Health, Health Care Financing, Coverage and Reimbursement Policy

Rule R414-310

Medicaid Primary Care Network Demonstration Waiver

Notice of Proposed Rule

(Amendment)

DAR File No.: 35334
Filed: 10/13/2011 11:40:41 AM

RULE ANALYSIS

Purpose of the rule or reason for the change:

The purpose of this amendment is to clarify the recertification period for re-enrollment in the Primary Care Network (PCN) program.

Summary of the rule or change:

This amendment clarifies the process for re-enrolling in the PCN program after each 12-month certification period. It also changes the benefit effective date to the first day of the application month and clarifies how changes during the certification period may affect eligibility. It further removes provisions that no longer apply and clarifies change reporting and proper notice requirements to comply with federal requirements on due process. It also updates and corrects certain references and citations in the rule text.

State statutory or constitutional authorization for this rule:

• Section 26-18-3
• Section 26-1-5

This rule or change incorporates by reference the following material:

• Updates 42 CFR 433.138(b) and 435.610, published by Government Printing Office, 10/01/2010
• Updates Section 1915(b) of the Compilation of the Social Security Laws, published by Social Security Administration, 01/01/2011
• Updates 20 CFR 416 Subpart K, Appendix, published by Government Printing Office, 10/01/2010
• Updates 42 CFR 435.907 and 435.908, published by Government Printing Office, 10/01/2010
• Updates 42 CFR 435.911 and 435.912, published by Government Printing Office, 10/01/2010
• Updates 42 CFR 431.206, 431.210, 431.211, 431.213, 431.214, and 435.919, published by Government Printing Office, 10/01/2010

Anticipated cost or savings to:

the state budget:

The Department does not anticipate any impact to the state budget because Medicaid recipients whose enrollment ends for failure to complete a timely recertification usually complete the recertification within the following month and their medical assistance is restored without any break in coverage. Changing the effective date to the first day of the month could result in minor costs if the Department holds another open enrollment period. Nevertheless, the Department has no claims data to quantify these insignificant costs because most recipients do not access services until they are approved for medical assistance. There is no cost or savings to local governments because they do not fund PCN services or determine PCN eligibility.

local governments:

There is no cost or savings to local governments because they do not fund PCN services or determine PCN eligibility.

small businesses:

The Department does not anticipate any impact to small businesses because Medicaid recipients whose enrollment ends for failure to complete a timely recertification usually complete the recertification within the following month and their medical assistance is restored without any break in coverage. Changing the effective date to the first day of the month could result in a minor increase in revenue to small businesses if the Department holds another open enrollment period. Nevertheless, the Department has no claims data to quantify these insignificant gains because most recipients do not access services until they are approved for medical assistance. Moreover, this change does not impose any new requirements that result in costs to businesses.

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

The Department does not anticipate any impact to PCN providers and to PCN recipients because recipients whose enrollment ends for failure to complete a timely recertification usually complete the recertification within the following month and their medical assistance is restored without any break in coverage. Changing the effective date to the first day of the month could result in a minor increase in revenue to providers if the Department holds another open enrollment period. Nevertheless, the Department has no claims data to quantify these insignificant gains because most recipients do not access services until they are approved for medical assistance. Moreover, this change does not impose any new requirements that result in costs to PCN providers and does not reduce any coverage or create out-of-pocket expenses for PCN recipients.

Compliance costs for affected persons:

The Department does not anticipate any impact to a single PCN provider or to a PCN recipient because recipients whose enrollment ends for failure to complete a timely recertification usually complete the recertification within the following month and their medical assistance is restored without any break in coverage. Changing the effective date to the first day of the month could result in a minor increase in revenue to a provider if the Department holds another open enrollment period. Nevertheless, the Department has no claims data to quantify this insignificant gain because most recipients do not access services until they are approved for medical assistance. Moreover, this change does not impose any new requirements that result in costs to a single PCN provider and does not reduce any coverage or create out-of-pocket expenses for a single PCN recipient.

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

This proposed rule amendment strengthens due process protections consistent with federal law that will avoid Medicaid providers extending services and inappropriately being denied reimbursement. Requirements for periodic reviews of an individual's continued eligibility for medical assistance are strengthened and requirements for a recipient to make timely reports of changes and to provide verification of changes are mandated. It further clarifies that the agency cannot end eligibility while it gives recipients time to respond to a request for verification and while it makes a redetermination decision. In addition, this amendment clarifies the requirement to provide appropriate advance notice of an adverse action in accordance with due process requirements.

David Patton, PhD, 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
CANNON HEALTH BLDG
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

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:

12/01/2011

This rule may become effective on:

12/08/2011

Authorized by:

David Patton, Executive Director

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

R414-310. Medicaid Primary Care Network Demonstration Waiver.

R414-310-1. Authority and Purpose .

(1) This rule is authorized by [Utah Code] Sections 26-1-5 and 26-18-3. The Primary Care Network Demonstration is authorized by a waiver of federal Medicaid requirements approved by the [federal] Center s for Medicare and Medicaid Services and allowed under Section 1115 (a) of the Social Security Act.

(2) The purpose of this[ This] rule is to establish[es the] eligibility requirements for enrollment under the Medicaid Primary Care Network Demonstration Waiver.

 

R414-310-2. Definitions.

The definitions in Rule R414-1 apply to this rule. In addition, the following definitions apply throughout this rule:

(1) "American Indian or Alaska Native" means someone having origins in any of the original peoples of North and South America (including Central America) and who maintains tribal affiliation or community attachment.

[ (1) "Applicant" means an individual who applies for benefits under the Primary Care Network program, but who is not an enrollee.

] (2) "Best estimate" means the [Department's]eligibility agency's determination of a household's income for the upcoming certification period based on past and current circumstances and anticipated future changes.

(3) "Co[-]payment and co[-]insurance" means a portion of the cost for a medical service for which the enrollee is responsible to pay for services received under the Primary Care Network.

(4) "Creditable Health Coverage" means any health insurance coverage as defined in 45 CFR 146.113.

([4]5) "Deeming" or "deemed" means a process of counting income from a spouse or an alien's sponsor to decide what amount of income after certain allowable deductions, if any, must be considered income to an applicant or enrollee.

([5]6) "Department" means the Utah Department of Health.

(7) "Due process month" means the month that allows time for the enrollee to return all verification, and for the eligibility agency to determine eligibility and notify the enrollee.

(8) "Eligibility agency" means the Department of Workforce Services (DWS) that determines eligibility for the Primary Care Network program under contract with the Department.

