Health, Health Care Financing, Coverage and Reimbursement Policy

Rule R414-320

Medicaid Health Insurance Flexibility and Accountability Demonstration Waiver

Notice of Proposed Rule

(Amendment)

DAR File No.: 35335
Filed: 10/13/2011 11:52:28 AM

RULE ANALYSIS

Purpose of the rule or reason for the change:

The purpose of this amendment is to change the review process for re-enrollment in Utah's Premium Partnership for Health Insurance (UPP) program.

Summary of the rule or change:

This amendment updates due process requirements for completing a periodic review of eligibility for medical assistance, clarifies requirements for an UPP recipient to make timely reports of changes and to provide verification, clarifies that the agency cannot end eligibility during the verification process, and clarifies the requirement for the agency to provide advance notice of an adverse action. This amendment 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 also updates citations in the rule text and removes provisions that no longer apply.

State statutory or constitutional authorization for this rule:

• Section 26-18-3

This rule or change incorporates by reference the following material:

• Updates 42 CFR 435.911 and 435.912, published by Government Printing Office, 10/01/2010
• Adds 42 CFR 435.907 and 435.908, published by Government Printing Office, 10/01/2010
• Updates 20 CFR 416 Subpart K, Appendix, published by Government Printing Office, 10/01/2010
• Updates 42 CFR 433.138(b), 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 most UPP recipients whose eligibility ends when they fail to complete a periodic review usually complete the review process during the month that follows and their medical assistance is reinstated without a break in coverage. Further, the change to the effective date of eligibility does not increase costs to the Department because UPP recipients only receive payment after they pay for health insurance premiums upon receiving UPP approval.

local governments:

There is no impact to local governments because they do not fund or determine eligibility for the UPP program.

small businesses:

The Department does not anticipate any impact to small businesses because most UPP recipients whose eligibility ends when they fail to complete a periodic review usually complete the review process during the month that follows and their medical assistance is reinstated without a break in coverage. Further, this change does not impose any new costs on businesses.

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

The Department does not anticipate any impact to UPP recipients because most UPP recipients whose eligibility ends when they fail to complete a periodic review usually complete the review process during the month that follows and their medical assistance is reinstated without a break in coverage. Further, the change to the effective date of eligibility does not increase savings to UPP recipients because they only receive payment after they pay for health insurance premiums upon receiving UPP approval. This change does not reduce UPP coverage and it does not impose new costs on UPP providers.

Compliance costs for affected persons:

The Department does not anticipate any compliance costs to a single UPP recipient because most UPP recipients whose eligibility ends when they fail to complete a periodic review usually complete the review process during the month that follows and their medical assistance is reinstated without a break in coverage. Further, this change does not reduce UPP coverage and it does not impose new costs on a single UPP provider.

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.

W. 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.

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

R414-320-1. Authority.

(1) This rule is authorized by [Title 26, Chapter 18]Sections 26-1-5 and 26-18-3 and allowed under Section 1115 (a) of the Social Security Act. This rule establishes the eligibility requirements for enrollment and the benefits enrollees receive under the Health Insurance Flexibility and Accountability Demonstration Waiver (HIFA), which is Utah's Premium Partnership for Health Insurance (UPP).

 

R414-320-2. Definitions.

The definitions in Sections 26-40-102 and Rule R414-1 apply to this rule. In addition, [T]the following definitions apply throughout this rule:

(1) "Adult" means an individual who is [at least] 19 [and not yet]through 6[5]4 years of age.

[ (2) "Applicant" means an individual who applies for benefits under the UPP program, but who is not an enrollee.

] ([3]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.

[ (4) "Child" means an individual who is younger than 19 years of age.

] ([5]3) "Children's Health Insurance Program" or "CHIP" means the program for medical benefits under the Utah Children's Health Insurance Act, Title 26, Chapter 40[provides medical services for children under age 19 who do not otherwise qualify for Medicaid].

([6]4) "Consolidated Omnibus Budget Reconciliation Act" or "COBRA" continuation coverage is a temporary extension of employer health insurance coverage whereby a person who loses coverage under an employer's group health plan can remain covered for a certain length of time. To receive UPP reimbursement, the COBRA health plan must be a n UPP Qualified Health Plan.

([7]5) "Creditable Health Coverage" means any health insurance coverage as defined in 45 CFR 146.113.

([8]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 Utah's Premium Partnership for Health Insurance (UPP) program under contract with the Department.

[ (9) "Enrollee" means an individual who applies for and is found eligible for the UPP program.

] ([10]9) "Employer-sponsored health plan" means a health insurance plan offered through an employer. To receive UPP reimbursement, the employer must contribute at least 50 % of the cost of the health insurance premium of the employee and offer a UPP Qualified Health Plan.

(10) "Enrollee" means an individual who applies for and is found eligible for the UPP program.

