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.: 36564
Filed: 07/31/2012 09:14:45 AM

RULE ANALYSIS

Purpose of the rule or reason for the change:

The purpose of this change is to add insurance that an employer offers through the Utah Health Exchange (UHE) as a form of creditable health insurance.

Summary of the rule or change:

This amendment adds insurance that an employer offers through UHE as a form of creditable health insurance. It also adds, clarifies, and deletes certain definitions, clarifies effective dates, and clarifies reenrollment and benefits in Utah's Premium Partnership for Health Insurance (UPP) program. It further removes the requirement for children to apply for UPP only during an open enrollment period and makes other minor corrections.

State statutory or constitutional authorization for this rule:

• Section 26-1-5
• Section 26-18-3

Anticipated cost or savings to:

the state budget:

The Department does not anticipate any impact to the state budget because this amendment does not add new coverage to the UPP program, does not impose new costs on UPP providers and recipients, and does not eliminate existing UPP coverage.

local governments:

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

small businesses:

The Department does not anticipate any budget impact because this change does not affect UPP coverage and does not impose new costs and requirements on small businesses.

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

The Department does not anticipate any budget impact because this change does not impose new costs on PCN providers and recipients, does not add new UPP coverage, and does not eliminate existing UPP coverage.

Compliance costs for affected persons:

The Department does not anticipate any compliance costs because this change does not impose new costs on a single UPP provider or recipient, does not add new coverage to the UPP program, and does not eliminate existing UPP coverage.

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

As the Utah Health Exchange enters the market, these changes will allow these policies to be recognized as a form of creditable insurance. No fiscal impact expected.

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:

09/14/2012

This rule may become effective on:

10/01/2012

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.

R414-320-2. Definitions.

The definitions in Section[s] 26-40-102 and Rules R414-1 and R414-301 apply to this rule. In addition, the following definitions apply throughout this rule:

(1) "Adult" means an individual who is 19 through 64 years of age.

(2) "Best estimate" means the 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) "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.

(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 under Utah's Premium Partnership for Health Insurance (UPP) program, the COBRA health plan must be an UPP [Q]qualified [H]health [P]plan.

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

(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. The due process month is not counted as part of the certification period.

(8) "Eligibility agency" means the Department of Workforce Services (DWS) that determines eligibility for [Utah's Premium Partnership for Health Insurance (]the UPP[)] program under contract with the Department.

(9) "Employer-sponsored health plan" means a health insurance plan offered [through]by an employer either directly or through the Utah Health Exchange.[ 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, and is receiving UPP benefits.

(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.

(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 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 eligibility agency accepts applications for the UPP program.

(15) "Primary Care Network" or ["](PCN )["] 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) "Review month" means the last month of the [eligibility]certification 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.

] (1[9]8) "UPP Qualified Health Plan" means a health plan 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 employer contributes at least 50% of the cost of the employee's health insurance premium when the plan is offered directly through the employer. If the employer offers plans through the Utah Health Exchange, the employer must contribute at least 50% of the cost of the employee's health insurance premium for either the employer's default plan or the plan the employee selects. If the plan is a COBRA continuation plan, the employer does not have to contribute to the premium.

([e]f) 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.

(19) "Utah Health Exchange" or (UHE) means an internet portal where Utah employers and their employees can find information about available employer-sponsored health insurance plans, select a plan, and enroll online.

(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 , including employer-sponsored health plans available under UHE, 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 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) The provisions of Section R414-301-3 apply to applicants and enrollees of the UPP program except that reportable changes for UPP applicants and enrollees are defined in Subsection R414-320-3(3).

([1]2) 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) adults with children living in the home;

(b) adults without children living in the home;

(c) adults enrolled in the PCN program;

(d) [children enrolled in the CHIP program;

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

([f]e) other groups designated in advance by the 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 eligibility agency or outreach staff.

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

(4) The eligibility agency shall notify an applicantor enrollee about an eligibility determination or other action that affects eligibility.

(5) An applicant or enrollee may review information that the eligibility agency uses to make an eligibility determination.

(6) Eligibility policy manuals are available for review at any 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 receives under the UPP program if the eligibility agency determines that the individual is not eligible to receive the benefits.