(9) "Employer-sponsored health plan" means health insurance that meets the requirements of Subsection R414-320-2(19)(a), (b), (c), (d) and (e).

([6]10) "Enrollee" means an individual who has applied for and has been found eligible for the Primary Care Network program and has paid the enrollment fee.

([7]11) "Enrollment fee" means a payment that an applicant or an enrollee must pay to the [Department]eligibility agency to enroll in and receive coverage under the Primary Care Network program.

[ (8) "Employer-sponsored health plan" means health insurance that meets the requirements of R414-320-2 (8) (a) (b) (c) (d) and (e).

] (12) "Income annualizing" means a process of determining the average annual income of a household, based on the past history of income and expected changes.

[ (9) "Income averaging" means a process of using a history of past and current income and averaging it over a determined period of time that is representative of future income.

] (1[0]3) "Income anticipating" means a process of using current facts regarding rate of pay, number of working hours, and expected changes to anticipate future income.

[ (11) "Income annualizing" means a process of determining the average annual income of a household, based on the past history of income and expected changes.

] (14) "Income averaging" means a process of using a history of past and current income and averaging it over a determined period of time to represent future income.

[ (12) "Local office" means any Department of Workforce Services office location, outreach location, or telephone location where an individual may apply for medical assistance.

] (1[3]5) "Open enrollment " means a [time] period during which the [Department]eligibility agency accepts applications for the Primary Care Network program.

(1[4]6) "Primary Care Network" or "PCN" means the program for benefits under the Medicaid Primary Care Network Demonstration Waiver.

(1[5]7) "[Recertification]Review month" means the last month of the eligibility period for an enrollee during which the eligibility agency redetermines an enrollee's eligibility for a new certification period.

(1[6]8) "Spouse" means any individual who has been married to an applicant or enrollee and has not legally terminated the marriage.

[ (17) "Verifications" means the proofs needed to decide if an individual meets the eligibility criteria to be enrolled in the program. Verifications may include hard copy documents such as a birth certificate, computer match records such as Social Security benefits match records, and collateral contacts with third parties who have information needed to determine the eligibility of the individual.

] (1[8]9) "Student health insurance plan" means a health insurance plan that is offered to students directly through a university or other educational facility or through a private health insurance company that offers coverage plans specifically for students.

([19]20) "Utah's Premium Partnership for Health Insurance" or "UPP" means the program described in Rule R414-320.

(21) "Verification" means the proof needed to decide whether an individual meets the eligibility criteria to be enrolled in the UPP program. Verification may include hard copy documents such as a birth certificate, computer match records such as Social Security benefits match records, and collateral contacts with third parties who have information needed to determine the eligibility of the individual.

 

R414-310-3. Applicant and Enrollee Rights and Responsibilities.

(1) Any person may apply during an open enrollment period who meets the limitations set by the Department. The open enrollment period may be limited to:

(a) an individual[s] with children under the age of 19 in the home;

(b) an individual[s] without children under the age of 19 in the home;

(c) [those]an individual who is enrolled in the PCN program;

(d) [those]an individual who is enrolled in the UPP program;

(e) [those]an individual who is enrolled in the General Assistance program;

(f) [those that were]an individual who is enrolled in the Medicaid program within [the last thirty]30 days [prior to]before the [beginning of the] open enrollment period begins; or

(g) [such]any [other] group [designated in advance by]that the Department designates in advance to be consistent with efficient administration of the program.

(2) If a person needs help to apply, he may have a friend or family member help, or he may request help from the [local office]eligibility agency or outreach staff.

(3) An [A]applicant[s and] or enrollee[s] must provide requested information and verification[s] within the time limits given. The [Department will]eligibility agency shall allow the client at least [10]ten calendar days from the date of a request to provide information and may grant [additional]more time to provide information and verification[s] upon request of the applicant or enrollee.

(4) An [A]applicant[s and] or enrollee[s have] has a right to be notified about the decision made on an application, or other action taken that affects their eligibility for benefits.

(5) An [A]applicant[s and] or enrollee[s] may look at information in [their]his case file that [was]the eligibility agency use[d]s to make an eligibility determination.

(6) Anyone may look at the eligibility policy manuals located at any [Department local]eligibility agency office.

(7) An individual must repay any benefits that the individual receive[d]s under [the Primary Care Network program]PCN if the [Department]eligibility agency determines that the individual [was]is not eligible to receive [such]the benefits.

(8) An [A]applicant[s and] or enrollee[s] must report certain changes to the [local office]eligibility agency within ten calendar days of the day the change becomes known. The [local office shall notify]eligibility agency shall notify the applicant at the time of application of the changes that the enrollee must report. Some examples of reportable changes include:

(a) An enrollee in [the Primary Care Network program]PCN begins to receive coverage or to have access to coverage under a group health plan or other health insurance coverage[.];

[ (b) An enrollee in the Primary Care Network program begins to have access to coverage under a group health plan or other health insurance coverage.

] ([c]b) An enrollee in [the Primary Care Network program]PCN begins to receive coverage under, or begins to have access to student health insurance, Medicare Part A or B, or the Veteran's Administration Health Care System[.];

([d]c) An enrollee leaves the household or dies[.];

([e]d) An enrollee or the household moves out of state[.];

([f]e) Change of address of an enrollee or the household[.]; or

([g]f) An enrollee enters a public institution or an institution for mental diseases.

(9) An applicant or enrollee has a right to request an agency conference or a fair hearing as described in Sections R414-301-5 and R414-301-6.

(10) An enrollee in [the Primary Care Network program]PCN is responsible for paying any required co[-]payments or co[-]insurance amounts to providers for medical services that the enrollee receives that are covered under [the Primary Care Network program]PCN.

 

R414-310-4. General Eligibility Requirements.

(1) The provisions of Sections R414-302-1, R414-302-2, [R414-302-3,] R414-302-5, and R414-302-6 concerning United States (U.S.) citizenship, alien status, state residency, use of social security numbers, and applying for other benefits, apply to applicants and enrollees of [the Primary Care Network program]PCN.

(2) An individual who is not a U.S. citizen or national, [and]or who does not meet the alien status requirements of Section R414-302-1 is not eligible for any services or benefits under [the Primary Care Network program]PCN.

(3) An [A]applicant[s and] or enrollee[s are] is not required to provide Duty of Support information to enroll in [the Primary Care Network program]PCN. An individual who would be eligible for Medicaid , but fails to cooperate with Duty of Support requirements required by the Medicaid program , cannot enroll in [the Primary Care Network program]PCN.