(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.

[ (11) "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.

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

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

] (13) "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.

(14) "Open enrollment" means a time period during which the [Department]eligibility agency accepts applications for the UPP program.

[ (15) "Public Institution" means an institution that is the responsibility of a governmental unit or that is under the administrative control of a governmental unit.

] ([16]15) "Primary Care Network" or "PCN" [program provides primary care medical services to uninsured adults who do not otherwise qualify for Medicaid]means the program for benefits under the Medicaid Primary Care Network Demonstration Waiver.

(16) "Public Institution" means an institution that is the responsibility of a governmental unit or is under the administrative control of a governmental unit.

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

(18) "Spouse" means any individual who has been married to an applicant or enrollee and has not legally terminated the marriage.

(19) "UPP Qualified Health Plan" means a health plan[, which]that meets all of the following requirements:

(a) Health plan coverage includes:

(i) physician visits;

(ii) hospital inpatient services;

(iii) pharmacy services;

(iv) well child visits; and

(v) children's immunizations.

(b) Lifetime maximum benefits must be at least $1,000,000.

(c) The deductible may not exceed $2,500 per individual.

(d) The plan must pay at least 70% of an inpatient stay after the deductible.

(e) The plan does not cover any abortion services; or the plan only covers abortion services in the case where the life of the mother would be endangered if the fetus were carried to term or in the case of rape or incest.

(20) "Utah's Premium Partnership for Health Insurance" or "UPP" means a medical assistance program that provides cash reimbursement for all or part of the insurance premium paid by an employee for health insurance coverage through an employer-sponsored health insurance plan or COBRA continuation coverage that covers either the eligible employee, the eligible spouse of the employee, dependent children, or the family.

(21) "Verification" means the proof needed to decide if an individual meets the eligibility criteria to be enrolled in the program. Verification[s] 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.

 

R414-320-3. Applicant and Enrollee Rights and Responsibilities.

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

(a) [A]adults with children living in the home;

(b) [A]adults without children living in the home;

(c) [A]adults enrolled in the PCN program;

(d) [C]children enrolled in the CHIP program;

(e) [A]adults or children who were enrolled in the Medicaid program within the last thirty days [prior to]before the beginning of the open enrollment period; or

(f) [O]other groups designated in advance by the [Department]eligibility agency 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]applicant or enrollee 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) The eligibility agency shall notify an [A]applicant[s and]or enrollee[s have a right to be notified] about [the decision made on an application,]an eligibility determination or other action [taken] that affects [their] eligibility[ for benefits].

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

(6) [Anyone may look at the e]Eligibility policy manuals [located at]are available for review at any [Department local]eligibility agency office and on the Internet. These manuals are not available for review at call centers and outreach locations.

(7) An individual must repay any benefits that the individual receive[d]s under the UPP program 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]learning of 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 e]Examples of reportable changes include:

(a) An enrollee stops paying for coverage under an employer-sponsored health plan or COBRA continuation coverage[.];

(b) An enrollee changes health insurance plans[.];

(c) An enrollee has a change in the amount of the premium [they are paying]that the enrollee pays for an employer-sponsored health insurance plan or COBRA continuation coverage[.];

(d) An enrollee begins to receive coverage under, or begins to have access to Medicare or the Veteran's Administration Health Care System[.];

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

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

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

(h) An enrollee enters a public institution or an institution for mental diseases.

[ (i) An enrollee's subsidy for COBRA continuation coverage provided under Section 3001 of the American Recovery and Reinvestment Act of 2009, Pub. L. No. 111 5, Stat. 123 115 ends.

] (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 must continue to pay premiums and remain enrolled in an employer-sponsored health plan or COBRA continuation coverage to be eligible for benefits.

(11) An [E]eligible child[ren] may choose to enroll in [their]his parent's or guardian's employer-sponsored health insurance plan or COBRA continuation coverage and receive UPP benefits, or [they] may choose direct coverage through CHIP. A child under the age of 19 may enroll in an employer-sponsored health insurance plan offered by the child's employer or COBRA continuation coverage, or may choose direct coverage through CHIP.

 

R414-320-4. 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 adult applicants and enrollees of UPP.

(2) The provisions of Sections R382-10-6, R382-10-7, and R382-10-9 concerning U.S. citizenship, alien status, state residency and social security numbers apply to child applicants and enrollees.

(3) An individual who is not a U.S. citizen or national, [and]or who does not meet the alien status requirements of Sections R414-302-1 or R382-10-6 is not eligible for any services or benefits under the UPP program.

(4) The eligibility agency may not require an [A]applicant[s and] or enrollee[s] for the UPP program [are not required] to provide Duty of Support information. An adult who [would be]is eligible for Medicaid , but fails to cooperate with Duty of Support requirements required by the Medicaid program , [can]may not enroll in the UPP program.

