can be given.

Medicaid Policy

Effective Date: June 1, 2026

Previous Policy

Use the following guidelines to determine if an individual is a Utah resident.

A. Living in the State

The person must be physically present in the state or temporarily absent to be a resident of Utah.

1. A resident need not have a permanent residence or a fixed address.

Example: An individual who is residing in an emergency shelter or stays temporarily in other people’s houses.

2. Temporary absences after a person has been residing in Utah do not affect residency, if the individual intends to return to Utah when the reason for the temporary absence is accomplished. Reasons for temporary absences may include schooling, medical care, visits, temporary employment, military service, or temporary religious or other volunteer services such as the Peace Corps.

3. Do not deny or terminate Medicaid because of a temporary absence if the person intends to return to Utah, unless another state has decided the person is a resident in that state for the purpose of Medicaid eligibility.

If the National Change of Address (NCOA) data source shows an out of state address, follow the steps in 811-4 . If there is a PARIS match from another state, follow the steps in 751-1 .

4. To decide if the absence is temporary, you may need to find out if:

a. the absence is for a specific period-of-time,

b. the person is maintaining their home in Utah, or

c. other factors exist that indicate the person intends to return to Utah when the reason for the absence ends.

d. For someone who has recently moved to Utah, see Section 207-6 .

B. Duration

Residency does not require a person to be in the State for a specific period-of-time before becoming a resident. The person may declare intent to be a resident effective with the first day they arrived in Utah.

C. Reason for Living in Utah

Consider the reason why the individual is in Utah, the reason may indicate that the individual is not in Utah voluntarily or is in Utah only temporarily. If the individual is in Utah involuntarily or temporarily, they do not meet Utah residency requirements.

For example:

An individual from Arizona is visiting or traveling through the state, and is arrested for a crime and jailed. This individual is not in the state voluntarily and is not a state resident.

An individual from Nevada is in Utah to give their baby up for adoption and intends to move back to Nevada after the baby is born. This individual is in the state temporarily and is not a state resident.

D. Citizenship

Citizenship is not relevant to the determination of state residency. A non-citizen may be a Utah resident even if his immigration status is temporary. Non-citizens may have dual intent - intent to remain in the U.S. if permitted to stay and intent to leave if Department of Homeland Security requires them to leave.

E. Intent

An individual who is capable of expressing intent may do so on the application form. Unless there is an indication that the person does not meet residence requirements, accept the applicant's statement. See Section 207-2 for information on "Who is Capable of Expressing Intent" and Section 207-5 for "Factors Indicating No Intent to Reside in Utah". If other factors indicate a conflict, the applicant’s statement of intent must be verified.

Example: Bill came to Utah and has been living here for 3 months. He applied for medical benefits and stated he is a resident of Utah. SNAP benefits are open in Idaho. Since another state is providing benefits intent is not clear and needs to be verified.

F. Residents of Public Institutions Such as Jails or Prisons

1. An individual residing in a public institution such as a jail or prison is a resident of Utah if the person was a resident before being placed. An individual who lived in another state, but was arrested and placed in jail in Utah is not a Utah resident.

2. If another state places the person in a public institution in Utah, the individual is not a Utah resident. Residency does not change from the previous state. (See Sec. 207-5 and 207-6 )

3. State residency does not change when an individual in a public institution goes directly to a hospital for an inpatient stay. (See Sec. 215-6 for policy on receiving Medicaid during an inpatient hospital stay.)

G. Residents of Other Institutions

1. Any individual placed in an institution by another state is a resident of that state. This includes individuals from another state placed in a Utah nursing home or hospital. (Sec. 207-5 )

2. A competent individual who leaves an institution after having been placed by another state is a resident of the state in which the individual is physically located.

3. For residents of an institution who are not placed by another state, see sec. 207-3 and 207-4 .

H. Individuals Receiving a State Supplementary Payment (SSP)

An individual of any age who receives an SSP is a resident of the state paying the SSP. If an individual receiving an SSP from another state moves to Utah, see Sec. 207-5 .

I. Individuals Receiving Title IV-E Payments

An individual of any age who receives federal payments for foster care or adoption assistance under Title IV-E is a resident of the state in which the individual lives. A IV-E eligible foster child placed in another state by Utah will receive Medicaid from the state in which the child is placed. Utah will continue to make the IV-E foster care payment. A IV-E eligible child with a Utah Adoption Assistance Agreement who moves to another state will receive Medicaid from the state in which the child resides.

J. Cases of Disputed Residency Between Two states

If an individual has come to Utah from another state, and the two states cannot resolve which state is the person's state of residency, the individual is a resident of the state in which the individual is physically located.

Medicaid Policy

Previous Policy

As a general rule, emancipated individuals are capable of expressing intent unless they are significantly mentally impaired. However, different rules apply to individuals age 21 and over, and individuals under age 21. See Section 207-3 to determine the residency of adults age 21 and over, and Section 207-4 to determine the residency of children under age 21.

A person is not capable of expressing intent if:

He is judged legally incompetent; or

He has an IQ of 49 or less, or has a mental age of 7 or less, according to tests acceptable to the Division of Services for People with Disabilities; or

He is found incapable based on medical documentation received from a physician, psychologist, or other person licensed by Utah in the field of intellectual and developmental disorders; or

For individuals under age 21, see Section 207-4 .

Medicaid Policy

Previous Policy

A. Individuals not Residing in an Institution

An individual age 21 and older who is not residing in an institution is a Utah resident if voluntarily living in the state and meets one of the following two criteria: Intends to reside, including without a fixed address,

OR

Entered Utah with a job commitment or to seek employment, whether or not he is currently working. When someone has just moved to Utah, see Sec. 207-6 .

An individual age 21 and older not residing in an institution who is not capable of stating intent is a resident of the state in which the individual is living.

B. Individuals Residing in an Institution

If an institutionalized individual age 21 or older lost the ability to state intent before age 21, the state of residence is: The state of residence of the parent applying for Medicaid on the individual's behalf, if the parent resides in a different state. (If the individual has a guardian, use the guardian's state of residence.); The parent's or legal guardian's state of residence at the time of placement; or The current state of residence of the parent or guardian filing the application if the parent or guardian resides in the state in which the individual is institutionalized. If the institutionalized individual does not have parents or a legal guardian who is responsible for the individual, use the state of residence of the individual who files the application as the state of residence for the institutionalized individual.

Any institutionalized individual age 21 or older who became incapable of expressing intent at or after reaching age 21 is a resident of the state in which he or she is physically present except when another state places the individual in the institution.

If an individual age 21 or older has been placed by another state in an institution in Utah that furnishes food, shelter and some treatment or services to 4 or more persons unrelated to the proprietor, then the individual is a resident of the state that made the placement. See Section 207-5 , D.

Any other institutionalized individual age 21 or older, meaning someone who has not lost the ability to state intent, the state of residence is the state where the individual is living with the intent to reside.

Medicaid Policy

Previous Policy

Individuals Under Age 21 not Residing in an Institution

Title IV-E and State Supplemental Payment Recipients. (See Sec. 207-1 )

Individual not receiving Title IV-E or SSP payments . If the individual is able to state intent and is emancipated from his or her parent or is married, the individual is a resident of Utah if he or she lives in the state voluntarily and meets one of the following two criteria:

Intends to reside, including without a fixed address,

OR

Entered Utah with a job commitment or to seek employment, whether or not he is currently working. When someone has just moved to Utah, see Sec . 207-6 .

The state of residence of an individual under age 21 who is not institutionalized and who does not meet the criteria in 1 or 2, is:

The state where the individual resides, including without a fixed address, when the individual does not reside with a parent or caretaker relative; or

The state of residency of the parent or caretaker relative with whom the individual resides. (See 207-3 and 207-5 to determine residency of parent or caretaker relative.)

I f the parents are unable to claim Utah residency due to the requirements of their nonimmigrant status, and they request Medicaid for their citizen children, they may claim Utah residence for those children.

Individuals Under Age 21 Living in Institutions

For the purposes of this section, an "institution" is an establishment that furnishes food, shelter and some treatment or services to 4 or more persons unrelated to the proprietor. A "wilderness camp" could be an institution if it provides food, shelter (even tents) and some treatment or services to 4 or more teens unrelated to the proprietor.

An institutionalized individual under age 21 who is not emancipated is a resident of the State:

Where the parent (or legal guardian, if parental rights have been terminated) is living at the time of placement, or

Where the parent (or legal guardian, if parental rights have been terminated) who filed the application is living, or

Where the person who applied for Medicaid on the child's behalf is living, if the child has been abandoned by his parents and no legal guardian has been appointed, if the child is institutionalized in that same state.

An individual residing in an institution who is under age 21, capable of stating intent, and emancipated or married, is a resident of the state in which the individual is living with the intent to reside.

Non-IV-E Foster Care and Adoption Assistance

Foster Child Not Receiving IV-E Foster Care Assistance

When another state places a foster child in Utah and the child is receiving non-IV-E foster care, the child cannot receive Utah Medicaid. The state making the placement is responsible to provide Medicaid for the child.

Child With Adoption Assistance But Not IV-E Eligible

When a non-IV-E child with an adoption assistance agreement originating from another state moves to Utah, the child can receive Utah Medicaid if the state originating the adoption assistance agreement is a member of the Interstate Compact on Adoption and Medical Assistance (ICAMA).

If the state is not a member of ICAMA, the child is not eligible for Utah Medicaid. The state making the payment is responsible to provide Medicaid for the child. Refer to Family Medicaid Sec. 355 . If the state originating the adoption assistance agreement is not on the ICAMA list, the eligibility worker should verify that the state is not a member of ICAMA by contacting the originating state or the Utah ICAMA administrator. States join periodically and the list could be outdated.

Medicaid Policy

Effective Date: December 5, 2017

Previous Policy

An individual's actions and actual circumstances may be a more accurate and persuasive expression of intent than the client's statement.

A. Ownership of an Exempt Home in Another State

If an individual owns a home in another state and claims that the home is exempt as his residence, or because an institutionalized individual intends to return to that home, do not accept that client's statement of intent to reside in Utah.

B. Employment in Another State

1. If an individual is employed in another state and does not make a reasonable claim that he resides in Utah even though he works out-of-state, do not accept that client's statement of intent to reside in Utah.

2. An individual on a temporary leave from a job located in another state, such as vacation break or temporary shut downs, may not be a Utah resident.

3. If the individual cannot make a reasonable claim that he maintains residency in Utah even though working in another state, the individual is not a Utah resident.

C. Temporary Visits

If an individual has come to Utah for a temporary purpose ( 207-1 ) and intends to leave within a foreseeable period of time when that temporary purpose will be accomplished, then do not accept that client's statement of intent to reside in Utah.

D. Placement by Another State

An individual placed in a Utah institution by an agency of another state is not a Utah resident. For the purposes of this section, an "institution" is an establishment that furnishes food, shelter and some treatment or services to 4 or more persons unrelated to the proprietor.

1. Placement. Placement is more than just providing information or assisting an individual in locating an institution in another state. Placement requires a state agency to have authority to act on behalf of the individual. An individual is not "placed" by a state agency if he is capable of expressing intent and independently decides to come to Utah.

2. Agency of a State. An agency of a state includes an entity recognized under the laws of that State as being under contract with that State, as well as any governmental agency of that State.

3. Reason for Placement in Utah. The State other than Utah also retains responsibility for an individual when placement is made in Utah because the other State lacks a sufficient number of appropriate facilities to provide services to its residents.

E. Receiving SSP From Another State

When a person receives a State Supplemental Payment (SSP), the state making the payment is the state of residence.

1. Choosing to Reside in Utah. A person may choose to become a Utah resident by stating that he or she intends to live in the state or entered with a job commitment or seeking employment, and by asking the Social Security Administration to transfer all State Supplemental benefits to the Utah address. (This usually means the individual must contact Social Security to submit a change of residency.) If the person chooses to transfer the State Supplemental benefits to Utah and states an intent to reside in Utah, that person may be a Utah resident even though he received an SSP from another state.

2. Retroactive Assistance. A person receiving an SSP from another state may not decide retroactively to reside in Utah. You can approve coverage in the retroactive period only if evidence shows that the person was in the state during the retroactive period with an intent to reside in Utah. Before approving coverage for the retroactive period, require the person to take immediate steps to change the SSP to Utah, if it has not been changed already.

Medicaid Policy

Previous Policy

Moving to Utah

An individual who moves to Utah from another state with the intent to become a Utah resident can receive Medicaid in Utah even if the other state provided Medicaid for the month of application. If the individual received a State Supplemental Payment from the other state, see Section 207-5 , E.

An individual is not a Utah resident until he or she arrives in Utah. (See Sec. 711 )

An individual is not a Utah resident while en route to Utah from another state.

Other family members do not become Utah residents until they arrive in Utah, too.

The effective date for Utah Medicaid cannot begin until the day the individual becomes a Utah resident. (See Sec. 711 )

Institutionalized individuals from other states

An individual placed in a Utah institution by another state, or an agency acting on behalf of another state, is a resident of the placing state. This includes placement in a public institution in Utah such as a jail or prison. When such individual is taken from the public institution and admitted to a hospital for an inpatient stay, the individual's state of residency does not change.

When a competent individual is no longer a resident of an institution, the state of residence is the state where the individual is living with the intent to reside. If the individual is not competent when he leaves the facility, the state of residence is where the individual is physically present.

The eligibility agency cannot deny Medicaid to an institutionalized individual, except for someone placed by an agency of the other state, on the grounds that the individual did not establish residence in Utah before entering the institution, if the individual meets the defined residency rules.

Moving Out of Utah

When an individual moves out of Utah, consider him a Utah resident through the end of the month in which he moved out of Utah.

After an unemancipated person is found to meet Utah residency requirements, his eligibility is not affected by a change of residency on the part of his parents, legal guardian or the person who applied for Medicaid on his behalf. If the individual remains in Utah, he is a Utah resident.

Medicaid Policy

Previous Policy

To be eligible for Utah Medicaid, a person must be a Utah resident. The following subsections explain how to determine if someone is a Utah resident.

Medicaid Policy

Effective Date: February 1, 2023

No Previous Policy

The age of a member may be a factor for some medical programs when determining eligibility. The member’s age on the first day of the month is applied to the entire month for eligibility. This applies at application as well as for ongoing eligibility. The member must be the required age for eligibility for at least one full day during the month.

Example:

Jane was born on April 1, 2000. Jane applies for benefits on April 1, 2019. When reviewing for eligible programs, Jane would not be eligible for any child programs in the month of application due to age. If Jane requested retroactive medical coverage, she would be considered 18 for any retroactive month.

John was born on June 1, 2000. John has been receiving Child Medicaid benefits since January 2019. John’s Child Medicaid program would close on May 31, 2019. John would need to be looked at for other medical programs for June.

Medicaid Policy

No Previous Policy

To be an institution, all the following criteria must be met.

It has an owner, a manager, or other person in charge.

It provides food, shelter, and some treatment or service to its residents.

It is designed to provide or is providing a residence and services for four or more people who are not related to the owner (there may be less than four people living there).

Medicaid Policy

Previous Policy

A. All Programs

1. A person living in a household is a resident of that household. The person must be living in the household during the month or must be temporarily absent ( 401-4 , 404-6 and 408-2 for Temporary Absence). If the person is temporarily absent, the person must intend to return to the household when the purpose for the temporary absence ends. (See B. or C. below) If the person moves to an institution, follow policy in 215-3 , 215-4 , 215-5 or 215-6 to determine residency.

2. I ndividuals do not have to live in a fixed residence to qualify for Medicaid. They may be homeless, in an emergency shelter, or living temporarily with someone else. If someone is homeless, certain deeming rules are not applied. (See 410 )

3. For Disability Medicaid, a child born in a hospital who meets disability criteria becomes a resident of the parents' household the month after the child is released from the hospital and moves to the home. (See 410 for deeming policies.)