(4) An [I]individual[s] who must pay a spenddown or premium to receive Medicaid can enroll in [the Primary Care Network program]PCN if :

(a) [they]the individual meet s [the]PCN program eligibility criteria in any month [they]that the individual do es not receive Medicaid ; and[as long as]

(b) the Department [has not stopped]does not stop enrollment under the provisions of Subsection R414-310-16(2). If the Department [has] stop[ped]s enrollment, the individual must wait for an [applicable] open enrollment period to enroll in the PCN program.

 

R414-310-5. Verification and Information Exchange.

(1) The provisions of Section R414-308-4 regarding verification of eligibility factors apply to applicants and enrollees of [the Primary Care Network program]PCN.

(2) The Department shall safeguard[s] information about applicants and enrollees [according to]to comply with the provisions [found in]of Section R414-301-4.

 

R414-310-6. Residents of Institutions.

The provisions of Subsection R414-302-4(1)[, (3)] and (4) apply to applicants and enrollees of [the Primary Care Network program]PCN.

 

R414-310-7. Creditable Health Coverage.

(1) The Department adopts 42 CFR 433.138(b) and 435.610, [2004]2010 ed., and Section 1915(b) of the Compilation of the Social Security Laws, in effect January 1, 20[04]11, which are incorporated by reference.

(2) [An]Subject to Subsection R414-310-7(10), an individual who is covered under a group health plan or other creditable health insurance coverage, as defined in 29 CFR 2590.701-4, 2010 ed.[by the Health Insurance Portability and Accountability Act of 1996 (HIPAA)], at the time of application is not eligible for enrollment in [the Primary Care Network program]PCN. This includes coverage under Medicare Part A or B, student health insurance, and the Veteran's Administration Health Care System. [However]Nevertheless, an individual who is enrolled in the Utah Health Insurance Pool may enroll in [the Primary Care Network program]PCN.

(3) The [E]eligibility agency determines PCN eligibility[for the Primary Care Network program] for an individual who has access to but has not yet enrolled in health insurance coverage through an employer or a spouse's employer [will be determined] as follows:

(a) If the cost of the least expensive health insurance plan offered by the employer does not exceed 15% of the household's countable gross income as defined in this rule, the individual is not eligible for [the Primary Care Network program]PCN.

(b) If the cost of the least expensive health insurance plan is 5% or more of the household's countable gross income, the individual may enroll in the employer's health insurance plan and the UPP program during an open enrollment period. The employer's health plan must meet the requirements of Subsection R414-320-2(19).

([b]c) If the cost of the least expensive health insurance plan offered by the employer exceeds 15% of the household's countable gross income, [and the employer offers a health plan that meets the requirements of R414-320-2 (8) (a) (b) (c) (d) and (e), ]the individual may choose to enroll in either [the Primary Care Network program]PCN or the UPP program . The following conditions apply:

(i) to enroll in UPP, the employer's health insurance plan must meet the requirements of Subsection R414-320-2(19); and

(ii) [unless] enrollment for [one of these programs]the program that the individual chooses to enroll in has not been stopped under the provisions of Subsections R414-310-16(2) or R414-320-16(2).

([c]d) If the cost of the least expensive health insurance plan offered by the employer exceeds 15% of the household's gross income, but the employer does not offer a health plan that meets the requirements in Subsection R414-320-2[(8)(a) (b) (c) (d) and (e)](19), the individual may only enroll in the PCN program.

([d]4) The eligibility agency considers the individual [is considered] to have access to coverage even [if]when the employer only offers coverage [only] during an open enrollment period.

(5) The cost of coverage includes a deductible if the employer plan has a deductible that must be met before it will pay any claims. If the employee must be enrolled to enroll the spouse, the cost of coverage for the spouse includes the cost to enroll the employee and the spouse.

([4]6) 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 in [the Primary Care Network program]PCN, even [if]when the individual must wait for a Medicare open enrollment period to apply for Medicare benefits.

([5]7) An individual who is enrolled in the Veteran's Administration (VA) Health Care System is not eligible for enrollment in [the Primary Care Network program]PCN. An individual who is eligible to enroll in the VA Health Care System, but who has not yet enrolled, may be eligible for [the Primary Care Network program]PCN 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 Primary Care Network program]PCN ends once the individual becomes enrolled in the VA Health Care System.

([6]8) Individuals who are full-time students and who can enroll in student health insurance coverage are not eligible to enroll in [the Primary Care Network program]PCN.

(9) An individual who voluntarily terminates health insurance coverage is ineligible to enroll in PCN for six months after the date that the earlier health insurance ends.

(a) To be eligible to enroll in PCN, the six-month ineligibility period must end by the earlier of the following dates:

(i) the last day of the open enrollment period during which the individual applies for PCN; or

(ii) the last day of the month that follows the month in which the individual applies for PCN, if the open enrollment period does not expire before that following month ends.

(b) If the six-month ineligibility period does not end by the earlier of the dates mentioned in Subsection R414-310-7(9)(a)(i)(ii), the eligibility agency shall deny the application.

(c) The effective date of enrollment in PCN must be after the six-month ineligibility period ends.

[ (7) The Department shall deny eligibility if the applicant or spouse has voluntarily terminated health insurance coverage within the six months immediately prior to the application date for enrollment under the Primary Care Network program. An applicant or an applicant's spouse can be eligible for the Primary Care Network if their prior insurance ended more than six months before the application date.]

(10) An applicant or applicant's spouse who voluntarily discontinues health insurance coverage under a Consolidated Omnibus Budget Reconciliation Act (COBRA ) plan or under the [s]State Health Insurance Pool, or who is involuntarily terminated from an employer's plan may be eligible for [the Primary Care Network program]PCN without a six[ ] -month [waiting]ineligibility period.

(a) An individual is eligible to enroll in PCN if the individual's health insurance coverage expires before the end of the calendar month that follows the month in which he applies for PCN.

(b) The PCN enrollment date must be after health insurance coverage ends.

([8]11) Notwithstanding the limitations in [this s]Section R414-310-7, an individual with creditable health coverage operated or financed by [the] Indian Health Services may enroll in [the Primary Care Network program]PCN.

([9]12) An [I]individual[s] 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, a student health insurance plan, Medicare Part A or B, or the VA Health Care System.

([10]13) The [Department shall deny]eligibility agency shall deny an application or recertification if the applicant or enrollee fails to respond to questions about health insurance coverage for any individual that the household seeks to enroll or recertify in the program.

 

R414-310-8. Household Composition.