(5) An [I]individual[s] who must pay a spenddown , poverty level, pregnant woman asset copayment, or MWI premium to receive Medicaid [can]may enroll in UPP if :

(a) [they]the individual meet s [the]UPP program eligibility criteria ;[ in any month they do]

(b) the individual elects not to receive Medicaid in the month that the individual wishes to enroll in UPP; and

(c) [as long as] the [Department has not stopped]eligibility agency continues open enrollment under the provisions of Section R414-320-16. If the [Department has]agency stop[ped]s enrollment, the individual must wait for an [applicable] open enrollment period to enroll in UPP.

 

R414-320-5. Verification and Information Exchange.

(1) [The]An applicant and enrollee must provide verification of eligibility factors as requested by the [Department]eligibility agency and in accordance with the provisions of Section R414-308-4.

(2) The Department and the eligibility agency may release information concerning an applicant[s and] or enrollee[s] and their household[s] to other state and federal agencies to determine eligibility for other public assistance programs.

(3) The [Department]eligibility agency shall safeguard[s] information about applicants and enrollees to comply with the provisions of Section R414-301-4.

[ (4) There are no provisions for taxpayers to see any information from client records.

(5) The director or designee shall decide if a situation is an emergency warranting release of information to someone other than the client. The Department may only release information to an agency with comparable rules for safeguarding records. The information that the Department releases cannot include information obtained through an income match system.

]

R414-320-6. Residents of Institutions.

(1) Residents of public institutions are not eligible for the UPP program.

(2) A child under the age of 18 is not a resident of an institution if the child is living temporarily in the institution while arrangements are being made for other placement.

(3) A child who resides in a temporary shelter for a limited period of time is not a resident of an institution.

 

R414-320-7. Creditable Health Coverage.

(1) The Department adopts 42 CFR 433.138(b), 20[09]10 ed., which is incorporated by reference.

(2) An applicant 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)], is not eligible for enrollment.

([a]3) An applicant who is covered by COBRA continuation coverage may be eligible for UPP enrollment.

([3]4) The eligibility agency determines [E]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 individual's cost of the employer-sponsored coverage is less than 5% of the household's countable gross income, the individual is not eligible for the UPP program.

(b) If the cost of the employer-sponsored coverage equals or exceeds 5% of the household's gross income, the individual may enroll in UPP.

([b]c) 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 UPP or may choose direct coverage through PCN if PCN enrollment [has not been stopped]continues under the provisions of Section R414-310-16.

([c]d) If the cost of the employer-sponsored coverage is greater than or equal to 5% of the household's countable gross income, a child may choose enrollment in UPP or direct coverage through CHIP.

(e) The cost of coverage includes a deductible if the employer plan has one that must be met before it will pay any claims. For a spouse or dependent child, if the employee must be enrolled to enroll the spouse or dependent child, the cost of coverage includes the cost to enroll the employee and the spouse or dependent child.

([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.]An individual who voluntarily terminates health insurance coverage is ineligible to enroll in UPP for 90 days after the earlier insurance ends.

(a) For an individual to enroll in UPP, the 90-day ineligibility period must expire:

(i) by the end of the open enrollment period during which the individual applies for UPP; or

(ii) by the end of the month which follows the month that the individual applies for UPP if the open enrollment period continues.

(b) If the 90-day ineligibility period does not end by the earlier of those two dates, the eligibility agency shall deny the application.

(c) An effective date of enrollment can only occur after the 90-day ineligibility period.

([b]8) An applicant, applicant's spouse, or dependent child may be eligible for enrollment in UPP without a 90-day ineligibility period if that person discontinues coverage under a COBRA plan, the Utah Comprehensive Health Insurance Pool, [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]or who involuntarily discontinues coverage under an employer's plan.

([a]9) An applicant, applicant's spouse, or dependent child can be eligible for the UPP program if their [prior]earlier insurance ended more than 90 days before the application date.

([7]10) An eligible individual with access to an employer's sponsored health plan who also has[with] creditable health coverage operated or financed by Indian Health Services may enroll in the UPP program to receive reimbursement for their employer-sponsored health plan.

([8]11) The individual must enroll in a n UPP Qualified Health Plan either with an employer-sponsored health plan or a COBRA continuation health plan within 30 days of the date of the approval notice to enroll in UPP.

([9]12) Individuals must report at application and [recertification]review 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 or parent's employer, Medicare Part A or B, the VA Health Care System, or COBRA continuation coverage.

([10]13) The [Department shall deny]eligibility agency shall deny an application or [recertification]review 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.

 

R414-320-8. Household Composition.

(1) The following individuals are included in the household when determining household size for the purpose of computing financial eligibility for the UPP program:

(a) The individual;

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

(c) All children of the individual or the individual's spouse who are under age 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) The eligibility agency shall determine household composition for an eligible child in accordance with Subsection R382-10-11(1).

