Health, Health Care Financing, Coverage and Reimbursement Policy

Rule R414-310

Medicaid Primary Care Network Demonstration Waiver

Notice of Proposed Rule

(Amendment)

DAR File No.: 36565
Filed: 07/31/2012 09:21:09 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 makes other minor corrections.

State statutory or constitutional authorization for this rule:

• Section 26-18-3
• Section 26-1-5

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 Primary Care Network (PCN) program, does not impose new costs on PCN providers and recipients, and does not eliminate existing PCN coverage.

local governments:

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

small businesses:

The Department does not anticipate any budget impact because this change does not affect PCN 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 PCN coverage, and does not eliminate existing PCN 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 PCN provider or recipient, does not add new coverage to the PCN program, and does not eliminate existing PCN 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 [email protected]

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

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.

R414-310. Medicaid Primary Care Network Demonstration Waiver.

R414-310-2. Definitions.

The definitions in Rules R414-1 and R414-301 apply to this rule. In addition, the following definitions apply throughout this rule:

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

(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 Title 26, Chapter 40, Utah Children's Health Insurance Act.

([3]4) "Copayment and coinsurance" means a portion of the cost for a medical service for which the enrollee is responsible to pay for services received under the Primary Care Network.

([4]5) "Creditable Health Coverage" means any health insurance coverage as defined in 45 CFR 146.113.

([5]6) "Deeming" or "deemed" means a process of counting income from a spouse or an alien's sponsor to decide what amount of income after certain allowable deductions, if any, must be considered income to an applicant or enrollee.

([6]7) "Department" means the [Utah ]Department of Health.

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

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

(9) "Employer-sponsored health plan" means a health insurance plan offered by an employer either directly or through the Utah Health Exchange[that meets the requirements of Subsection R414-320-2(19)(a), (b), (c), (d) and (e)].

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

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

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

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

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

(15) "Open enrollment" means a period during which the eligibility agency accepts applications for the Primary Care Network program.

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

(17) "[Review]Recertification month" means the last month of the [eligibility]certification period for an enrollee during which the eligibility agency shall redetermine eligibility for a new certification period if the [s an] enrollee['s]completes the recertification process timely[ 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) "Student health insurance plan" means a health insurance plan that is offered to students directly through a university or other educational facility or through a private health insurance company that offers coverage plans specifically for students.

(19) "Utah Health Exchange" or (UHE) means an internet portal for Utah employers and their employees where the 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 the program described in Rule R414-320.

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

]

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

(1) The provisions of Section R414-301-3 apply to applicants and enrollees of the PCN program except that reportable changes for PCN applicants and enrollees are defined in Subsection R414-310-3(3).

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

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

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

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

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

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

(f) an individual who is enrolled in the Medicaid program within 30 days before the open enrollment period begins; or

(g) any group that the Department designates in advance to be consistent with efficient administration of the program.

[ (2) If a person needs help to apply, he may have a friend or family member help, or he may request help from the 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 client 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) An applicant or enrollee has a right to be notified about the decision made on an application, or other action taken that affects their eligibility for benefits.

(5) An applicant or enrollee may look at information in his case file that the eligibility agency uses to make an eligibility determination.

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

(7) An individual must repay any benefits that the individual receives under PCN 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 the day the change becomes known. The eligibility agency shall notify the applicant at the time of application of the changes that the enrollee must report. Some examples of reportable changes include:

(a) An enrollee in PCN begins to receive coverage or to have access to coverage under a group health plan or other health insurance coverage;

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

(c) An enrollee leaves the household or dies;

(d) An enrollee or the household moves out of state;

(e) Change of address of an enrollee or the household; or

(f) 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 in PCN is responsible for paying any required copayments or coinsurance amounts to providers for medical services that the enrollee receives that are covered under PCN.

 

R414-310-7. Creditable Health Coverage.

(1) The Department adopts 42 CFR 433.138(b) and 435.610, 2010 ed., and Section 1915(b) of the Compilation of the Social Security Laws, in effect January 1, 2011, which are incorporated by reference.

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

(3) The eligibility agency determines PCN eligibility for an individual who has access to but has not yet enrolled in employer-sponsored health insurance coverage through an employer or a spouse's employer as follows:

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

(b) If the individual's cost [of]for the least expensive health insurance plan offered by the employer directly, or for the employer's default plan offered through UHE, is 5% or more of the household's countable gross income, the individual may enroll in the employer['s]-sponsored health insurance plan and the UPP program during an UPP open enrollment period. The employer['s]-sponsored health plan must meet the requirements of Subsection R414-320-2(1[9]8).

(c) If the individual's cost [of]for the least expensive health insurance plan offered by the employer, or for the employer's default plan offered through UHE, exceeds 15% of the household's countable gross income, the individual may choose to enroll in either PCN or the UPP program. The following conditions apply:

(i) to enroll in UPP, the employer['s]-sponsored health insurance plan the individual enrolls in, or the plan the employee selects through UHE, must meet the requirements of Subsection R414-320-2(1[9]8); and

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

(d) If none of the plans offered by the employer, either directly or through UHE, meet the requirements of Subsection R414-320-2(18), and the individual's cost to enroll exceeds 15% of the household's countable gross income, the individual may only enroll in the PCN program during a PCN open enrollment period.

