DAR File No. 38819

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.: 38819
Filed: 08/26/2014 10:53:05 AM

RULE ANALYSIS

Purpose of the rule or reason for the change:

The purpose of this change is to clarify eligibility policy for Utah's Premium Partnership for Health Insurance (UPP) program when a member of a UPP household becomes eligible for Medicaid without a cost.

Summary of the rule or change:

This amendment clarifies eligibility policy for UPP when a member of a UPP household becomes eligible for Medicaid without a cost.

State statutory or constitutional authorization for this rule:

• Section 26-1-5
• Pub. L. No. 111-148
• Section 26-18-3

Anticipated cost or savings to:

the state budget:

There is no impact to the state budget because this amendment only clarifies UPP eligibility policy.

local governments:

There is no impact to local governments because they neither fund UPP nor determine eligibility for the program.

small businesses:

There is no impact to small businesses because this amendment only clarifies UPP eligibility policy.

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

There is no impact to UPP providers and to UPP recipients because this amendment only clarifies UPP eligibility policy.

Compliance costs for affected persons:

There is no impact to a single UPP provider or to a UPP recipient because this amendment only clarifies UPP eligibility policy.

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

No impact on business because this simply clarifies current practice.

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:

10/15/2014

This rule may become effective on:

11/01/2014

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.

R414-320-12. Effective Date of Enrollment and Enrollment Period.

(1) Subject to Section R414-320-6, and the limitations in Section R414-306-4, the effective date of enrollment in the UPP program is the first day of the application month.

(a) The effective date of enrollment for a newborn or adopted child is the date of birth or the date of adoption, if the request is made within 30 days of the date of birth or adoption.

(b) If the request to add a newborn or adopted child is made after 30 days of the date of birth or the date of adoption, enrollment is effective on the first day of the month in which the date of request occurs.

(2) An individual who is approved for the UPP program must enroll in the employer-sponsored health plan or COBRA within 30 days of receiving an approval notice from the eligibility agency.

(3) If the applicant does not enroll in the employer-sponsored health insurance plan or COBRA within 30 days of the date that the eligibility agency sends the UPP approval notice, the eligibility agency shall deny the application.

(4) 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. The enrollee must verify the premium payment.

(5) The effective date of enrollment for an individual moving directly from Medicaid, PCN, or CHIP is the first day of the month after eligibility for Medicaid, PCN, or CHIP ends.

(6) The effective date of reenrollment in UPP after the eligibility agency completes the periodic review, is the first day of the month after the review month, or the first day after the due process month. Subsection R414-320-11(5) defines the effective date of reenrollment when the enrollee completes the review process in the three calendar months after the case is closed for incomplete review.

(7) An individual who becomes eligible for UPP is enrolled for a 12-month certification period that begins with the first month of eligibility.

(8) 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 and was covered by the parent's or guardian's health insurance plan;

(c) The individual becomes entitled to receive Medicare;

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

(e) The individual is determined eligible for Medicaid when the household requests a new eligibility determination for any household member;

([e]f) The individual dies;

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

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

(9) The eligibility agency shall end eligibility if an adult enrollee discontinues enrollment in employer-sponsored insurance or COBRA. The enrollee may switch to the PCN program if the enrollee meets PCN eligibility requirements.

 

R414-320-13. Change Reporting and Benefit Changes.

(1) Enrollees are required to report changes to the eligibility agency as defined in Subsection R414-320-3(2).

(a) The eligibility agency shall determine the effect of the change and make the appropriate change in the enrollee's eligibility.

(b) The eligibility agency shall send proper notice of changes in eligibility.

(2) 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.

(3) An eligible household may request enrollment for an individual not enrolled in UPP; the application date for the individual is the date of the request.

(a) A new application form is not required.

(b) The eligibility agency determines the individual's eligibility for UPP in accordance with Section R414-320-11.

(c) The eligibility agency shall determine the effective date of enrollment for individuals in accordance with Section R414-320-12.

(d) The eligibility agency shall waive the requirement found in Subsection R414-320-6(2) if the individual is a newborn or adopted child, and the request to add the child is made within 30 days of the date of birth or adoption.

(e) A new income test must be completed for the individual. If the individual's income places the UPP household over the income limit for UPP, the individual is not eligible to enroll in UPP.

(f) All other eligibility requirements must be met.

(4) If an eligible household requests a new eligibility determination for any household member during the certification period, the eligibility agency shall determine if any enrolled household member is eligible for Medicaid coverage.

(a) An enrollee who is eligible for Medicaid coverage without a cost is no longer eligible for UPP.

(b) An enrollee who must meet a spenddown or MWI premium to receive Medicaid and chooses not to meet the spenddown or MWI premium may remain on UPP.[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 a spenddown or MWI premium, the enrollee may choose to remain on UPP.]

 

KEY: CHIP, Medicaid, PCN, UPP

Date of Enactment or Last Substantive Amendment: [April 21, ]2014

Notice of Continuation: October 13, 2011

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