No. 35298 (Amendment): Rule R382-10. Eligibility

(Amendment)

DAR File No.: 35298
Filed: 09/28/2011 01:10:02 PM

RULE ANALYSIS

Purpose of the rule or reason for the change:

The purpose of this change is to modify the periodic review process to comply with federal due process requirements under the Children's Health Insurance Program (CHIP).

Summary of the rule or change:

This amendment modifies the requirements for completing a periodic review of an individual's continued eligibility for medical assistance to comply with federal due process requirements. It also clarifies the requirements for a recipient to make timely reports of changes and to provide verification of changes. It further clarifies that the agency cannot end eligibility while it gives recipients time to respond to a request for verification and while it makes a redetermination decision. In addition, this amendment clarifies the requirement to provide appropriate advance notice of an adverse action in accordance with due process requirements, changes the benefit effective date to the first day of the application month subject to certain limitations, updates citations, removes provisions that no longer apply, and makes other minor corrections.

State statutory or constitutional authorization for this rule:

• Title 26, Chapter 40

This rule or change incorporates by reference the following material:

• Updates Sections 2110(b) and (c) of the Compilation of Social Security Laws, published by Social Security Administration, 01/01/2011

Anticipated cost or savings to:

the state budget:

The Department does not anticipate any impact to the state budget because most CHIP recipients whose eligibility ends for failure to complete a periodic review usually complete the review process during the month that follows and their medical assistance is reinstated without a break in coverage. Further, the Department does not anticipate any impact for the change to the benefit effective date because the Department pays a set rate to managed health organizations for CHIP eligible children, the rate for the first month of coverage is the same for a full or partial month, and the Department does not modify these rates for this change.

local governments:

There is no impact to local governments because they do not determine CHIP eligibility or fund services for CHIP recipients.

small businesses:

The Department does not anticipate any impact to small businesses because most CHIP recipients whose eligibility ends for failure to complete a periodic review usually complete the review process during the month that follows and their medical assistance is reinstated without a break in coverage. Further, the Department does not anticipate any impact for the change to the benefit effective date because the Department pays a set rate to managed health organizations for CHIP eligible children, the rate for the first month of coverage is the same for a full or partial month, and the Department does not modify these rates for this change.

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

The Department does not anticipate any impact to CHIP providers and no out-of-pocket expenses for CHIP recipients because most recipients whose eligibility ends for failure to complete a periodic review usually complete the review process during the month that follows and their medical assistance is reinstated without a break in coverage. Further, the Department does not anticipate any impact for the change to the benefit effective date because the Department pays a set rate to managed health organizations for CHIP eligible children, the rate for the first month of coverage is the same for a full or partial month, and the Department does not modify these rates for this change.

Compliance costs for affected persons:

The Department does not anticipate any compliance costs to a single CHIP provider and no out-of-pocket expenses to a CHIP recipient because most recipients whose eligibility ends for failure to complete a periodic review usually complete the review process during the month that follows and their medical assistance is reinstated without a break in coverage. Further, the Department does not anticipate any cost for the change to the benefit effective date because the Department pays a set rate to managed health organizations for a CHIP eligible child, the rate for the first month of coverage is the same for a full or partial month, and the Department does not modify these rates for this change.

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

This proposed rule amendment strengthens due process protections consistent with federal law that will avoid Medicaid providers extending services and inappropriately being denied reimbursement. Requirements for periodic reviews of an individual's continued eligibility for medical assistance are strengthened and requirements for a recipient to make timely reports of changes and to provide verification of changes are mandated. It further clarifies that the agency cannot end eligibility while it gives recipients time to respond to a request for verification and while it makes a redetermination decision. In addition, this amendment clarifies the requirement to provide appropriate advance notice of an adverse action in accordance with due process requirements.

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
Children's Health Insurance Program
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 [e-mail]

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:

11/14/2011

This rule may become effective on:

11/21/2011

Authorized by:

David Patton, Executive Director

RULE TEXT

R382. Health, Children's Health Insurance Program.

R382-10. Eligibility.

R382-10-1. Authority.

(1) This rule is authorized by Title 26, Chapter 40.

(2) The purpose of this[This] rule is to set[s] forth the eligibility requirements for coverage under the Children's Health Insurance Program (CHIP).[ It is authorized by Title 26, Chapter 40.]

 

R382-10-2. Definitions.

