Health, Health Care Financing, Coverage and Reimbursement Policy

Rule R414-320

Medicaid Health Insurance Flexibility and Accountability Demonstration Waiver

Change in Proposed Rule

DAR File No.: 32925
Filed: 11/24/2009 03:12:13 PM

RULE ANALYSIS

Purpose of the rule or reason for the change:

The purpose of this change is to allow an individual who receives continuation coverage under the Consolidated Omnibus Budget Reconciliation Act (COBRA) to enroll in Utah's Premium Partnership for Health Insurance (UPP).

Summary of the rule or change:

Section R414-320-7 is changed to allow an individual who is covered under COBRA at the time of application to enroll in UPP. (DAR NOTE: This change in proposed rule has been filed to make additional changes to a proposed amendment that was published in the September 15, 2009, issue of the Utah State Bulletin, on page 36. Underlining in the rule below indicates text that has been added since the publication of the proposed rule mentioned above; strike out indicates text that has been deleted. You must view the change in proposed rule and the proposed amendment together to understand all of the changes that will be enforceable should the agency make this rule effective.)

State statutory or constitutional authorization for this rule:

• Section 26-18-3

Anticipated cost or savings to:

the state budget:

This change does not impact the state budget because children who enroll in UPP are already qualified for and may enroll in the Children's Health Insurance Program (CHIP). In addition, adults who enroll in UPP are already qualified for and may enroll in the Primary Care Network Program (PCN). The state, therefore, does not incur any additional costs for COBRA enrollees.

local governments:

This change does not impact local governments because they do not fund or provide UPP services.

small businesses:

There is no budget impact because this change does not create any new requirements for small businesses.

persons other than small businesses, businesses, or local governmental entities:

There are nominal savings to individuals who qualify for the COBRA and UPP programs. Nevertheless, there is insufficient data to determine these savings based on the number of individuals who will qualify for the UPP program and the current cost of their COBRA insurance. There are no additional costs to providers based on any new requirements.

Compliance costs for affected persons:

There are no compliance costs because there are no additional costs to a child or adult who is already enrolled in CHIP or PCN. Furthermore, there are no additional costs to a single provider based on new requirements.

Comments by the department head on the fiscal impact the rule may have on businesses:

No fiscal impact to business is predicted, but public input during the comment period will be carefully evaluated.

David N. Sundwall, MD, Executive Director

The full text of this rule may be inspected, during regular business hours, at the Division of Administrative Rules, or at:

Health
Health Care Financing, Coverage and Reimbursement Policy
288 N 1460 W
SALT LAKE CITY, UT 84116-3231

Direct questions regarding this rule to:

• Craig Devashrayee at the above address, by phone at 801-538-6641, by FAX at 801-538-6099, or by Internet E-mail at [email protected]

Interested persons may present their views on this rule by submitting written comments to the address above no later than 5:00 p.m. on:

01/14/2010

This rule may become effective on:

01/21/2010

Authorized by:

David Sundwall, Executive Director

R414. Health, Health Care Financing, Coverage and Reimbursement Policy.

R414-320. Medicaid Health Insurance Flexibility and Accountability Demonstration Waiver.

 

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R414-320-7. Creditable Health Coverage.

(1) The Department adopts 42 CFR 433.138(b), 2007 ed., which is incorporated by reference.

(2) An individual who is covered under a group health plan or other creditable health insurance coverage, as defined by the Health Insurance Portability and Accountability Act of 1996 (HIPAA), is not eligible for enrollment.

(a) An applicant who is covered by COBRA continuation coverage [and who applies for UPP from the dates of October 1, 2009, through November 30, 2009, is]may be eligible for UPP enrollment.

[(b) Beginning on December 1, 2009, an applicant who is enrolled in COBRA continuation coverage and has not applied for the UPP program is not eligible for UPP enrollment.

](3) Eligibility for an individual who has access to but has not yet enrolled in employer-sponsored health insurance coverage will be determined as follows:

(a) If the cost of the employer-sponsored coverage is less than 5% of the household's gross income, the individual is not eligible for the UPP program.

(b) For adults, if the cost of the employer-sponsored coverage exceeds 15% of the household's gross income the adult may choose to enroll in the UPP program or may choose direct coverage through the Primary Care Network program if enrollment has not been stopped under the provisions of R414-310-16.

(c) A child may choose enrollment in UPP or direct coverage under the CHIP program if the cost of the employer sponsored coverage is equal to or more than 5% of the household's gross income.

(4) An individual who is covered under Medicare Part A or Part B, or who could enroll in Medicare Part B coverage, is not eligible for enrollment, even if the individual must wait for a Medicare open enrollment period to apply for Medicare benefits.

(5) An individual who is enrolled in the Veteran's Administration (VA) Health Care System is not eligible for enrollment. An individual who is eligible to enroll in the VA Health Care System, but who has not yet enrolled, may be eligible for the UPP program while waiting for enrollment in the VA Health Care System to become effective. To be eligible during this waiting period, the individual must initiate the process to enroll in the VA Health Care System. Eligibility for the UPP program ends once the individual becomes enrolled in the VA Health Care System.

(6) The Department shall deny eligibility if the applicant, spouse, or dependent child has voluntarily terminated health insurance coverage within the 90 days immediately prior to the application date for enrollment under the UPP program.

(a) An applicant, applicant's spouse, or dependent child can be eligible for the UPP program if their prior insurance ended more than 90 days before the application date.

(b) An applicant, applicant's spouse, or dependent child who voluntarily discontinues health insurance coverage under a COBRA plan, or under the Utah Comprehensive Health Insurance Pool, or who is involuntarily terminated from an employer's plan may be eligible for the UPP program without a 90 day waiting period.

(7) An individual with creditable health coverage operated or financed by Indian Health Services may enroll in the UPP program.

(8) Individuals must report at application and recertification whether each individual for whom enrollment is being requested has access to or is covered by a group health plan or other creditable health insurance coverage. This includes coverage that may be available through an employer or a spouse's employer, Medicare Part A or B, the VA Health Care System, or COBRA continuation coverage.

(9) The Department shall deny an application or recertification if the applicant or enrollee fails to respond to questions about health insurance coverage for any individual the household seeks to enroll or recertify.

 

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KEY: Medicaid, PCN, CHIP, UPP

Date of Enactment or Last Substantive Amendment: [July 1, 2009]2010

Authorizing, and Implemented or Interpreted Law: 26-18-3; 26-1-5