This filing was published in the 05/15/2008, issue, Vol. 2008, No. 10, of the Utah State Bulletin.
Health, Health Care Financing, Coverage and Reimbursement Policy
Medicaid Health Insurance Flexibility and Accountability Demonstration Waiver
NOTICE OF PROPOSED RULE
DAR File No.: 31358
Filed: 05/01/2008, 03:37
Received by: NL
Purpose of the rule or reason for the change:
In accordance with H.B. 133, 2008 General Session, this change implements a requirement that allows individuals who qualify for Utah's Premium Partnership for Health Insurance (UPP) to enroll in their employer's health insurance outside of an employer health benefit plan open enrollment period. (DAR NOTE: H.B. 133 (2008) is found at Chapter 383, Laws of Utah 2008, and was effective 05/05/2008.)
Summary of the rule or change:
This change removes language regarding an employer open enrollment period because application during an open enrollment period will no longer be a factor in determining eligibility for UPP. This amendment also changes the time frame for determining eligibility from 45 to 30 days to match other medical programs. In addition, this change explains the 30-day requirement for clients to enroll in their employer-sponsored health insurance, upon receiving notice of qualifying for the UPP program. This change also makes other minor clarifications to the rule.
State statutory or constitutional authorization for this rule:
Sections 26-18-3 and 26-1-5
This rule or change incorporates by reference the following material:
42 CFR 433.138(b), 435.911, and 435.912, 2007 ed.
Anticipated cost or savings to:
the state budget:
There is no budget impact because any increases in UPP enrollment only contribute to the enrollment limit of 1,000 adults, for which the Legislature has previously appropriated funds.
There is no budget impact because local governments do not fund the UPP program.
small businesses and persons other than businesses:
There is insufficient data to quantify total dollar amounts. Nevertheless, there are additional health insurance costs for small businesses because this change allows individuals who qualify for UPP to enroll in employer-sponsored health insurance outside of the employer's regular open enrollment periods. On the other hand, this change also produces savings to small businesses because the more individuals who enroll in an employer's health insurance plan may reduce the per person cost to the employer. There are also additional initial costs for individuals who qualify for UPP because the program requires them to pay part of their employer's health insurance premium. These total costs are reduced, however, as their health insurance begins to pay for medical costs that were previously the responsibility of the individual.
Compliance costs for affected persons:
There is insufficient data to quantify total dollar amounts. Nevertheless, there are additional health insurance costs for a small business because this change allows individuals who qualify for UPP to enroll in employer-sponsored health insurance outside of the employer's regular open enrollment periods. On the other hand, this change also produces savings to a small business because the more individuals who enroll in an employer's health insurance plan may reduce the per person cost to the employer. There are also additional initial costs for an individual who qualifies for UPP because the program requires the individual to pay part of his employer's health insurance premium. These total costs are reduced, however, as the individual's health insurance begins to pay for medical costs that were previously the individual's responsibility.
Comments by the department head on the fiscal impact the rule may have on businesses:
Allowing applicants for state assistance with medical needs to enroll in the Utah Premium Partnership program regardless of the timing of their employer's open enrollment period is mandated by statute. There may be some fiscal impact on business as more employees enroll in employer sponsored health insurance. David N. Sundwall, MD, 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@example.com
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:
This rule may become effective on:
David N. Sundwall, Executive Director
R414. Health, Health Care Financing, Coverage and Reimbursement Policy.
R414-320. Medicaid Health Insurance Flexibility and Accountability Demonstration Waiver.
The following definitions apply throughout this rule:
(1) "Adult" means an individual who is at least 19 and not yet 65 years of age.
(2) "Applicant" means an individual who applies for benefits under the UPP program, but who is not an enrollee.
(3) "Best estimate" means the Department's determination of a household's income for the upcoming certification period based on past and current circumstances and anticipated future changes.
(4) "Child" means an individual who is younger than 19 years of age.
(5) "Children's Health Insurance Program" or "CHIP" provides medical services for children under age 19 who do not otherwise qualify for Medicaid.
(6) "Department" means the Utah Department of Health.
(7) "Enrollee" means an individual who applies for and is found eligible for the UPP program.