4. Deciding who lives with the individual can affect eligibility processes such as whose income and resources to count for medically needy programs. See section 410 for ABD deeming, and 404-5 for Family Medically Needy Medicaid. For MAGI based programs the household size and whose income to count are governed by tax rules ( 401-2 and 440-2 ).

5. Joint custody situations. The physical living arrangements of a child determine in which household to include the child ( 401-4 , 404-6 and 408-2 ).

Medicaid Policy

Previous Policy

An individual living in an institution is a resident of that institution.

The following are not considered to be a resident of that institution:

An individual in a public institution for a temporary period pending other arrangements appropriate for the individual’s needs.

An individual living in a public educational or vocational training institution for the purpose of getting an education or vocational training.

Determine when an individual starts to be a resident of an institution based upon which type of institution the individual is residing in. For individuals in medical institutions, see 215-4 . For individuals in non-medical institutions, see 215-6 .

Medicaid Policy

Previous Policy

This section describes how to decide if someone is a resident of a medical institution.

Definition of a Medical Institution

A medical institution is a facility designed primarily to provide medical care. Medical institutions include, but are not limited to:

Hospitals

Skilled nursing facilities

Intermediate care facilities

The Utah State Developemental Center

Institutions for Mental Disease (including the Utah State Hospital)

Who is Eligible When Living in a Medical Institution?

Residents of most medical institutions may be eligible for Medicaid if they meet all other eligibility factors. (See D. below on specialized institutions.) A person is a "resident of a medical institution" if the stay lasts or is expected to last more than 30 consecutive days. Persons are not residents of medical institutions if their stay is 30 consecutive days or less. See C.3. for an exception that applies to disabled infants.

Who is a Resident of a Medical Institution?

Unmarried People or People Married to Residents of Medical Institutions.

The person is a resident of a household the month he or she enters the institution.

The person becomes a resident of an institution beginning the month after entering if the stay is expected to or does last more than 30 days.

The person remains a resident of the institution during each full calendar month until the month he leaves the institution and returns home. The month he returns home he is a resident of a household.

The person remains a resident of a household if he leaves the medical institution before the end of the month immediately after the month of entry.

If the person dies in the institution, he or she is a resident of an institution in the month of death, UNLESS death occurs in the month of entry.

Married person whose spouse is NOT a resident of a medical institution.

The person becomes a resident of the medical institution the month of entry when the stay is expected to or does last over 30 days.

He remains a resident of an institution throughout the month of discharge.

He becomes a resident of the household the month after he leaves the institution and returns home.

A baby born in a hospital who meets disability criteria.

The baby is a resident of the hospital from the month of birth through the month of discharge. The stay does not have to exceed 30 days.

The baby stops being a resident of an institution the month AFTER the baby leaves the institution.

The baby is a resident of a household beginning the month after the month of discharge.

A baby born at home is a resident of the household in the month of birth.

See Section 303-2 , #1 on how to decide disability. See Nursing Home Policy, Section 463-1 for income counting policy.

Moving from one medical institution to another medical institution without returning to the home does not change how residency is determined.

A person who is in a non-Medicaid medical facility may be eligible for Medicaid coverage of Ancillary Services only. There is an exception if the facility is an IMD. See Section 215-5 .

NOTE on treatment of a home: An individual who enters a medical institution may state an intent to return home. See section 521-1 if the person owns a home to decide if the home is an excluded resource.

Specialized Institutions

Residents of medical institutions primarily engaged in providing diagnosis, treatment or care to persons with tuberculosis are not eligible for Medicaid. [Note: Utah does not have any tuberculosis institutions, but some neighboring states do.]

Special eligibility rules apply to persons living in an Institution for Mental Disease. These eligibility rules are described in Sec. 215-5 .

Medicaid Policy

Previous Policy

A. Definition

An IMD (Institution for Mental Disease) is a hospital, nursing facility, or other institution of more than 16 beds that is primarily engaged in providing diagnosis, treatment, or care of persons with mental diseases or for the treatment of Substance Use Disorder (SUD). Services provided may include medical attention, nursing care, and related services. The Utah State Hospital in Provo is an example of an IMD. A psychiatric care unit within a regular medical hospital is not an IMD.

To decide which month a person first becomes a resident, see 215-4 about married or unmarried persons. Certain residents of an IMD can qualify for Medicaid or Medicare Cost Sharin g.

B. Requirements for Residents of IMDs

1. To qualify for Medicaid or Medicare Cost Sharing, residents of an IMD must be:

a. 65 years old and older; or

b. Individuals 21-64 years old who reside in an IMD, other than the Utah State Hospital, licensed to provide treatment for serious mental illness. ( Table XIX ) ; or

c. Children admitted to the Utah State Hospital by the end of the month in which they turn 21 years old. If they are a resident of the Utah State Hospital when they turn 21, they may receive Medicaid through the month they turn 22. Eligibility ends the month after turning 22; or

d. Individuals receiving Substance Use Disorder (SUD) treatment as a resident in a residential treatment center ( Table XVIII ).

2. Residents of an IMD who cannot be eligible for Medicaid or Medicare Cost-Sharing programs are:

a. Chil dren under age 21 who reside in an IMD, other than the Utah State Hospital, licensed to provide treatment for serious mental illness ( Table XIX ).

Children who reside in the Utah State Hospital are an exception to this rule and may be eligible for Medicaid or Medicare Cost Sharing.

b. A resident of the Utah State Hospital who was not a resident when they turned 21.

c. Individuals 22-64 years old who reside in the Utah State Hospital. 21 year olds in the Utah State Hospital must meet the criteria in B.1.c. to qualify for Medicaid coverage.

Note: Res idents preparing for discharge who are not eligible for Medicaid, may apply for Medicaid prior to their discharge date ( 703-7 ).

C. Residency in an IMD

1. A person who meets the IMD residency requirements and has become a resident of an IMD remains a resident until unconditionally released. This applies even if the person moves to a different residential setting, but has not been released by the IMD.

2. Residents of an IMD who do not meet the Medicaid eligibility requirements for IMD residents, as defined in B of this section, may qualify for Medicaid when placed on conditional or convalescent leave.

a. Convalescent leave is when the resident is sent home from the institution for a trial visit.

b. Conditional leave is when the resident is released from the institution on the condition that the resident receives outpatient treatment, or some other condition of release. If an IMD temporarily releases a patient from the IMD to receive medical treatment, the patient is not on a conditional release. The resident is still considered a resident of the IMD while getting the medical treatment, even if the medical treatment involves an inpatient stay at a hospital.

3. To de cide if a person meets disability criteria when the person is leaving the State Hospital, see 303-10 .

Medicaid Policy

Previous Policy

Definition

Non-medical institutions include jails, prisons, juvenile correctional facilities and community residence facilities. Other institutions may also be non-medical. Medicaid policy differs for residents of public or private non-medical institutions.

Residents of Private Non-Medical Institutions

Residents of private non-medical institutions can receive Medicaid if they meet all other factors of eligibility.

Residents of Public Non-Medical Institutions

A public non-medical institution is an institution that is the responsibility of a governmental unit or that is under the administrative control of a governmental unit. Residents of some public, non-medical institutions are not eligible for Medicaid. Individuals living in the following institutions may be eligible for Medicaid coverage, if all other factors of eligibility are met. See 604 for suspending benefits for incarcerated individuals. Residents of a public non-medical institution who are within 90 days of release may be eligible for pre-release services with Medicaid.

A community residence facility. An eligible community residence facility must meet the following requirements:

Designed for and actually serving 16 or fewer individuals;

Cannot be located on the grounds of or adjacent to an ineligible institution.

Must operate primarily as a facility that provides other services the residents need, such as:

social services;

help with personal living activities;

training in socialization and life skills; or

occasional or incidental medical or remedial care.

A halfway house. An eligible halfway house ( Table XVI ) must meet following the requirements:

Residents of the facility must have freedom of movement and association as outlined according to the following tenets:

Residents are not precluded from working outside the facility;

Residents can use community facilities ‘at will’, such as libraries, grocery stores, recreation areas, or schools; and

Residents can seek health care treatment in the community to the same extent as other Medicaid enrollees in the state.

‘At will’ includes facility operational rules or “house rules”. For example, the facility may be locked or closed during certain hours of the day, residents may be required to report in during certain times, or sign in and out, etc.

Home Confinement, also known as "house arrest" “ankle monitor,” or “electronic monitoring.” If the conditions of home confinement fit the definition of freedom of movement described in 2.a. and b., the individual is eligible for Medicaid.

Residency When Entering or Leaving a Non-Medical Institution

Anyone who moves from a household to a private, non-medical institution, or a public, non-medical institution that meets one of the exceptions in C. above, is still a resident of a household for the month they are admitted to the institution.

An individual who moves from a household to a jail or prison may continue to be a resident of a household. See 401-4 for MAGI Programs and 408-2 and 408-6 for ABD Programs.

If the individual enters a public institution that does not meet one of the exceptions in C. above, Medicaid eligibility is available for the portion of the month during which the individual was not in the public institution.

When a person leaves to receive inpatient services in a hospital, an IMD, the State Developmental Center, or a long-term care facility, the individual is not a resident of a public non-medical institution from the date of admission to the date of discharge from the hospital, IMD, State Developmental Center or long-term care facility. Medicaid eligibility is available for the portion of the month during which the individual is inpatient in the hospital, IMD, State Developmental Center or long-term care facility if the individual meets all other factors of eligibility.

If the individual is not a member of the community household during the inpatient stay in a hospital, IMD, State Developmental Center, or long-term care facility. Base eligibility on the individual's circumstances while the individual is an inpatient, not on the circumstances of the household in which the individual lived before entering the public, non-medical institution such as a jail or prison.

If the individual is disabled, or claiming to be disabled see 303 .

When a child residing in a public, non-medical institution is admitted for an inpatient stay in a medical hospital, IMD, State Developmental Center or long-term care facility, determine eligibility based on the child's income and assets ( 215-3 ).

Anyone who moves from a non-medical institution to a household becomes a resident of a household for the remainder of the month during which they move into the household.

See 703-7 for policy on applying for medical assistance before the person has left the institution, when a person is about to leave the Utah State Hospital, jail or prison, and when an incarcerated individual is admitted for an inpatient stay in a hospital, IMD, State Developmental Center, or long-term care facility.

Disability Decision When Leaving a Public Institution

If the individual was determined disabled before entering the public institution, or while living in a public institution, see 303-10 to determine their eligibility for Disability Medicaid.

Medicaid Policy

Contact DHHS Policy Specialist for Previous Policy

Medicaid policy defines all dwellings as either a household or an institution. Residents of households are eligible for Medicaid if all other factors of eligibility are met. Residents of certain institutions are not eligible for Medicaid. Residents of other institutions may be eligible for Medicaid if all other factors of eligibility are met.

Review the following policies to decide when an individual is a resident of a household or an institution.

215-1 What is an Institution?

215-2 Who is a Resident of a Household?

215-3 Who is a Resident of an Institution?

215-4 Residents of Medical Institutions

215-5 Residents of Institutions for Mental Disease

215-6 Residents of Non-Medical Institutions

Medicaid Policy

No Previous Policy

Once a Social Security number (SSN) is provided by the applicant or recipient it must be verified as the correct number for that person.

Verification of the Social Security Number by Computer Match

First check to see if the SSN has already been verified by computer match. If the SSN has already been verified by the computer match, no other verification is needed.

If the SSN is not known, the computer match system will attempt to verify it with Social Security records once the number has been entered into the system.

Do not deny, delay or discontinue medical assistance while waiting for the computer match verification.

Verification of Social Security Numbers That Do Not Match

At review, check to see if a computer match has verified the SSN. If the SSN number has not been verified require the person to provide hard copy verification of the Social Security number. Any one of the following forms of verification is acceptable:

An official Social Security card; OR

Other official documents from the Social Security Administration (SSA) which identify the correct SSN. These include, but are not limited to, award letters, and benefit checks; OR

A form 5028 or 2880 from the Social Security Administration which includes the SSN.

Individuals who fail to provide verification of their SSN after being informed of a computer match error are not eligible. Provide 10-day advance notice before closing a case or removing a person from the coverage.

Medicaid Policy

No Previous Policy

Applicants or recipients who are required to provide a Social Security number but do not have one, must apply for a Social Security number. They must provide verification that they have applied before they can receive or continue to receive medical assistance. Any of the following are acceptable verification that an application for a Social Security number has been made:

A form 5028, 2880 or a computer letter for the Social Security Administration.

A birth certificate or a form SSA-2853 showing that the parent asked to apply for a Social Security number when they provided the birth registration information. The birth certificate must include the child's name, an indication the SSN was requested, and the signature of a hospital official. The form SSA-2853 must include the child's name and a signature of a hospital official.

Do not deny, delay or discontinue medical assistance while waiting for a SSN to be issued.

At review, request that the household provide SSN's for any household members who previously verified that they had applied for one.

Individuals who fail to provide their SSN after one has been issued are not eligible. Provide 10-day advance notice before closing a case or removing a person from the coverage.

Medicaid Policy

Previous Policy

The following are exceptions to the requirement to provide a Social Security Number:

Applicants who do not meet U.S. citizenship or non-citizen status requirements, who cannot legally obtain an SSN and who could only qualify for emergency medical services are not required to provide a SSN. Certain children who qualify as lawfully present ( 205-2.1 ) will not have an SSN.

Children under the age of one year who are receiving Child 0-1 coverage until they turn age 1, are not required to provide a SSN until after they turn age 1. (See Section 347 )

Children placed for adoption who do not have a SSN are not required to provide a SSN until after the adoption is finalized.

Household members who do not want medical assistance do not have to provide a SSN.

Household members who refuse to obtain a SSN due to well-established religious objections.

Medicaid Policy

No Previous Policy

Good cause exists if the applicant/recipient reports that he or she cannot apply for the SSN because of a lack of information to give to SSA, but has made every effort to get that information.

Good cause does not include delays due to illness, lack of transportation, or temporary absences from the state.

Allow the applicant to receive Medicaid for the month of application and one additional month when good cause has been determined.

After the second month, the recipient must submit proof each month there is good cause for not applying for the SSN.

Remove the recipient at the end of the second month, giving 10-day notice, if the application for the SSN has not been completed and the member has not submitted proof of continued good cause.

In the case of a child placed for adoption, good cause exists until the adoption is finalized in the Utah Courts. Finalization cannot occur until the child has lived with the adopting parents six months. Do not require additional good cause proof until after the child has been in the parents' home at least six months. If finalization is delayed, you may need to ask for verification about the delay from the placing agency or the parents' lawyer. It may take more than a month after finalization to get a birth certificate for the child, which is needed before the parent(s) may apply for a SSN for the child.

Medicaid Policy

No Previous Policy

With few exceptions, all applicants and recipients who request or receive medical assistance must provide their correct Social Security number. A Social Security card or other verification of the Social Security number is not required unless the number cannot be verified by computer match. If an applicant does not have a Social Security number he or she must apply for one and provide the number once one has been assigned.

Medicaid Policy

Contact DHHS Policy Specialist for Previous Policy

Resource Page

Many aged, blind and disabled members can be eligible for Medicare. If they are, Medicaid will not pay for most of their prescription drugs. See resource page to learn what Medicare is and who can be eligible.

Medicaid Policy

Previous Policy

Medicaid recipients who are eligible to receive Part B Medicare must be enrolled, or must apply for Part B. The State pays the Part B premium for individuals eligible for Medicaid or a Medicare Cost-Sharing program.

1. Individuals who have been issued a Medicare number and are receiving premium-free Medicare Part A, but who have declined Part B will be enrolled through the automated BUY-IN system after they are approved for Medicaid or a Medicare Cost-Sharing program. The person's Medicare number shows the person is eligible and allows the automatic enrollment of the individual. They do not need to go to the Social Security office to enroll.

2. Individuals who are receiving a Title II benefit such as SSA disability or retirement will become eligible for Medicare automatically. Their Medicare eligibility begins once they turn age 65 or have received disability benefits for 24 months. They do not have to apply for Medicare.

