Health, Health Care Financing, Coverage and Reimbursement Policy

Section R414-320-7

Creditable Health Coverage

Notice of 120-Day (Emergency) Rule

DAR File No.: 33529
Filed: 04/01/2010 07:53:10 AM

RULE ANALYSIS

Purpose of the rule or reason for the change:

This change ensures the government funds that subsidize the purchase of health insurance plans are only used for plans that meet the requirements of federal law, which restricts the use of federal funds to cover abortion services.

Summary of the rule or change:

Subsidies through Utah's Premium Partnership for Health Insurance (UPP) will not be paid to individuals who enroll in health plans that cover abortion services beyond the limited circumstances required under federal law.

Emergency rule reason and justification:

Regular rulemaking procedures would place the agency in violation of federal or state law, and cause an imminent budget reduction because of budget restraints or federal requirements.

This change is necessary to comply with restrictions on the use of federal funds for abortion, and is in accordance with the Patient Protection and Affordable Care Act (Exec. Order No. 13535, 75 Fed. Reg. 15599 (March 24, 2010)).

State statutory or constitutional authorization for this rule:

• Section 26-1-5
• Section 26-18-3

Anticipated cost or savings to:

the state budget:

This change may result in minimal savings to the state budget. Nevertheless, it is impossible to know at this time how many individuals or families would become ineligible for the UPP program if their health plan were to cover elective abortion.

local governments:

There is no impact to local governments because they do not fund or provide UPP services to Medicaid clients.

small businesses:

This change may result in a minimal reduction in health care premium costs if families drop their health insurance at work. Nevertheless, it is impossible to know at this time how many individuals or families would become ineligible for the UPP program if their health plan were to cover elective abortion.

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

This change may result in a minimal loss in revenue to health plans if families drop their health insurance. Nevertheless, it is impossible to know at this time how many individuals or families would become ineligible for the UPP program if their health plan were to cover elective abortion.

Compliance costs for affected persons:

There may be limited loss of income for health plans and out-of-pocket expenses to an individual or family. Nevertheless, it is impossible to know at this time how many individuals or families would become ineligible for the UPP program if their health plan were to cover elective abortion.

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

Changes in federal law and executive orders require this rule change to assure compliance with federal and state law.

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 cdevashrayee@utah.gov

This rule is effective on:

04/01/2010

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.

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 may be eligible for UPP enrollment.

(3) An individual is not eligible for UPP if the individual enrolls in an employer-sponsored health plan or in COBRA continuation coverage that covers abortion services for any reason other than in the case where the life of the mother would be endangered if the fetus is carried to term or in the case of rape or incest.

([3]4) 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]5) 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]6) 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]7) 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]8) An individual with creditable health coverage operated or financed by Indian Health Services may enroll in the UPP program.

([8]9) 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]10) 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.

 

KEY: CHIP, Medicaid, PCN, UPP

Date of Enactment or Last Substantive Amendment: April 1, 2010

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