(1) The following individuals are included in the household when determining household size for the purpose of computing financial eligibility for [the Primary Care Network Program]PCN:

(a) the individual;

(b) the individual's spouse living with the individual;

(c) any children of the individual or the individual's spouse who are under the age of 19 and living with the individual; and

(d) an unborn child if the individual is pregnant, or if the applicant's legal spouse who lives in the home is pregnant.

(2) A household member who is temporarily absent for schooling, training, employment, medical treatment or military service, or who will return home to live within 30 days from the date of application is considered part of the household.

(3) Any household member defined in Subsection R414-310-8(1) who is not a U.S. citizen or national, or who is not a qualified resident alien is included in the household size. The eligibility agency counts that individual's income the same way that it counts the income of a U.S. citizen, national, or qualified resident alien.

 

R414-310-9. Age Requirement.

(1) An individual must be at least 19 and not yet 65 years of age to enroll in [the Primary Care Network program]PCN.

(2) The month in which an individual['s] turns 19[th] years of age[birthday occurs] is the first month that the person [can]may enroll in [be eligible for enrollment in the Primary Care Network program]PCN. The effective date of enrollment for an applicant who meets the eligibility criteria for PCN and who turn 19 or 65 years of age is defined in Section R414-310-15.

[ (a) If the individual could qualify for Medicaid in that month without paying a spenddown or premium, the individual cannot enroll in the Primary Care Network program until the following month.

(b) If the individual could enroll in the Children's Health Insurance Program, the individual cannot enroll in the Primary Care Network program until the following month.

(3) The benefit effective date for the Primary Care Network program cannot be earlier than the date of the 19th birthday.

(4) The individual's 65th birthday month is the last month the person can be eligible for enrollment in the Primary Care Network program.

]

R414-310-10. Income Provisions.

(1) To be eligible to enroll in [the Primary Care Network program]PCN, a household's countable gross income must be equal to or less than 150% of the federal , non-farm , poverty guideline for a household of the same size. An individual with income above 150% of the federal poverty guideline is not allowed to spend down income to be eligible under [the Primary Care Network program]PCN. All gross income, earned and unearned, received by the individual and the individual's spouse is counted toward household income, unless this section specifically describes a different treatment of the income. Income that is excluded under this section is not countable income.

[ (2) The Department does not count as income any payments from sources that federal laws specifically prohibit from being counted as income to determine eligibility for the Primary Care Network.

] ([3]2) Any income in a trust that is available to, or is received by a household member, is income of the person for whom it is received. It is countable income if the eligibility agency counts that person's income to determine eligibility.

([4]3) Payments received from the Family Employment Program, Working Toward Employment program, refugee cash assistance or adoption support services as authorized under Title 35A, Chapter 3 are countable income.

([5]4) Rental income is countable income. The following expenses [can]may be deducted:

(a) taxes and attorney fees needed to make the income available;

(b) upkeep and repair costs necessary to maintain the current value of the property;

(c) utility costs only if they are paid by the owner; and

(d) interest only on a loan or mortgage secured by the rental property.

([6]5) Cash contributions made by non-household members are counted as income unless the parties have a signed written agreement for repayment of the funds.

([7]6) The interest earned from payments made under a sales contract or a loan agreement is countable income to the extent that the household member continues to receive these payments[that these payments will continue to be received] during the certification period.

([8]7) Needs-based Veteran's pensions are counted as income. Only the portion of a Veteran's Administration check to which the individual is legally entitled is countable income. Any portion of the payment that is for other family members counts as that family member's income.

([9]8) Child support payments that a household member receive[d]s for a dependent child living in the home are counted as that child's income , and do not count as income of the parent.

([10]9) In-kind income, which is goods or services provided to the individual from a non-household member and which is not in the form of cash, for which the individual performed a service or which is provided as part of the individual's wages is counted as income. In-kind income for which the individual did not perform a service, or did not work to receive, is not counted as income.

([11]10) Supplemental Security Income and State Supplemental payments are countable income.

([12]11) Income, unearned and earned, [shall be]is deemed from an alien's sponsor, and the sponsor's spouse, if any, when the sponsor has signed an Affidavit of Support pursuant to Section 213A of the Immigration and Nationality Act [on or] after December 1[9]8, 1997. Sponsor deeming will end when the alien becomes a naturalized U.S. citizen, or has worked 40 qualifying quarters as defined under Title II of the Social Security Act or can be credited with 40 qualifying work quarters. [Beginning a]After December 31, 1996, a creditable qualifying work quarter is one during which the alien did not receive any federal means-tested public assistance.

([13]12) Income that is [defined]excluded [in]under 20 CFR 416 Subpart K, Appendix, [2004]2010 edition, which is incorporated by reference, is not countable.

([14]13) Payments that are prohibited under other federal laws from being counted as income to determine eligibility for federally-funded medical assistance programs are not countable.

([15]14) Death benefits are not countable income to the extent that the funds are spent on the deceased person's burial or last illness.

([16]15) A bona fide loan that an individual must repay and that the individual has contracted in good faith without fraud or deceit, and genuinely endorsed in writing for repayment is not countable income.

([17]16) Child Care Assistance under Title XX is not countable income.

([18]17) Reimbursements of Medicare premiums [received by]that an individual receives from the Social Security Administration [or the State Department of Health] are not countable income.

([19]18) [Earned and unearned income of a child who is under age 19 is not counted if the child is not the head of a household.] If the spouse of an applicant or enrollee is under the age of 19, the eligibility agency counts that spouses earned and unearned income only if the spouse is the head of the household.

([20]19) Educational income, such as educational loans, grants, scholarships, and work-study programs are not countable income. The individual must verify enrollment in an educational program.

(2[1]0) Reimbursements for employee work expenses incurred by an individual are not countable income.

(2[2]1) The value of food stamp assistance is not countable income.

(2[3]2) Income paid by the U.S. Census Bureau to a temporary census taker to prepare for and conduct the census is not countable income.

[ (24) The additional $25 a week payment to unemployment insurance recipients provided under Section 2002 of the American Recovery and Reinvestment Act of 2009, Pub. L. No. 111 5, which an individual may receive from March 2009 through June 2010 is not countable income.

] (2[5]3) The one-time economic recovery payments received by individuals receiving social security, supplemental security income, railroad retirement, or veteran's benefits under the provisions of Section 2201 of the American Recovery and Reinvestment Act of 2009, Pub. L. No. 111 5, 123 Stat. 115, and refunds received under the provisions of Section 2202 of the American Recovery and Reinvestment Act of 2009, Pub. L. No. 111 5, 123 Stat. 115, for certain government retirees are not countable income.

