No. 38096 (Amendment): Rule R382-10. Eligibility

(Amendment)

DAR File No.: 38096
Filed: 11/01/2013 06:12:37 PM

RULE ANALYSIS

Purpose of the rule or reason for the change:

The purpose of this change is to comply with provisions of the Patient Protection and Affordable Care Act (PPACA) through changes that relate to the treatment of applications and reviews, determining income, income budgeting, and by using Modified Adjusted Gross Income (MAGI)-based methodology.

Summary of the rule or change:

This amendment defines general provisions for accepting and processing applications and reviews, defines provisions for determining countable income, specifies methodologies used to determine best estimates of income, and outlines provisions to determine household composition through MAGI-based methodology. The rule also defines the new process for quarterly premiums and the sanction period for failure to pay a premium. It also updates incorporations by reference and makes other technical changes.

State statutory or constitutional authorization for this rule:

• Section 26-1-5
• Pub. L. No. 111-148
• Title 26, Chapter 40

This rule or change incorporates by reference the following material:

• Updates 42 CFR 457.315, published by Government Printing Office, 10/01/2012
• Updates 42 CFR 457.320(d), published by Government Printing Office, 10/01/2012
• Updates 42 CFR 457.330, published by Government Printing Office, 10/01/2012
• Updates 42 CFR 457.340(b), published by Government Printing Office, 10/01/2012
• Updates 42 CFR 457.343, published by Government Printing Office, 10/01/2012
• Updates 42 CFR 457.348, published by Government Printing Office, 10/01/2012
• Adds 78 FR 42313, published by Government Printing Office, 07/15/2013
• Adds 78 FR 42312, published by Government Printing Office, 07/15/2013

Anticipated cost or savings to:

the state budget:

The impact to the state budget is addressed in the companion rule filing for Rule R414-304. (DAR NOTE: The proposed amendment to Rule R414-304 is under DAR No. 38100 in this issue, November 15, 2013, of the Bulletin.)

local governments:

There is no impact to local governments because they neither fund services for the Children's Health Insurance Program (CHIP) nor make CHIP eligibility determinations.

small businesses:

This amendment does not impose any new costs or requirements because it does not affect services for CHIP recipients and small businesses do not make CHIP eligibility determinations. In addition, this amendment does not affect business revenue because the conversion process to MAGI-based methodology does not systematically increase or decrease CHIP eligibility.

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

Some CHIP recipients may realize savings roughly equivalent to the anticipated state costs because more individuals will become eligible for CHIP services. Nevertheless, this amendment does not affect provider revenue because the conversion process to MAGI-based methodology does not systematically increase or decrease CHIP eligibility.

Compliance costs for affected persons:

There are no compliance costs because this amendment can only result in out-of-pocket savings to a single CHIP recipient. Furthermore, this amendment does not affect provider revenue because the conversion process to MAGI-based methodology does not systematically increase or decrease CHIP eligibility.

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

The changes may modify individual eligibility but will have no impact on business.

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:

12/16/2013

This rule may become effective on:

01/01/2014

Authorized by:

David Patton, Executive Director

RULE TEXT

R382. Health, Children's Health Insurance Program.

R382-10. Eligibility.

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

(1) A parent or an adult who assumes responsibility for the care or supervision of a child may apply or reapply for CHIP benefits on behalf of a child. 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.

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

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

(5) If the eligibility agency determines that the child received CHIP coverage during a period when the child [is]was 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.

(6) The parent or child, or other responsible person acting on behalf of a child must report certain changes to the eligibility agency within ten calendar days of the day the change becomes known. [Some examples of r]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 leaves the household or dies.

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

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

(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.

(8) An applicant and enrollee have the right to be notified about actions that the agency takes 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 Section[s] R414-301-[5]6 and Section R414-301-[6]7.

(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.

 

R382-10-6. Citizenship and Alienage.

(1) To be eligible to enroll in CHIP, a child must be a citizen or national of the United States (U.S.) or a qualified alien.

(2) The provisions of Section R414-302-[1]3 regarding citizenship and alien status requirements apply to applicants and enrollees of CHIP.