(1) The Department [adopts]incorporates by reference the definitions found in Sections 2110(b) and (c) of the Compilation of Social Security Laws, in effect January 1, 2011[Act as enacted by Pub. L. No. 105-33 which is incorporated by reference in this rule].

(2) ["Agency" means any local office or outreach location of either the Department of Health or Department of Workforce Services that accepts and processes applications for CHIP.]The Department adopts the definitions in Section R382-10-2.

(3) "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.

[ (3) "Applicant" means a child on whose behalf an application has been made for benefits under the Children's Health Insurance Program, but who is not an enrollee.

] (4) "Best estimate" means the [Department's]eligibility agency's determination of a household's income for the upcoming eligibility period, based on past and current circumstances and anticipated future changes.

(5) "Children's Health Insurance Program" or "CHIP" means the program for benefits under the Utah Children's Health Insurance Act, Title 26, Chapter 40.

(6) "Co-payment and co-insurance" means a portion of the cost for a medical service for which the enrollee is responsible to pay for services received under CHIP.

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

(8) "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.

(9) "Eligibility agency" means the Department of Workforce Services (DWS) that determines eligibility for CHIP under contract with the Department.

([7]10) "Employer-sponsored health plan" means health insurance that meets the requirements of Subsection R414-320-2[(8) (a) (b) (c) (d) and (e)](19).

(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.

[ (8) "Income averaging" means a process of using a history of past or current income and averaging it over a determined period of time that is representative of future income.

] ([9]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 or current income and averaging it over a determined period of time that is representative of future income.

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

(11) "Local office" means any office location, outreach location, or telephone location where an individual may apply for medical assistance.

] ([12]14) "Quarterly Premium" means a payment that enrollees must pay every three months to receive coverage under CHIP.

([13]15) "[Renewal]Review month" means the last month of the eligibility period for an enrollee[.]during which the eligibility agency redetermines an enrollee's eligibility for a new certification period.

([14]16) "Utah's Premium Partnership for Health Insurance" or "UPP" means the program described in Rule R414-320.

([15]17) "Verification[s]" means the proof[s] needed to decide if a child meets the eligibility criteria to be enrolled in the program. Verification[s] may include hard copy documents such as a birth certificate, computer match records such as Social Security benefits match records, and collateral contacts with third parties who have information needed to determine the eligibility of a child.

 

R382-10-3. Actions on Behalf of a Minor.

(1) A parent , legal guardian or an adult who [has] assume[d]s responsibility for the care or supervision of a child who is under 19 years of age may apply for CHIP enrollment, provide information required by this rule, or otherwise act on behalf of a child in all respects under the statutes and rules governing the CHIP program.

([a]2) If[The child, if 18 years old or an emancipated minor,] the child's parent , responsible adult, or legal guardian wants to designate an authorized representative, he must so indicate in writing to the [Department] eligibility agency[who is authorized as the child's representative].

([b]3) A child who is under 19 years of age and is independent of a parent or legal guardian may assume these responsibilities. The [Department]eligibility agency may not require a child who is independent to have an authorized representative if the child can act on his own behalf; however, the eligibility agency may designate an authorized representative if the child needs a representative but [is unable to]cannot make a choice either in writing or orally in the presence of a witness.

([2]4) Where the statutes or rules governing the CHIP program require a child to take an action, the parent , legal guardian, designated representative or adult who [has] assume[d]s responsibility for the care or supervision of the child is responsible to take the action on behalf of the child. If the parent or adult who [has] assume[d]s responsibility for the care or supervision of the child fails to take an action, the failure is attributable as the child's failure to take the action.

([3]5) The eligibility agency shall consider [N]notice to the parent , legal guardian, designated representative, or adult who [has] assume[d]s responsibility for the care or supervision of [the]a child [is]to be notice to the child. The eligibility agency shall send notice to a child who assumes responsibility for himself.

 

R382-10-4. Applicant and Enrollee Rights and Responsibilities.

(1) A parent or an adult who [has] assume[d]s responsibility for the care or supervision of a child may apply or reapply for [Children's Health Insurance Program]CHIP benefits on behalf of a child. [An emancipated child or an 18 year old]A child who is independent may apply on his own behalf.

(2) If a person needs assistance to apply, the person may request assistance from a friend, family member, the eligibility agency, or outreach staff.