(8) "Employer-sponsored health plan" means a health insurance plan offered through an employer where:
(a) the employer contributes at least 50 percent of the cost of the health insurance premium of the employee;
(b) coverage includes at least physician visits, hospital inpatient services, pharmacy, well child visits, and children's immunizations;
(c) lifetime maximum benefits are at least $1,000,000;
(d) the deductible is no more than $1,000 per individual; and
(e) the plan pays at least 70% of an inpatient stay after the deductible.
(9) "Utah's Premium Partnership for Health Insurance" (UPP) program 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 that covers either the eligible employee, the eligible spouse of the employee, dependent children, or the family.
(10) "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.
(11) "Income anticipating" means a process of using current facts regarding rate of pay, number of working hours, and expected changes to anticipate future income.
(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.
"Local office" means any [
Bureau of Eligibility Services ] office location, outreach location, or telephone
location where an individual may apply for medical assistance.
(14) "Open enrollment means a time period during which the Department accepts applications for the UPP program.
(15) "Public Institution" means an institution that is the responsibility of a governmental unit or that is under the administrative control of a governmental unit.
(16) "Primary Care Network" or "PCN" program provides primary care medical services to uninsured adults who do not otherwise qualify for Medicaid.
(17) "Recertification month" means the last month of the eligibility period for an enrollee.
(18) "Spouse" means any individual who has been married to an applicant or enrollee and has not legally terminated the marriage.
(19) "Verifications" means the proofs needed to decide if an individual meets the eligibility criteria to be enrolled in the program. Verifications may include hard copy documents such as a birth certificate, computer match records such as Social Security benefits match records, and collateral contacts with third parties who have information needed to determine the eligibility of the individual.
R414-320-4. General Eligibility Requirements.
(1) The provisions of R414-302-1, R414-302-2, R414-302-3, R414-302-5, and R414-302-6 apply to adult applicants and enrollees.
(2) The provisions of R382-10-6, R382-10-7, and R382-10-9 apply to child applicants and enrollees.
(3) An individual who is not a U.S. citizen and does not meet the alien status requirements of R414-302-1 or R382-10-6 is not eligible for any services or benefits under the UPP program.
(4) Applicants and enrollees for the UPP program are not required to provide Duty of Support information. An adult who would be eligible for Medicaid but fails to cooperate with Duty of Support requirements required by the Medicaid program cannot enroll in the UPP program.
Individuals who must pay a spenddown or premium to receive Medicaid can
enroll in the UPP program if they meet the program eligibility criteria in any
month they do not receive Medicaid as long as the Department has not stopped
enrollment under the provisions of R414-320-[
15]. If the Department has stopped enrollment, the
individual must wait for an applicable open enrollment period to enroll in the
R414-320-7. Creditable Health Coverage.
Department adopts 42 CFR 433.138(b), [
2005] ed., which is
incorporated by reference.
(2) An individual who is covered under a group health plan or other creditable health insurance coverage, as defined by the Health Insurance Portability and Accountability Act of 1996 (HIPAA), is not eligible for enrollment.
(3) Eligibility for an individual who has access to but has not yet enrolled in employer-sponsored health insurance coverage will be determined as follows:
(a) If the cost of the employer-sponsored coverage is less than 5% of the household's gross income, the individual is not eligible for the UPP program.
(b) For adults, if the cost of the employer-sponsored coverage exceeds 15% of the household's gross income the adult may choose to enroll in the UPP program or may choose direct coverage through the Primary Care Network program if enrollment has not been stopped under the provisions of R414-310-16.
(c) A child may choose enrollment in UPP or direct coverage under the CHIP program if the cost of the employer sponsored coverage is equal to or more than 5% of the household's gross income.[
(d) An individual is considered to have access to coverage even if
the employer offers coverage only during an employer's open enrollment period.]
(4) An individual who is covered under Medicare Part A or Part B, or who could enroll in Medicare Part B coverage, is not eligible for enrollment, even if the individual must wait for a Medicare open enrollment period to apply for Medicare benefits.
(5) An individual who is enrolled in the Veteran's Administration (VA) Health Care System is not eligible for enrollment. An individual who is eligible to enroll in the VA Health Care System, but who has not yet enrolled, may be eligible for the UPP program while waiting for enrollment in the VA Health Care System to become effective. To be eligible during this waiting period, the individual must initiate the process to enroll in the VA Health Care System. Eligibility for the UPP program ends once the individual becomes enrolled in the VA Health Care System.