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

] (4) The eligibility agency considers the individual to have access to coverage even when the employer only offers coverage during an open enrollment period , if the individual has at least one opportunity to enroll, or if the first opportunity to enroll occurs within 30 days of either the date of application or the first day of the recertification month.

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

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

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

(8) Individuals who are full-time students and who can enroll in student health insurance coverage are not eligible to enroll in PCN.

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

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

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

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

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

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

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

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

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

(11) Notwithstanding the limitations in Section R414-310-7, an individual with creditable health coverage operated or financed by Indian Health Services may enroll in PCN.

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

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

 

R414-310-9. Age Requirement.

(1) An individual must be at least 19 and not yet 65 years of age to enroll in PCN.

(2) The month in which an individual turns 19 years of age is the first month that the person may enroll in PCN. The effective date of enrollment for an applicant who meets the eligibility criteria for PCN and who turn s 19 or 65 years of age is defined in Section R414-310-15.

 

R414-310-10. Income Provisions.

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

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

(3) The eligibility agency shall count as income [P]payments that a household member receive[d]s from the Family Employment Program, Working Toward Employment program, refugee cash assistance or adoption support services as authorized under Title 35A, Chapter 3 , Employment Support Act[are countable income].

(4) The eligibility agency shall count [R]rental income[ is countable income]. The eligibility agency may deduct the following expenses[ may be deducted]:

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

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

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

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

(5) The eligibility agency shall count as income [C]cash contributions made by non-household members [are counted as income] unless the parties have a signed written agreement for repayment of the funds.

(6) The eligibility agency shall count as income the interest earned from payments made under a sales contract or a loan agreement [is countable income] to the extent that the household member continues to receive these payments during the certification period.

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

(8) The eligibility agency shall count solely as the child's income[C]child support payments that a [household member receives for a dependent child living in the home are counted as that child's income, and do not count as income of the parent]parent receives for a dependent child when that child lives in that parent's home.

(9) The eligibility agency may only count[I]in-kind income[, which is] when a non-household member provides goods or services [provided] to the individual [from a non-household member and which is not in the form of cash, for which]in exchange for services the individual perform s.[ed 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.]

(10) The eligibility agency shall count as income Supplemental Security Income and State Supplemental payments[ are countable income].

(11) The eligibility agency shall count as[I]income, unearned and earned income that[,] is deemed from an alien's sponsor, and the sponsor's spouse, if any, when the sponsor has signed an Affidavit of Support pursuant to Section 213A of the Immigration and Nationality Act after December 18, 1997. Sponsor deeming will end when the alien becomes a naturalized U.S. citizen, or has worked 40 qualifying quarters as defined under Title II of the Social Security Act or can be credited with 40 qualifying work quarters. After December 31, 1996, a creditable qualifying work quarter is one during which the alien did not receive any federal means-tested public assistance.

(12) The eligibility agency may not count as [I]income payments that [is]are excluded under 20 CFR 416 Subpart K, Appendix, 2010 edition, which is incorporated by reference[, is not countable].

(13) 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].

(14) 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.

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

(16) The eligibility agency may not count as income Child Care Assistance under Title XX[ is not countable income].

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

(18) The eligibility agency may only count earned and unearned income of an individual's spouse who is under 19 years of age when that spouse is the head of the household.[If the spouse of an applicant or enrollee is under the age of 19, the eligibility agency counts that spouses earned and unearned income only if the spouse is the head of the household.]

(19) 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.

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

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

(22) 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].

[ (23) 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.

]

R414-310-14. Eligibility Decisions and Recertification.

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

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

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

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

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

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

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

(4) To enroll, the individual must meet the eligibility criteria for enrollment in PCN, pay the enrollment fee, and enroll during an open enrollment period under Section R414-310-16.

(5) 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 the verification date is later.

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

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

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

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

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

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

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

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

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

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

(10) If the enrollee fails to respond to the request for recertification during the recertification month or does not provide all verification with in the application processing period after responding timely to the recertification request, the enrollee may reapply in the calendar month that follows the effective closure date , without waiting for an open enrollment period.

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

(b)] by fil[e]ing a new application before the end of the [due process ]month that follows the [review]recertification month.

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

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

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

(11) The enrollee must wait for the next open enrollment period to reapply for PCN if the enrollee fails to [respond to a request for recertification or does not file a new application before the end of the month that follows the review month]complete the recertification process as defined in Subsection R414-310-14(9) or (10).