([2]3) 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.

(4) Any household member who is defined in Subsection R414-320-8(1) or Subsection R414-320-8(2) 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 shall count that individual's income the same way that it counts the income of a U.S. citizen, national, or a qualified resident alien.

 

R414-320-9. Age Requirement.

[ (1) An individual must be younger than 65 years of age to enroll in the UPP program.

] ([2]1) [The individual's 65th birthday month] An individual must enroll in the UPP program before the end of the month in which he turns 65 years of age.[is the last month the person can be eligible for enrollment in the UPP program.]

(a) An individual must apply for UPP before he turns 65 years of age.

(b) The eligibility agency shall deny eligibility if it does not receive an application before an individual turns 65 years of age.

 

R414-320-10. Income Provisions.

(1) For an adult to be eligible to enroll, gross countable household income must be equal to or less than 150% of the federal non-farm poverty guideline for a household of the same size.

(2) For children to be eligible to enroll, gross countable household income must be equal to or less than 200% of the federal non-farm poverty guideline for a household of the same size.

(3) 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. The eligibility agency shall use the countable gross income of parents who live with a child to determine the child's eligibility. The agency may not count any income that it excludes under Section R414-320-10.

[ (4) 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 UPP program.

] ([5]4) Any income in a trust that [is available to, or is received by] a household member[,] receives becomes the income of the individual for whom it is received. The income is countable [income]if the eligibility agency uses it to determine eligibility.

([6]5) Payments that a household member receive[d]s from the Family Employment [P]program, Working Toward Employment program, or from refugee cash assistance or adoption support services as authorized under Title 35A, Chapter 3 , are countable income.

([7]6) Rental income is countable income. The eligibility agency may deduct the following expenses[ can 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.

([8]7) The eligibility agency shall count as income [C]cash contributions [made by]from non-household members [are counted as income] unless the parties [have a] sign[ed] a written agreement [for]to repay[ment of] the funds.

([9]8) The eligibility agency shall count as income [T]the interest earned from payments [made] under a sales contract or a loan agreement [is countable income] to the extent that the agency continues to receive these payments [will continue to be received] during the certification period.

([10]9) The eligibility agency shall count as income [N]needs-based [V]veteran's pensions[ are counted as income]. Nevertheless, [O]the agency counts only the portion of a Veteran's Administration check to which the individual is legally entitled[ is countable income]. Any portion of the payment for another family member counts solely as that family member's income.

([11]10) The eligibility agency shall count solely as the child's income the [C]child support payments that a parent receive[d]s for a dependent child [living]when that child lives in the home[are counted as that child's income].

([12]11) The eligibility agency may only count [I]in-kind income when a non-household member provides goods or services to an individual in exchange for services that the individual performs.[,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.]

([13]12) The eligibility agency shall count as income [S]supplemental [S]security [I]income and [S]state [S]supplemental payments[ are countable income].

([14]13) The eligibility agency may not count [I]income that is [defined in]excluded under 20 CFR 416 Subpart K, Appendix, [2004]2010 edition, which is incorporated by reference[, is not countable].

([15]14) The eligibility agency may not count as income [P]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].

([16]15) The eligibility agency may not count as income [D]death benefits [are not countable income] to the extent that the funds are spent on the deceased person's burial or last illness.

([17]16) The eligibility agency may not count as income [A]a bona fide loan that an individual [must repay and that the individual has contracted]contracts in good faith [without fraud or deceit,] and [genuinely] endorse[d]s in writing [for repayment]to repay[ is not countable income].

([18]17) The eligibility agency may not count as income [C]child [C]care [A]assistance under Title XX[ is not countable income].

([19]18) The eligibility agency may not count as income [R]reimbursements of Medicare premiums [received by]that an individual receives from the Social Security Administration or the Department[ are not countable income].

([20]19) [Earned and unearned income of a child is not countable income if the child is not the head of a household.]The eligibility agency may only count earned and unearned income of an eligible child who is under 19 years of age when the child is the head of the household. When the applicant or enrollee's spouse is under the age of 19, the agency may only count the spouse's earned and unearned income when the spouse is under the age of 19 and is the head of the household.

(2[1]0) The eligibility agency may not count as income [E]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[2]1) The eligibility agency may not count [R]reimbursements for employee work expenses incurred by an individual[ are not countable income].

(2[3]2) The eligibility agency may not count [T]the value of food stamp assistance[ is not countable income].

(2[4]3) The eligibility agency may not count [I]income paid by the U.S. Census Bureau to a temporary census taker to prepare for and conduct the census[ is not countable income].

(2[5]4) The eligibility agency may not count [T]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[6]5) The eligibility agency may not count [T]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].

(2[7]6) The eligibility agency may not count a 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].

[ (28) 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.

