COBI 2015 - Eligibility Policy

Overview
Issues
Performance
Background
Financials

Sources Uses

FY 2016 Appropriation

The Bureau of Eligibility Policy is responsible to ensure Medicaid and Children's Health Insurance Program (CHIP) eligibility policy is in compliance with all State and federal statutes. It is also responsible to monitor the contract with the Department of Workforce Services to ensure timely and accurate Medicaid and CHIP eligibility determinations. The Department of Workforce Services determines the eligibility for nearly all clients to receive Medicaid services. The Department of Human Services contracts with the Department of Health to perform Medicaid eligibility. The Department of Human Services determines Medicaid eligibility for children in the custody of other states that reside in Utah, children in foster care, and for children receiving adoption assistance. Additionally, the Department of Human Services maintains Medicaid eligibility for children in the custody of Utah, but living in other states where they do not qualify for Medicaid.

Funding History

Related Publications

Medicaid and CHIP Enrollment Trends Since the Beginning of Mandatory Medicaid Expansion

Appropriation Overview

During the 2015 General Session, the Legislature appropriated for Fiscal Year 2016, $2,566,800 from all sources for Eligibility Policy. This is a 4 percent increase from Fiscal Year 2015 revised estimated amounts from all sources. The total includes $591,800 from the General/Education Funds, an increase of 4.7 percent from revised Fiscal Year 2015 estimates.

Percentage of Medicaid cases with incorrect eligibility determination and/or inadequate documentation of eligibility (State Auditor findings)

The Bureau operates the Buyout Program which determines if purchasing private health insurance would save the Medicaid program money for high risk clients. If so, Medicaid pays the health premiums for that plan. The Bureau houses the Medicaid Eligibility Quality Control Unit responsible for reviewing and verifying the accuracy of all Medicaid eligibility determinations. Additionally, the Bureau includes the State's Medical Review Board which determines an individual's disability status in order to qualify for Medicaid.

The Department has a website that allows registered providers to verify a client's Medicaid eligibility and plan enrollment electronically. The website will also indicate if a client has co-pays to receive services.

Intent Language

HB0003: Item 78

Under Section 63J-1-603 of the Utah Code, the Legislature intends up to $475,000 provided for the Department of Health's Medicaid and Health Financing line item in Item 24 of Chapter 13, Laws of Utah 2014 shall not lapse at the close of Fiscal Year 2015. The use of nonlapsing funds is limited to compliance with federally mandated projects and the purchase of computer equipment and software.

HB0003: Item 78

Under Section 63J-1-603 of the Utah Code, the Legislature intends up to $1,000,000 provided for the Department of Health's Medicaid and Health Financing line item in Item 70 of Chapter 282, Laws of Utah 2014 shall not lapse at the close of Fiscal Year 2015. The use of nonlapsing funds is limited to the purchase of telehealth equipment.

SB0002: Item 72

The Legislature intends that the Inspector General of Medicaid Services pay the Attorney General's Office the full state cost of the one attorney FTE that it is using at the Department of Health.

SB0007S01: Item 3

All General Funds appropriated to the Department of Health - Medicaid and Health Financing line item are contingent upon expenditures from Federal Funds - American Recovery and Reinvestment Act (H.R. 1, 111th United States Congress) not exceeding amounts appropriated from Federal Funds - American Recovery and Reinvestment Act in all appropriation bills passed for fiscal year 2016. If expenditures in the Medicaid and Health Financing line item from Federal Funds - American Recovery and Reinvestment Act exceed amounts appropriated to the Medicaid and Health Financing line item from Federal Funds - American Recovery and Reinvestment Act in fiscal year 2016, the Division of Finance shall reduce the General Fund allocations to the Medicaid and Health Financing line item by one dollar for every one dollar in Federal Funds - American Recovery and Reinvestment Act expenditures that exceed Federal Funds - American Recovery and Reinvestment Act appropriations.

SB0007S01: Item 3

The Legislature intends that the Department of Health report on the following performance measures for the Medicaid and Health Financing line item: (1) average decision time on pharmacy prior authorizations (Target = 24 hours or less), (2) percent of clean claims adjudicated within 30 days of submission (Target = 98%), and (3) total count of Medicaid and CHIP clients educated on proper benefit use and plan selection (Target = 90,000 or more) by January 1, 2016 to the Social Services Appropriations Subcommittee.

SB0007S01: Item 14

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Funding Source

Expenditure Category

Appropriation Type:

Appropriation History by

Sources of Finance	FY11 Actual	FY12 Actual	FY13 Actual	FY14 Actual	FY15 Approp	FY15 Change	FY15 Revised	FY16 Change	FY16 Approp
General Fund	131,600	701,900	492,500	173,200	474,600	87,700	562,300	24,700	587,000
General Fund, One-time	0	98,000	16,500	1,400	2,700	0	2,700	2,100	4,800
Federal Funds	903,000	1,188,800	1,038,800	1,018,000	1,096,300	119,600	1,215,900	48,100	1,264,000
Dedicated Credits Revenue	582,400	647,100	966,900	937,900	917,500	(423,200)	494,300	20,500	514,800
Transfers	0	0	0	0	0	0	0	3,600	3,600
Transfers - Medicaid - DHS	0	0	28,300	101,700	0	72,600	72,600	(200)	72,400
Transfers - Medicaid - Internal DOH	0	0	0	0	0	10,800	10,800	(100)	10,700
Transfers - Within Agency	600,000	119,200	115,600	90,300	166,100	(56,500)	109,600	(100)	109,500
Lapsing Balance	0	0	(99,600)	(11,700)	0	0	0	0	0
Total	$2,217,000	$2,755,000	$2,559,000	$2,310,800	$2,657,200	($189,000)	$2,468,200	$98,600	$2,566,800

Categories of Expenditure	FY11 Actual	FY12 Actual	FY13 Actual	FY14 Actual	FY15 Approp	FY15 Change	FY15 Revised	FY16 Change	FY16 Approp
Personnel Services	1,943,900	1,994,900	2,083,600	2,175,000	2,454,100	(121,500)	2,332,600	96,200	2,428,800
In-state Travel	200	400	1,600	4,700	1,300	3,400	4,700	0	4,700
Out-of-state Travel	0	2,400	5,400	0	0	0	0	0	0
Current Expense	106,400	713,700	426,400	85,700	164,400	(78,800)	85,600	900	86,500
DP Current Expense	19,300	43,600	35,600	45,400	37,400	7,900	45,300	1,500	46,800
Capital Outlay	0	0	6,400	0	0	0	0	0	0
Other Charges/Pass Thru	147,200	0	0	0	0	0	0	0	0
Total	$2,217,000	$2,755,000	$2,559,000	$2,310,800	$2,657,200	($189,000)	$2,468,200	$98,600	$2,566,800

Show Table | Show Additional Information

Other Indicators	FY11 Actual	FY12 Actual	FY13 Actual	FY14 Actual	FY15 Approp	FY15 Change	FY15 Revised	FY16 Change	FY16 Approp
Budgeted FTE	25.50	24.20	23	27.90	30.30	(2.30)	28	0	28
Actual FTE	26.90	25.70	25.80	25.70	0	0	0	0	0

COBI contains unaudited data as presented to the Legislature by state agencies at the time of publication. For audited financial data see the State of Utah's Comprehensive Annual Financial Reports.