Effective 7/1/2023

26B-3-206.  Medicaid waiver for children with disabilities and complex medical needs.

(1)  As used in this section:

Terms Used In Utah Code 26B-3-206 v2

  • CMS: means the Centers for Medicare and Medicaid Services within the United States Department of Health and Human Services. See Utah Code 26B-3-101
  • Medicaid program: means the state program for medical assistance for persons who are eligible under the state plan adopted pursuant to Title XIX of the federal Social Security Act. See Utah Code 26B-3-101
  • Process: means a writ or summons issued in the course of a judicial proceeding. See Utah Code 68-3-12.5
  • State: when applied to the different parts of the United States, includes a state, district, or territory of the United States. See Utah Code 68-3-12.5
(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. § 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 on an ongoing basis;

(c)  requires periodic reevaluations of an enrolled child’s eligibility and other applicants or eligible children waiting for services in the program based on the additional eligibility criteria; and

(d)  at the time of reevaluation, allows the department to disenroll a child if the child is no longer a qualified child.

(4)  The department shall:

(a)  establish by rule made in accordance with Title 63G, Chapter 3, Utah Administrative Rulemaking Act, criteria to prioritize qualified children’s participation in the program based on the following factors, in the following priority order:

(i)  the complexity of a qualified child’s medical condition; and

(ii)  the financial needs of the qualified child and the qualified child’s family;

(b)  convene a public process to determine the benefits and services to offer a qualified child under the program;

(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 participation criteria established under 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).

Amended by Chapter 286, 2023 General Session
Renumbered and Amended by Chapter 306, 2023 General Session

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