 

R382-10-7. Utah Residence.

(1) The Department adopts and incorporates by reference, 42 CFR 457.320(d), October 1, 2012 ed.  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.

 

R382-10-9. Social Security Numbers.

(1) The eligibility agency may request an applicant 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 (b), October 1, 2012 ed. , which is incorporated by reference.

(2) 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 an SSN.

(4) The Department may assign a unique CHIP identification number to an applicant or beneficiary who meets one of the exceptions to the requirement to provide an 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.

(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]July 1, 2013 ed., is not eligible for CHIP assistance.

([3]a) 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 reaches the lifetime maximum coverage under that plan is eligible for enrollment.

] ([5]b) 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]countable MAGI-based income for the individual, is not eligible for CHIP. The child is considered to have access to coverage even when the employer only offers coverage during an open enrollment period, and the child has had at least one chance to enroll.

([6]3) 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]countable MAGI-based income for the individual; 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 has a deductible that must be met before the plan 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. If the employer-sponsored health plan includes dental, the applicant may choose to enroll the child in the dental plan and receive an additional reimbursement from UPP 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.

(d) A child who chooses to enroll in the employer-sponsored health plan or COBRA coverage and UPP may discontinue the employer-sponsored health plan or COBRA coverage and 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]4) Subject to the provisions published in 78 FR 42313, which the Department adopts and incorporates by reference, [T]the eligibility agency shall deny eligibility and impose a 90-day waiting period for enrollment under CHIP if the applicant or a custodial parent voluntarily terminates health insurance that provides coverage in Utah within the 90 days before the application date for enrollment under CHIP. In addition, the agency may not apply a 90-day waiting period in the following situations:

(a) a non-custodial parent voluntarily terminates coverage;

(b) the child is voluntarily terminated from insurance that does not provide coverage in Utah;

(c) the child is voluntarily terminated from a limited health insurance plan;

(d) a child is terminated from a custodial parent's insurance because ORS reverses the forced enrollment requirement.

([a]5) 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]a) If eligible, enrollment in CHIP begins the day after the 90-day ineligibility period ends.

([c]b) 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]CHIP eligibility.

(6) The Department shall comply with the provisions of enrollment after the waiting period in accordance with 78 FR 42312, which the Department adopts and incorporates by reference.

([8]7) If an applicant or an applicant's parent voluntarily terminates coverage under a Consolidated Omnibus Budget Reconciliation Act (COBRA) plan or under the Health Insurance Pool (HIP), or if an applicant is involuntarily terminated from an employer's plan, the applicant is eligible for CHIP without a 90-day ineligibility period.

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

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

([11]10) The eligibility agency shall deny an application or 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]11) 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 effective the end of 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]3) if the change is reported timely. Failure to make a timely report may result in overpayment.

 

R382-10-11. Household Composition and Income Provisions.

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

(a) At 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;

(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;

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

(g) Children of a former spouse when a divorce is finalized.]The Department adopts and incorporates by reference, 42 CFR 457.315, October 1, 2012 ed., regarding the household composition and income methodology to determine eligibility for CHIP.

(2) Any individual described in Subsection R382-10-11(1) 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) 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.

](3) The household size includes the number of unborn children that a pregnant household member expects to deliver.

(4) The eligibility agency counts children who are 19 or 20 years old and are full-time students in the household size of individuals whose household size is determined under the non-tax filer rules found in 42 CFR 435.603(f)(3).

(5) The eligibility agency may not count as income any payments from sources that federal law specifically prohibits from being counted as income to determine eligibility for federally-funded programs.

(6) The eligibility agency may not count as income any payments that an individual receives pursuant to the Individual Indian Money Account Litigation Settlement under the Claims Resettlement Act of 2010, Pub. L. No. 111 291, 124 Stat. 3064.

(7) The eligibility agency counts as income, cash support received from a tax filer who claims the individual as a tax dependent when that dependent is not the spouse or child of the tax filer, but only the amount that exceeds a minimal amount set by the Department.