([2]3) The applicant must provide verification[s] requested by the eligibility agency to establish the eligibility of the child, including information about the parents.

([3]4) Anyone may look at the eligibility policy manuals located on-line or at any [local]eligibility agency office, except at outreach or telephone locations.

([4]5) [The parent or other individual who arranged for medical services on behalf of the child shall repay the Department for services paid for by the Department under this program if the child is determined not to be eligible for CHIP.]If the eligibility agency determines that the child is not eligible for CHIP, the parent or legal guardian who arranges for medical services on behalf of the child must repay the Department for the cost of services.

([5]6) The parent[(s)] or child, or other responsible person acting on behalf of a child must report certain changes to the [local office]eligibility agency within ten calendar days of the day the change becomes known. Some examples of reportable changes include:

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

[ (b) An enrollee begins to have access to coverage under a group health plan or other health insurance coverage.

] ([c]b) An enrollee leaves the household or dies.

([d]c) An enrollee or the household moves out of state.

([e]d) Change of address of an enrollee or the household.

([f]e) An enrollee enters a public institution or an institution for mental diseases.

(7) An applicant and enrollee may review the information that the eligibility agency uses to determine eligibility.

([6]8) An [A]applicant[s] and enrollee[s] have the right to be notified about actions that the agency takes [regarding their]to determine their eligibility or continued eligibility, the reason the action was taken, and the right to request an agency conference or agency action as defined in Sections R414-301-5 and R414-301-6.

(9) An enrollee in CHIP must pay quarterly premiums, co-payments, or co-insurance amounts to providers for medical services that the enrollee receives under CHIP.

 

R382-10-5. Verification and Information Exchange.

[(1) The applicant and enrollee upon renewal must provide verification of eligibility factors as requested by the agency.

(a) The agency will provide the enrollee a written request of the needed verifications.

(b) The enrollee has at least 10 calendar days from the date the agency gives or mails the verification request to the enrollee to provide verifications.

(c) The due date for returning verifications, forms or information requested by the agency is the close of business on the date the agency sets as the due date in a written request to the enrollee, but not less than 10 calendar days from the date such request is given to or mailed to the enrollee.

(d) The agency allows additional time to provide verifications if the enrollee requests additional time by the due date. The agency will set a new due date that is at least 10 calendar days from the date the enrollee asks for more time to provide the verifications or forms.

(e) If an enrollee has not provided required verifications by the due date, and has not contacted the agency to ask for more time to provide verifications, agency denies the application, renewal, or ends eligibility.](1) The provisions of Section R414-308-4 apply to applicants and enrollees of CHIP.

(2) The Department and the eligibility agency shall safeguard applicant and enrollee information in accordance with Section R414-301-4.

([2]3) The Department or the eligibility agency may release information concerning applicants and enrollees and their households to other state and federal agencies to determine eligibility for other public assistance programs.

([3]4) The Department and the eligibility agency [must]shall release information to the Title IV-D agency and Social Security Administration to determine benefits.

([4]5) The Department and the eligibility agency may verify information by exchanging information with other public agencies as described in 42 CFR 435.945, 435.948, 435.952, 435.955, and 435.960.

 

R382-10-6. Citizenship and Alienage.

(1) To be eligible to enroll in [the program]CHIP, a child must be a citizen or national of the United States or a qualified alien[ as defined in Pub. L. No. 104-193(401) through (403), (411), (412), (421) through (423), (431), and (435), and amended by Pub. L. No. 105-33(5302)(b) and (c), (5303), (5305)(b), (5306), (5562), (5563), and (5571)].

(2) The provisions of Section R414-302-1 regarding citizenship and alien status requirements apply to applicants and enrollees of CHIP.

[ (2) Hmong or Highland Lao veterans who fought on behalf of the Armed Forces of the United States during the Vietnam conflict and who are lawfully admitted to the United States for permanent residence, and their family members who are also qualified aliens, may be eligible to enroll in the program regardless of their date of entry into the United States.

(3) One adult household member must declare the citizenship or alien status of all applicants in the household. The applicant must provide verification of his citizenship or alien status.

(4) A qualified alien, as defined in Pub. L. No. 104-193(431) and amended by Pub. L. No. 105-33(5302)(c)(3), (5562), and (5571), admitted into the United States prior to August 22, 1996, may enroll in the program.