3. Medicaid recipients who are not eligible for premium-free Part A Medicare and who are not on Part B must apply for Medicare Part B when they reach age 65. This includes individuals receiving only SSI payments. Resident non-citizens must be at least 65 and have lived in the U.S. for 5 years to qualify for Medicare. Do not require individuals to apply for Part A Medicare if they will owe a premium. These individuals must apply for Part B Medicare through Social Security Administration.

a. Approve Medicaid pending the application for Part B for an otherwise eligible individual.

b. Notify the recipient of the requirement, provide the information they need to apply, and allow at least 30 days for the individual to apply for Part B.

c. Close the Medicaid case if an individual fails to apply after being notified of this requirement, and has not asked for more time to apply.

3. Individuals whose SSDI benefits end, but who are still receiving Medicare benefits are generally still considered disabled by SSA. They can continue to be eligible for Disabled Medicaid if the individual is still disabled. Decide why SSDI benefits ended ( 303-2 ) .

4. Individuals who are entitled to or receiving Medicare are not eligible for Medicaid under the Adult Expansion program. Eligibility under this group ends when a recipient becomes entitled to Medicare.

See 223-1 in Resource section for information on who is eligible and how enrollment occurs.

Medicaid Policy

Contact DHHS Policy Specialist for Previous Policy

What Is SSI?

SSI is a federal financial assistance program for elderly, disabled, and blind individuals. Eligibility for SSI benefits is based on the need of the individual.

People applying for, or receiving, Medicaid assistance are not required to apply for SSI.

However, members who are age 65 or older, disabled, or blind may benefit from the SSI program if they have low income and resources. Share information with members about SSI and refer members to the Social Security office if the member wants to apply.

Medicaid Policy

Effective Date: June 1, 2025

Previous Policy

MAGI-Based Eligibility Groups

Members whose eligibility is determined for a MAGI-based eligibility group are not required to apply for VA benefits. This is because the VA benefits do not count as income for the MAGI-based income determination.

Non-MAGI-Based Eligibility Groups

Members whose eligibility is determined for a non-MAGI-based eligibility group are not required to apply for VA benefits.

Medicaid Policy

Previous Policy

Definition of Other Benefits

Other benefit is Medicare Part B.

Policy Requirement

Medicare benefits .

Individuals who are eligible to receive Medicare must apply for Part B benefits if they are not already receiving Medicare, and the Medicare benefits will not begin automatically. See 223-2 for details.

Medicare Part B starts automatically when an individual is receiving Social Security benefits and reaches the applicable eligibility date. No application is required.

If an individual already has Part A Medicare, but is not enrolled in Part B, the Part B enrollment will occur automatically when the individual becomes eligible for Medicaid or a Medicare Cost-Sharing program. The individual does not have to apply for Part B with Social Security.

The Medicare number is required to start the BUY-IN process.

Minor children receiving survivor's benefits and spouses under age 65 who are receiving survivor's benefits based on caring for young children are not entitled to Medicare benefits and are not required to apply for Medicare to be eligible for Medicaid.

When a child or incapacitated person may qualify for Medicare Part B, the parent, guardian or responsible person must take all steps to apply for and receive such benefits. If the parent, guardian or responsible person does not take steps to receive such benefits, the child or incapacitated person is ineligible for Medicaid.

Income Benefits Individuals Do Not Have to Apply For

Social Security Retirement, Survivors, Disability Insurance and Early Retirement when the individual is age 62 or older and either has a work history or has been married for at least 10 years to an individual who has a work history.

An individual under full retirement age who claims to be disabled and has a work history.

An individual age 62 or older, who has a work history must not apply for early retirement, or regular retirement. If the individual is not at full retirement age and claims to be disabled, or is determined disabled by the MRB, the individual must not apply for disability benefits.

An individual who does not have sufficient work history to apply for disability benefits under his or her own Social Security record. [NOTE: Social Security disability insurance requires a different number of covered work quarters for different aged workers.]

Spouses of an insured person may be eligible for early retirement at age 62 and regular retirement if they are of full retirement age.

Children of an insured person may be eligible for survivor's benefits if the insured person is deceased, or is receiving SS disability or retirement benefits.

Children who became disabled before age 22 may be eligible for a Disabled Adult Child benefit if the insured parent is deceased, or is receiving SS disability or retirement benefits.

Individuals who do not receive VA benefits must apply for them or for increased payments, if they could possibly be eligible. (See Sec. 223-4 )

Do not require the individual to apply for such benefits if the benefit does not count as income. This includes VA Aid and Attendance and some benefits for veteran's children. (See Sec. 415-2 )

An individual whose eligibility is determined using MAGI-based methodologies does not have to apply for VA benefits, as these benefits do not count as income under the MAGI-based methodology.

Railroad Retirement (retirement, survivor or disability)

Civil Service, federal, state, or local government (retirement, disability or survivor benefits), or military retirement or military survivor's benefits.

Unemployment Compensation or Worker's Compensation funds.

Other similar benefits such as private retirement or disability benefits. This includes non-governmental benefits such as making money available from trust funds and inheritances. Do not require a person to apply for a retirement pension if the person is still working and would have to quit working to receive the benefits.

Survivor's Benefits. Some of the above programs provide benefits for spouses and divorced spouses age 62and older; widow/widower and disabled widow/widower benefits; surviving minor child or disabled adult child benefits; and benefits for a spouse caring for young children. Individuals who may qualify for these benefits must apply for them. A change in circumstances in a person's life may make the person eligible for these benefits.

Income available from an institutionalized or waiver-eligible spouse.

Applicants and recipients do not have to receive income available from a Medicaid-eligible spouse in a nursing home, or a spouse eligible under certain home and community waivers under the policy that allows a deduction from the institutionalized spouse's income for a community spouse. However, the nursing home or waiver spouse can choose to contribute all, part or none of the allowed spousal income deduction to the community spouse.

Do not deny Medicaid to a community spouse because of the decision made by the nursing home or waiver spouse. Count as income only the actual amount given to the community spouse. The allowed deduction from income of the nursing home or waiver spouse must equal the amount actually contributed to the community spouse.

Applicants and recipients are not required to apply for SSI benefits, FEP benefits or crime victim's compensation funds.

Applicants and recipients do not have to apply for benefits that do not count as income for Medicaid purposes. This includes things such as VA Aid and Attendance, earned income tax credits, Victim's Compensation funds, or for MAGI-based eligibility groups any Veteran's benefits. (See sec. 415-2 and 417 on income exclusions.)

Household members who will not be receiving medical assistance are not required to apply for benefits to which they may be entitled. This is true even if we deem income or would deem income from that person.

Applicants and recipients are not required to apply for Advanced Premium Tax Credits through the Exchange.

Time Allowed to Apply for Benefits

When you decide an applicant or a recipient may be eligible for Medicare Part B, tell the individual in writing what benefits they are required to apply for Medicare Part B and the due date for verification.

If the agency has the needed information that shows an applicant is eligible for Medicaid, and the only other thing needed is to apply for Medicare Part B,

approve the Medicaid application.

Notify the individual of the requirement to apply for Medicare Part B.

Do not close benefits before the due date for applying for Medicare Part B.

If an individual is required to apply for Medicare Part B benefits, allow the member at least 90 days to apply.

If the due date is a non-business day, the due date becomes the business day following that due date.

The member must verify that they have applied for Medicare Part B.

If the member requests more time, give the member more time to file an application for Medicare Part B and provide verification to the agency. Verification is due by the close of business on the due date to be considered received timely.

The member must continue to do what is needed to complete the application process and receive a decision about Medicare Part B, such as providing verification to the pertinent agency.

If the member does not apply, fails to take other steps to complete the process, or fails to claim good cause for not applying, close the case. Reopen the case if the member verifies before the closure date that he has applied, is taking additional steps to get Medicare Part B or has good cause for not applying.

If eligibility ends for a household member due to failure to apply for Medicare Part B and the household case remains open, treat the date the individual verifies applying for Medicare Part B as a new application date.

If the Medicaid case closes, and the individual reapplies for medical assistance, notify the individual that he is still required to apply for Medicare Part B.

Claiming Good Cause

If a individual claims good cause for not applying for Medicare Part B, ask the individual for a written statement with the reason for the good cause. Request verification if needed.

Good cause may exist if the individual lacks sufficient information about the insured person under whose work history benefits may be available.

Social Security, or other agencies, may not be able to match records without sufficient information to assure the identity and relationship of the insured person and the applicant.

If the individual cannot get the needed information, or if getting that information would cause possible harm to the individual or family, good cause may exist.

Agencies like Social Security do not contact the insured person when a person applies for benefits under the insured person's work history. Therefore, fear of harm from the insured person because the individual applies for Medicare Part B should not be a reason for not applying as long as the individual has sufficient information about the insured person to file.

Review Sec. 225-4 on good cause reasons for not cooperating with TPL. The reasons and evidence requirements can be similar.

Contact the OEP Program Specialist, if you need to discuss whether good cause exists.

If the member establishes good cause, continue Medicaid. Update the good cause claim at each renewal if it still exists. If good cause no longer exists at renewal, notify the member of the requirement to apply for Medicare Part B. If the member fails to apply for Medicare Part B, close the Medicaid case.

Medicaid Policy

Previous Policy

The fact an individual in the household is on strike does not make anyone in the household ineligible for any Medicaid program, not even the individual on strike. A strike is defined to also include a work slowdown or work stoppage.

A change in the income as a result of an individual in the household being on strike could affect what programs household members qualify to receive. Review the case to decide if any changes are needed.

Medicaid Work Incentive Program

A person eligible under the Medicaid Work Incentive program who is out on strike is still considered employed until such time as the person's employment is terminated. The change in income could affect the premium owed for the MWI program. [ Note : If the recipient does not expect to receive any earned income in the month, workers may have to post $1 of earned income to determine eligibility on the MWI program .]

MAGI-Based and Non-MAGI-Based eligibility groups

If a parent in a two-parent home is on strike, determine if deprivation for PCR and the Family Medically Needy programs is met due to one of the parents being unemployed or employed less than 100 hours.

The loss of income may affect the countable income for the individual and other household members.

Medicaid Policy

Previous Policy

Requirement for Applicants

To be eligible for Medicaid or QMB, (but not SLMB and QI-1), applicants must provide information about any possible third party who may be responsible to pay their medical expenses. An applicant may claim good cause for not providing this information ( 225-4 ). The applicant may provide TPL information verbally, on the application form or on a Form 19. Verbal TPL information must be narrated in the case record.

DO NOT approve Medicaid for any adult until he or she has provided the required TPL information.

Requirement for Parent

An adult parent, or an emancipated minor parent must provide TPL information for his or her children who will receive Medicaid.

If the parent refuses without good cause, do not approve Medicaid for the parent. Open Medicaid only for the eligible children. Do not deny Medicaid to children because of a parent's failure to complete TPL requirements.

Refer the TPL information from the application or Form 19 to ORS.

Requirement to Apply for Medicare Part B

Applicants and recipients who may be eligible for Part B Medicare benefits must apply for such benefits after they become eligible for Medicaid ( 223-2 ). If eligible for Part B Medicare, the Medicaid agency will pay the monthly Part B premium for months the individual is eligible for Medicaid, QMB, SLMB or QI benefits.

The state automatically enrolls individuals in Part B Medicare after they become eligible for Medicaid if they are receiving Part A or have been on Part B in the past ( 223-2 ). Do not require these individuals to do a Part B enrollment.

TPL Requirement when Review is Treated as an Application

An adult recipient's medical assistance will end if the recipient fails to complete their review. Section 721-1 discusses the process for completing an eligibility review. If the recipient provided updated TPL information during the failed review process, do not request it again as part of the application process.

Medicaid Policy

Previous Policy

Reporting Changes

Adult recipients and emancipated minor recipients of medical assistance must report all changes and additions in third party liability. They must also cooperate in the establishment and collection of third party claims. This includes cooperating in the establishment of paternity for born children. (See Section 225-3 )

Members must report TPL changes within 30 days of when the change occurs.

Members must provide updated TPL information at each eligibility review. Section 721-1 discusses the process for completing an eligibility review. If the recipient provided updated TPL information during the failed review process, do not request it again as part of the application process.

Cooperation

ORS will tell workers if the recipient is not cooperating. If a recipient who is not cooperating does not claim Good Cause, he or she will not be eligible for Medicaid again until ORS reports that the recipient is again cooperating. (See Section 225-5 for applying the sanction.)

TPL Resulting from Accidents or Legal Actions

Recipients must report when they are involved in a lawsuit or settlement involving injury, accident or medical claims such as a malpractice suit. Notify ORS of any pending settlements, and of any payments the member receives. ORS may seek recovery of any related Medicaid costs. Recipients must also report if they are involved in an accident or suffer an injury that insurance such as auto or homeowner's insurance may cover.

Medicaid Policy

Previous Policy

A. Changes and Updates

Recipients must report changes in Third Party Liability (TPL) information within 30 days of the change. If the 30th day is a Non-business Day , recipients have until the Business Day following that 30th day. They can report changes to the eligibility agency in writing, over the phone, by available electronic methods, or in person.

Reported Changes.

When workers are notified of a change in TPL, the eligibility worker must gather the new TPL information from the recipient(s).

Reviews.

The eligibility worker is required to complete an ex parte review whenever possible (see 721-1 ). The worker does not update the TPL information as part of the ex parte review. However, the notice of decision will remind the recipient to report any TPL change that occurs.

If an ex parte can't be completed, eREP will send a prepopulated review form which includes TPL questions for the customer to complete. If the member leaves the TPL information blank or incomplete, contact the customer to gather the necessary information.

Eligibility workers may gather TPL information by:

sending a TPL form to the recipient to complete, sign and return

by phone or

by sending a notice to the customer to request the information.

An adult recipient's medical assistance will end if the recipient fails to complete their review. Section 721-1 discusses the process for completing an eligibility review. If the recipient provided updated TPL information during the failed review process, do not request it again as part of the application process.

Report to ORS.

Eligibility workers must report TPL changes to the Office of Recovery Services. Do not report TPL information to the Health Program Representatives (HPR) with the Office of Managed Health Care.

B. Accidents, Injuries

The eligibility worker must notify ORS of any information received about a possible TPL arising from the negligence of others, or from accidents or injury situations (such as automobile accidents, public liabilities, homeowner's accidents, etc.) Provide ORS with as much of the following information as you can:

recipient name and case number,

date (or approximate date) of the accident or injury,

nature of the accident or injury, and

any other pertinent information, such as the company involved, policy holder, and court information.

Remember that money received from a TPL source for medical expenses cannot count as income for Medicaid eligibility if it is recouped by ORS.

Medicaid Policy

Effective Date: September 1, 2018

Previous Policy

An applicant or recipient who can establish "good cause" may receive Medicaid without completing TPL requirements. Good cause means the individual has an acceptable reason for not cooperating with TPL. See A below.

Eligibility workers must sent the form TPL-1 which explains good cause for non-cooperation with TPL and the consequences for non-cooperation without good cause to applicants and recipients who claim good cause.

The applicant or recipient must provide information or evidence to show that good cause may exist.

Do not deny, delay, or stop assistance during the process of deciding if good cause exists.

Reasons and Proof of Good Cause

Applicants or recipients may claim good cause to protect the best interests of the family. Good cause includes the following circumstances:

The child on Medicaid was conceived because of incest or forcible rape.

Evidence : Birth certificates; Department of Health and Human Services, court, or law enforcement records.

Legal proceedings for the adoption of a child on Medicaid are pending before a court of competent jurisdiction.

Evidence : Court records; Department of Health and Human Services records; placement agreement; adoption agency or attorney report.

A public or licensed private social agency is helping the applicant or recipient make a decision concerning possible adoption of the child on Medicaid, AND the discussions have not gone on for more than three months.

Evidence : Written notice from the social agency working with the individual.