]

R414-320-11. Budgeting.

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

] (1) Subject to the limitations in Subsection R414-320-10(19), [The gross income of]the eligibility agency shall count the gross income of [all household members]the individual and the individual's spouse, or of an eligible child's parents [is counted in determining]to determine the eligibility of the applicant or enrollee, unless the income is excluded under this rule. The eligibility agency shall deduct from the gross income only those[Only] expenses 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]eligibility agency 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]review for continuing eligibility. The [Department]eligibility agency determines prospective eligibility by using the best estimate of the household's average monthly income that is expected to be received or made 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 [is expected to be received]the household expects to receive 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 the same household]that a 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]that 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.

 

R414-320-12. Assets.

There is no asset test for eligibility in the UPP program.

 

R414-320-13. Application Procedure.

(1) [The application is the initial request from an applicant for UPP enrollment. The application process includes gathering information and verifications to determine the individual's eligibility for enrollment.]The Department adopts 42 CFR 435.907 and 435.908, 2010 ed., which are incorporated by reference.

(2) The applicant must complete and sign a written application or complete an application on-line via the Internet to enroll in the UPP program. The provisions of Section R414-308-3 apply to applicants of the UPP program.

(3) The [Department]eligibility agency shall reinstate a n UPP case without requiring a new application if the case [was closed]closes 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 any time before the [Department]eligibility agency completes an eligibility decision on the application.

([6]5) If an eligible household requests enrollment for a new household member, the application date for the new household member is the date of the request. A new application form is not required. However, the household shall provide the information necessary to determine eligibility for the new member, including information about access to creditable health insurance.

(a) [Benefits for the new household member will be allowed from the date of request or the date an application is received]The effective date of enrollment in UPP for the new household is defined in Section R414-320-15. Coverage continues through the end of the [current] certification period.

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

(c) A household may add a [A new household]new member [may be added] only [if the Department has not stopped enrollment]during an open enrollment period under Section R414-320-[15]16.

(d) The eligibility agency shall consider [I]income of the new member[ will be considered] at the next scheduled [recertification]review.

([7]6) A child who loses Medicaid coverage [because he or she]when the child [has] reache[d]s the maximum age limit [and does not qualify for any other Medicaid program without paying a spenddown,] may enroll in UPP without waiting for the next open enrollment period.

([8]7) A child who loses Medicaid coverage because [he or she]the child is no longer deprived of parental support and either does not qualify for any other Medicaid program , or only qualifies for a Medicaid program that requires [without] paying a spenddown, may enroll in UPP without waiting for the next open enrollment period , unless the child qualifies for a different Medicaid program without cost.

([9]8) A [new] child who is born to or [adopted by]placed for adoption with an enrollee may [be] enroll[ed] in UPP without waiting for the next open enrollment period if the child does not qualify for a Medicaid program without cost.

 

R414-320-14. Eligibility Decisions and [Recertification]Eligibility Reviews.

(1) The Department adopts 42 CFR 435.911 and 435.912, 20[09]10 ed., which are incorporated by reference.

(2) When an individual applies for UPP, the [local office shall]eligibility agency shall determine [if]whether the individual is eligible for Medicaid. An individual who qualifies for Medicaid without paying a spenddown, a poverty level, pregnant woman asset copayment, or an MWI premium cannot enroll in the UPP program. If the individual appears to qualify for Medicaid, but additional information is required to determine eligibility 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]The eligibility agency shall deny the application if the individual does not provide the requested information.

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

(b) At [recertification, the local office shall first review eligibility] each review for UPP reenrollment, the eligibility agency shall decide whether the enrollee is eligible for Medicaid. If the individual qualifies for Medicaid without a spenddown, a poverty level, pregnant woman asset copayment or an MWI premium, the individual cannot [be] reenroll[ed] in the UPP 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]The eligibility agency shall deny the application if the individual does not provide the requested information.

(3) To enroll, the individual must meet enrollment [eligibility] criteria [at a time when the Department has not already stopped enrollment]during an open enrollment period under the provisions of Section R414-320-16.

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

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

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

(c) [T]the applicant cannot be located; or

(d) [T]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 date is later.

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

](5) The eligibility agency shall complete a periodic review of an enrollee's eligibility for medical assistance at least once every 12 months. The periodic review is a review of eligibility factors that may be subject to change. The eligibility agency uses available, reliable sources to gather necessary information to complete the review.

(6) The eligibility agency may ask the enrollee to respond to a request to complete the review process. The eligibility agency shall end the enrollee's eligibility after the review month if the enrollee fails to respond to the request. The eligibility agency shall treat any response as a new application if the enrollee responds to the request or reapplies after the review month. The application processing period applies for this new request for coverage.

(a) The eligibility agency may ask the enrollee for verification to redetermine eligibility.