(5) A qualified alien, as defined in Pub. L. No. 104-193(431) and amended by Pub. L. No. 105-33(5302)(c)(3), (5562), and (5571), newly admitted into the United States on or after August 22, 1996, may enroll in the program after five years have passed from his date of entry into the United States.

]

R382-10-7. Utah Residence.

(1) A child must be a Utah resident to be eligible to enroll in the program.

(2) An American Indian or Alaska Native child in a boarding school is a resident of the state where his parents reside. A child in a school for the deaf and blind is a resident of the state where his parents reside.

(3) A child is a resident of the state if he is temporarily absent from Utah due to employment, schooling, vacation, medical treatment, or military service.

(4) The child need not reside in a home with a permanent location or fixed address.

 

R382-10-8. Residents of Institutions.

(1) Residents of institutions described in Section 2110(b)(2)(A) of the Compilation of Social Security Laws[Act as enacted by Pub. L. No. 105-33] are not eligible for the program.

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

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

 

R382-10-9. Social Security Numbers.

(1) The [Department]eligibility agency may request an applicant[s] to provide the correct Social Security Number (SSN) or proof of application for a SSN for each household member at the time of application for the program. The eligibility agency shall use the SSN in accordance with the requirements of 42 CFR 457.340.

(2) [A child may not be denied CHIP enrollment for failure to provide a SSN.]The eligibility agency shall require that each applicant claiming to be a U.S. citizen or national provide their SSN for the purpose of verifying citizenship through the Social Security Administration in accordance with Section 2105(c)(9) of the Compilation of the Social Security Laws.

(3) The eligibility agency may request the SSN of a lawful permanent resident alien applicant, but may not deny eligibility for failure to provide a SSN.

 

R382-10-10. Creditable Health Coverage.

(1) To be eligible for enrollment in the program, a child must meet the requirements of Sections 2110(b)(1)(C) and (2)(B) of the Compilation of Social Security Laws[Act as enacted by Pub. L. No. 105-33].

(2) A child who is covered under a group health plan or other health insurance that provides coverage in Utah, including coverage under a parent's or legal guardian's employer, as defined in 29 CFR 2590.701-4, 2010 ed.[ by the Health Insurance Portability and Accountability Act of 1996 (HIPAA)], is not eligible for CHIP assistance.

(3) A child who is covered under health insurance that does not provide coverage in the State of Utah is eligible for enrollment.

(4) A child who is covered under a group health plan or other health coverage but [has] reache[d]s the lifetime maximum coverage under that plan is eligible for enrollment.

(5) A child who has access to health insurance coverage, where the cost to enroll the child in the least expensive plan offered by the employer is less than 5% of the household's gross annual income, is not eligible for CHIP. The child is considered to have access to coverage even [if]when the employer only offers coverage [only] during an open enrollment period , and the child has had at least one chance to enroll.

[(6) A child who has access to an employer-sponsored health plan where the least expensive plan is equal to or greater than 5% of the household's gross annual income, and the employer offers an employer-sponsored health plan that meets the requirements of R414-320-2 (8) (a), (b), (c), (d) and (e), may choose to enroll in the employer-sponsored health plan and receive reimbursement through the UPP program or may choose to enroll in the CHIP program.

(a) If the employer-sponsored health plan does not include dental benefits, the child may enroll in CHIP dental benefits.

(b) A child who chooses to enroll in the UPP program may switch to CHIP coverage at any time.](6) An eligible child who has access to an employer-sponsored health plan may choose to enroll in either CHIP or the employer-sponsored health plan.

(a) If the child chooses to enroll in the employer-sponsored health plan, the child may enroll in and receive premium reimbursement through the UPP program if enrollment is not closed. The health plan must meet the following conditions:

(i) The cost of the least expensive plan equals or exceeds 5% of the household's gross annual income; and

(ii) The plan meets the requirements of Subsection R414-320-2(19).

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

(c) If the child enrolls in the employer-sponsored health plan or COBRA coverage and UPP, but the plan does not include dental benefits, the child may receive dental-only benefits through CHIP.

(d) If the applicant enrolls the child in the employer-sponsored health plan or COBRA coverage and the plan includes dental, the applicant may choose to enroll the child in the dental plan and receive an additional reimbursement of up to $20 per month, or may choose not to enroll the child in the dental plan and receive dental-only benefits through CHIP.

