PocketLaw | Utah Code | Health coverage improvement program --

Health coverage improvement program -- Eligibility -- Annual report -- Expansion of eligibility for adults with dependent children.

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Affected by 63I-2-226 on 1/1/2023

Effective 5/12/2020
26-18-411. Health coverage improvement program -- Eligibility -- Annual report -- Expansion of eligibility for adults with dependent children.

(1) For purposes of this section:
- (a) "Adult in the expansion population" means an individual who:
  - (i) is described in 42 U.S.C. Sec. 1396a(a)(10)(A)(i)(VIII); and
  - (ii) is not otherwise eligible for Medicaid as a mandatory categorically needy individual.
- (b) "Enhancement waiver program" means the Primary Care Network enhancement waiver program described in Section 26-18-416.
- (c) "Federal poverty level" means the poverty guidelines established by the Secretary of the United States Department of Health and Human Services under 42 U.S.C. Sec. 9909(2).
- (d) "Health coverage improvement program" means the health coverage improvement program described in Subsections (3) through (10).
- (e) "Homeless":
  - (i) means an individual who is chronically homeless, as determined by the department; and
  - (ii) includes someone who was chronically homeless and is currently living in supported housing for the chronically homeless.
- (f) "Income eligibility ceiling" means the percent of federal poverty level:
  - (i) established by the state in an appropriations act adopted pursuant to Title 63J, Chapter 1, Budgetary Procedures Act; and
  - (ii) under which an individual may qualify for Medicaid coverage in accordance with this section.

(2) Beginning July 1, 2016, the department shall amend the state Medicaid plan to allow temporary residential treatment for substance abuse, for the traditional Medicaid population, in a short term, non-institutional, 24-hour facility, without a bed capacity limit that provides rehabilitation services that are medically necessary and in accordance with an individualized treatment plan, as approved by CMS and as long as the county makes the required match under Section 17-43-201.

(3) Beginning July 1, 2016, the department shall amend the state Medicaid plan to increase the income eligibility ceiling to a percentage of the federal poverty level designated by the department, based on appropriations for the program, for an individual with a dependent child.

(4) Before July 1, 2016, the division shall submit to CMS a request for waivers, or an amendment of existing waivers, from federal statutory and regulatory law necessary for the state to implement the health coverage improvement program in the Medicaid program in accordance with this section.

(5)
- (a) An adult in the expansion population is eligible for Medicaid if the adult meets the income eligibility and other criteria established under Subsection (6).
- (b) An adult who qualifies under Subsection (6) shall receive Medicaid coverage:
  - (i) through the traditional fee for service Medicaid model in counties without Medicaid accountable care organizations or the state's Medicaid accountable care organization delivery system, where implemented;
  - (ii) except as provided in Subsection (5)(b)(iii), for behavioral health, through the counties in accordance with Sections 17-43-201 and 17-43-301;
  - (iii) that integrates behavioral health services and physical health services with Medicaid accountable care organizations in select geographic areas of the state that choose an integrated model; and
  - (iv) that permits temporary residential treatment for substance abuse in a short term, non-institutional, 24-hour facility, without a bed capacity limit, as approved by CMS, that provides rehabilitation services that are medically necessary and in accordance with an individualized treatment plan.
- (c) Medicaid accountable care organizations and counties that elect to integrate care under Subsection (5)(b)(iii) shall collaborate on enrollment, engagement of patients, and coordination of services.

(6)
- (a) An individual is eligible for the health coverage improvement program under Subsection (5) if:
  - (i) at the time of enrollment, the individual's annual income is below the income eligibility ceiling established by the state under Subsection (1)(f); and
  - (ii) the individual meets the eligibility criteria established by the department under Subsection (6)(b).
- (b) Based on available funding and approval from CMS, the department shall select the criteria for an individual to qualify for the Medicaid program under Subsection (6)(a)(ii), based on the following priority:
  - (i) a chronically homeless individual;
  - (ii) if funding is available, an individual:
    - (A) involved in the justice system through probation, parole, or court ordered treatment; and
    - (B) in need of substance abuse treatment or mental health treatment, as determined by the department; or
  - (iii) if funding is available, an individual in need of substance abuse treatment or mental health treatment, as determined by the department.
- (c) An individual who qualifies for Medicaid coverage under Subsections (6)(a) and (b) may remain on the Medicaid program for a 12-month certification period as defined by the department. Eligibility changes made by the department under Subsection (1)(f) or (6)(b) shall not apply to an individual during the 12-month certification period.

(7) The state may request a modification of the income eligibility ceiling and other eligibility criteria under Subsection (6) each fiscal year based on projected enrollment, costs to the state, and the state budget.

(8) Before September 30 of each year, the department shall report to the Health and Human Services Interim Committee and to the Executive Appropriations Committee:
- (a) the number of individuals who enrolled in Medicaid under Subsection (6);
- (b) the state cost of providing Medicaid to individuals enrolled under Subsection (6); and
- (c) recommendations for adjusting the income eligibility ceiling under Subsection (7), and other eligibility criteria under Subsection (6), for the upcoming fiscal year.

(9) The current Medicaid program and the health coverage improvement program, when implemented, shall coordinate with a state prison or county jail to expedite Medicaid enrollment for an individual who is released from custody and was eligible for or enrolled in Medicaid before incarceration.

(10) Notwithstanding Sections 17-43-201 and 17-43-301, a county does not have to provide matching funds to the state for the cost of providing Medicaid services to newly enrolled individuals who qualify for Medicaid coverage under the health coverage improvement program under Subsection (6).

(11) If the enhancement waiver program is implemented, the department:
- (a) may not accept any new enrollees into the health coverage improvement program after the day on which the enhancement waiver program is implemented;
- (b) shall transition all individuals who are enrolled in the health coverage improvement program into the enhancement waiver program;
- (c) shall suspend the health coverage improvement program within one year after the day on which the enhancement waiver program is implemented;
- (d) shall, within one year after the day on which the enhancement waiver program is implemented, use all appropriations for the health coverage improvement program to implement the enhancement waiver program; and
- (e) shall work with CMS to maintain any waiver for the health coverage improvement program while the health coverage improvement program is suspended under Subsection (11)(c).

(12) If, after the enhancement waiver program takes effect, the enhancement waiver program is repealed or suspended by either the state or federal government, the department shall reinstate the health coverage improvement program and continue to accept new enrollees into the health coverage improvement program in accordance with the provisions of this section.

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