[ (26) The Consolidated Omnibus Reconciliation Act (COBRA) premium subsidy provided under Section 3001 of the American Recovery and Reinvestment Act of 2009, Pub. L No. 111 5, 123 Stat. 115, is not countable income.

(27) The making work pay credit provided under Section 1001 of the American Recovery and Reinvestment Act of 2009, Pub. L. No. 111 5, 123 Stat. 115, is not countable income.

]

R414-310-11. Budgeting.

[ This section describes methods that the Department uses to determine the household's countable monthly or annual income.

] (1) Subject to the limitation in Subsection R414-310-10(18), [T]the eligibility agency counts the gross income of all household members [is counted in]to determin[ing]e the eligibility of the applicant or enrollee, unless the income is excluded under this rule. The agency only deducts [Only]required expenses from the gross income[that are required] to make an income available to the individual[ are deducted from the gross income]. No other deductions are allowed.

(2) The [Department]eligibility agency determines monthly income by taking into account the months of pay where an individual receives a fifth paycheck when paid weekly, or a third paycheck when paid every other week. The [Department]eligibility agency multiplies the weekly amount by 4.3 to obtain a monthly amount[. The Department] and multiplies income paid biweekly by 2.15 to obtain a monthly amount.

(3) The [Department shall]eligibility agency determine s an individual's eligibility prospectively for the upcoming certification period at the time of application and at each recertification for continuing eligibility. The [Department]eligibility agency determines prospective eligibility by using the best estimate of the household's average monthly income that [is]the agency expect[ed]s the household to [be] receive[d] or [made]to become available to the household during the upcoming certification period. The [Department]eligibility agency prorates income that is received less often than monthly over the certification period to determine an average monthly income. The [Department]eligibility agency may request [prior]earlier years' tax returns as well as current income information to determine a household's income.

(4) Methods of determining the best estimate are income averaging, income anticipating, and income annualizing. The [Department]eligibility agency may use a combination of methods to obtain the [most accurate] best estimate. The best estimate may be a monthly amount that the agency [is] expect[ed]s the household to [be] receive[d] each month of the certification period, or an annual amount that is prorated over the certification period. The [Department]eligibility agency may use different methods for different types of income [received in]that the same household receives.

(5) The [Department]eligibility agency determines farm and self-employment income by using the individual's most recent tax return forms. If tax returns are not available, or are not reflective of the individual's current farm or self-employment income, the [Department]eligibility agency may request income information from the most recent time period during which the individual had farm or self-employment income. The [Department]eligibility agency deducts 40% of the gross income as a deduction for business expenses to determine the countable income of the individual. For individuals who have business expenses greater than 40%, the [Department]eligibility agency may exclude more than 40% if the individual can demonstrate that the actual expenses were greater than 40%. The [Department]eligibility agency deducts the same expenses from gross income that the Internal Revenue Service allows as self-employment expenses.

(6) The [Department]eligibility agency may annualize income for any household and specifically for households that have self-employment income, receive income sporadically under contract or commission agreements, or receive income at irregular intervals throughout the year.

(7) The [Department]eligibility agency may request additional information and verification about how a household is meeting expenses if the average household income appears to be insufficient to meet the household's living expenses.

 

R414-310-12. Assets.

There is no asset test for eligibility in [the Primary Care Network program]PCN.

 

R414-310-13. Application Procedure.

(1) The Department adopts 42 CFR 435.907 and 435.908, [2004]2010 ed., which are incorporated by reference.

(2) To enroll in PCN, [T]the applicant must complete and sign a written application or complete an online application [on-line via the Internet]during an open enrollment period[ to enroll in the Primary Care Network program]. The provisions of Section R414-308-3 apply to PCN applicants[ of the Primary Care Network].

(a) The eligibility agency shall review an application to determine eligibility for the PCN program if the application is pending approval when the open enrollment period begins.

(b) An applicant must follow the provisions of Section R414-310-14 to reapply for each recertification.

(3) The [Department]eligibility agency shall reinstate a medical case without requiring a new application if the agency closes the case [was closed] in error.

[ (4) The Department shall continue enrollment without requiring a new application if the case was closed for failure to complete a recertification or comply with a request for information or verification:

(a) if the enrollee complies before the effective date of the case closure or by the end of the month immediately following the month the case was closed; and

(b) the individual continues to meet all eligibility requirements.

] ([5]4) An applicant may withdraw an application for [the Primary Care Network program]PCN any time before the [Department]eligibility agency completes an eligibility decision on the application.

([6]5) [The]An applicant or enrollee [shall]must pay an annual enrollment fee for each 12-month recertification period to enroll in [the Primary Care Network Program]PCN. Upon the eligibility agency determining that the individual meets the eligibility criteria for enrollment, the individual must pay the enrollment fee when he applies and recertifies for PCN.[ once the local office has determined that the individual meets the eligibility criteria for enrollment.]

(a) An applicant must pay the enrollment fee within 30 days of the date on the notice that approves enrollment.

(b) To reenroll after the individual recertifies, the individual must pay the enrollment fee within 30 days of the date on the notice that approves enrollment, or by the end of the month that follows the review month, whichever is longer.

([a]c) The [Department]eligibility agency does not require an American Indian[s] or Alaska Native to pay an enrollment fee. This enrollment fee waiver applies to both the individual and the spouse if both are enrolled and at least one of them is an American Indian or Alaska Native. If only one spouse is enrolled in PCN and is not an American Indian or Alaska Native, that spouse must pay the enrollment fee to enroll in PCN.

([b]d) Coverage [does not begin until]may only become effective when the [Department]eligibility agency receives the enrollment fee. The provisions of Section R414-310-15 determine the effective date of enrollment. The eligibility agency shall deny enrollment if the individual does not pay the enrollment fee timely.

([c]e) The enrollment fee covers both the individual and the individual's spouse if the spouse is also eligible for enrollment in [the Primary Care Network Program]PCN.

[ (d) The enrollment fee is required at application and at each recertification.

] ([e]f) The applicant or enrollee must pay the enrollment fee to DWS[must be paid to the local office] in cash, by debit or credit card, or by check or money order made out to [the Department of Health or to the Department of Workforce Services]DWS.

([f]g) The enrollment fee for an individual or married couple receiving General Assistance from [the Department of Workforce Services]DWS is $15. The enrollment fee for an individual or couple who does not receive General Assistance but whose countable income is less [that]than 50[percent]% of the federal poverty guideline applicable to their household size is $25. The enrollment fee for any other individual or married couple is $50.