]([8]3) An applicant or enrollee must report certain changes to the eligibility agency within ten calendar days of learning of the change. The eligibility agency shall notify the applicant at the time of application of the changes that the [enrollee]individual must report. 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 t]The amount of the premium that the enrollee pays for an employer-sponsored health insurance plan or COBRA continuation coverage changes;

(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.

([9]4) 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]5) 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]6) An eligible child may choose to enroll in his parent's or guardian's employer-sponsored health insurance plan or COBRA continuation coverage and receive UPP benefits, or 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 and UPP, or may choose direct coverage through CHIP.

 

R414-320-5. Verification and Information Exchange.

(1) An applicant and enrollee must provide verification of eligibility factors as requested by the 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 or enrollee and [their]his household to other state and federal agencies to determine eligibility for other public assistance programs.

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

 

R414-320-7. Creditable Health Coverage.

(1) The Department adopts 42 CFR 433.138(b), 2010 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., is not eligible for enrollment.

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

(4) The eligibility agency determines UPP eligibility for an individual who has access to but has not yet enrolled in employer-sponsored health insurance coverage who meets the requirements of Subsection R414-320-2(14) as follows:

(a) If the individual's cost [of]for the employer-sponsored coverage offered by the employer directly, or for the employer's default plan offered through UHE, is less than 5% of the household's countable gross income, the individual is not eligible for the UPP program.

(b) If the individual's cost [of]for the employer-sponsored coverage offered by the employer directly, or for the employer's default plan offered through UHE, equals or exceeds 5% of the household's countable gross income, the individual may enroll in UPP.

(c) For adults, if the individual's cost [of]for the employer-sponsored coverage offered by the employer directly, or for the employer's default plan offered through UHE, exceeds 15% of the household's countable gross income , the adult may choose to enroll in UPP or may choose direct coverage through PCN if PCN enrollment continues under the provisions of Section R414-310-16.

(d) If the cost to enroll a child in[of] the employer-sponsored coverage offered by the employer directly, or the employer's default plan offered through UHE, is greater than or equal to 5% of the household's countable gross income, a child may choose enrollment in the employer-sponsored health plan and UPP or direct coverage through CHIP.

(e) The cost of coverage includes a deductible if the employer -sponsored plan has [one]a deductible 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.

(5) An eligible individual who has access to or who is enrolled in a COBRA plan may choose to enroll in UPP and the COBRA plan if the individual's cost for the COBRA plan exceeds 5% of the household's gross countable income and the plan meets the criteria to be an UPP qualified health plan as defined in R414-320-2(16).

([5]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 UPP enrollment, even if the individual must wait for a Medicare open enrollment period to apply for Medicare benefits.

([6]7) An individual who is enrolled in the Veteran's Administration (VA) Health Care System is not eligible for UPP 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's coverage [becomes enrolled] in the VA Health Care System begins.

([7]8) 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 by the earlier of:

(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.

([8]9) 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, or [who] involuntarily discontinues coverage under an employer['s]- sponsored health plan.

(a) An individual is eligible to enroll in UPP if the individual's prior health insurance coverage expires before the end of the calendar month that follows the month in which he applies for UPP, and the individual has access to another employer-sponsored health insurance plan that meets the criteria of an UPP qualified health plan.

(b) The UPP enrollment date must be after the prior health insurance coverage ends.

([9]10) An applicant, applicant's spouse, or dependent child can be eligible for the UPP program if [their]his earlier insurance ended more than 90 days before the application date.

(1[0]1) An eligible individual with access to an employer['s] -sponsored health plan who also has creditable health coverage operated or financed by Indian Health Services may enroll in the UPP program to receive reimbursement for [their]his employer-sponsored health plan.

(1[1]2) The individual must enroll in an UPP [Q]qualified [H]health [P]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.

(1[2]3) Individuals must report at application and 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.

(1[3]4) The eligibility agency shall deny an application or 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.

 

R414-320-9. Age Requirement.

(1) An individual must be under age 65 to be eligible for UPP and must enroll in the UPP program before [the end of the month in which he turns 65 years of age.

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

([b]2) The eligibility agency shall deny eligibility if it does not receive an application before an individual turns 65 years of age.

 

R414-320-13. Application Procedure.

(1) 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 eligibility agency shall reinstate an UPP case without requiring a new application if the case closes in error.

(4) An applicant may withdraw an application any time before the eligibility agency completes an eligibility decision on the application.

(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) 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 certification period.