Cooperation with TPL is expected to result in physical or emotional harm to the individual, the spouse, or any of the individual's children. Emotional harm is any emotional impairment that substantially affects functioning. If the claim is based in whole or in part on anticipated emotional harm, consider the present emotional health, history of emotional health, intensity and probable duration of emotional impairment, degree of cooperation required, and extent of involvement required. Document these considerations carefully in the case record.

Evidence : Medical records or written statements from a mental health professional; court records; medical records; Department of Health and Human Services or Workforce Services records showing it is reasonable to expect harm to result from TPL cooperation.

Determine Good Cause

The supervisor will decide if the individual has good cause for non-cooperation with TPL. When the supervisor decides if good cause exists, send a notice to the applicant/recipient. Individuals may appeal the decision through the administrative hearing process.

Decide based on:

Information contained in any Department of Health and Human Services or Workforce Services records,

Evidence supplied by the applicant/recipient,

Investigation of the evidence provided, or

A combination of evidence and investigation.

Evidence

The applicant or recipient must provide supporting evidence within 20 days from the date good cause is claimed. The supervisor may grant an extension. Note the extension in the case file. The eligibility worker should help the individual get the necessary evidence.

If the person anticipates physical harm but cannot provide supporting evidence of abuse or threats of abuse, you may accept sworn statements from people with knowledge of the circumstances and personal knowledge about the applicant or recipient. The sworn statements do not need to establish that abuse has occurred or been threatened, but must support the individual's credibility. The supervisor will decide if the person has established good cause.

Investigation of good cause Claim

The supervisor will investigate the good cause claim if evidence is not available.

When doing an investigation, use any reasonable evidence that is easily accessible. Investigation may include contact with government or private social service agencies, or individuals who may have knowledge of the circumstances and could provide information to support the individual's claim.

Do not release information from DWS or DHHS records to others outside DWS or DHHS. Do not release information to anyone within DWS or DHHS unless the person has a valid, work-related need to know the information.

DO NOT give information to anyone who may harm the individual or the individual's family.

Contact with an absent parent might be necessary to establish good cause. Before making contact, the applicant or recipient must be notified and must respond. He or she may:

Allow the contact, or

Present more evidence so the contact is unnecessary, or

Agree to denial of the good cause claim, or

Withdraw the application or request removal from the case.

Enforcement Without Cooperation

If the individual has good cause for non-cooperation, the supervisor must decide if ORS could pursue verification of the TPL, collection, and enforcement without harming the individual or the individual's family WITHOUT THE COOPERATION OF THE INDIVIDUAL. Record the decision in the case file and notify ORS. Before ORS proceeds with action, notify the applicant or recipient and record his or her response.

When the supervisor has decided ORS can pursue TPL without harming the individual or the individual's family, the individual must either:

allow the collection or enforcement, OR

withdraw the application, OR

request removal from the case.

Medicaid Policy

Contact DHHS Policy Specialist for Previous Policy

Deny Medicaid eligibility to adult applicants who fail to cooperate with Third Party Liability (TPL) without good cause. If an adult recipient cooperates at first, and then later fails to cooperate, sanction the adult from the Medicaid coverage. Do not deny eligibility to or remove dependent children from Medicaid because the adult on the case does not meet TPL requirements. A dependent child is someone who is under age 18; or, for Family category programs, who is between age 18 and 19 in secondary schooling or training full time, and is expected to complete the schooling or training before turning age 19. A child is no longer dependent once the child has married or been emancipated by a court of law.

A person is cooperating if all the TPL information he or she knows has been provided, even if every detail is not known. Do not deny Medicaid eligibility or close a case for failure to cooperate when a third party, such as an ex-spouse, refuses to give the TPL information to the individual. However, the individual needs to provide the name of the ex-spouse and whatever information he or she can about how to contact the ex-spouse.

Use the following procedures when a individual has failed to cooperate.

Failure to complete the TPL questions on the application or the Form 19.

If the adult applicants do not provide the information to complete the TPL questions either on the application or Form 19-TPL Questionnaire, request this information during the application process.

Adult recipients must also report changes in a timely way, and when adding a household member, must provide TPL information for the person they want to add.

If the adult applicants or recipients fail to meet the TPL requirement without good cause, the eligibility worker will code the adults out of the Medicaid coverage. Approve, or continue Medicaid for all eligible children in the household when all other eligibility requirements are met. Before ending eligibility for an adult recipient, provide 10-day notice that benefits will end.

If the adults want to comply later with the TPL requirement, treat it like a new application request with the application date being the date on which they met the TPL requirement. Coverage would start with the month they comply and can include the retroactive period prior to the date they comply. (See Sec. 705-1 )

Failure to cooperate with TPL procedures or withholding TPL information AFTER initially meeting the TPL requirements.

The ORS Medicaid Unit will decide when to apply a sanction in this case. If ORS determines that an individual is not cooperating, they will notify the local office. The sanction may be removed ONLY when the ORS Medicaid Unit agrees that the individual is cooperating. See 225-5 #3 for ending the sanction.

Informing the Individual

Workers must tell applicants during the application process that the applicant must provide TPL information to be eligible for Medicaid unless they claim good cause.

• Remember, the children can still be eligible. Do not deny Medicaid for a child because of an adult's refusal to provide TPL information.

If ORS requests a worker to apply a sanction to a recipient who is not cooperating, follow the procedures below.

Advance Notice

Send a notice to the recipient explaining that all adults will be ineligible for Medicaid because of non-cooperation with TPL. Tell them when coverage will end if they do not cooperate. Always give 10-day notice before removing the adults from the coverage.

Remove From the Coverage

After providing the 10-day advance notice, withhold medical assistance only for all adults on the case. Continue Medicaid benefits ONLY for the children.

When Does the Ineligibility or Sanction End?

If the eligibility worker denied eligibility, add the adults back to the case when they comply with the TPL requirement. Eligibility can be reinstated beginning the month they comply. Coverage can also include the retroactive period prior to the date they comply with the TPL requirement.

• If the case is open for the children, do not require a new application. Use the date they meet the TPL requirement as the date of application to determine the retroactive period. (See Sec. 705-1 .) Document the request and the date of compliance.

• If there was no open case because there are no covered children, the individual must reapply for Medicaid, unless they have cooperated before the end of the application processing time line.

If ORS requested the sanction, DO NOT restore Medicaid coverage until ORS verifies that the individual is now cooperating. If a sanctioned individual expresses a desire to cooperate, contact ORS. Medicaid coverage may begin at the first of the month in which the individual begins to cooperate, as per the ORS office. You cannot provide coverage for any month or partial month of the retroactive period if the individual was being sanctioned by ORS in such month.

Medicaid Policy

Previous Policy

A. What is the Buyout?

The Buyout is a federal law that allows the State to purchase group health insurance for an individual who is eligible for Medicaid when it is cost effective for the State. The cost effectiveness is based on whether the individual has major medical expenses, such as a pregnancy or a long term illness. The Buyout will be done in cooperation with Medicaid eligibility workers. The Division of Integrated Healthcare, Buyout Unit processes the Buyout.

Currently employed applicants or recipients who are not participating in their employer-sponsored group health insurance may be required to enroll, with Medicaid paying the premium for this insurance, as one of the Medicaid covered benefits. Children (up to age 26) may be eligible for Buyout on their parent's insurance.

In some instances, an individual may purchase a group health insurance through an employer within the first 60 days after termination of employment. This is referred to as COBRA coverage. It will frequently be in the State's best interest to purchase COBRA insurance coverage if an individual has a major medical problem and has just terminated employment.

B. Responsibilities of the Eligibility Worker

Complete the TPL questions on the application or Form 19 with the applicant. Go over the specific questions which relate to a potential Buyout option with each applicant and recipient. If the member expects any major medical expenses, there is a potential Buyout opportunity when the member:

is currently enrolled in health insurance, OR

has had health insurance coverage in the past sixty days, OR

is employed and the employer has insurance for employees but the member has not enrolled.

Refer the information about a potential Buyout by sending a FAX of the Form 19 and a copy of both sides of the member's health insurance card (if applicable) to the Buyout unit at the Division of Integrated Healthcare (DIH). If you have questions, or are concerned about a short COBRA deadline, you may call the Buyout staff. See Table IX for phone numbers.

Do not refer the following for Buyout, as they are not cost effective for DIH to purchase:

A "Medigap" insurance policy for any Medicare recipient.

Nursing home residents with health insurance.

Eligibility workers must allow a deduction from income on spenddown cases for the amount of the health insurance payment if the coverage is purchased. The fact that the State makes the payment has no bearing on whether the deduction can be allowed as a health insurance expense.

Eligibility workers will initiate any sanctions for non-cooperation as informed to do so by ORS. See Section 225-5 .

If there is a potential Buyout opportunity, eligibility workers should explain to members that the state will contact them ONLY IF the state decides to pay the health insurance premium. If a member wants to assure coverage under an employer's health plan or a COBRA option, the member should take the necessary steps to enroll in the insurance including paying any premiums that are due. The member should not wait to see if the state will pay the premium.

C. Responsibilities of the Division of Integrated Healthcare Buyout Unit

The DIH Buyout unit will research the possibility of doing a Buyout, and determine if it is cost effective. If DIH buys the insurance, they will send a letter to the member and a copy to the eligibility worker informing them of this action. No notice will be sent unless the DIH decides to buy the insurance.

DIH will process the premium payments. DIH will process the referrals for Buyout and make the decision on cost effectiveness. DIH will notify members and workers of participation in Buyout. DIH will process the payments to employers or other group health insurance companies for members when it was determined cost effective.

D. Responsibilities of the Office of Recovery Services

ORS will coordinate sanctions for individuals who refuse to enroll in the group health insurance when it was determined cost effective for the State. If a sanction is to be imposed, ORS will notify the eligibility worker to apply the sanction.

Medicaid Policy

Contact DHHS Policy Specialist for Previous Policy

A third party is an individual, institution, corporation, or public/private agency that may be responsible for paying all or part of the medical cost of an applicant or recipient. A third party may include health, accident, or hospital insurance; liability insurance, such as auto and homeowner's policies; industrial accident claims; court judgments; and a child's right to medical support from an absent parent.

Medicaid Policy

Previous Policy

A. Who Must Be Asked To Cooperate With ORS/CSS

Medicaid applicants and recipients must be asked to cooperate with the Office of Recovery Services/Child Support Services (ORS/CSS) to establish paternity for children born out of wedlock and to initiate and/or enforce medical support orders to collect payment for medical care from any third party. This includes parents and non-parent specified relatives who are applying for or receiving Medicaid for a child, unrelated caretakers or guardians applying on behalf of a child, and children applying on their own behalf.

In most cases, parents and non-parent caretaker relatives must cooperate or they are not eligible to receive any type of Medicaid coverage for themselves. Ask the following people to cooperate.

1. Natural, adoptive or stepparents of a child for whom they are requesting or receiving Medicaid. This includes minor parents under age 18. (See exceptions listed in B. below.)

2. Non-parent specified relatives of a child for whom they are requesting or receiving Medicaid. (See exceptions listed in B. below.)

3. Unrelated caretakers or guardians of a child for whom they are requesting or receiving Medicaid; however, do not sanction an unrelated caretaker or guardian for non-cooperation. (See exceptions listed in B. below.)

4. A child who does not live with a specified relative or adult guardian, who is applying for or receiving Medicaid on his/her own behalf; however, do not sanction an unemancipated child for non-cooperation. (See exceptions listed in B. below.)

B. When is it Not Necessary to Complete an ORS/CSS Application

1. A different referral process ( 415-5 ) has been established for children in certain living arrangements. Do not complete an ORS/CSS application on the absent parent(s) for the following children:

o Children placed in foster care;

o Children in the Utah State Hospital (USH);

o Children in the Utah State Development Center (USDC);

o Children in nursing homes;

o Children in community placements;

o Children in the custody of the Division of Youth Corrections; and

o Children who are residents of institutions or on an HCB waiver requiring 24 hour out of home care.

2. Parents of children residing in institutions are responsible for child support. Tell the parent that ORS will contact them later about payment of the child support obligation. Also, give the parent a copy of the pamphlet Utah-DHS ORS PM 604, Parents Child Support Obligation for Children in Care.

3. The requirement to complete an ORS/CSS application does not apply to all children who receive Medicaid or who reside in Medicaid households. Do not complete an application on the parents of children described below:

o Children receiving Refugee Assistance;

o Children receiving SSI or a State Supplemental Payment;

o Children living with both responsible parents, and there is no absent parent;

o Children living in the household who are not applying for or receiving Medicaid; and

o Unborn children.

4. Unemancipated children, including minor parents

a. Request a minor parent complete Duty of Support procedures against the absent parent of her child. Do not sanction an unemancipated minor parent who refuses to complete the Duty of Support procedures.

b. If a minor is not living with both parents, request that the minor complete Duty of Support procedures against the absent parent. Do not sanction an unemancipated minor parent who refuses to complete the Duty of Support procedures.

o If possible, when a minor is unemancipated, contact the absent parents or stepparents of the minor parent to determine whether or not they are providing support. You may use Form 544, Statement of Non-Support, for this purpose. Alternatively, you may contact the parents by telephone. If it is not possible to contact the parents or stepparents, document why the contact could not be made.

5. Children over age 18 who do not live with their parents

a. A child who is 18 or older and is not living with parents is not required to complete Duty of Support against the parents.

b. If a child is age 18 or older and is a parent, the child must cooperate with Duty of Support against the absent parent of her or his child.

6 . An individual receiving the Medicaid Cancer Program ( 390 ).

C. Pregnant Women and Medical Support Enforcement (MSE)

Do not require a pregnant woman to cooperate with MSE until the month after her 12 month postpartum period ends.

1. Provide the pregnant woman with information regarding the benefits of establishing paternity and obtaining support from the absent parents.

2. At the end of the 12 month postpartum period, determine her eligibility for other medical programs ( 827 ).

3. If eligible for a Medicaid Program she must comply with MSE requirements.

a. Send the form 619M to her and give her 60 days to comply with MSE.

b. If she does not comply with the requirements and does not wish to claim good cause ( 227-3 & 227-4 ), apply the sanction for failure to comply ( 227-6 ).

c. If she was sanctioned prior to her most recent pregnancy for non-cooperation with MSE requirements, she does not get an additional 60 days to comply. Send the form 619 M and apply the sanction.

d. She must comply for all children who are receiving Medicaid, if they have a parent absent from the household.

D. Initial Cooperation

An applicant must indicate on the application whether she intends to cooperate with medical support enforcement. If the applicant indicates an intent to cooperate, she has met the initial requirements.

If an applicant indicates that she will not cooperate, refer to E. on steps to take.

E. What the Eligibility Worker Must Do

1. New Cases -

a. If an applicant states an intent to cooperate:

i. Send the member the form 619M, which explains the MSE requirements. It also explains the option to claim good cause ( 227-3 ).

ii. When all the factors of eligibility are met, complete an eligibility decision.

iii. Allow the individual 60 days from the date of approval to comply with MSE requirements.

b. Once the applicant is determined eligible, she is a recipient and must complete the support enforcement requirements. Follow the procedure: Medical Support Enforcement – ORS Referrals , to determine the steps that a recipient must take to be considered cooperating.

c. If an applicant states she does not intend to cooperate, mail the form 619M giving her 10 days to claim good cause. If she does not cooperate or claim good cause by the due date, she is not eligible for medical assistance. Deny her Medicaid program and give her proper notice.

2. Reopening Cases -

a. When reopening a Medicaid case within 60 days of the closure for someone who has already cooperated, use form AREN, Notification to ORS/CSS of DHHS or DWS Case Reinstatement , to notify ORS/CSS that the case will be reinstated. It is not necessary to have the applicant complete a new ORS/CSS application.

b. When reopening a case that has been closed for more than 60 days, the individual is an applicant. Refer to E.1. for applicants.