([g]h) [The Department]DWS may refund the enrollment fee if it decides that the person [was]is ineligible for the program; however, [the Department]DWS may retain the enrollment fee to the extent that the individual owes any overpayment of benefits [that were]that DWS pa[id]ys in error on behalf of the individual[ by the Department].

([7]6) If an eligible household requests enrollment for a spouse, the application date for the spouse is the date of the request. The eligibility agency may not require a[A] new application form[ is not required]; however, the household [shall]must provide [the]requested information [necessary] to determine eligibility for the spouse[,]. The household must provide [including] information about access to creditable health insurance[,] that includ[ing]es Medicare Part A or B, student health insurance, and the VA Health Care System.

(a) [Coverage or benefits for the spouse will be allowed from the date of request or the date an application is received]The effective date of enrollment to add a spouse to an open PCN case is defined in Section R414-310-15. Coverage continues through the end of the [current] certification period.

(b) The eligibility agency may not require [A]a new enrollment fee [is not required] to add a spouse during the [current] certification period.

(c) The eligibility agency may not require [A]a new income test [is not required] to add [the]a spouse for the months remaining in the [current] certification period.

(d) An eligible household may only add a [A] spouse [may be added only] if [the Department]DWS [has]does not stop[ped] enrollment under Subsection R414-310-16 (2).

(e) The eligibility agency shall count [I]income of the spouse [will be considered] and require payment of the enrollment fee [will be required] at the next scheduled recertification.

 

R414-310-14. Eligibility Decisions and Recertification.

(1) The Department adopts 42 CFR 435.911 and 435.912, [2004]2010 ed., which are incorporated by reference.

(2) When an individual applies for PCN, the [local office]eligibility agency shall determine [if]whether the individual is eligible for Medicaid or CHIP.

(a) An individual who qualifies for Medicaid without paying a spenddown , a poverty level pregnant woman asset copayment or a n MWI premium cannot enroll in [the Primary Care Network program]PCN. An applicant who turns 19 years of age during the application month and qualifies for Medicaid or CHIP during that month may enroll in PCN the following month in accordance with Section R414-310-15.

(b) If the individual appears to qualify for Medicaid , or CHIP, but additional information is required to [determine eligibility for Medicaid]make that determination, the applicant must provide additional information requested by the eligibility worker. [Failure to provide the requested information shall result in the application being denied.]The eligibility agency shall deny the application if the individual fails to provide the requested information.

([a]3) If the individual qualifies for Medicaid and PCN, but must pay a spenddown , poverty level, pregnant woman asset copayment or MWI premium to qualify for Medicaid, the individual may choose to enroll in the PCN program .[ if it is an open enrollment period, and the individual meets all the applicable criteria for eligibility.] If the PCN program is not in an enrollment period, the applicant may choose to enroll in Medicaid[the individual must] and wait for an open enrollment period to reapply for PCN.

(a) PCN does not cover prenatal or delivery services for a pregnant woman.

(b) PCN does not provide long-term care services in a medical institution or under a home and community-based waiver.

[ (b) At recertification for PCN, the local office shall first review eligibility for Medicaid. If the individual qualifies for Medicaid without a spenddown or premium, the individual cannot be reenrolled in the PCN program. If the individual appears to qualify for Medicaid, the applicant must provide additional information requested by the eligibility worker. Failure to provide the requested information shall result in the application being denied.

] ([3]4) To enroll, the individual must meet the eligibility criteria for enrollment in [the Primary Care Network program]PCN, pay the enrollment fee, and [it must be a time when the Department has not stopped]enroll during an open enrollment period under [s]Section R414-310-16.

([4]5) The [local office shall]eligibility agency shall complete a determination of eligibility or ineligibility for each application unless:

(a) the applicant voluntarily withdraws the application and the [local office]eligibility agency sends a notice to the applicant to confirm the withdrawal;

(b) the applicant die[d]s; [or]

(c) the applicant cannot be located; or

(d) the applicant [has]does not respond[ed] to requests for information within the 30 -day application period or by the verification due date[ the eligibility worker asked the information or verifications to be returned], if [that]the verification date is later.

(6) Upon determining that the applicant is eligible for PCN and upon receiving payment of the enrollment fee, the eligibility agency shall enroll the individual in PCN for a 12-month certification period. The eligibility agency shall end enrollment after the 12-month certification period.

[ (5) The enrollee must recertify eligibility at least every 12 months.

] (7) The eligibility agency shall provide an enrollee the opportunity to reenroll for a 12-month certification period when the certification period is near completion.

(a) The recertification is a reapplication to determine whether the enrollee is eligible to enroll in a new 12-month certification period.

(b) The eligibility agency shall notify the enrollee that PCN benefits end after the 12-month certification period.

(c) The eligibility agency shall inform the enrollee of the necessary steps to complete the recertification.

(8) At each recertification, the eligibility agency shall determine whether the enrollee is eligible for Medicaid. The individual may not reenroll in PCN if the individual qualifies for Medicaid without a cost. If the individual appears to qualify for Medicaid, the individual must provide additional information requested by the agency. The eligibility agency shall deny recertification if the individual fails to provide the requested information.

(9) The eligibility agency may request verification from the enrollee if the enrollee responds to the recertification request during the review month.

(a) The eligibility agency shall send a written request for the necessary verification.

(b) The application processing period is based on the date that the enrollee contacts the eligibility agency to complete the recertification.

(c) The eligibility agency shall determine eligibility if the enrollee provides all verification by the verification due date or by the end of the application processing period . The agency shall either approve a new 12-month certification period pending payment of the enrollment fee or deny eligibility for a new certification period. The eligibility agency shall notify the enrollee of its decision.

(10) If the enrollee fails to respond to the request for recertification or does not provide all verification with the application processing period, the enrollee may reapply in the calendar month that follows the effective closure date.

(a) The enrollee must reapply by responding to the recertification request and providing all requested verification; or

(b) file a new application before the end of the due process month that follows the review month.

(c) The application processing period is based on the date that the enrollee contacts the eligibility agency to complete the recertification, provides all requested verification, or reapplies.

(d) The benefits become effective upon the enrollee paying the required enrollment fee if the eligibility agency approves an enrollee for a new 12-month certification period.

(e) The eligibility agency shall notify the enrollee if the agency does not approve an enrollee for the new certification period.

(11) The enrollee must wait for the next open enrollment period to reapply for PCN if the enrollee fails to respond to a request for recertification or does not file a new application before the end of the month that follows the review month.