(6) The Department shall deny eligibility if the applicant, spouse, or dependent child has voluntarily terminated health insurance coverage within the 90 days immediately prior to the application date for enrollment under the UPP program.
(a) An applicant, applicant's spouse, or dependent child can be eligible for the UPP program if their prior insurance ended more than 90 days before the application date.
(b) An applicant, applicant's spouse, or dependent child who voluntarily discontinues health insurance coverage under a COBRA plan, or under the Utah Comprehensive Health Insurance Pool, or who is involuntarily terminated from an employer's plan may be eligible for the UPP program without a 90 day waiting period.
(7) An individual with creditable health coverage operated or financed by Indian Health Services may enroll in the UPP program.
(8) Individuals 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, Medicare Part A or B, or the VA Health Care System.
(9) The Department shall deny an application or recertification if the applicant or enrollee fails to respond to questions about health insurance coverage for any individual the household seeks to enroll or recertify.
R414-320-14. Eligibility Decisions and Recertification.
Department adopts 42 CFR 435.911 and 435.912, [
which are incorporated by reference.
(2) When an individual applies for UPP, the local office shall determine if the individual is eligible for Medicaid. An individual who qualifies for Medicaid without paying a spenddown or a premium cannot enroll in the UPP program. If the individual appears to qualify for Medicaid, but additional information is required to determine eligibility for Medicaid, the applicant must provide additional information requested by the eligibility worker. Failure to provide the requested information shall result in the application being denied.
(a) If the individual must pay a spenddown or premium to qualify for Medicaid, the individual may choose to enroll in the UPP program if it is an open enrollment period and the individual meets all the applicable criteria for eligibility. If the UPP program is not in an enrollment period, the individual must wait for an open enrollment period.
(b) At recertification, the local office shall first review eligibility for Medicaid. If the individual qualifies for Medicaid without a spenddown or premium, the individual cannot be reenrolled in the UPP program. If the individual appears to qualify for Medicaid, the applicant must provide additional information requested by the eligibility worker. Failure to provide the requested information shall result in the application being denied.
enroll, the individual must meet enrollment eligibility criteria at a time when the Department has not
already stopped enrollment under provisions of Section R414-320-[
15].[ An applicant may apply for UPP anytime
between the month before the applicant signs up for the employer's health
insurance plan and before coverage begins.
Otherwise, eligibility will be denied, and the individual may reapply
during another open enrollment period.]
(4) The local office shall complete a determination of eligibility or ineligibility for each application unless:
(a) The applicant voluntarily withdraws the application and the local office sends a notice to the applicant to confirm the withdrawal;
(b) The applicant died; or
(c) The applicant cannot be located; or
applicant has not responded to requests for information within the [
day application period or by the date the eligibility worker asked the
information or verifications to be returned, if that date is later.
(5) The enrollee must recertify eligibility at least every 12 months.
(6) The local office eligibility worker may require the applicant, the applicant's spouse, or the applicant's authorized representative to attend an interview as part of the application and recertification process. Interviews may be conducted in person or over the telephone, at the local office eligibility worker's discretion.
(7) The enrollee must complete the recertification process and provide the required verifications by the end of the recertification month.
(a) If the enrollee completes the recertification and continues to meet all eligibility criteria, coverage will be continued without interruption.
(b) The case will be closed at the end of the recertification month if the enrollee does not complete the recertification process and provide required verifications by the end of the recertification month.
(c) If an enrollee does not complete the recertification by the end of the recertification month, but completes the process and provides required verifications by the end of the month immediately following the recertification month, coverage will be reinstated as of the first of that month if the individual continues to be eligible.
(8) The eligibility worker may extend the recertification due date if the enrollee demonstrates that a medical emergency, death of an immediate family member, natural disaster or other similar cause prevented the enrollee from completing the recertification process on time.
R414-320-15. Effective Date of Enrollment and Enrollment Period.
(1) The effective date of enrollment is the day that a completed and signed application or an on-line application is received by the local office and the applicant meets all eligibility criteria. The effective date for applications submitted by fax and online is the date of the electronic transmission. The Department shall not provide any benefits before the effective enrollment date.