(e) A child who chooses to enroll in the employer-sponsored health plan or COBRA coverage may switch to CHIP coverage at any time without a 90-day ineligibility period for voluntarily discontinuing health insurance. Eligibility continues through the current certification period without a new eligibility determination.

(7) The [Department]eligibility agency shall deny eligibility if the applicant or a custodial parent [has] voluntarily terminate[d]s health insurance that provides coverage in Utah within the 90 days [prior to]before the application date for enrollment under CHIP.

(a) If the 90-day ineligibility period for CHIP ends in the month of application, or by the end of the month that follows, the eligibility agency shall determine the applicant's eligibility.

(b) If eligible, enrollment in CHIP begins the day after the 90-day ineligibility period ends.

(c) If the 90-day ineligibility period does not end by the end of the month that follows the application month, the eligibility agency shall deny the application.

(8) If an[An] applicant or an applicant's parent[(s) who] voluntarily terminates coverage under a Consolidated Omnibus Budget Reconciliation Act (COBRA ) plan or under the Health Insurance Pool (HIP), or [who]if an applicant is involuntarily terminated from an employer's plan , the applicant is eligible for CHIP without a 90 -day [waiting]ineligibility period.

([8]9) A child with creditable health coverage operated or financed by the Indian Health Services is not excluded from enrolling in the program.

([9]10) An applicant must report at application and [renewal]review whether any of the children in the household for whom enrollment is being requested has access to or is covered by a group health plan, other health insurance coverage, or a state employee's health benefits plan.

([10]11) The [Department shall deny]eligibility agency shall deny an application or [renewal]review if the enrollee fails to respond to questions about health insurance coverage for children that the household seeks to enroll or renew in the program.

(12) A recipient must report when a child enrolls in health insurance coverage within ten calendar days of the date of enrollment or the date that benefits are effective, whichever is later. The eligibility agency shall end eligibility after the month in which the agency sends proper notice of the closure. A child may switch to UPP in accordance with Subsection R382-10-10(6) if the change is reported timely. Failure to make a timely report may result in overpayment.

 

R382-10-11. Household Composition.

(1) The following individuals who reside together must be included in the household for purposes of determining the household size[ and whose income will be counted], whether or not the individual is eligible to enroll in the program:

(a) A t least one child who meets the CHIP age requirement and who does not have access to and is not covered by a group health plan or other health insurance;

(b) Siblings, half-siblings, adopted siblings, and step-siblings of the eligible child if they are under 19 years of age. They may also be eligible for CHIP if they meet the CHIP eligibility criteria[who meets the CHIP age requirement if these individuals also meet the CHIP age requirement];

(c) Parents and stepparents of any child who is included in the household size;

(d) Children of any child included in the household size;

(e) The spouse of any child who is included in the household size;[ and]

(f) Unborn children of anyone included in the household size[.]; and

(g) Children of a former spouse when a divorce [has been]is finalized.

(2) Any individual described in Subsection R382-10-11(1) [of this Section] who is temporarily absent solely by reason of employment, school, training, military service, or medical treatment, or who will return home to live within 30 days from the date of application, is part of the household.

[(3) A household member described in Subsection (1) of this Section who does not qualify to enroll in the CHIP program due to his alien status is included in the household size and his income is counted as household income.](3) Any household member described in Subsection R382-10-11 (1) who is not a citizen, a national, or a qualified alien is included in the household size. The eligibility agency counts the income of these individuals the same way that it counts the income for household members who are citizens, nationals, or qualified aliens.

 

R382-10-12. Age Requirement.

(1) A child must be under 19 years of age sometime during the application month to enroll in the program. An otherwise eligible child who turns 19 years of age during the application month may receive CHIP for the application month and the four-day grace period.

(2) The month in which a child[' s 19th birthday occurs] turns 19 years of age is the last month of eligibility for CHIP enrollment.

 

R382-10-16. Application and [ Renewal ] Eligibility Reviews .

[ The application is the initial request from an applicant for CHIP enrollment for a child. The application process includes gathering information and verifications to determine the child's eligibility for enrollment in the program. Renewal is the process of gathering information and verifications on a periodic basis to determine continued eligibility of an enrollee.

] (1) The applicant must complete and sign a written application or an on-line application to [become enrolled]enroll in the CHIP program. The application process includes gathering information and verification to determine the child's eligibility for enrollment in the program.

(2) The [Department]eligibility agency may accept[s] any Department-approved application form for medical assistance programs offered by the state as an application for CHIP enrollment.