[ (6) The local office eligibility worker may require the applicant, the applicant's spouse, or the applicant's authorized representative to attend an interview as part of the application and recertification process. Interviews may be conducted in person or over the telephone, at the local office eligibility worker's discretion.

(7) The enrollee must complete the recertification process and provide the required verifications by the end of the recertification month.

(a) If the enrollee completes the recertification, continues to meet all eligibility criteria and pays the enrollment fee, coverage will be continued without interruption.

(b) The case will be closed at the end of the recertification month if the enrollee does not complete the recertification process and provide required verifications by the end of the recertification month.

(c) If an enrollee does not complete the recertification by the end of the recertification month, but completes the process and provides required verifications by the end of the month immediately following the recertification month, coverage will be reinstated as of the first of that month if the individual continues to be eligible and pays the enrollment fee.

(8) The eligibility worker may extend the recertification due date if the enrollee demonstrates that a medical emergency, death of an immediate family member, natural disaster or other similar cause prevented the enrollee from completing the recertification process on time.

]

R414-310-15. Effective Date of Enrollment, Change Reporting and Enrollment Period.

[(1) The effective date of enrollment in the Primary Care Network program is the day that a completed and signed application is received by the medical eligibility agency as defined in Subsection R414-308-3(2)(a) and (b) and the applicant meets all eligibility criteria, including payment of the enrollment fee. The Department shall not provide any benefits or pay for any services received before the effective enrollment date.

] (1) Subject to the limitations in Sections R414-306-6 and R414-310-7, the effective date of PCN enrollment is the first day of the month in which the eligibility agency receives an application with the following exceptions:

(a) An applicant who turns 19 years of age during the application month and before the end of the open enrollment period in the application month is enrolled in PCN as follows:

(i) The eligibility agency shall enroll the applicant in Medicaid if the applicant qualifies for Medicaid during the application month without cost. In this instance, enrollment in PCN becomes effective for the month that follows the application month if the applicant neither qualifies for Medicaid nor qualifies without cost and chooses not to pay for Medicaid during that following month;

(ii) The eligibility agency shall enroll the applicant in CHIP if the applicant qualifies for enrollment in CHIP during the application month. Enrollment in PCN then becomes effective for the following month;

(iii) If the applicant is not eligible for Medicaid without cost and is not eligible for CHIP in the application month, enrollment in PCN becomes effective in the application month, but no earlier than when the applicant turns 19 years of age;

(iv) The applicant is not eligible for PCN if the applicant turns 19 years of age after the open enrollment period.

(b) An applicant who turns 65 years of age during the application month and applies before age 65 may enroll in PCN, which coverage becomes effective on the first day of the application month subject to the limitations in Section R414-310-15. The applicant is not eligible for PCN if the applicant is not eligible for Medicaid without cost in the application month. The eligibility agency shall end enrollment after the month in which the applicant turns 65 years of age.

(c) The eligibility agency shall deny enrollment to an individual if the individual applies for PCN upon turning 65 years of age.

(d) Subject to the limitations in Section R414-310-15 and the open enrollment requirement, the effective date of enrollment for the spouse of an enrollee is the first day of the month in which the enrollee requests to add the spouse.

(2) The eligibility agency shall enroll an applicant who meets all eligibility criteria and pays the enrollment fee for a 12-month certification period that begins with the first month of enrollment. The applicant must pay the enrollment fee before any benefits for a 12-month certification period become effective. The Department may not provide any benefits or pay for any services that an applicant receives before the effective date of enrollment.

([2]3) The effective date of re[-]enrollment for [a]PCN recertification [in the Primary Care Network program] is the first day [of the month] after the [recertification]review month, if the recertification is completed as described in either Subsection R414-310-14([7]9) or (10). The enrollee must continue to meet all eligibility criteria and pay the enrollment fee timely before benefits become effective for the new 12-month certification period.

[ (3) If the enrollee does not complete the recertification as described in R414-310-14(7), and the enrollee does not have good cause for missing the deadline, the case will remain closed and the individual may reapply during another open enrollment period.

(4) An individual found eligible for the Primary Care Network program shall be eligible from the effective date through the end of the first month of eligibility and for the following 12 months. If the enrollee completes the recertification process in accordance with R414-310-14(7) and continues to be eligible, the recertification period will be for an additional 12 months beginning the month following the recertification month.]

(4) The [E]eligibility agency [could]shall end eligibility before the end of a 12-month certification period for any of the following reasons:

(a) the individual turns 65 years of age[ 65];

(b) the individual becomes a full-time student who is entitled to receive student health insurance[,] and Medicare, or becomes covered by Veterans Administration Health Insurance;

(c) the individual dies;

(d) the individual moves out of state or cannot be located; or

(e) the individual enters a public institution or an Institut[e]ion for Mental Disease.

(5) [An individual enrolled in the Primary Care Network program]The eligibility agency shall end PCN enrollment [loses eligibility] when the individual enrolls in any type of group health plan or other creditable health insurance coverage including an employer-sponsored health plan, except under the following circumstances:

(a) An individual who gains access to or enrolls in an employer-sponsored health plan may switch to the UPP program . The[if the] individual [notifies]must notify the [local office]eligibility agency within ten calendar days of enrolling in the plan or within ten days after coverage begins, whichever is longer, to switch to UPP.[ before the coverage in the employer-sponsored health plan begins, and if the] The individual must meet the requirements defined in Subsection R414-310-7(3)(b) and (c) [are met]except that the individual does not have to enroll in UPP during an open enrollment period[.];

(b) The eligibility agency shall continue PCN eligibility through the end of the certification period if the individual gains access to an employer-sponsored health plan but does not enroll in the plan. The eligibility agency shall end eligibility after the due process month if the enrollee does not return requested verification upon receiving proper notice;

(i) The individual is not eligible to reenroll for a new 12-month certification period if the enrollee has access to an employer-sponsored health plan that costs less than 15% of the enrollee's countable gross income at the next recertification;

(ii) The enrollee may choose to switch to UPP if the enrollee can enroll in the employer's health plan upon recertifying, and the plan meets the requirements of Subsection R414-310-7(3)(b) and (c) and costs 5% or more of the enrollee's countable gross income. The enrollee may reenroll in PCN if the cost exceeds 15% of the enrollee's countable gross income.

([b]6) An individual who enrolls in the Utah Health Insurance Pool [(H.I.P.)] does not lose PCN eligibility[in the Primary Care Network].

(7) An enrollee who fails to report changes or return verifications timely must repay any overpayment of benefits for which the individual is not eligible to receive.