(8) The eligibility agency determines eligibility by deducting an amount equal to 5% of the federal poverty guideline for the applicable household size from the MAGI-based household income determined for the individual.

 

[R382-10-13. Income Provisions.

(1) To be eligible to enroll in the Children's Health Insurance Program, gross household income must be equal to or less than 200% of the federal non-farm poverty guideline for a household of equal size.

(a) All gross income, earned and unearned, received by the parents and stepparents of any child who is included in the household size, counts toward household income, unless this section specifically describes a different treatment of the income.

(b) When a CHIP household is scheduled for a renewal of eligibility, the household may give consent to the eligibility agency to access the household's most recent adjusted gross income from the Utah State Tax Commission. Only CHIP eligible households can elect this option. When the household elects this option, the eligibility agency shall use the adjusted gross income from the most recent tax record as the countable income of the household to determine eligibility for CHIP.

(2) The Department may not count as income any payments from sources that federal law specifically prohibits from being counted as income to determine eligibility for federally-funded programs.

(3) The Department may count any income in a trust that is available to, or is received by any of the following household members:

(a) a parent or spouse of a parent;

(b) an eligible child who is the head of the household;

(c) a spouse of an eligible child if the spouse is 19 years of age or older; or

(d) a spouse who is under 19 years old and is the head of the household.

(4) Payments received from the Family Employment Program, General Assistance, or refugee cash assistance is countable income.

(5) Rental income is countable income. The following expenses can 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.

(6) Deposits to joint checking or savings accounts are countable income, even if the deposits are made by a non-household member. An applicant or enrollee who disputes household ownership of deposits to joint checking or savings accounts shall be given an opportunity to prove that the deposits do not represent income to the household. Funds that are successfully disputed are not countable income.

(7) Cash contributions made by non-household members are counted as income unless the parties have a signed written agreement for repayment of the funds.

(8) The interest earned from payments made under a sales contract or a loan agreement is countable income to the extent that these payments will continue to be received during the eligibility period.

(9) In-kind income, which is goods or services provided to the individual from a non-household member and which is not in the form of cash, for which the individual performed a service or 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) SSI and State Supplemental Payments are countable income.

(11) Death benefits are not countable income to the extent that the funds are spent on the deceased person's burial or last illness.

(12) 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.

(13) Child Care Assistance under Title XX is not countable income.

(14) Reimbursements of Medicare premiums received by an individual from Social Security Administration or the Department are not countable income.

(15) Needs-based Veteran's pensions are counted as income. The Department may only count the portion of a Veteran's Administration benefit to which the individual is legally entitled.

(16) The Department may not count the income of a child under the age of 19 if the child is not the head of a household.

(17) The Department shall count the income of the spouse of an eligible child if:

(a) the spouse is 19 years of age or older; or

(b) the spouse is under 19 years old and is the head of the household.

(18) 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.

(19) Reimbursements for expenses incurred by an individual are not countable income.

(20) Any payments made to an individual because of his status as a victim of Nazi persecution as defined in Pub. L. No. 103 286 are not countable income, including payments made by the Federal Republic of Germany, Austrian Social Insurance payments, and Netherlands WUV payments.

(21) Victim's Compensation payments as defined in Pub. L. No. 101 508 are not countable income.

(22) Disaster relief funds received if a catastrophe has been declared a major disaster by the President of the United States as defined in Pub. L. No. 103 286 are not countable income.

(23) Income of an alien's sponsor or the sponsor's spouse is not countable income.

(24) If the household expects to receive less than $500 per year in taxable interest and dividend income, then they are not countable income.

(25) Income paid by the U.S. Census Bureau to a temporary census taker to prepare for and conduct the census is not countable income.

(26) The additional $25 a week payment to unemployment insurance recipients provided under Section 2002 of the American Recovery and Reinvestment Act of 2009, Pub. L. No. 111 5, 123 Stat. 115, which an individual may receive from March 2009 through June 2010 is not countable income.

(27) 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.

(28) The Consolidated Omnibus Reconciliation Act (COBRA) premium subsidy provided under Section 3001 of the American Recovery and Reinvestment Act of 2009, Pub. L. No. 111 5, 123 Stat. 115, is not countable income.