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

(c) A household may add a new member only during an open enrollment period under Section R414-320-16. A child is not subject to the open enrollment period.

(d) The eligibility agency shall consider income of the new member at the next scheduled review.

[ (6) A child who loses Medicaid coverage when the child reaches the maximum age limit may enroll in UPP without waiting for the next open enrollment period.

(7) A child who loses Medicaid coverage because 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 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.

(8) A child who is born to or placed for adoption with an enrollee may enroll 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 Eligibility Reviews.

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

(2) When an individual applies for UPP, the eligibility agency shall determine whether the individual is eligible for Medicaid.

(a) 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. The eligibility agency shall deny the application if the individual does not provide the requested information.

([a]b) 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 employer-sponsored health insurance and the UPP program. The individual may enroll in UPP only during an open enrollment period, except that a child is not subject to an open enrollment period, and [when the individual]must meet[s] all the eligibility criteria.

([b]c) At 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 reenroll in the UPP program. If the individual appears to qualify for Medicaid, the applicant must provide additional information requested by the eligibility worker. The eligibility agency shall deny the [application]review if the individual does not provide the requested information.

(3) To enroll in UPP, the individual must meet enrollment criteria during an open enrollment period under the provisions of Section R414-320-16, except that a child is not subject to open enrollments.

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

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

(b) the applicant dies;

(c) the applicant cannot be located; or

(d) the applicant does not respond to requests for information within the 30-day application period or by the verification due date, if that date is later.

(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]effective at the end of the review month if the enrollee fails to respond to the request. The eligibility agency shall treat [any]a response from the enrollee to complete the review or reapply as a new application if the enrollee responds to the review request or reapplies [after]by the end of the month immediately following 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 eligibility agency shall waive the open enrollment period requirement and the requirement found at Subsection R414-320-7(2) if the enrollee completes the review process or reapplies in the calendar month immediately following the effective closure date.

[ (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 review 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 review request on time 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 that follows the review month.

(b) The eligibility agency shall extend eligibility to the due process month when the agency does not send[s] proper notice of an adverse change. The eligibility agency shall send proper notice of the adverse decision that becomes effective the first of the month after the due process month.

(9) The eligibility agency shall extend eligibility to the due process month if the enrollee responds to the review 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 effective the end of[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]notify the enrollee.

(d) The eligibility agency shall waive the open enrollment period during the due process month , and for a reapplication received before the effective closure date. The eligibility agency also waives the requirement found at Subsection R414-320-7(2) if the enrollee completes the review or reapplies before the effective closure date.

(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.

(11) The eligibility agency shall waive the open enrollment period and the requirement found at Subsection R414-320-7(2) if an enrollee reapplies in the calendar month immediately following the effective closure date.

(12) The enrollee must reapply if the case closes for one or more calendar months and must meet all eligibility criteria.

 

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

(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.]

(3) If the applicant does not enroll in the employer-sponsored health insurance or COBRA continuation coverage that meets the requirements of Subsection R414-320-2(14) within 30 days of the date that the eligibility agency sends the UPP approval notice, DWS shall deny the application. The individual may reapply during another open enrollment period, except that a child is not subject to the open enrollment period.

(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 and the family requests UPP coverage within 30 days of the birth or placement for adoption. If the family makes the request after 30 days of the birth or placement for adoption, enrollment becomes effective on the first day of the month in which the date of report occurs.

(a) The requirement found at Subsection R414-320-7(2) does not apply if the request for UPP enrollment occurs during such 30 days.

(b) If the request for UPP enrollment is made more than 30 days after the date of birth or date of placement for adoption, the child must meet the requirements of Section R414-320-7.

(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]without waiting for an open enrollment period. Eligibility for the spouse becomes effective the month after coverage for Medicaid or PCN ends if there is no break in coverage. A spouse moving back to UPP from Medicaid may reenroll in UPP even if the spouse is enrolled in the employer-sponsored health insurance at the time of request and there is no break in coverage between Medicaid and UPP.

(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. The spouse does not have to wait for an open enrollment period.[

(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 the 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 ]is not moving from another medical assistance program to UPP, the eligibility agency shall determine the effective date of enrollment in accordance with Subsection R414-320-15(1).

(c) If the child is a newborn or has recently been placed for adoption with the enrollee, the provision in Subsection R414-320-15(4) applies.