(8) The individual may file a new application or make a request to the eligibility agency to reenroll if a PCN case closes for any reason.

(a) The individual must file a new application or make a request to reenroll within the calendar month that follows the effective closure date;

(b) The eligibility agency shall process the request as a new application. The agency shall waive the open enrollment period and determine whether the individual is still eligible for PCN;

(c) The eligibility agency shall continue eligibility through the end of the certification period if the agency determines that the individual is eligible for PCN;

(d) The eligibility agency shall approve the individual for a new certification period if the certification period ends when the agency determines that the individual is eligible. The individual must pay the enrollment fee for the new 12-month certification period;

(e) The eligibility agency shall deny the request to reenroll and send a notice to the individual if the agency determines that the individual is not eligible for PCN.

(9) The eligibility agency shall determine eligibility for PCN if a Medicaid-eligible recipient reports a change during a PCN enrollment month that makes the recipient ineligible for Medicaid or causes a spenddown. The effective date of enrollment for PCN is the day after the Medicaid case closes if the agency determines that the recipient is eligible for PCN and the recipient pays the enrollment fee timely.

([6]10) If a [Primary Care Network]PCN case closes for any reason, other than to become covered by another Medicaid or UPP program, and remains closed for one or more calendar months, the individual must submit a new application to the [local office]eligibility agency during an enrollment period to reapply. The individual must meet all the requirements of a new applicant including paying a new enrollment fee.

([7]11) If a [Primary Care Network]PCN case closes because the enrollee is eligible for another Medicaid program or UPP, the individual may request to reenroll in [the Primary Care Network program]PCN if there is no break in coverage between the programs, even if the [State]eligibility agency [has stopped enrollment]ends open enrollment under Subsection R414-310-16(2).

(a) If the individual's 12-month certification period has not ended, the individual may reenroll for the [remainder]rest of that certification period. The individual is not required to complete a new application or have a new income eligibility determination. The individual must continue to meet the criteria defined in Section R414-310-7. The individual is not required to pay a new enrollment fee for the months remaining in the [current] certification period.

(b) If the 12-month certification period from the [prior]earlier enrollment [has ended]ends, the individual may still reenroll in [the Primary Care Network program]PCN. [However, the]The individual must [complete a new application,] meet eligibility and income guidelines, and pay a new enrollment fee for the new 12-month certification period.

[ (c) If there is a break in coverage of one or more calendar months between programs, the individual must reapply during an open enrollment period for the Primary Care Network program.

] (12) If the eligibility agency requests verification of a reported change and the enrollee fails to return the verification, the eligibility agency shall end eligibility after the month in which the agency sends proper notice. The eligibility agency shall treat the verification as a new application if the enrollee returns the verification within one calendar month after the effective closure date. The eligibility agency shall waive the open enrollment period and continue eligibility for the rest of the certification period if the agency determines that the enrollee is eligible for PCN. The eligibility agency shall send a denial notice to the enrollee if the agency determines that the enrollee is not eligible for PCN.

(13) A change in income does not make the enrollee ineligible for PCN; however, the individual may request the eligibility agency to make a Medicaid determination of eligibility.

(a) The eligibility agency shall change coverage to Medicaid and end PCN enrollment if the enrollee requests a Medicaid determination of eligibility and the reported change makes the enrollee eligible for Medicaid without cost.

(b) The enrollee may choose to remain on PCN through the end of the certification period if the enrollee requests a Medicaid determination of eligibility and the reported change makes the enrollee eligible for Medicaid with a spenddown or MWI premium.

 

R414-310-16. Enrollment Limitation.

(1) [The Department]The eligibility agency shall limit enrollment in [the Primary Care Network program]PCN.

(2) [The Department]The eligibility agency may stop enrollment of new individuals at any time based on availability of funds.

(3) [The Department]The eligibility agency [and local offices shall]may not accept applications [n]or maintain waiting lists during a [time] period that enrollment of new individuals is stopped.

(4) If enrollment [has not been]is not stopped, an individual[s] may apply for [the Primary Care Network program]PCN.

(5) An individual who becomes ineligible for Medicaid or CHIP, or who must pay a spenddown , poverty level, pregnant woman asset copayment or MWI premium for Medicaid, but who was not previously enrolled in [the Primary Care Network program]PCN, may apply to enroll in [the Primary Care Network program]PCN if the [State]eligibility agency [has]does not stop[ped] enrollment under Subsection R414-310-16(2). If the agency stops enrollment[has been stopped], the individual must wait for an open enrollment period to apply.

 

R414-310-17. Notice and Termination.

(1) The [d]Department adopts 42 CFR 431.206, 431.210, 431.211, 431.213, 431.214, and 435.919, [2004]2010 ed., which are incorporated by reference.

(2) The [local office shall notify]eligibility agency shall notify an applicant or enrollee in writing of the eligibility decision made on the application or the recertification.

(3) The [local office shall]eligibility agency shall [terminate]end an individual's enrollment upon enrollee request or upon discovery that the individual is no longer eligible.

[(4) The local office shall terminate an individual's enrollment if the individual fails to complete the recertification process on time.]The eligibility agency shall end enrollment after the 12-month certification period. An enrollee may reenroll for a new 12-month certification period without waiting for an open enrollment period by completing the recertification process, or by reapplying before the last day of the month that follows the effective closure date.

 

R414-310-18. Improper Medical Coverage.

(1) Improper medical coverage occurs when:

(a) an individual receives medical assistance for which the individual is not eligible, including benefits that the individual receives pending a fair hearing or during an undue hardship waiver if the enrollee fails to act as required by the eligibility agency;

(b) an individual receives a benefit or service that is not part of the benefit package for which the individual is eligible;

(c) an individual pays too much or too little for medical assistance benefits; or

(d) the Department pays too much or too little for medical assistance benefits on behalf of an eligible individual.

([1]2) An individual who receives benefits under [the Primary Care Network program]PCN for which [he]the individual is not eligible [is responsible to]must repay the Department for the cost of the benefits that the individual receives[received].

([2]3) An alien and the alien's sponsor are jointly liable for benefits that an individual receive[d]s for which the individual [was]is not eligible.

([3]4) An overpayment of benefits includes all amounts paid by the Department for medical services or other benefits on behalf of an enrollee , or for the benefit of the enrollee during a[time] period [that]in which the enrollee [was]is not [actually] eligible to receive [such]the benefits.

 

KEY: Medicaid, primary care, covered-at-work, demonstration

Date of Enactment or Last Substantive Amendment: [September 1, 2009]2011

Notice of Continuation: June 13, 2007

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