Medicaid waiver for children with disabilities and complex medical needs.

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  • (1) As used in this section:
    • (a) "Additional eligibility criteria" means the additional eligibility criteria set by the department under Subsection (4)(e).
    • (b) "Complex medical condition" means a physical condition of an individual that:
      • (i) results in severe functional limitations for the individual; and
      • (ii) is likely to:
        • (A) last at least 12 months; or
        • (B) result in death.
    • (c) "Program" means the program for children with complex medical conditions created in Subsection (3).
    • (d) "Qualified child" means a child who:
      • (i) is less than 19 years old;
      • (ii) is diagnosed with a complex medical condition;
      • (iii) has a condition that meets the definition of disability in 42 U.S.C. Sec. 12102; and
      • (iv) meets the additional eligibility criteria.
  • (2) The department shall apply for a Medicaid home and community-based waiver with CMS to implement, within the state Medicaid program, the program described in Subsection (3).
  • (3) If the waiver described in Subsection (2) is approved, the department shall offer a program that:
    • (a) as funding permits, provides treatment for qualified children;
    • (b) accepts applications for the program during periods of open enrollment; and
    • (c) if approved by CMS:
      • (i) requires periodic reevaluations of an enrolled child's eligibility based on the additional eligibility criteria; and
      • (ii) at the time of reevaluation, allows the department to disenroll a child who does not meet the additional eligibility criteria.
  • (4) The department shall:
    • (a) seek to prioritize, in the waiver described in Subsection (2), entrance into the program based on the:
      • (i) complexity of a qualified child's medical condition; and
      • (ii) financial needs of a qualified child and the qualified child's family;
    • (b) convene a public process to determine:
      • (i) the benefits and services to offer a qualified child under the program; and
      • (ii) additional eligibility criteria for a qualified child;
    • (c) evaluate, on an ongoing basis, the cost and effectiveness of the program;
    • (d) if funding for the program is reduced, develop an evaluation process to reduce the number of children served based on the criteria in Subsection (4)(a); and
    • (e) establish, by rule made in accordance with Title 63G, Chapter 3, Utah Administrative Rulemaking Act, additional eligibility criteria based on the factors described in Subsections (4)(a)(i) and (ii).




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