 

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

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

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

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

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

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

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

(b) An otherwise eligible applicant who turns 65 years of age during the application month and applies before age 65 may enroll in PCN, which coverage becomes effective [on the first day of the application month subject to the limitations]as defined in Sub[S]section R414-310-15 (1). The applicant is not eligible for PCN if the applicant is [not] eligible for Medicaid without cost in the application month. The eligibility agency shall end enrollment [after]effective the end of the month in which the applicant turns 65 years of age.

(c) The eligibility agency shall deny enrollment to an individual if the individual applies for PCN [upon turning]on or after the date the individual turns 65 years of age.

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

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

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

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

(c) the individual dies;

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

(e) the individual enters a public institution or an Institution for Mental Disease.

(5) The eligibility agency shall end PCN enrollment when the individual enrolls in any type of group health plan or other creditable health insurance coverage including an employer-sponsored health plan .[, except under the following circumstances:] The eligibility agency shall continue PCN eligibility through the end of the certification period if the individual gains access to an employer-sponsored health plan but does not enroll in the plan.

([a]6) An [individual]enrollee who gains access to or enrolls in an employer-sponsored health plan may choose to enroll in the employer-sponsored health plan and switch to the UPP program.

(a) The individual must notify the eligibility agency within ten calendar days of enrolling in the plan or within ten days after coverage begins, whichever is longer, to switch to UPP.

(b) The [individual must meet the] requirements defined in Subsection R414-310-7(3)(b) [and]or (c) must be met except that the individual does not have to enroll in UPP during an open enrollment period[;

(b) The eligibility agency shall continue PCN eligibility through the end of the certification period if the individual gains access to an employer-sponsored health plan but does not enroll in the plan].

(c) The eligibility agency continues the current certification period without doing a new income determination when a PCN enrollee switches to UPP.

(7) The eligibility agency shall determine if an enrollee who gains access to an employer-sponsored health plan during the certification period but does not enroll in such plan may reenroll in PCN at the next recertification as follows:[end eligibility after the due process month if the enrollee does not return requested verification upon receiving proper notice;]

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

([ii]b) The enrollee may choose to switch to UPP if the enrollee can enroll in the employer['s]-sponsored health plan upon recertifying, and the plan meets the requirements of Subsection R414-310-7(3)(b) [and]or (c) and costs 5% or more of the enrollee's countable gross income. The enrollee does not have to wait for an UPP open enrollment period and must enroll in the employer-sponsored health plan to switch to UPP.

(c) The enrollee may reenroll in PCN if the cost exceeds 15% of the enrollee's countable gross income.

([6]8) An individual who enrolls in the Utah Health Insurance Pool does not lose PCN eligibility.

([7]9) An enrollee who fails to report changes or return verifications timely must repay any overpayment of benefits for which the individual is not eligible to receive.

([8]10) The individual may file a new application or make a request to the eligibility agency to reenroll if a PCN case closes for any reason.

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

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

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

(d) The eligibility agency shall approve the individual for a new certification period if the certification period has ended[s] when the agency determines that the individual [is]continues to be eligible. The individual must pay the enrollment fee timely for the new 12-month certification period;

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

([9]11) The eligibility agency shall determine eligibility for PCN if a Medicaid-eligible recipient reports a change during a PCN enrollment month that makes the recipient ineligible for Medicaid or causes a spenddown. The effective date of enrollment for PCN is the day after the Medicaid case closes if the agency determines that the recipient is eligible for PCN and the recipient pays the enrollment fee timely.

(1[0]2) If a PCN case closes for any reason, other than to become covered by another Medicaid or UPP program, and remains closed for one or more calendar months, the individual must submit a new application to the eligibility agency during an enrollment period to reapply. The individual must meet all the requirements of a new applicant including paying a new enrollment fee.

(1[1]3) If a PCN case closes because the enrollee is eligible for another Medicaid program or UPP, the individual may request to reenroll in PCN if there is no break in coverage between the programs, even if the eligibility agency ends open enrollment under Subsection R414-310-16(2).

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

(b) If the 12-month certification period from the earlier enrollment [ends]has ended and the individual is moving from Medicaid to PCN, the individual may still reenroll in PCN. The individual must meet eligibility and income guidelines, and pay a new enrollment fee for the new 12-month certification period.

(1[2]4) If the eligibility agency requests verification of a reported change and the enrollee fails to return the verification, the eligibility agency shall end eligibility [after]effective the end of the month in which the agency sends proper notice. The eligibility agency shall treat the receipt of verification as a new application if the enrollee returns the verification within one calendar month after the effective closure date.

(a) The eligibility agency shall waive the open enrollment period and continue eligibility for the rest of the certification period if the agency determines that the enrollee is eligible for PCN.

(b) The eligibility agency shall send a denial notice to the enrollee if the agency determines that the enrollee is not eligible for PCN.

(1[3]5) A change in income during the certification period does not make the enrollee ineligible for PCN for the months remaining in the current certification period; however, the individual may request the eligibility agency [to] make a Medicaid determination of eligibility.

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

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

 

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

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

Notice of Continuation: June 4, 2012

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