(29) The making work pay credit provided under Section 1001 of the American Recovery and Reinvestment Act of 2009, Pub. L. No. 111 5, 123 Stat. 115, is not countable income.

(30) The eligibility agency may not count as income any payments that an individual receives pursuant to the Individual Indian Money Account Litigation Settlement under the Claims Resolution Act of 2010, Pub. L. No. 111 291, 124 Stat. 3064.

(31) The eligibility agency may not count as income any federal tax refund and refundable credit that an individual receives between January 1, 2010, and December 31, 2012, pursuant to the Tax Relief Unemployment Insurance Reauthorization and Job Creation Act of 2010, Pub. L. No. 111 312, 124, Stat 3296.

]

R382-10-1[4]3. Budgeting.

(1) The [Department]eligibility agency [shall count the gross income for parents and stepparents of any child included in the household size to determine a child's eligibility, unless the income is excluded under this rule. The Department may only deduct required expenses from the gross income to make an income available to the individual. No other deductions are allowed.]determines countable household income according to MAGI-based methodology as required by 42 CFR 457.315.

(2) [The Department shall determine monthly income by taking into account the months of pay where an individual receives a fifth paycheck when paid weekly, or a third paycheck when paid every other week. The Department shall multiply the weekly amount by 4.3 to obtain a monthly amount. The Department shall multiply income paid bi-weekly by 2.15 to obtain a monthly amount.

(3)] The [Department]eligibility agency shall determine a child's eligibility and cost[-] sharing requirements prospectively for the upcoming eligibility period at the time of application and at each renewal for continuing eligibility.

(a) The [Department]eligibility agency [shall] determines prospective eligibility by using the best estimate of the household's average monthly income [that is] expected to be received or made available to the household during the upcoming eligibility period.

(b) The eligibility agency shall include in its estimate, reasonably predictable income changes such as seasonal income or contract income, to determine the average monthly income expected to be received during the certification period.

(c) The [Department]eligibility agency [shall] prorates income that is received less often than monthly over the eligibility period to determine an average monthly income.[ The Department may request prior years' tax returns as well as current income information to determine a household's income.]

[(4) A household may elect upon renewal to have the Department use the most recent adjusted gross income (AGI) from the Utah State Tax Commission. The eligibility agency shall then use AGI instead of requesting verification of current income. If the use of AGI should result in an adverse decision or change, the household may provide verification of current income.

]([5]3) Methods of determining the best estimate are income averaging, income anticipating, and income annualizing. The [Department]eligibility agency may use a combination of methods to obtain the most accurate best estimate. The best estimate may be a monthly amount that is expected to be received each month of the eligibility period, or an annual amount that is prorated over the eligibility period. Different methods may be used for different types of income received in the same household.

([6]4) The [Department]eligibility agency [shall] determines farm and self-employment income by using the individual's recent tax return forms or other verifications the individual can provide. If tax returns are not available, or are not reflective of the individual's current farm or self-employment income, the [Department]eligibility agency may request income information from a recent time period during which the individual had farm or self-employment income. [The Department shall deduct 40% of the gross income as a deduction for business expenses to determine the countable income of the individual. For individuals who have business expenses greater than 40%, the Department may exclude more than 40% if the individual can demonstrate that the actual expenses are greater than 40%.] The [Department]eligibility agency [shall] deducts the same expenses from gross income that the Internal Revenue Service allows as self-employment expenses to determine net self-employment income.

[(7) The Department may annualize income for any household and in particular for households that have self-employment income, receive income sporadically under contract or commission agreements, or receive income at irregular intervals throughout the year.

]

R382-10-1[5]4. Assets.

An asset test is not required for CHIP eligibility.

 

R382-10-1[6]5. Application and Eligibility Reviews.

(1) The Department adopts and incorporates by reference 78 FR 42312 . The Department also adopts and incorporates by reference 42 CFR 457.330, 457.343, and 457.348, October 1, 2012 ed. [The applicant must complete and sign a written application or an on-line application to 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 eligibility agency may accept 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]2) The provisions of Section R414-308-3 apply to applicants for CHIP, except for Subsection R414-308-3(10) and the three months of retroactive coverage.