(3) Individuals may apply for enrollment in person, through the mail, by fax, or online.

(4) The provisions of Section R414-308-3 apply to applicants for CHIP.

([4]5) The [Department]eligibility agency may interview applicants, the applicant's parents, and any adult who [has] assume[d]s responsibility for the care or supervision of the child to assist in determining eligibility.

(6) The eligibility agency shall complete a periodic review of an enrollee's eligibility for CHIP 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 shall use available, reliable sources to gather necessary information to complete the review.

(7) The eligibility agency may ask the enrollee to respond to a request to complete the review process. If the enrollee fails to respond to the request during the review month, the agency shall end the enrollee's eligibility after the review month. If the enrollee responds to the review or reapplies in the month after the review month, the eligibility agency shall treat the response as a new application. The application processing period then 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. If the enrollee fails to return verification within the application processing period or if the enrollee is determined ineligible, the eligibility agency shall send a denial notice to the enrollee.

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

(d) If the eligibility agency closes the case for one or more calendar months, the enrollee must reapply for CHIP.

(e) If the enrollee becomes eligible, the new certification period begins the first day of the month after the closure date.

(8) If the enrollee responds to the review request during the review month, the eligibility agency may request verification from the enrollee.

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

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

(c) If the enrollee provides all verification by the due date in the review month, the eligibility agency shall determine eligibility and notify the enrollee of its decision.

(i) If the eligibility agency sends proper notice of an adverse decision during the review month, the agency shall change eligibility for the month that follows.

(ii) If the eligibility agency does not send proper notice of an adverse change for the month that follows, the agency shall extend eligibility to that month. The eligibility agency shall send proper notice of an adverse decision that becomes effective after the due process month and the enrollee does not owe a premium for the due process month.

(9) If the enrollee responds to the review in the review month and the verification due date is in the month that follows, the eligibility agency shall extend eligibility to the month that follows. The enrollee must provide all verification by the verification due date.

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

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

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

(d) The eligibility agency may not continue eligibility while it determines eligibility. The new certification date for the application is the day after the effective closure date if the enrollee is found eligible.

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

([5]11) If eligibility for CHIP enrollment ends, the [Department shall]eligibility agency shall review the case for eligibility under any other medical assistance program without requiring a new application. The [Department]eligibility agency may request additional verification from the household if there is insufficient information to make a determination.

 

R382-10-17. Eligibility Decisions.

(1) The [Department must]eligibility agency shall determine eligibility for CHIP within 30 days of the date of application. If the eligibility agency [a decision can not]cannot make a decision [be made] in 30 days because the applicant fails to take a required action and requests additional time to complete the application process, or if circumstances beyond the [Department's]eligibility agency's control delay the eligibility decision, [the Department shall]the eligibility agency shall document the reason for the delay in the case record.[ The Department must inform the applicant of the status of the application and the time frame for completing the application process.]

(2) The [Department]eligibility agency may not use the time standard as a waiting period before determining eligibility, or as a reason for denying eligibility [because the Department]when the agency [has]does not determine[d] eligibility within that time.

(3) The [Department shall]eligibility agency shall complete a determination of eligibility or ineligibility for each application unless:

(a) the applicant voluntarily [withdrew]withdraws the application and the [Department sent]eligibility agency sends a notice to the applicant to confirm the withdrawal;

(b) the applicant died; or

(c) the applicant [can not]cannot be located or [has]does not respond[ed] to requests for information within the 30 -[ ]day application period.

(4) The [Department must]eligibility agency shall redetermine eligibility at least every 12 months.

(5) At application and [renewal]review, the [Department must]eligibility agency shall determine if any child applying for CHIP enrollment is eligible for coverage under Medicaid.

(a) The enrollee must provide any additional verification needed to determine if a child is eligible for Medicaid or the eligibility agency shall deny the application or review.

(b) A child who is eligible for Medicaid coverage is not eligible for CHIP.

(c) A n eligible child who must meet a spend[-]down to receive Medicaid and chooses not to meet the spenddown [can be enrolled]may enroll in CHIP.

(d) If the use of the adjusted gross income (AGI) at a review causes the household to appear eligible for Medicaid, the eligibility agency shall request verification of current income and other factors needed to determine Medicaid eligibility. The eligibility agency cannot renew CHIP coverage if the household fails to provide requested verification.