(2) The effective date of enrollment cannot be before the month in which the applicant pays a premium for the employer-sponsored health insurance and is determined as follows:
(a) The effective date of enrollment is the date an application is received and the person is found eligible, if the applicant enrolls in and pays the first premium for the employer-sponsored health insurance in the application month.
(b) If the
applicant will not pay a premium for the employer-sponsored health insurance in
the application month, the effective date of enrollment is the first day of the
month in which the applicant pays a premium for the employer-sponsored health
insurance. The applicant must enroll in
the employer-sponsored health insurance no later than [
the end of the month
following the month the application is received].
(c) If the
cannot] enroll in the employer-sponsored
health insurance [ by the end of the month immediately following the
application month], the application shall be denied and the individual
will have to reapply during another open enrollment period.
(3) The effective date of enrollment for a newborn or newly adopted child is the date the newborn or newly adopted child is enrolled in the employer-sponsored health insurance if the family requests the coverage within 30 days of the birth or adoption. If the request is more than 30 days after the birth or adoption, enrollment is effective the date of report.
(4) The effective date of re-enrollment for a recertification is the first day of the month after the recertification month, if the recertification is completed as described in R414-320-13.
(5) If the enrollee does not complete the recertification as described in R414-320-13, and the enrollee does not have good cause for missing the deadline, the case will remain closed and the individual may reapply during another open enrollment period.
(6) An individual found eligible shall be eligible from the effective date through the end of the first month of eligibility and for the following 12 months. If the enrollee completes the redetermination process in accordance with R414-320-13 and continues to be eligible, the recertification period will be for an additional 12 months beginning the month following the recertification month. Eligibility could end before the end of a 12-month certification period for any of the following reasons:
(a) The individual turns age 65;
(b) The individual becomes entitled to receive Medicare, or becomes covered by Veterans Administration Health Insurance;
(c) The individual dies;
(d) The individual moves out of state or cannot be located;
(e) The individual enters a public institution or an Institute for Mental Disease.
(7) If an adult enrollee discontinues enrollment in employer-sponsored insurance coverage, eligibility ends. If the enrollment in employer-sponsored insurance is discontinued involuntarily and the individual notifies the local office within 10 calendar days of when the insurance ends, the individual may switch to the PCN program for the remainder of the certification period.
(8) A child enrollee may discontinue employer-sponsoreed health insurance and move to direct coverage under the Children's Health Insurance Program at any time during the certification period without any waiting period.
(9) An individual enrolled in the Primary Care Network or the Children's Health Insurance Program who enrolls in an employer-sponsored plan may switch to the UPP program if the individual reports to the local office within 10 calendar days of enrolling in an employer-sponsored plan and before coverage on the employer-sponsored plan begins.
(10) If a UPP case closes for any reason, other than to become covered by another Medicaid program or the Children's Health Insurance Program, and remains closed for one or more calendar months, the individual must submit a new application to the local office during an open enrollment period to reapply. The individual must meet all the requirements of a new applicant.
(11) If a UPP case closes because the enrollee is eligible for another Medicaid program or the Children's Health Insurance Program, the individual may reenroll if there is no break in coverage between the programs, even if the State has stopped enrollment under R414-320-15.
(a) If the individual's 12-month certification period has not ended, the individual may reenroll for the remainder of that certification period. The individual is not required to complete a new application or have a new income eligibility determination.
(b) If the 12-month certification period from the prior enrollment has ended, the individual may still reenroll. However, the individual must complete a new application and 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.
KEY: Medicaid, PCN, CHIP
Date of Enactment or
Last Substantive Amendment: [
Authorizing, and Implemented or Interpreted Law: 26-18-3; 26-1-5
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For questions regarding the content or application of this rule, please contact Craig Devashrayee at the above address, by phone at 801-538-6641, by FAX at 801-538-6099, or by Internet E-mail at firstname.lastname@example.org
For questions about the rulemaking process, please contact the Division of Administrative Rules (801-538-3764). Please Note: The Division of Administrative Rules is NOT able to answer questions about the content or application of these administrative rules.
Last modified: 05/14/2008 3:03 PM