(b) Upon receiving verification, the eligibility agency shall redetermine eligibility and notify the enrollee. The agency shall send a denial notice to the enrollee if the enrollee fails to return verification within the application processing period or if the agency determines that the enrollee is ineligible.

(c) The eligibility agency may not continue eligibility while it makes a new eligibility determination.

(d) The enrollee must reapply if the case closes for one or more calendar months.

(e) The new certification period begins the day after the closure date if the enrollee becomes eligible.

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

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

(b) The enrollee has at least ten calendar days from the notice date to provide the requested verification to the eligibility agency.

(8) The eligibility agency shall determine eligibility and notify the enrollee of its decision if the enrollee responds to the request and provides all verification by the verification due date.

(a) The eligibility agency shall send proper notice of an adverse decision when the decision affects eligibility for the due process month.

(b) The eligibility agency shall extend eligibility to the due process month when the agency sends proper notice of an adverse change. The eligibility agency shall send proper notice of the adverse decision that becomes effective after the due process month.

(9) The eligibility agency shall extend eligibility to the due process month if the enrollee responds to the request during the review month and the verification due date is during the due process month. The enrollee must provide all verification by the verification due date. If the enrollee responds to the request during the review month and the

(a) The eligibility agency shall determine eligibility and send proper notice of its decision when the enrollee provides all requested verification by the verification due date.

(b) The eligibility agency shall end eligibility after the month in which it sends proper notice of the closure date if the enrollee does not provide all requested verification by the verification due date.

(c) The eligibility agency shall treat the date that it receives all verification as a new application date if the enrollee returns all verification after the verification due date and before the effective closure date. The agency shall determine the enrollee's eligibility and send proper notice to the enrollee.

(d) The eligibility agency shall waive the open enrollment period during the due process month.

(e) The eligibility agency may not continue eligibility while it makes an eligibility determination. If the agency determines that an enrollee is eligible, the new certification date for the application is the day after the effective closure date.

(10) The eligibility agency shall provide ten-day notice of a case closure if the agency determines that the enrollee is ineligible or if the enrollee fails to provide verification by the verification due date.

[(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 and continues to meet all eligibility criteria, coverage will be continued without interruption.

(b) If the enrollee does not complete the recertification process and provide required verifications by the end of the recertification month, the Department will close the case at 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.

(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.

]

R414-320-15. Effective Date of Enrollment , Change Reporting and Enrollment Period.

[(1) The effective date of enrollment is the day that a completed and signed application is received at a local office as defined in Subsection R414-308-3(2)(a) and (b), and the applicant meets all eligibility criteria and enrolls in and pays the first premium for the employer-sponsored health insurance or COBRA continuation coverage in the application month.

](1) Subject to Sections R414-320-7, R414-320-9 and R414-320-16 and the limitations in Section R414-306-6, the effective date of enrollment in the UPP program is the first day of the application month. An individual who is approved for the UPP program must enroll in the employer-sponsored health plan or COBRA continuation coverage within 30 days of receiving an approval notice from the eligibility agency. Eligibility for UPP is a qualifying event and employers must allow the individual to enroll in the health insurance plan upon approval.

(2) The Department may not reimburse the enrollee for premiums before the effective date of enrollment and not before the month in which the enrollee pays a health insurance or COBRA premium that the enrollee verifies to the eligibility agency. individual pays a premium for coverage for the spouse or dependent child.

[(2) The effective date of enrollment cannot be before the month in which the applicant pays a premium for the employer-sponsored health insurance or COBRA continuation coverage and is determined as follows:

(a) The effective date of enrollment is the date an application is received and the person is found eligible, if the applicant enrolls in and pays the first premium for the employer-sponsored health insurance or COBRA continuation coverage in the application month.

(b) If the applicant will not pay a premium for the employer-sponsored health insurance or COBRA continuation coverage in the application month, the effective date of enrollment is the first day of the month in which the applicant pays a premium. The applicant must enroll in the employer-sponsored health insurance or COBRA continuation coverage no later than 30 days from the day on which the Department of Workforce Services sends the applicant written notice that he meets the qualifications for UPP.

]([c]3) If the applicant does not enroll in the employer-sponsored health insurance or COBRA continuation coverage within 30 days [from the day on which the Department of Workforce Services sends the applicant]of the date that the eligibility agency sends the UPP approval [written] notice , [that he meets the qualifications for UPP,]DWS shall deny the application .[ shall be denied and the] The individual [will have to]may reapply during another open enrollment period.

([3]4) The effective date of enrollment for a newborn or newly adopted child is the date of birth or the date that the child is placed for adoption if the newborn or newly adopted child is enrolled in the employer-sponsored health insurance or COBRA continuation coverage [if]and the family requests [the]UPP coverage within 30 days of the birth or placement for adoption. If the family makes the request [is more than]after 30 days [after]of the birth or placement for adoption, enrollment [is]becomes effective on the first day of the month in which the date of report occurs.