(e) If the AGI causes the household to qualify for a more expensive CHIP plan, the household may choose to verify current income. If current income verification shows the family is eligible for a lower cost plan, the eligibility agency shall change the household's eligibility to the lower cost plan effective the month after verification is provided.

(6) If an enrollee asks for a new income determination during the CHIP certification period and the eligibility agency finds the child is eligible for Medicaid, the agency shall end CHIP coverage and enroll the child in Medicaid.

 

R382-10-18. Effective Date of Enrollment and Renewal.

(1) [The]Subject to the limitations in Sections R414-306-6 and R382-10-10, the effective date of CHIP enrollment is the [date]first day of the application month.[ a completed and signed application is received at a local office by the close of normal business hours on a weekday and not on a Saturday, Sunday, or a state or federal holiday. This applies to paper applications delivered in person or by mail, paper applications sent via facsimile transmission, and electronic applications sent via the internet. If a local office receives an application after the normal close of business hours on a weekday or on a Saturday, Sunday, or a state or federal holiday, the effective date of CHIP enrollment is the next weekday.

(2) The effective date of CHIP enrollment for applications delivered to an outreach location is as follows:

(a) If the application is delivered at a time when the outreach staff is working at that location, the effective date of enrollment is the date the outreach staff receives the application.

(b) If the application is delivered on a non-business day or at a time when the outreach office is closed, the effective date of enrollment is the last business day that a staff person from the state medical eligibility agency was available to receive or pick up applications from the location.

(3) An applicant must provide the verifications needed to process an application and determine eligibility no later than the close of business on the last day of the application period. If the last day of the application processing period falls on a day of the week when the medical eligibility office is closed, then the applicant has until the close of business on the next day that the medical eligibility agency is open. An applicant may request more time to provide verifications. The request must be made by the last day of the application processing period.]

([4]2) If the eligibility agency receives an application during the first four days of a month,[T]the [Department may]agency shall allow a grace enrollment period [beginning]that begins no earlier than four days before the date that the agency receives a completed and signed application[ is received by the Department]. During the grace enrollment period, the individual must receive medical services, meet eligibility criteria, and have an emergency situation that prevents the individual from applying. The Department [shall]may not pay for any services that the individual receive[d]s before the effective enrollment date.

([5]3) For a family who enrolls[has] a child [enrolled] in CHIP and who adds a newborn or adopted child, the effective date of enrollment is the date of birth or placement for adoption if the family requests the coverage within 30 days of the birth or adoption. If the family makes the request [is made] more than 30 days after the birth or adoption, enrollment in CHIP will be effective beginning the first day of the month in which the date of report occurs, subject to the limitations in Sections R414-306-6, R382-10-10 and the provisions of Subsection R382-10-18(2)[except as otherwise provided in R382-10-18(1)].

([6]4) The effective date of enrollment for a [renewal]new certification period after the review month is the first day of the month after the [renewal]review month, if the [renewal]review process is completed by the end of the [renewal]review month . If a due process month is approved, the effective date of enrollment for a renewal is the first day of the month after the due process month. The enrollee must complete the review process and continue to be eligible to be reenrolled in CHIP at review[, or by the last day of the month immediately following the renewal month, and the child continues to be eligible].

[ (7) If the renewal process is not completed by the end of the renewal month, the case will be closed unless the enrollee has good cause for not completing the renewal process on time. Good cause includes a medical emergency, death of an immediate family member, or natural disaster, or other similar occurrence.

(8) The Department may require an interview with the parent, child, or adult who has assumed responsibility for the care or supervision of a child, or other authorized representative as part of the renewal process.

]

R382-10-19. Enrollment Period.

[ (1) The enrollment period begins with either the date of application, or an earlier date as defined in R382-10-18, if the applicant is determined eligible for CHIP enrollment. Covered services the child received on or after the effective date of enrollment are payable by CHIP for a child who was eligible upon application.

] ([2]1) [A]Subject to the provisions in Subsection R382-10-19(2), a child eligible for CHIP enrollment receives 12 months of coverage that begins with the effective month of enrollment. If the eligibility agency allows a grace enrollment period that extends into the month before the application month, the days of the grace enrollment period do not count as a month in the 12-month enrollment period.