Medicaid Policy

Previous Policy

Refusal to Cooperate - Applicant

If an applicant refuses to cooperate, mail the form 619M. Allow 10 days to claim good cause. If she does not cooperate or claim good cause by the due date, she is not eligible for medical assistance. Give proper notice.

Refusal to Cooperate - Recipient

After a recipient has agreed to cooperate, she needs to complete the initial ORS/CSS application process.

Refusal to cooperate is when a recipient:

States that she will complete the initial ORS/CSS application process, but fails to do so, and does not want to claim good cause for not cooperating.

Claims good cause for not completing the initial ORS/CSS application process, and then refuses to cooperate when the initial good cause claim is denied.

Completes the initial ORS/CSS application process and then refuses to provide additional information requested by ORS/CSS and does not want to claim good cause or still refuses to provide the information if the good cause claim is denied.

If the recipient does not cooperate, the ORS/CSS worker will notify the eligibility worker.

If the parent/caretaker relative claims good cause for not cooperating, no sanction can be applied until the good cause procedures are completed. ORS/CSS will stop all action on the Medical Support Enforcement case until the good cause process is complete ( 227-3 and 227-4 ).

If a parent/caretaker relative refuses to cooperate with Medical Support Enforcement as described in No.1, a., b. or c. above and does not claim good cause or the good cause claim is denied, the parent or caretaker relative is ineligible for any Medicaid program.

Provide ORS/CSS with any information you may have regarding the absent parent(s) of the children.

ORS/CSS will still pursue Medical Support Enforcement for the children on child Medicaid cases even if the parent/caretaker relative refuses to cooperate and has been sanctioned.

Inform the recipient the Medical Support Enforcement will proceed as long as the children continue to receive Medicaid.

If the child is eligible for blind or disabled Medicaid, sanction the non-cooperating parent and caretaker relative and continue coverage for the child under the blind or disabled Medicaid program. Inform ORS/CSS that the non-cooperating adult has been sanctioned and they should not pursue support enforcement for the child.

If the parent or caretaker relative could be eligible under the parent/caretaker relative group, aged, blind or disabled Medicaid or Medicare Cost-Sharing programs, the parent or caretaker relative may choose to have the child's Medicaid coverage closed so that he or she may receive coverage. In this case, inform ORS/CSS that the child's Medicaid case has been closed and they should not pursue support enforcement for the child.

Medicaid Policy

Previous Policy

Good Cause Reasons and Acceptable Evidence

The applicant or recipient may claim good cause in order to protect the best interests of the child or the parent/non-parent caretaker relative. The individual who claims good cause must provide supporting evidence of their claim. The following are reasons for not cooperating with Medical Support Enforcement requirements and examples of acceptable evidence:

The child for whom support is sought was conceived as a result of incest or rape.

Evidence includes: Birth certificates, medical, Department of Health and Human Services/DCFS, court, or law enforcement records which verify that the conception of the child was due to incest or rape.

Legal proceedings for the adoption of the child are pending before a court of competent jurisdiction.

Evidence includes: Court documents, any Department of Health and Human Services/DCFS records, letter from a licensed adoption agency or attorney.

A public or licensed private social agency is helping the individual resolve the issue of whether to keep or relinquish the child for adoption and the discussions have not gone on for more than three months.

Evidence includes: Written notice from the public or licensed private social agency assisting the individual to resolve the issue.

Cooperation in establishing paternity or securing support is reasonably expected to result in:

Physical or emotional harm to the child; or

Physical or emotional harm to the parent or specified/caretaker relative that reduces the capacity to care adequately for the child.

The source of physical or emotional harm may be from individuals other than the absent parent.

Evidence includes: Medical records or written statements from a mental health professional indicating emotional health history, current emotional health, or diagnosis or prognosis concerning the emotional health of the child or caretaker relative. Other records such as court, medical, police, child protective services, DCFS, or ORS/CSS records, which indicate that the absent parent might inflict physical or emotional harm on the child or caretaker relative, or has done so in the past.

Emotional harm is defined as an emotional impairment that substantially affects the individual's functioning.

When the claim is based in whole or in part on anticipated emotional harm, consider the present emotional health and history, the intensity and probable duration of the emotional impairment, the degree of cooperation required, and the extent of involvement of the child in the paternity or support activity to be taken. Document these considerations.

Determining Good Cause for Not Cooperating

The agency will send the individual the form 124GC requesting documentation to prove good cause.

The supervisor will then make the good cause determination based on:

Information contained in any Department of Workforce Services, Department of Health and Human Services records.

Evidence supplied by the applicant or recipient, or

Investigation of the information provided, or

A combination of both evidence and investigation.

Acceptable evidence -

The applicant/recipient must provide supporting evidence within TWENTY DAYS from the day the claim was made. An extension may be granted by the supervisor. Document the extension.

Acceptable evidence to support the good cause claim is listed above. If the applicant or recipient cannot provide supporting evidence, accept sworn statements from persons with knowledge of the circumstances which verify the good cause claim. Such statements need not establish whether abuse has occurred or been threatened, but must support the claimant's credibility. The supervisor will determine if the individual has established good cause for not cooperating.

Investigation of Evidence -

If evidence is not available or if evidence other than what is listed above is presented,the supervisor will investigate the circumstances of the good cause claim. When an investigation is made, any reasonable evidence easily accessible to the agency (i.e. Department of Health and Human Services/DCFS records) may be used as the basis for a determination.

Do not release information from DCFS records to individuals outside of the Department of Workforce Services, the Department of Health and Human Services.

DO NOT give information to the absent parent that could jeopardize the child or the specified/caretaker relative.

Contact with the absent parent might be necessary to establish good cause. Before such a contact is made, the individual must be notified of the contact and respond by:

permitting the contact

presenting additional evidence so that the contact becomes unnecessary, or

c agreeing to a denial of the good cause claim, or

withdrawing the application or closing the case.

Enforcement Without Cooperation

The supervisor may determine that there is good cause for not cooperating but that ORS/CSS could proceed with Medical Support Enforcement WITHOUT THE COOPERATION OF THE RECIPIENT and it would not result in harm to the child or to the caretaker relative. Record the basis for the decision in the case file.

Before ORS/CSS may proceed with Medical Support Enforcement, a notice must be sent informing the applicant/recipient that ORS/CSS will proceed with Medical Support Enforcement activities without his or her cooperation. Once the notice has been sent, the recipient has 10 days to:

Agree that Medical Support Enforcement activities can continue without the participation of the recipient.

Present additional evidence that supports the claim that Medical Support Enforcement activities without their cooperation would pose a risk to the child or caretaker relative, OR

Withdraw the application, or request that the medical assistance case be closed.

If the recipient fails to respond within 10 days, close the case for failure to provide information. If the 10th day is a n on-business Day , the individual has until the business day following the 10th day to respond.

If the recipient requests the medical assistance case closed, close the case accordingly.

Medicaid Policy

Previous Policy

Procedure Non-Cooperation with ORS - Medical Enforcement

Procedure Determining and Completing Good Cause For Not Cooperating With ORS

Whenever applicants or recipients decide that they do not want to cooperate with Medical Support Enforcement requirements, they must be given the opportunity to claim good cause before applying a sanction.

The previously mentioned procedures will instruct the eligibility worker on how to proceed in this situation.

Medicaid Policy

No Previous Policy

The circumstances that lead to the approval of good cause for not cooperating could change between the time the initial claim was approved and the next review. If you have reason to believe that the circumstances have changed, review the good cause claim at the next eligibility review. Document the reasons you expect changes in these circumstances before reviewing the good cause claim.

If the changes show that good cause no longer exists, the recipient must comply with Medical Support Enforcement requirements.

Recipients may request a good cause determination at any time during the certification period or at review.

Medicaid Policy

Previous Policy

Imposing a Sanction

If an applicant or recipient who must cooperate refuses to cooperate with Medical Support Enforcement requirements and does not claim good cause, he or she is not eligible for Medicaid coverage. Make the Absent Parent evidence reflect this for the non-cooperating person. Determine eligibility and authorize coverage for the other household members.

There are two times when you might sanction a individual:

When an applicant states that he or she will not cooperate and does not want to claim good cause.

If the applicant does not want to claim good cause, apply the sanction.

If the applicant claims good cause, a sanction cannot be applied until a determination is made regarding the good cause claim. ( 227-4 )

If the initial claim of good cause is denied, and the individual still refuses to complete the ORS/CSS application, apply the sanction.

This does not require notification from ORS.

When ORS notifies you that a recipient who completed stated an intent to cooperate and either completed the ORS/CSS application, completed the forms, or who has been cooperating, but is now refusing to cooperate.

Give the recipient the opportunity to claim good cause before applying the sanction. ( 227-4 )

If the recipient claims good cause, the sanction cannot be applied until a determination is made regarding the good cause claim.

If the recipient does not want to claim good cause and does not want to cooperate after being notified about the non-cooperation issue or if the good cause claim is denied, apply the sanction

Additional Information

Do not sanction the dependent child(ren) in the household when a parent refuses to cooperate. Do not sanction a dependent child who is not a minor parent and who does not live with an adult caretaker relative if he or she refuses to cooperate. If a dependent child is emancipated and is a minor parent, sanction the child if he or she refuses to cooperate with Medical Support Enforcement requirements for his/her own child.

When a sanctioned individual makes the decision to cooperate sometime after the first of the month, the Medicaid coverage will become effective the first day of the same month.

Medicaid Policy

Previous Policy

Medicaid applicants and recipients must cooperate with the Office of Recovery Services/Child Support Services (ORS/CSS) to establish paternity and obtain medical support from any responsible absent parent of a child for whom they are applying or who is receiving Medicaid.

Adult applicants must indicate on the application whether they intend to cooperate with establishing paternity and obtaining medical support.

Adult recipients may be sanctioned from receiving Medicaid if they fail to cooperate with Medical Support Enforcement procedures. A recipient who is sanctioned from Medicaid for non-cooperation is not eligible for any other type of Medicaid including institutional, Waiver Medicaid orMedicare Cost-Sharing programs.

For Medicaid, parents are not required to assign their rights to child support payments. Households that receive Medicaid, but do not receive FEP cash assistance, do not have to turn child support payments over to ORS/CSS and any child support collected by ORS/CSS will be forwarded to the parent. Child support payments are not counted as income for MAGI-based eligibility groups. Child support payments are counted as unearned income in determining eligibility for non-MAGI-based Medicaid programs, which includes medically needy programs. (See Sec. 415-5 )

Natural or adoptive parents who do not live in the same household as their children are still responsible for the support of their children until each child reaches age eighteen or is emancipated by marriage or court order. A referral to ORS/CSS must be done on an absent natural or adoptive parent of children who are applying for or receiving Medicaid. However, the natural parent of a child who has been adopted is no longer responsible for the child once the parental rights have been relinquished.

Step-parents who no longer live in the same household as their step-children or who are no longer married to the biological or adoptive parent of their step-children are not responsible for the support of their step-children. Do not do a referral to ORS/CSS on absent step-parents.

Medicaid Policy

Previous Policy

Who is a Parent

Parents are either legal parents or step-parents.

A legal parent includes:

A biological parent. This includes a birth mother or a father whose paternity of a child has been established according to state law.

An individual who has relinquished their parental rights is no longer the legal parent of the child.

A man is presumed to be the father of a child in the following situations, even if the marriage is later declared invalid:

He is married to the birth mother at the time of birth.

His ex-wife gives birth to the child within 300 days from the termination of their marriage.

Individuals adjudicated by a court to be a child's parent.

An individual who has legally adopted a child (adoption has been finalized).

An individual confirmed to be the intended parent by the court under a gestational agreement.

An individual who affirms to be the intended parent under an assisted reproduction agreement.

Such an agreement is a written consent to assisted reproduction by a married women that is signed by the women and her husband.

A step-parent is the spouse of a legal parent whose parental relationship to the child is only through the marriage.

How to Establish Parental Relationship

Accept the client's statement for parental relationship to the child unless the agency has conflicting information.

If there is a reason to doubt the client's statement, request the individual provide on of the documents found in Table VIII .

Medicaid Policy

Contact DHHS Policy Specialist for Previous Policy

In Utah, common-law marriage is legal and valid only when it has been established by Court or Administrative Order.

Living arrangements by themselves are not enough to establish a common-law marriage.

Even the fact that a child is born of the couple does not prove common-law marriage.

Medicaid Policy

Previous Policy

Relationship of Medicaid Household Members

An applicant must declare the relationships between household members. The relationship of household members is a factor used in eligibility decisions.

Relationships applicable to medical assistance eligibility include:

Parent to child.

Spouse to spouse (legally married and not divorced).

Sibling to sibling, including biological, adopted and step-siblings.

Caretaker relative to a dependent related child.

For programs using the MAGI-based methodology, an unrelated individual in the household may factor into the eligibility determination ( 401-2 ).

Establishing Relationships of Household Members

Accept the client's statement about the relationships of the household members. They may be living with the individual or temporarily absent. If the agency has conflicting information, request other verifications.

See Table VIII for documents that can verify relationship. In some cases, a combination of documents may be needed.

Medicaid Policy

Contact DHHS Policy Specialist for Previous Policy

This section of the policy manual describes the action required of eligibility staff to assure Medicaid compliance with H.I.P.A.A.

Effective April 14, 2003, all Medicaid recipients must be informed in writing of the privacy practices of the Utah Department of Health and Human Services, Division of Integrated Healthcare (DIH).

Eligibility staff are required to furnish all Medicaid applicants a copy of the NOTICE OF PRIVACY PRACTICES .

If Medicaid recipients have additional questions or concerns regarding their privacy rights, eligibility staff should refer them to the DIH's Privacy Officer at (801) 538-9925.

Medicaid Policy

Effective Date: May 1, 2018

Previous Policy

A. Electronic Verification

Do not delay an eligibility decision, decrease, terminate, or deny benefits on the basis of a person's non-citizen status if the electronic verification procedures have not yet been completed.

B. Verifying Immigration Status

Follow the SAVE Verification for non-citizen Status procedure when verifying immigration status. Document in the case file all results received.

At "Initial' request, verify the individual's status using the "A" number listed on the immigration document.

If the information from the electronic inquiry matches the document, no further action is needed.

If the information from the electronic inquiry does not match or information does not exist, complete a secondary verification. Do not close or deny a case based upon the information received through an initial electronic verification inquiry.

When you cannot access the electronic database, the information about the non-citizen is not recorded in the computer file, or the information received back from the secondary verification tells you to complete another verification, complete the manual verification outlined in the procedure.

Medicaid Policy

Previous Policy

The policies in section 300 explain the different Medicaid programs and the criteria a individual must meet to receive Medicaid. There are both non-financial and financial criteria.

The Medicaid programs have two main classifications:

· Programs using the Modified Adjusted Gross Income (MAGI) methodology; and

· Programs that do not use the MAGI methodology (non-MAGI).

When a member becomes ineligible for any medical program, always review the member for eligibility under other medical programs ( 827 ).

A. Categories of Coverage

Individuals must meet the criteria under one of the following categories of coverage to receive assistance under Medicaid. The categories of coverage are as follows:

· Aged (persons 65 and older)

· Blind or Disabled

· A parent or caretaker relative caring for a dependent child

· A child under age 19

· A pregnant woman

· Foster care children and children who aged out of foster care

· An individual with breast or cervical cancer

· A person with tuberculosis

· A refugee

· Medicare eligible individuals

· Adults age 19 through 64

B. MAGI Based Programs

1. Child ( 347 )

2. Non-IV-E Foster Care ( 354 )

3. Parent/Caretaker Relative ( 345 )

4. Adult Expansion ( 348 )

5. Pregnant Women (349 )

6. Targeted Adult ( 346 )

7. Tuberculosis Positive ( 392 )

8. UPP (Utah Premium Partnership) ( 1000 )

C. Non-MAGI Based Programs

1. Aged ( 303 , 329 )

2. Blind and Disabled ( 303 , 329 , 330 )

3. Breast and Cervical Cancer ( 390 )

4. Home and Community Based Waivers ( 380 )

5. Medicaid Work Incentive ( 314 )

6. Medically Needy ( 345 , 347 , 349 )

7. Medicare Cost-Sharing ( 320 )

8. New Choices Waiver ( 386 )

9. IV-E Foster Care ( 354 )

10. Nursing Home ( 370 )

11. Presumptive Eligibility ( 356 )

12. Refugee ( 394 )

13. Subsidized Adoption ( 355 )

14. 4-Month Extended and 12-Month Transitional ( 343 )

Medicaid Policy

Previous Policy

Who Meets Disability

Individuals meet the definition of blindness or disability when they have:

Been approved for or receive SSI because of blindness or disability.