(5) An enrollee may request to add a spouse to UPP coverage during the certification period.

(a) If the spouse had previous UPP coverage, but became eligible for Medicaid or PCN, the enrollee may add the spouse to UPP whose eligibility becomes effective the month after coverage for Medicaid or PCN ends if there is no break in coverage.

(b) If the spouse did not have previous UPP coverage, but is moving directly from PCN to UPP coverage, the effective date of enrollment is the first day of the month after PCN ends.

(c) If the spouse is not moving directly from PCN to UPP coverage, the spouse may enroll in UPP during an open enrollment period. The eligibility agency shall determine the effective date of enrollment in accordance with Subsection R414-320-15(1).

(6) An enrollee may request to add a dependent child to UPP coverage during the certification period.

(a) If the child had previous UPP coverage, but became eligible for Medicaid or CHIP, the effective date of enrollment is first day of the month after Medicaid or CHIP ends if there is no break in coverage.

(b) If the child did not have previous UPP or CHIP coverage, the enrollee may add the child to UPP during an open enrollment period unless the child is a newborn or is a child who has been placed for adoption with the enrollee. The eligibility agency shall determine the effective date of enrollment in accordance with Subsection R414-320-15(1).

([4]7) The effective date of re[-]enrollment [for a recertification]in UPP after the eligibility agency completes the periodic eligibility review, is the first day [of the month] after the [recertification]due process month[, if the recertification is completed]. The eligibility agency shall complete the review as described in S ubsection R414-320-[13]14(7) or (8),[.]and the enrollee must continue to meet eligibility criteria.

[ (5) If the enrollee does not complete the recertification as described in Section R414-320-13, 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.

] ([6]8) An individual [found]who becomes eligible [shall be eligible from the effective date through the end of the first month of eligibility and for the following 12 months]for UPP is enrolled for a 12-month certification period that begins with the first month of eligibility. If the enrollee completes the [redetermination]review process [in accordance with Section R414-320-13] and continues to be eligible, the recertification period [will be]continues for an additional 12 months , except that the eligibility agency may not count a due process month associated with a review in the new 12-month recertification period.[ beginning the month following the recertification month.]

(9) The eligibility agency shall end eligibility[Eligibility could end] 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 entitled to receive Medicare ;[, or]

(c) The individual becomes covered by VA Health Insurance , or fails to apply for VA health system coverage when potentially eligible;

([c]d) The individual dies;

([d]e) The individual moves out of state or cannot be located; or

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

([7]10) The eligibility agency shall end eligibility [I]if an adult enrollee discontinues enrollment in employer-sponsored insurance or COBRA continuation coverage[, eligibility ends]. The enrollee may switch to the PCN program for the rest of the certification period[I]if the enrollee discontinues enrollment in employer-sponsored insurance[is discontinued] involuntarily[,] and[the individual] does not enroll in COBRA continuation coverage, or if the individual discontinues COBRA coverage voluntarily or involuntarily.

(a) The[and the individual] enrollee must notif[ies]y the [local office]eligibility agency within ten calendar days [of when the insurance]after the enrollee's insurance coverage ends[, the individual may switch to the PCN program for the remainder of the certification period].

(b) The eligibility agency shall complete a new eligibility determination and the individual must pay a PCN enrollment fee for the new 12-month certification period if the change occurs in the last month of the UPP certification period.

(11) When the enrollee reports other changes, the eligibility agency shall determine the effect of the change and make the appropriate change in the enrollee's eligibility. The eligibility agency shall send proper notice of changes in eligibility. The agency may end eligibility if the enrollee fails to report changes within ten calendar days. Other changes that may affect eligibility or benefits occur when:

(a) an enrollee changes health insurance plans or has a COBRA qualifying event; or

(b) the amount of the premium changes that the enrollee pays for an employer-sponsored health insurance plan or COBRA continuation coverage.

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

([8]13) A child enrollee may discontinue employer-sponsored health insurance or COBRA continuation coverage and move to direct coverage under CHIP at any time during the certification period without any waiting period.

([9]14) An individual who is enrolled in PCN or CHIP and who enrolls in an employer-sponsored health plan or COBRA continuation coverage may switch to the UPP program . The [if the] individual must report[s] to the [local office]eligibility agency within ten calendar days of [enrolling in]signing up for an employer-sponsored plan or COBRA continuation coverage , [and before coverage begins]or within ten days after coverage begins, whichever is later.

(a) The eligibility agency shall add the individual for the rest of the certification period if the household has an open UPP case.

(b) The eligibility agency shall approve a new 12-month certification period if the household does not have an open UPP case.

([10]15) If a n UPP case closes for any reason, other than to become covered by another Medicaid program , PCN or CHIP, and remains closed for one or more calendar months, the individual must submit a new application to the [local office]eligibility agency during an open enrollment period to reapply. The individual must meet all the requirements of a new applicant.