(7) The effective date of reenrollment in UPP after the eligibility agency completes the periodic eligibility review, is the first day of the month after the review month, or[is] the first day after the due process month. The eligibility agency shall complete the review as described in Subsection R414-320-14([7]8) or ([8]9), and the enrollee must continue to meet eligibility criteria.

(8) An individual who becomes eligible for UPP is enrolled for a 12-month certification period that begins with the first month of eligibility. If the enrollee completes the review process and continues to be eligible, the recertification period 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.

(9) The eligibility agency 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;

(b) An enrolled child turns 19 years of age;

([b]c) The individual becomes entitled to receive Medicare;

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

([d]e) The individual dies;

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

([f]g) The individual enters a public institution or an Institution for Mental Disease.

(10) The eligibility agency shall end eligibility if an adult enrollee discontinues enrollment in employer-sponsored insurance or COBRA continuation coverage.

(a) The enrollee may switch to the PCN program for the rest of the certification period if the enrollee discontinues enrollment in employer-sponsored insurance involuntarily and does not enroll in COBRA continuation coverage, or if the individual discontinues COBRA coverage voluntarily or involuntarily. The individual must meet the PCN income test.

([a]b) The enrollee must notify the eligibility agency within ten calendar days after the enrollee's insurance coverage ends to be eligible to switch to PCN outside of an open enrollment period.

([b]c) 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.

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

(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 individual must report to the eligibility agency within ten calendar days of signing up for an employer-sponsored plan or COBRA continuation coverage, 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 or PCN case. If the household has an open PCN case, eligibility under UPP continues through the end of the PCN certification period.

(15) If an 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 eligibility agency during an open enrollment period to reapply, except that a child is not subject to the open enrollment period. The individual must meet all the requirements of a new applicant.

(16) If an UPP case closes because the enrollee is eligible for another Medicaid program, PCN or CHIP, the individual may reenroll in UPP if there is no break in coverage between the programs, even when the eligibility agency stops enrollment under Subsection R414-320-16(2).

(a) The individual may reenroll during the current 12-month certification period for UPP, PCN or CHIP. The eligibility agency may not require the individual to complete a new application or have a new income eligibility determination.

(b) The individual may still reenroll [during]in UPP if the previous 12-month certification period has ended and the individual is moving from Medicaid. 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, except that a child is not subject to the open enrollment period.

(d) If the individual reapplies in the month immediately following the closure, the eligibility agency waives the open enrollment period and the provision in Subsection R414-320-7(2). The individual must meet all other UPP requirements.

(17) The eligibility agency shall end eligibility effective at the end of the month[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 with[out] 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 eligibility agency accepts applications for enrollment at times when sufficient funding is available to justify enrollment of more individuals. The eligibility agency limits the number it enrolls according to the funds available for the program.

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

(3) The eligibility agency may not accept applications or maintain waiting lists during a period that it stops enrollment of new individuals.

(4) A child is not subject to the open enrollment requirement to enroll in UPP.

 

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.

(2) An individual who receives benefits under the UPP program for which the individual is not eligible must repay the Department for the cost of the benefits that he receives.

(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 period that the enrollee is not eligible to receive the benefits.

 

R414-320-19. Benefits.

(1) The UPP program shall provide cash reimbursement to enrollees.

(2) The reimbursement may not exceed the amount that the enrollee pays toward the cost of the employer-sponsored health plan, employer-sponsored plans selected through UHE, or COBRA continuation coverage.

(3) The UPP program may reimburse an adult up to $150 each month.

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

(a) When the employer-sponsored insurance does not include dental benefits, a child may receive cash reimbursement up to $120 for the medical insurance cost and may receive dental-only benefits through CHIP.

(b) When the employer also offers employer-sponsored [insurance includes ]dental coverage, the applicant may choose to enroll a child in the employer-sponsored dental coverage, in which case, the UPP program will pay the child[and receive] an additional [reimbursement of up to ]$20. The enrollee may also choose to only enroll the child in the employer-sponsored health insurance and UPP, and not enroll the child in the employer-sponsored dental coverage, in which case the child may[also elect to] receive dental-only benefits through CHIP.

 

KEY: CHIP, Medicaid, PCN, UPP

Date of Enactment or Last Substantive Amendment: [December 23, 2011]2012

Notice of Continuation: October 13, 2011

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