Been approved for or receive Social Security Disability insurance (SSDI).

Individuals age 62-65 may receive Early Retirement while applying for disability benefits. If the person has applied for disability benefits, the SSA match record may show an estimated date of disability onset. This does not mean the individual has been determined disabled. Request verification that disability has been approved before authorizing Disability Medicaid for these individuals.

1619(a) or 1619(b) status. See Section 330-2

Been approved for or receives survivor’s benefits such as Childhood Disability Benefits (for adults) ( 330-1 ), or Disabled Widow/Widower Benefits ( 330-4 ).

Been determined blind or disabled by the State Medicaid Disability Office. Receipt of unemployment benefits does not preclude someone from being determined disabled.

Died. People are disabled for this reason only in the month of death.

SSI in suspense status due to assets in ABLE account.

Individuals continue to meet the definition of blindness or disability when:

SSDI benefits have stopped because the disabled individual is working above the Substantial Gainful Activity level. SSA refers to these individuals as the Working Disabled. If the individual was eligible for Medicare, he may continue to be eligible for Medicare.

The individual was determined disabled before or after entering an IMD or a public institution, has not left the IMD or public institution for 30 continuous days or more, and has not received a disability denial from Social Security after such approval date. (See Sec. 303-10 to decide when to request a new disability determination.)

A individual reapplies or completes the eligibility review process within 12 months of when the SMDO redetermination should have occurred. Open Medicaid during the SMDO process if the individual is otherwise eligible. Allow the individual a minimum of 30 days to submit SMDO related documents. See section 303-3 .

If Medicaid has been closed for more than 12 months from the month in which the SMDO review should have occurred, a new disability decision is required before the Medicaid may be opened.

SSI or SSDI Benefits Stop

Individuals continue to meet the definition of blindness or disability without requiring a new disability determination for 12 months after SSI or SSDI benefits stop for a reason other than no longer being blind or disabled. Complete an SMDO disability review at the end of the 12 months if SSI or SSDI benefits have not restarted. See Section 303 .

Some examples of when SSI or SSDI benefits may stop are:

The individual had too much income.

The individual made false or misleading statements to SSA.

The individual’s SSI payment stopped only due to a transfer of assets for less than fair market value.

The individual entered a nursing home.

The individual entered a public institution.

The individual is a qualified non-citizen, has exhausted the time-limited SSI benefit period and does not meet at least one of the additional SSI eligibility criteria for non-citizens required by various public laws.

The individual’s whereabouts are unknown to SSA.

The individual’s SSI status is "eligible but not paid".

Medicaid Policy

Previous Policy

Individuals who claim to be blind or disabled must complete the Medicaid Disability Application (Form 354). Request medical records and/or doctors’ reports and make a referral to the State Medicaid Disability Office (SMDO), also known as the Medical Review Board (MRB) after receiving the Form 354. Provide assistance if the individual needs help to complete the form.

A. New Disability Determinations

Ask for a new disability determination when individuals say they are blind or disabled in the following situations:

1. The individual has not applied for SSI or SSDI.

2. SSA denied SSI or SSDI for a reason other than blindness or disability, such as too much income, non-citizen status, transfer of assets, or insufficient work history.

3. SSA denied SSI or SSDI because the individual has earned income above the Substantial Gainful Activity level (SGA), and SSA did not review medical evidence.

4. The individual has applied for SSI or SSDI only once in the previous 12 calendar months and SSA has not made a decision.

5. SSA denied SSI or SSDI less than 12 months ago because there was no disability and the individual has a new disabling medical condition that SSA did not consider.

6. SSA denied SSI or SSDI more than 12 months ago because there was no disability and the individual did not appeal.

7. The individual appealed an SSA denial for SSI or SSDI, it has been more than 12 months since the date of the latest SSA appeal decision upholding the denial, and the individual has either exhausted the SSA appeal process or has not filed any further appeals with SSA.

8. The individual has a pending appeal with SSA on a denial for SSI or SSDI, and the individual has a new disabling medical condition that SSA did not consider (only applicable to applicants).

9. The SSI date of disability onset is after the baby left the hospital. See 303-4 if the SSI date of disability is during the baby’s hospital stay.

10. The individual alleges the disability began before the date established by Social Security.

11. The individual is 65 years or more and he requests coverage under the Medicaid Work Incentive program. When a individual 65 years or older requests MWI, the SMDO must determine disability. For someone who was disabled before age 65 and eligible for MWI, complete a disability review within 12 months of when the person turns 65 if he is still working and needs MWI coverage ( 314 ).

12. The individual's Medicaid has been closed more than 12 months from the month in which the SMDO review should have occurred.

13. The individual is eligible on a different coverage group and requests a disability coverage group to access disability related services.

Note : Refer to 303-10 to determine whether a disability decision from the SMDO must be requested for a individual leaving a public institution.

B. Periodic Disability Determinations

The State Medicaid Disability Office (SMDO) conducts periodic disability determinations for ongoing cases when the member does not have a disability decision from Social Security.

1. The SMDO disability approval includes a date for redetermination. Begin gathering medical records for the redetermination no earlier than the 1 st day of the month the redetermination is due.

2. Do not close the case while the SMDO re-determines disability unless the member is not eligible because of other eligibility factors. Give members a minimum of 30 days to submit SMDO related verification.

3. Consider the member disabled and begin the SMDO review process if a member reapplies or completes the eligibility review process within 12 months of when the SMDO redetermination should have occurred. Open Medicaid during the SMDO process if the member is otherwise eligible.

4. Only the Social Security Administration or the State Medicaid Disability Office can decide a person is no longer disabled.

5. Do not make a referral to the SMDO for a re-determination if:

a. SSA has denied disability and the member is in the SSA appeal process. This applies even if he is receiving continued benefits during the SSA appeal. If the individual is an applicant, refer to A(8)

b. The individual reapplies or completes the eligibility review process before the SMDO redetermination due date. Consider the individual disabled and begin the SMDO redetermination process in the month the redetermination is due.

c. SSA approves disability before the scheduled SMDO re-determination. The member is disabled, and no further SMDO re-determinations are needed while the member is receiving SSI or SSDI.

Note : Refer to 303-10 to determine whether a disability redetermination must be requested for a member leaving a public institution.

C. Incarceration

1. A member with a SMDO disability approval continues to meet disability status while incarcerated and upon release.

· The SMDO may have approved disability before or during the incarceration.

2. Do not attempt to gather documentation for a SMDO redetermination while the member is incarcerated.

3. If the DMD has gathered documentation for the SMDO redetermination before the individual becomes incarcerated, the DMD will forward the documentation to the SMDO, even if incomplete. The DMD must notify the SMDO the member is incarcerated.

· The SMDO will not complete a redetermination unless the existing records clearly show the individual continues to meet or no longer meets disability criteria.

4. Upon the individual’s release, check the due date for the SMDO redetermination. Unless Social Security has made a disability decision since the individual was incarcerated, proceed as follows:.

· If the due date has passed, begin the process of gathering information for the redetermination. Continue Disability Medicaid (if otherwise eligible) during the redetermination.

· If the due date is in the future, set a task to begin the redetermination at the appropriate time.

· If SSA denied disability status, follow policy in Section A above to decide if the SMDO can make a new determination.

5. Develop medical documentation and refer incarcerated applicants for a SMDO determination when the applicant indicates having a disability.

· If the SMDO cannot determine the disability with the medical records provided, or if the SMDO denies disability, determine eligibility for other Medicaid programs.

D. Fair Hearings

If the SMDO decides the indivudal is not disabled, the individual may request a fair hearing from the DHHS Office of Administrative Hearings ( 125-1 ).

1. The individual can ask for a disability reconsideration as part of the hearing request. This may include providing medical records not previously reviewed by the SMDO.

2. If the SMDO has already reconsidered a case, the next level of appeal is the fair hearing. The SMDO cannot conduct a second reconsideration.

Medicaid Policy

Contac t DHHS P olicy Specialist for Previous Policy

The effective date of disability will be one of the following dates.

The date that SSA reports as the disability onset date for SSI or SSDI eligibility based on an approved disability decision for SSI, SS DI, Disabled Widow/Widower, or Disabled Adult Child beneficiary benefits.

The date the State Medicaid Disability Office reports as the disability start date on the Form 121.

Consider the individual disabled for the whole month when the disability onset date is anytime during that month.

Consider a baby to be disabled from birth if the baby is born in a hospital, AND

SSA or State Medicaid Disability Office disability onset date is during the hospital stay; OR

The baby dies in the hospital without ever being away from the hospital for longer than 23 hours at any one time. In this circumstance, you do not have to ask for a disability decision from the MRB, even if the month of death is different than the month the infant was born.

Medicaid Policy

Effective Date: February 1, 2017

Previous Policy

When Social Security denies an individual's application for SSI or SSDI, take the following actions:

If the SSI or SSDI denial or closure reason is that the person is not blind or disabled and the individual does not claim a new condition, use the SSA decision for 12 months from the date of the decision.

Close or deny Blind or Disabled Medicaid.

Consider eligibility for other medical assistance programs.

See section 303-7 if the individual appeals the SSA decision.

If the individual was denied SSI or SSDI for not being disabled within the past 12 months and claims a new disabling medical condition, ask for a new State Medicaid Disability Office determination.

NOTE : When SSA denies disability after the MRB has approved disability, but before the worker has authorized benefits, the case must be denied based on the SSA decision.

If the denial or closure is for something other than disability see sections 303-2 and 303-3 .

Medicaid Policy

Previous Policy

This section is applicable to Blind or Disabled Medicaid recipients who appeal an SSA decision that the recipient is not blind or disabled.

Reopen Blind or Disabled Medicaid back to the date of the Medicaid closure when:

The individual appeals the SSI or SSDI denial or closure; and

You receive proof of the appeal no later than 10 days after the appeal was filed.

Keep Blind or Disabled Medicaid open until one of the following occurs:

The member fails to file an appeal to the next step in the SSA review process.

The SSA administrative review process is exhausted.

The member requests the case be closed.

Something else changes that makes the member ineligible.

Do not request a disability review from the State Medicaid Disability Office while the SSA appeal is pending unless the member has a new disabling condition that SSA did not consider.

Close the Blind or Disabled Medicaid if the final SSA decision is still a denial. See section 825 .

The member may appeal in federal court. The member cannot continue to get Medicaid during an appeal in federal court unless the most recent SSA denial occurred over 12 months ago .

Continue Medicaid if SSA approves the blindness or disability as a result of the appeal. No overpayment has occurred.

Medicaid Policy

Previous Policy

1. Open BM or DM when:

a. BM or DM was denied because SSA or the State Medicaid Disability Office denied blindness or disability, and

b. The member appealed the decision, and

c. The blindness or disability was approved.

2. Eligibility may begin as early as three months before the date of the application that was denied but no earlier than the date of the disability onset.

3. A person who is not receiving medical assistance would have to contact the Medicaid office to request eligibility back to the original application date when the appeal is through SSA.

4. Recalculate any spenddown using DM rules. If the member owes less spenddown under DM the member may ask for a refund. To get a refund, other family members would have to qualify for Medicaid without a spenddown.

5. Contact Medicaid Claims if you open DM for a member who was on Refugee Medicaid so the medical bills are paid from the right funding source.

Medicaid Policy

Previous Policy

Members who are going through the disability determination process may be eligible on a different medical program while awaiting a disability determination. If Social Security or the State Medicaid Disability Office later decides the person is disabled, the member may be eligible for Disabled Medicaid for all or some of the past months.

The available benefits may be different under Disabled Medicaid than it was under the Adult Expansion program. If the member will have a spenddown on Disabled Medicaid, the member has the choice of whether to pay the spenddown for the past months. If the member does not want to pay the spenddown, do not change their eligibility from the previous medical program for those months.

1. Adults who have received coverage under the Adult Expansion program may be eligible for Disabled Medicaid coverage back to the date the disability began.

2. Eligibility may begin as early as three months before the month the application was received, but no earlier than the date of the disability onset. See 705 to determine the retroactive period.

3. An individual who meets the criteria for Disabled Medicaid without being on SSI and the Adult Expansion program can choose to remain on the Adult Expansion program.

4. If the Social Security Administration determines the individual eligible for SSI, they cannot choose to stay on Adult Expansion program.

5. If individuals qualify for Adult Expansion and a Medically Needy program, or a Disabled Medicaid program based on criteria other than SSI or SSI Protected Group status, they can choose which of the two programs is most beneficial for them. See 348 .

Medicaid Policy

Previous Policy

Link to e-Forms . Search for State Hospital Cover Sheet.

Individuals Leaving a Public Institution

A person who has been determined disabled remains disabled until there is a finding that the person is not disabled.

Leaving for a community setting . When a person leaving the State Hospital or a public institution applies for Medicaid, consider the person disabled without doing a disability review if:

The individual had been determined disabled before the individual entered the institution, or while the individual was there, and

There has not been a period of over 30 days when the individual was not a resident in an institution.

Approve the individual for disability Medicaid if a. and b. are true and all other factors of eligibility are met without requesting a new disability determination. See B. for policy on when to request a new disability determination.

Leaving for an inpatient hospital stay . An individual determined disabled before entering a public institution such as a jail or prison is still considered disabled when they leave the public institution and are admitted to a medical hospital for an inpatient stay.

Do not request a new disability review during an inpatient hospital stay when the individual will return to the public institution once the medical need ends.

The individual may be eligible for Medicaid only during the inpatient stay unless they are within 90 days of release from the public institution ( see 600 ).

If a individual was not determined disabled before entering the public institution or was denied disability before or after entering the public institution, request a disability decision if he claims a disability.

Disability Redeterminations

When a disabled individual meeting criteria in A.1. above moves from an institution into the community, and is approved for Medicaid, request a disability re-determination at the following times:

When the Medical Review date on the Form 121 from the most recent SMDO disability determination has already past; or

When the Medical Review date on the Form 121 from the most recent SMDO disability determination is within 30 days of the date the individual applies; or

SSA/SSI payments ended for a reason other than ‘not disabled’ over 12 months ago.

Do not close the case while the SMDO re-determines disability unless the individual is not qualified because of other eligibility factors.

Do not ask for a new disability determination or re-determination when:

The individual is still receiving SSDI benefits (individuals in the State Hospital continue to receive SSDI), or

The individual begins receiving SSI or SSDI benefits before you have made an eligibility decision.

If you have sent a referral to the SMDO, and SSI or SSDI benefits resume before the SMDO makes a redetermination decision, contact the SMDO and tell them disability benefits have resumed so they stop processing the decision.

Medicaid Policy

Introduction

Medicaid is available to individuals who are aged, blind or disabled.

· Aged Medicaid is available for people who are 65 or older.

· Blind Medicaid is for people who meet the Social Security criteria for being blind. They may not necessarily have other disabilities.

· Disabled Medicaid is for people who meet the Social Security disability criteria.

The Social Security Administration (SSA) defines the criteria used to decide someone is blind or disabled. People approved as blind or disabled by SSA do not need a disability decision from the State Medicaid Disability Office (SMDO). If an applicant does not have a decision from SSA, the SMDO can review medical evidence to decide if the person is disabled.

A. Basic Eligibility Criteria

1. Individuals who are 65 or older may qualify for Aged Medicaid. Eligibility for Aged Medicaid can begin the month the individual turns 65.