([11]16) If a n UPP case closes because the enrollee is eligible for another Medicaid program , PCN or [for] CHIP, the individual may reenroll in UPP if there is no break in coverage between the programs, even [if the]when [State has stopped]the eligibility agency stops enrollment under S ubsection R414-320-[15]16(2).

(a) [If the individual's 12-month certification period has not ended, the individual may reenroll for the remainder of that certification period.] The individual may reenroll during the12-month certification period. The eligibility agency may not require the individual [is not required] to complete a new application or have a new income eligibility determination.

(b) [If the 12-month certification period from the prior enrollment has ended, the individual may still reenroll.] The individual may still reenroll during the12-month certification period. [However, the individual must complete a new application and]The individual must meet eligibility and income guidelines for the new 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.

(17) The eligibility agency shall end eligibility after the month in which the agency sends proper notice if the agency requests verification of a reported change and the enrollee fails to return the verification. 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 if the enrollee is eligible, continue eligibility for the rest of the certification period. The eligibility agency shall send a denial notice to the enrollee if the enrollee is ineligible.

(18) An enrollee may request a Medicaid determination of eligibility when there is a change of income during the certification period.

(a) The eligibility agency shall end UPP enrollment and change the enrollee's coverage to Medicaid if the enrollee asks for a Medicaid determination and the reported change makes the enrollee eligible for Medicaid without cost.

(b) If the enrollee asks for a Medicaid determination and the reported change makes the enrollee eligible for Medicaid without a spenddown, MWI premium or a poverty level, pregnant woman asset copayment, the enrollee may choose to remain on UPP.

 

R414-320-16. Open Enrollment Period.

(1) The [Department]eligibility agency accepts applications for enrollment at times when sufficient funding is available to justify enroll[ing]ment of more individuals. The [Department]eligibility agency limits the number it enrolls according to the funds available for the program.

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

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

 

R414-320-17. Notice and Termination.

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

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

(3) The [Department shall]eligibility agency shall [terminate]end an individual's enrollment if the individual fails to complete the [recertification]periodic review process on time.

(4) The [Department shall notify]eligibility agency shall notify an enrollee in writing at least ten days before taking a proposed action adversely affecting the enrollee's eligibility. The notice must include[ Notices shall provide the following information]:

(a) [T]the action to be taken;

(b) [T]the reason for the action;

(c) [T]the regulations or policy that support [the]an adverse action;

(d) [T]the applicant's or enrollee's right to a hearing;

(e) [H]how an applicant or enrollee may request a hearing; and

(f) [T]the applicant or enrollee's right to represent himself, or use legal counsel, a friend, relative, or other spokesperson.

(5) The [Department]eligibility agency need not give ten-day notice of termination if:

(a) [T]the enrollee is deceased;

(b) [T]the enrollee [has moved]moves out[ ] -of[] -state and is not expected to return; or

(c) [T]the enrollee [has entered]enters a public institution or institution for mental disease[;].

[ (d) The enrollee has enrolled in other health insurance coverage, in which case eligibility may cease immediately and without prior notice.

]

R414-320-18. 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 an 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 not 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 UPP program for which [he]the individual is not eligible [is responsible to]must repay the Department for the cost of the benefits [received]that he receives.

([2]3) 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 the enrollee [was]is not [actually] eligible to receive [such]the benefits.

 

R414-320-19. Benefits.

(1) The UPP program shall provide[s] cash reimbursement to enrollees[ as described in this section].

(2) The reimbursement [shall]may not exceed the amount that the [individual]enrollee pays toward the cost of the employer-sponsored health plan or COBRA continuation coverage.

(3) [The amount of reimbursement]The UPP program may reimburse [for] an adult[ will be] up to $150 [per]each month[ per individual].

(4) [The amount of reimbursement]The UPP program may reimburse[for children will be] a child up to $120 [per]each month [per child] for medical coverage and an additional $20 if the[y] child [choose]elects to enroll in employer-sponsored dental coverage.

(a) When the employer-sponsored insurance does not include dental benefits, [the children]a child may receive cash reimbursement up to $120 for the medical insurance cost and [enroll in direct dental coverage under the CHIP Program]may receive dental-only benefits through CHIP.

(b) When the employer-sponsored insurance includes dental coverage, the applicant [will be given the choice of enrolling]may choose to enroll [the children]a child in the employer-sponsored dental coverage and [receiving]receive an additional reimbursement of up to $20 .[, or enrolling] The enrollee may also elect to receive dental-only benefits through CHIP[ in direct dental coverage through the CHIP Program].

 

KEY: CHIP, Medicaid, PCN, UPP

Date of Enactment or Last Substantive Amendment: [July 29, 2010]2011

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