(2) CHIP coverage may end before the end of the 12-month certification period if the child:

(a) [unless the child] turns 19 years of age before the end of the 12-month enrollment period[,];

(b) moves out of the state[,];

(c) becomes eligible for Medicaid[,];

(d) begins to be covered under a group health plan or other health insurance coverage[,]:

(e) enters a public institution or an institution for mental diseases[,]; or

(f) does not pay [his or her]the quarterly premium.

(3) The month that a child turns 19 years of age is the last month that the child [is]may be eligible for CHIP.

(4) Certain changes affect an enrollee's eligibility during the 12-month certification period.

(a) If an enrollee gains access to health insurance under an employer-sponsored plan or COBRA coverage, the enrollee may switch to UPP. The enrollee must report the health insurance within ten calendar days of enrolling, or within ten calendar days of when coverage begins, whichever is later. The employer-sponsored plan must meet UPP criteria.

(b) If income decreases, the enrollee may report the income and request a redetermination. If the change makes the enrollee eligible for Medicaid, the eligibility agency shall end CHIP eligibility and enroll the child in Medicaid.

(c) If the decrease in income causes the child to be eligible for a lower premium, the change in eligibility becomes effective the month after the eligibility agency receives verification of the change.

(d) If income increases during the certification period, eligibility remains unchanged through the end of the certification period.

(5) Failure to make a timely report of a reportable change may result in an overpayment of benefits.

 

R382-10-20. Quarterly Premiums.

(1) Each family with children enrolled in the CHIP program must pay a quarterly premium based on the countable income of the family during the first month of the quarter.

(a) A family whose countable income is equal to or less than 100% of the federal poverty level or who are American Indian or Alaska Native pays no premium.

(b) A family with countable income greater than 100% and up to 150% of the federal poverty level must pay a quarterly premium of $30.

(c) A family with countable income greater than 150% and up to 200% of the federal poverty level must pay a quarterly premium of $75.

(2) The eligibility agency shall end CHIP coverage and assess a $15 late fee to [A]a family who does not pay its quarterly premium by the premium due date[ will be terminated from CHIP and assessed a $15 late fee]. The agency may reinstate coverage[Coverage may be reinstated] when any of the following events occur:

(a) The family pays the premium and the late fee by the last day of the month immediately following the termination;

(b) The family's countable income decreased to below 100% of the federal poverty level prior to the first month of the quarter.

(c) The family's countable income decreases prior to the first month of the quarter and the family owes a lower premium amount. The new premium must be paid within 30 days.

(3) A family who se CHIP coverage [was terminated]ends [from CHIP]and who reapplies within one year for coverage[of the termination date,] must pay any outstanding premiums and late fees before the children can be re-enrolled.

(4) The eligibility agency may not charge the household a premium during a due process month associated with the periodic eligibility review.

(5) The eligibility agency shall assess premiums that are payable each quarter for each month of eligibility.

 

R382-10-21. Termination and Notice.

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

(2) The [Department shall notify]eligibility agency shall notify an enrollee in writing ten calendar days before taking a proposed action that adversely affect[ing]s the enrollee's eligibility.

(3) Notices under [this section]Section R382-10-21 shall provide the following information:

(a) the action to be taken;

(b) the reason for the action;

(c) the regulations or policy that support the action when the action is a denial, closure or an adverse change to eligibility;

(d) the applicant's or enrollee's right to a hearing;

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

(f) the applicant's or enrollee's right to represent himself, [or] use legal counsel, a friend, relative, or other spokesperson.

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

(a) the child is deceased;

(b) the child [has] move[d]s out[ ] -of - state and is not expected to return;

(c) the child [has] enter[ed]s a public institution or an institution for mental diseases; or

[ (d) the child has enrolled in other health insurance coverage, in which case eligibility ends the day before the new coverage begins.

] ([e]d) the child's whereabouts are unknown and the post office has returned mail to indicate that there is no forwarding address.

 

R382-10-22. Case Closure or Withdrawal.

The [Department shall]eligibility agency shall [terminate]end a child's enrollment upon enrollee request or upon discovery that the child is no longer eligible. An applicant may withdraw an application for CHIP benefits any time [prior to approval of]before the eligibility agency makes a decision on the application.

 

KEY: children's health benefits

Date of Enactment or Last Substantive Amendment: [August 22, ]2011

Notice of Continuation: May 19, 2008

Authorizing, and Implemented or Interpreted Law: 26-1-5; 26-40

 

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