2. Individuals who have a birth date on the first of the month, are eligible for Medicare beginning the first of the previous month but are not eligible for Aged Medicaid in that month.

3. People determined blind or disabled by either the SSA or the SMDO may receive Blind or Disabled Medicaid. Eligibility may begin in the first month for which the blindness or disability is effective, but no earlier than the 3rd month before the month of application.

4. Aged, blind or disabled individuals may qualify for other Medicaid programs, as well.

5. Individuals under 65 who claim to be blind or disabled, but have not been determined disabled by SSA, may receive a decision from the SMDO.

People must meet an asset test ( 503 ) as well as an income test ( 443-1 ), in addition to the non-financial criteria all Medicaid applicants and recipients must meet. Income criteria may include deeming income from an ineligible spouse ( 410-2 ), or for a child, deeming income from an ineligible parent. ( 410-3 )

B. Requesting a SMDO Decision

The following sections provide the requirements for requesting a decision from the SMDO about a person's blindness or disability.

303-2 Proof of blindness or disability

303-3 When to establish blindness or disability from the State Medicaid Disability Office

303-4 Effective date of disability

303-6 When SSI or SSDI Benefits End

303-7 Appeals of the SSA decision

303-8 Blind or Disabled Medicaid eligibility for past months

303-10 Persons being released from the State Hospital or a public institution

Medicaid Policy

Previous Policy

A. General Eligibility

The MWI program is for people of any age who are disabled and who have earned income.

1. People who are eligible for MWI:

· Can have countable assets of up to $15,000, and,

· Income up to 250% FPL for their household size. ( 462-1 )

· Eligible individuals must pay a premium to receive coverage when their countable income is more than 100% of the FPL. ( 462-1 )

2. Individuals who receive SSI or meet SSI Protected Group criteria, and pass the asset test, do not qualify for the MWI program.

3. A working disabled individual who meets the income and asset criteria for the 100% FPL program does not qualify for MWI. When the individual is married, use the rules for a married couple to decide if income is under 100% FPL.

4. If both members of a married couple are aged or disabled, but only one is working and disabled, decide if they both want Medicaid coverage.

a. If both want coverage, decide if they qualify for the 100% FPL group.

b. If they do not qualify for the 100% FPL group, determine eligibility for the medically needy spenddown group as a couple.

i. If eligible, they will need to meet the spenddown amount to receive coverage for both of them.

ii. If they choose not to meet the spenddown to qualify both of them, the working disabled spouse may qualify for the MWI program.

iii. If the couple fails the asset test for medically needy coverage, determine if the working disabled spouse qualifies for MWI.

5. If both members of a married couple are disabled and both are working, they can be on MWI as a couple.

B. Disability

The individual must meet the requirements for disability in section 303-2 .

1. If the person is age 65 or older, have the State Medicaid Disability Office (SMDO) complete continuing disability reviews because Social Security stops doing disability reviews once a person turns age 65.

2. For someone turning age 65 and receiving MWI, complete a disability review within 12 months after they reach age 65. [NOTE: Do not refer a individual to the SMDO if the SMDO previously decided someone was disabled and decided no further redeterminations are needed.]

C. Earned Income

The individual must have earned income, or be self-employed and working with the expectation of future earnings. Individuals do not have to earn a certain amount of income or work a minimum number of hours each month.

1. Verify the income is earned. Verification may include check stubs with FICA deductions or a statement from an employer

2. A self-employed individual may provide self-employment quarterly or annual tax returns, self-employment income and expense ledgers or contracts for work, or a written business plan.

a. The individual may not realize a net profit immediately; however, the individual may still qualify for MWI if actively engaged in self-employment.

b. Request income and expenses records as needed to determine a best estimate.

3. A business license may show a individual intends to do self-employment, but they may need to provide other documents indicating hours worked and expected earnings.

4. If an individual has started a new job, MWI eligibility can begin the month they start working. They do not have receive any earnings in that month.

5. Someone working on commission or doing contract work may not receive any earnings for some time. If they confirm they're working, MWI eligibility can begin the month they start working.

6. Income received from a college work-study qualifies as earned income.

D. Asset Exemptions and Special Circumstances

1. The asset limit for the MWI program is $15,000. ( 503 )

2. Special Asset Lifetime exemptions:

· Vehicles 521-4

· Retirement/Pension plans 521-13

Medicaid Policy

Previous Policy

A. Recipients of Medicare Part A and Part B

1. To be eligible for a Medicare Cost-Sharing, an individual must be entitled to Part A Medicare.

2. For SLMB and QI the individual must be receiving Part A Medicare, including paying the Part A premium if one is required. To be eligible for QDWI, the individual must be eligible to receive Medicare Part A by paying a premium. See 320-5 for QDWI policy.

3. See 223-1 for information on who can receive Part A Medicare.

B. Recipients of Medicare Part B-ID

1. To be eligible for the Medicare Part B-ID Cost-Sharing Program, an individual must be entitled to Medicare Part B-ID only.

2. The individual cannot have any other health insurance which will cover immunosuppressant drugs as it will disqualify an individual. Other health insurance includes but are not limited to:

· Medicare Part A and/or Part B

· Medicaid

· Marketplace

· Employer Insurance

C. Non-Financial Requirements

To be eligible for Medicare Cost Sharing and the Medicare Part B-ID cost-sharing programs, individuals must meet the same non-financial rules that apply to Medicaid. These include:

1. Citizenship or resident non-citizen requirements. Remember that Medicare recipients meet the U.S. Citizenship requirements ( 205 ).

2. Utah residency ( 207 ).

3. Duty of Support requirements, if applicable ( 227 ).

4. TPL requirements for the Qualified Medicare Beneficiaries program, but not for SLMB, QI or Part B-ID cost-sharing program ( 225 ).

5. Social Security number ( 221 ).

6. Individuals ineligible for Medicaid because they reside in a public institution, or reside in an IMD and do not meet the residency requirements defined in 215-5 , are not eligible for Medicare Cost Sharing ( 215-5 ).

D. Income Limit

1. Countable income is compared to a percentage of the federal poverty level. Countable income cannot exceed the applicable income limits ( Table VII ).

2. The following percentages of poverty apply to these programs. Spenddown is not allowed.

QMB 100% FPL SLMB 120% FPL QI-1 135% FPL QDWI 200% FPL

3. For the Medicare cost-sharing programs and the Medicare Part B-ID cost-sharing program, follow the rules in section 443 to determine countable income. Use those rules for all Medicare cost-sharing individuals even if they receive SSI. Follow these rules even if the person is not disabled. This may include the following individuals:

a. Individuals diagnosed with end-stage renal failure.

b. Individuals determined disabled by the Railroad Retirement Board, who have received such disability benefits for 24 months, and who have not been determined disabled by Social Security or the MRB.

4. Not everyone under age 65 who receives Medicare meets Social Security's disability criteria. The person must have been determined disabled by either Social Security or the Medicaid Disability Board to receive Disability Medicaid. However, if the individual is eligible for Medicare Part A, the individual may qualify for a Cost-Sharing program.

E. Asset Limit

Determine assets the same as they are for the aged, blind, and disabled Medicaid programs. The resource limits are higher than those for Medicaid ( Table II ).

There is no transfer of asset penalty for the cost-sharing programs.

F. Applications from Social Security

1. Beginning January 1, 2010, Social Security (SSA) will transmit data electronically to states to use as an application for Medicare Cost-Sharing programs. This data is from applications SSA receives for Low-Income Medicare Subsidies. Treat this electronic data like any other application for the Medicare Cost-Sharing programs ( 703-4 ).

2. Process the data received the same as any other application for Medicare Cost-Sharing programs. The applicant must receive the application disclosures and rights and responsibilities information. The electronic transmission of data meets the signature requirements for the application.

3. If the individual wants to apply for Medicaid in addition to the Medicare Cost-Sharing programs, the individual must complete and sign a Medicaid application. If the individual applies for Medicaid, inform the individual of the estate recovery requirements for Medicaid recipients age 55+.

4. Estate recovery does not apply to Medicare Cost-Sharing Programs.

Medicaid Policy

Previous Policy

A. QMB for Medicare Parts A and B

The benefits for QMB pays Medicare premiums for Part A (if applicable), premiums for Part B and deductibles and co-payment amounts for Part A and Part B Medicare-covered services. If an individual meets all the criteria for QMB coverage and they pay a premium to receive Part A Medicare, call the OEP Medicaid Program Specialist. Payment of a Part A Medicare premium is not automatic.

QMB members may be eligible for other Medicaid programs (except AEM or TAM).

The TPL process is required ( 225 ).

The effective date for QMB coverage is the first of the month after the month it is determined the member meets all the eligibility criteria for QMB. The member must also continue to meet all the same criteria in the month coverage begins.

The member must be entitled to Medicare Part A benefits for at least one month before QMB coverage begins.

There is no retroactive coverage. Coverage cannot begin in any month prior to or in the same month the case is processed.

B. QMB for Medicare Part B-ID

The benefits for QMB pays the Medicare premiums for Part B-ID which reduces the deductibles and co-payment amount for immunosuppressant drugs only through Medicare.

If a QMB member is eligible for other Medicaid programs, Marketplace insurance or, employer insurances that cover immunosuppressant drugs are not eligible for the QMB Part B-ID program.

The TPL process is required ( 225 ).

The effective date for QMB coverage is the first of the month after the month it is determined the member meets all the eligibility criteria for QMB. The member must also continue to meet all the same eligibility criteria in the month coverage begins.

There is not retroactive coverage. Coverage cannot begin in any month prior to or in the same month the case is processed.

Medicaid Policy

Previous Policy

A. SLMB for Medicare Part B

The benefit for SLMB pays the Medicare Part B premium only.

Members may receive SLMB and other Medicaid programs (except AEM or TAM) at the same time. Explain to members that SLMB only pays the Part B premium. SLMB does not pay the Medicare Part B deductible or co-payments. If the member becomes eligible for Medicaid by paying a spenddown, Medicaid will pay the Medicare deductibles and co-payments. Medicaid may also cover medical services that Medicare does not cover.

The TPL process is not required ( 225 ).

The effective date for coverage is the first day of the application month or the first day of any of the 3 retroactive months in which the individual meets all the requirements for SLMB. See 705-1 to determine the retroactive period. Always review eligibility for the retroactive months.

B. SLMB for Medicare Part B-ID

The benefit for SLMB pays the Medicare premium for Part B-ID only.

If a SLMB member is eligible for other Medicaid programs , Marketplace insurance, or employer insurances that cover immunosuppressant drugs, they are not eligible for the SLMB Part B-ID program.

The TPL process is required ( 225 ).

The effective date for coverage is the first day of the application month or the first day of any of the 3 retroactive months in which the individual meets all the requirements for SLMB. See 705-1 to determine the retroactive period. Always review eligibility for the retroactive months.

Medicaid Policy

Previous Policy

Q I for Medicare Part B

QI pays the Medicare Part B-ID premium only.

Do not open QI:

If the member will be receiving ongoing Medicaid, which includes someone who is meeting a spenddown, cost of care contribution or MWI premium each month, OR

In the retroactive period if the member is receiving Medicaid without a spenddown, cost of care contribution or MWI premium for such months or is going to meet such applicable payments in the retroactive period.

Open QI:

If the member doesn't want to meet the spenddown, cost of care contribution or MWI premium, OR

If the member wants to meet a spenddown, cost of care contribution or MWI premium for only one or two months or every other month, OR

If the member stops receiving Medicaid because the spenddown, cost of care contribution or MWI premium has not been met for two months and the member meets all the QI criteria. Do not require a new application, OR

If a member asks that the Medicaid program be closed because the member does not want to meet the spenddown, cost of care contribution or MWI premium and the member meets all the QI criteria. Do not require a new application, OR

If eligible for QI under any of the above situations, include any of the months in which the member did not meet the spenddown, cost of care contribution or MWI premium and meets the QI eligibility criteria for each month.

Close QI:

If the member meets the spenddown, cost of care contribution or MWI premium and either wants to continue meeting it monthly or does continue to meet it for more than two months in a row; OR

If the member will be receiving ongoing Medicaid.

TPL process is not required ( 225 )

QI is a permanent program; however, the funding is provided as an annual allocation for each state. When funds run low in a calendar year, the department will instruct DWS staff to deny any new applications. Open cases will be covered for the rest of that year.

If funding will not cover all QI members for the next calendar year, members open for QMB, SLMB or QI in the previous December receive priority enrollment in the new year. Priority is based on the date of the member’s most recent application for a cost-sharing program.

The benefit effective date for QI coverage is the first day of the application month or the first day of any of the three retroactive months in which the individual meets all the requirements for QI, given that funding is available. Always review eligibility for the retroactive months.

You can approve coverage for retroactive months in the previous year if funding was available for all QI members in the previous year.

If the agency had stopped allowing approval of QI cases because funding was insufficient in the previous year, January 1st of the current year is the earliest possible effective date for new applicants applying in the current calendar year

QI for Medicare PartB-ID

QI pays the Medicare Part B-ID premium only.

If a QI member is eligible for other Medicaid programs , Marketplace insurance, or employer insurance which cover immunosuppressant drugs, they are not eligible for the QI Part B-ID program.

TPL process is required ( 225 )

The benefit effective date for QI coverage is the first day of the application month or the first day of any of the three retroactive months in which the individual meets all the requirements for QI, given that funding is available. Always review eligibility for the retroactive months.

You can approve coverage for retroactive months in the previous year if funding was available for all QI members in the previous year.

If the agency had stopped allowing approval of QI cases because funding was insufficient in the previous year, January 1st of the current year is the earliest possible effective date for new applicants applying in the current calendar year.

Medicaid Policy

Contact DHHS Policy Specialist for Previous Policy

SSA allows some disabled people to keep Part A Medicare, by paying the premium. The member must be eligible for Part A Medicare under Section 1818A of the Social Security Act. A person eligible for Medicare Part A under Section 1818A is a person who:

Is disabled and under age 65, and

Was entitled to Medicare Part A because the person was entitled, for 24 calendar months, to Social Security Disability benefits, Child’s insurance benefits because of disability, Widows benefits because of disability, or disabled railroad retirement payments, but

Lost that entitlement only because of earnings that exceeded the substantial gainful activity amount, and

Is not otherwise entitled to Medicare Part A.

Benefits

QDWI pays the Part A premium.

TPL

TPL process is not required.

QDWI and Other Medicaid Programs

The member doesn’t qualify for QDWI:

If the member qualifies for Medicaid without a spenddown.

If the member qualifies for spenddown Medicaid or MWI and pays the spenddown or MWI premium.

Medicaid Policy

Contact DWS Program Specialist for previous policy

Follow the rules in section 443-3 .

Medicaid Policy

Contact DHHS Policy Specialist for Previous Policy

The purpose of the Low Income Subsidy is to provide extra help paying for prescription drugs on Medicare Part D. There are three groups eligible for the subsidy:

Group 1: All members who receive Medicare ( 223-1 ) and Medicaid or who are enrolled in a Medicare Cost Sharing Program are eligible to receive a Low Income Subsidy benefit for Medicare Part D.

Group 2: Members with income less than 135% FPL, based on countable household size, AND assets under the countable limit. See Table II Each individual can designate up to $1500 for burial funds which increases the above asset limits by the designated amount.

Group 3: Members with income less than 150% FPL, based on countable household size, AND assets under the countable limit See Table II Each individual can designate up to $1500 for burial funds which increases the above asset limits by the designated amount.

Household size, countable income and countable assets for the second and third groups do not follow policy for A, B and D Medicaid programs or the Medicare Cost Sharing program.

Eligibility for Medicare Part A and/or enrollment in Medicare Part B is required for groups 2 and 3. Eligibility for these groups will reduce the required premiums, annual deductible and co-payments for Medicare Part D.

Social Security has primary responsibility for enrollment for Group 2 and 3. All applications for the Low Income Subsidy have a self addressed and stamped envelope to send the application to Social Security. States are required to have the ability to process applications for these groups on a restricted basis.

Further questions regarding application requirements and processing by the state should be directed to the authorized staff.

Medicaid Policy

Previous Policy

What are the Medicare Cost-Sharing Programs?

The Medicare Cost-Sharing Programs help Medicare beneficiaries with their Medicare costs. These programs may pay the Medicare Part A, Part B and Part B-ID premiums, co-payments and deductibles. Individuals receiving these programs are eligible for the Medicare Low Income Subsidy to help pay the cost of their prescription drugs. Depending on the Part D plan they choose, they will have no premium or a small monthly premium, no yearly deductibles, no coverage gap and reduced co-payments. See section 705 for the rules on retroactive coverage. There are four programs:

Qualified Medicare Beneficiaries (QMB) - This program pays the Part B and Part B-ID Medicare premium, Medicare co-payments and deductibles. It may pay the Part A premium for some members.

Specified Low-Income Medicare Beneficiaries (SLMB) – This program pays the Part B and Part B-ID Medicare Premium.

Qualifying Individuals (QI) – This program pays the Part B and Part B-ID Medicare premium.

Qualified Disabled Working Individual (QDWI) – This program pays the Part A Medicare premium. (The federal Medicaid agency identifies these individuals. Contact the Health Program Specialist if you have questions.)

Refer to section 223-2 for a description of the Medicare premium buy-in process.

How Does Someone Apply?

An application for medical assistance is also an application for Medicare Cost Sharing programs if the person is entitled to Medicare Part A. For the Medicare Cost Sharing Programs Part B-ID, enrollment in Part A is not required. Screen all applications to decide if the individual is eligible for a Medicare Cost-Sharing program.

Effective January 1, 2010, Social Security will send electronic application data to states. This data is about individuals who have applied for a Medicare Part D Low-Income Subsidy. The electronic data is an application for the Medicare Cost Sharing programs. It is not an application for Medicaid. Individuals will need to complete a separate application with the Dept. of Workforce Services if they want to apply for Medicaid. See Sec. 320-1 , D.

When an ongoing member is about to become eligible for Medicare, decide if the member is eligible for a Medicare Cost-Sharing program. Do this during case reviews, too. A new application is not required for an open case.

Medicaid Policy

Contact DWS Policy Specialist for Previous Policy

In Utah SSI recipients must apply for Medicaid with DWS or DHHS ( 703 ). See section 731-4 for verification requirements for SSI recipients.

SSI recipients are people:

Who are receiving an SSI payment.

Who have 1619(b) status.

Who do not receive their SSI payments only because SSA has applied a penalty for false or misleading statements.

Who have the SSI payment reduced to $0 because SSI is withholding the payment to recover an overpayment.

SSI recipients meet:

Income eligibility for AM, BM and DM.

Citizenship or Qualified non-citizen Status.

Disability or blindness criteria for BM or DM if the member is under 65.

SSI recipients must meet:

Utah residency ( 207-1 ).

Asset limits ( 503 ).

Medical Support Enforcement ( 227 ).

Third Party Liability ( 225 ).

A person is an SSI recipient beginning the month before the first SSI payment month.

When the person meets SSI criteria in the SSI application month, the first payment will be for the month after the application month.

When SSI eligibility did not start in the SSI application month, but became effective for a later month, the first payment is made for the month after the month the person meets all of the SSI eligibility criteria.

A person who receives a lump sum SSI payment is an SSI recipient the month immediately before the first month for which the lump sum payment is made and for the months covered by the SSI lump sum payment.

If SSI payments stop and: The member is still an SSI recipient continue to determine eligibility as if the member were still receiving a payment. The member is no longer an SSI recipient, but is still blind or disabled ( 303-6 ), determine eligibility for protected Medicaid groups, 100% poverty group or spenddown AM, BM or DM. Have the MRB do a disability redetermination in 12 months if the member is not receiving Social Security Disability benefits. The member is no longer disabled, determine if the member is eligible for another Medicaid program.

Medicaid Policy

Previous Policy for Protected Medicaid Group for Disabled Adult Children

Previous Policy for DAC Income Test

Previous Policy for Changes that Affect DAC

Disabled people age 18 or older receiving childhood disability benefits (CDB) from Social Security may qualify for the SSI Protected Medicaid Group for Disabled Adult Children (DAC).

DAC Eligibility Criteria

To qualify for the Protected Medicaid Group for Disabled Adult Children, the individual must meet all the following criteria:

1. Became disabled before reaching age 22, and

2. Received SSI in at least one month after July 1, 1987, and

3. Lost SSI eligibility after July 1, 1987 because the individual started receiving or received an increase in Childhood Disability Benefits, and

4. Have countable income, not including the Childhood Disability Benefit, that is less than the SSI payment for one person or the SSI payment for two people if married to an ineligible spouse with deemable income, and

5. Be receiving a CDB payment from SSA.

DAC Income Test

Unmarried individual/Married individual Whose Spouse does not have Deemable Income

Do not include the amount of the Childhood Disability Benefit in the income test. If the individual’s only income is the Childhood Disability Benefit, the individual is income eligible for protected Medicaid as a DAC.

Unearned Income

Subtract the $20 general income disregard from the individual’s unearned income, other than VA needs based payments.

Add the result to the amount of any VA needs based payments. The result is the countable unearned income.

Earned Income

S ubtract Impairment related work expenses ( 431-2 ).

Subtract any part of the $20 general income disregard not used for unearned income.

Subtract $65 from the individual’s gross earned income.

Subtract ½ of the result of c(iii) from that result.

The result from c(iv) is the countable earned income.

Add the countable unearned income from b(ii) to c(v). The result is the total countable income.

Compare the countable income from d to the SSI payment for one person.

If the countable income is equal to or less than the SSI payment for one person, the individual is income eligible for protected Medicaid as a DAC.

If the countable income is more than the SSI payment for one person, the individual is not eligible for protected Medicaid as a DAC. Determine eligibility for other Medicaid programs.

Married individual Whose Spouse has Deemable Income

Do not include the amount of the Childhood Disability Benefit in the income test. If the individual’s spouse does not have deemable income, follow the procedure in #B1.

Unearned Income:

Subtract the $20 general income disregard from the unearned income, other than VA needs based payments.

Add the result to the amount of any VA needs based payments. The result is the countable unearned income.

Earned Income:

Subtract Impairment related work expenses ( 431-2 )

Subtract any part of the $20 general income disregard not used for unearned income.

Subtract $65 from the gross earned income.

Subtract ½ of the result of c(iii) from that result.

The result from c(iv) is the countable earned income.

Add the countable unearned income from b(ii) to the countable earned income from c(v). The result is the countable income.

Compare the countable income from d to the SSI payment for two people.

If the countable income is equal to or less than the SSI payment for two people, the individual is income eligible for protected Medicaid as a DAC.

If the countable income is more than the SSI payment for two people, the individual is not eligible for protected Medicaid as a DAC. Determine eligibility for other Medicaid programs.

Changes That Can Affect DAC Protected Medicaid

Check the individual’s DAC protected Medicaid when these changes happen:

If the income of the individual or individual's spouse, other than the Childhood Disability Benefit, increases, use the DAC income test to find out if the individual is still income eligible for protected Medicaid.

If SSA decides the individual is no longer disabled and stops the Childhood Disability Benefit, decide the individual’s eligibility for other Medicaid programs.

If the individual marries, check to see if the Childhood Disability benefit stopped. If it is stopped, determine the individual’s eligibility for other Medicaid programs. If the Childhood Disability Benefit continues, the individual retains DAC protected Medicaid if the individual meets the DAC income test.

Medicaid Policy

Previous Policy (329-1 was renumbered to 330-2 as of November 1, 2017)

These statuses allow disabled people who go to work to continue to be SSI recipients and to continue to receive Medicaid.

1619(a)

People who have 1619(a) status still receive SSI payments even though their monthly gross earned income exceeds the SGA level.

1619(b)

People who have 1619(b) status do not receive an SSI payment because of their earned income. These people are still considered SSI recipients even though they don’t get SSI payments.

Age does not affect 1619(a) or (b) status. Keep an individual with 1619(a) or 1619(b) status open on DM after age 65.

How to Identify 1619(b) Eligible

Only SSA can decide 1619(b) status. Clues that indicate 1619(b) status are:

A Y in the 1619(b) field on the Social Security electronic interface screen.

SSI payment stops because of the individual’s earned income.

Consider the individual 1619(b) eligible while you verify 1619(b) status with SSA if the individual:

Is still disabled or has a disability which is not likely to improve, and

Has earned income that exceeds the break-even point.

Changes that can affect 1619(b) Status

Marriage. Continue the Medicaid 1619(b) status if the electronic interface shows the individual still has 1619(b) status, Determine eligibility for other Medicaid programs if the electronic interface shows the individual does not have 1619(b) status.

Other income, or increases in earned income. Continue 1619(b) status if the electronic interface shows the individual still has 1619(b) status. Determine eligibility for other Medicaid programs if the electronic interface shows the individual does not have 1619(b) status.

Medicaid Policy

Effective Date: November 1, 2017

Previous Policy for Protected Medicaid for the Pickle Amendment Group

Previous Policy for Single Persons Age 18 and Older

Previous Policy for a Married Couple

Previous Policy For a child

The Pickle Amendment Protected Groups

Currently receives RSDI, and

Was eligible for and received SSI, then, lost SSI eligibility for any reason after April 1977, and

Was eligible for SSI and RSDI in at least one concurrent month, and

Would have countable income less than the SSI payment level if you deducted from current RSDI benefits, the RSDI COLA’s paid after the last month the person was eligible for and received SSI and was also eligible for RSDI. Deduct COLA’s from the RSDI of the person and the RSDI of the person’s spouse or financially responsible parents, and

Meets the other Medicaid eligibility requirements now.

Eligibility for the Pickle Amendment Group for Single Persons Age 18 and Older

Verify that the individual was eligible for and received SSI and lost eligibility for SSI after April 1977 and that the person receives RSDI now. The reason for losing SSI eligibility does not matter.

Determine the last month the individual was eligible for and received SSI and was also eligible for RSDI.

Deduct from the individual’s current RSDI benefits, the RSDI COLA’s the individual received after the last month the individual was eligible for and received SSI and was also eligible for RSDI ( Table XI ).

Use the reduced RSDI amount and any other income the individual has to determine countable income.

If the countable income is less than the SSI payment for one person, the individual is income eligible for protected Medicaid.

If the countable income is more than the SSI payment for one person, the individual is not income eligible for protected Medicaid. Determine eligibility for other Medicaid programs.

Eligibility for the Pickle Amendment Group for a Married Couple

Eligibility for the Pickle Amendment Group for spouses who are both eligible.

Verify that both spouses were eligible for and received SSI, lost eligibility for SSI after April 1977, and that both spouses receive RSDI now (Social Security RSDI--retirement, survivor's, disability insurance). The reason for losing SSI eligibility does not matter. They did not necessarily have to be married at the time they lost SSI eligibility.

Determine the last month the spouses were eligible for and received SSI and were also eligible for RSDI.

Deduct from both spouses’ current RSDI benefits, the RSDI COLA’s received after the last month they were eligible for and received SSI and were also eligible for RSDI. If the couple lost SSI at different times, use the larger reduction factor based on the date the first spouse lost SSI. Use the same reduction factor for both spouses ( Table XI ).

Use the reduced RSDI amount plus any other income the couple has to determine countable income. Use the worksheet for a Married Couple Both on Medicaid in section 443 except that you compare income to the SSI payment rate instead of 100% of poverty.

If the countable income is less than the SSI payment for two people, the couple is income eligible for protected Medicaid.

If the countable income is more than the SSI payment for two people, the couple is not income eligible for protected Medicaid. Determine eligibility for other Medicaid programs.

If one spouse chooses to not receive Medicaid coverage, then treat the spouse who wants Medicaid as a potential Pickle eligible individual whose spouse did not receive SSI in the past. See section 2 below.

Eligibility for the Pickle Amendment Group when one spouse did not receive SSI after April 1977

Verify that the eligible spouse who received SSI lost eligibility for SSI after April 1977 and receives RSDI now. The reason for losing SSI eligibility does not matter. The spouse who never received SSI in the past may or may not receive RSDI now, but protected status is not available because he or she has never received SSI.

Decide the last month the spouse who received SSI was eligible for and received SSI and was also eligible for RSDI. Use the Pickle Reduction Factor Table to reduce the only the former SSI recipient's current RSDI benefits. If the ineligible spouse receives RSDI, back out any COLA increases from the ineligible spouse's RSDI benefits before applying the income deeming deductions in 410-6 . Use the same reduction factor used for the former SSI recipient spouse ( Table XI ).

After reducing the RSDI of the ineligible spouse (if applicable), determine the deemable income from the ineligible spouse. Follow policy in 410-6 to decide how much income to deem from the ineligible spouse.

If the ineligible spouse has deemable income, add the deemable income to the former SSI recipient's reduced RSDI and any other income the former SSI recipient spouse has. Deduct the $20 general disregard, and the earned income disregards if applicable, from the combined income. Compare countable income to the SSI payment for two people.

If the countable income is less than the SSI payment for two people, the spouse who received SSI is eligible for protected Medicaid. The other spouse may qualify under a different Medicaid coverage group.

If the countable income is more than or equal to the SSI payment for two people, the spouse who received SSI is not eligible for protected Medicaid. Determine eligibility for other Medicaid programs.

If the ineligible spouse does not have deemable income, compare countable income of the former SSI recipient spouse to the SSI payment for one person. Deduct the $20 general disregard, and the earned income disregards if applicable, to determine the countable income.

If the countable income is less than the SSI payment for one person, the spouse who received SSI is eligible for protected Medicaid.

If the countable income is more than or equal to the SSI payment for one person, the spouse who received SSI is not eligible for protected Medicaid. Determine eligibility for other Medicaid programs.

Eligibility for the Pickle Amendment Group for a Child

If a child under age 18 used to receive SSI, and now receives Social Security survivor's benefits, the child might qualify for Medicaid under the Pickle Amendment. The child had to be eligible for SSI and RSDI benefits in at least one concurrent month. If the disabled child is over age 18 and lost SSI due to receipt of Social Security survivor's benefits, see section 330-1 for Disabled Adult Children.

Use this policy only if the child is unmarried and under age 18.

Verify that the child was eligible for and received SSI, lost eligibility for SSI after April 1977 and receives RSDI now. A child under age 18 may qualify for survivor's benefits if the child's parent is deceased or disabled. The reason for losing SSI eligibility does not matter, unless the child was determined no longer disabled.

Determine the last month in which the child was eligible for and received SSI and was eligible for RSDI. Use the applicable reduction factor from the Pickle Reduction Factor Table to reduce the child’s current RSDI benefit.

If a parent receives RSDI now, deduct from that parent’s current RSDI benefits, the RSDI COLA’s that parent received after the last month the child was eligible for and received SSI and was eligible for RSDI.

Determine the parents' deemable income. Use the parents' reduced RSDI income (if applicable) and any other income they have ( 410-5 ) .

Use the child's reduced RSDI amount and any other income of the child. Add the parents' deemable income to determine countable income ( 443 ). Deduct the $20 general disregard, and earned income deductions if applicable.

If the countable income is less than the SSI payment for one person, the child is income eligible for protected Medicaid.

If the countable income is more than the SSI payment for one person, the child is not income eligible for protected Medicaid. Determine eligibility for other Medicaid programs.

Pickle Reduction Factor Table

Medicaid Policy

Contact DHHS Policy Specialist for Previous Policy (337 was renumbered to 330-4 as of November 1, 2017)

Previous Policy for Determining Eligibility for Widow Protected Group (337-1 incorporated into 330-4 as of November 1, 2017)

Protected Disabled Widows and Widowers

Disabled people who lose SSI because they receive widow/widower benefits from SSA or an increase in these benefits can receive Medicaid in this protected group.