([5]3) Individuals can apply without having an interview. The eligibility agency may interview applicants and enrollee's, the parents or spouse, and any adult who assumes responsibility for the care or supervision of the child, when necessary to resolve discrepancies or to gather information that cannot be obtained otherwise.

([6]4) According to the provisions of Section 2105(a)(4)(F) of the Social Security Act, the Department provides medical assistance during a presumptive eligibility period to a child if a Medicaid eligibility worker with the Department of Human Services has determined, based on preliminary information, that:

(a) the child meets citizenship or alien status criteria as defined in Section R414-302-[1]3;

(b) the child is not enrolled in a health insurance plan; and

(c) the child's household income exceeds the applicable income limit for Medicaid, but does not exceed 200% of the federal poverty level for the applicable household size.

([7]5) A child determined presumptively eligible is required to file an application for medical assistance with the eligibility agency in accordance with the requirements of Section 1920A of the Social Security Act.

([8]6) A child may receive medical assistance during only one presumptive eligibility period in any six month period.

([9]7) The eligibility agency shall complete a periodic review of an enrollee's eligibility for CHIP medical assistance in accordance with the requirements of 42 CFR 457.343.[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. The eligibility agency may conduct the review without requiring the enrollee to provide additional information.]

([10]8) [The eligibility agency may ask the enrollee to respond to a request to complete the review process.] If [the]an enrollee fails to respond to [the]a request for information to complete the review during the review month, the agency shall end the enrollee's eligibility effective at the end of the review month and send proper notice to the enrollee.

(a) If the enrollee responds to the review or reapplies [in the month after the review month]within three calendar months of the review closure date, the eligibility agency shall treat the response as a new application without requiring the enrollee to reapply. 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.

(i)](b) If the enrollee is determined eligible based on this reapplication, the new certification period begins the first day of the month [after the closure date]in which the enrollee contacts the agency to complete the review if verification is provided within the application processing period. The four day grace period may apply.[

(ii)] 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]9) Except as defined in R382-10-15(8), [If] the enrollee must reapply for CHIP if the enrollee's case is closed for one or more calendar months[, the enrollee must reapply for CHIP].

[(11) 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]10) 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]11) 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 the effective date of an adverse decision. The enrollee does not owe a premium for the due process month.

(12) 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 effective at the end of 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.

(13) 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.

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

 

R382-10-1[7]6. Eligibility Decisions.

(1) The Department adopts and incorporates by reference 78 FR 42312, regarding eligibility screening.

(2) The eligibility agency shall determine eligibility for CHIP within 30 days of the date of application. If the eligibility agency cannot make a decision 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 eligibility agency's control delay the eligibility decision, the eligibility agency shall document the reason for the delay in the case record.

([2]3) If a child made presumptively eligible files an application for medical assistance in accordance with the requirements of Section 1920A of the Social Security Act, presumptive eligibility continues only until the eligibility agency makes an eligibility decision based on that application. Filing additional applications does not extend the presumptive eligibility period.

([3]4) The eligibility agency may not use the time standard as a waiting period before determining eligibility, or as a reason for denying eligibility when the agency does not determine eligibility within that time.

([4]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 died; or

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

([5]6) The eligibility agency shall redetermine eligibility [at least ]every 12 months.

([6]7) At application and review, the 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) A child who is eligible for Medicaid coverage is not eligible for CHIP.

([c]b) An eligible child who must meet a spenddown to receive Medicaid and chooses not to meet the spenddown 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.

] ([7]8) 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.

 

R382-10-1[8]7. Effective Date of Enrollment and Renewal.

(1) Subject to the limitations in Section[s] R414-306-6, [and]Section R382-10-10, and the provisions in Subsection R414-308-3(7), the effective date of CHIP enrollment is the first day of the application month.

(2) The presumptive eligibility period begins on the first day of the month in which a child is determined presumptively eligible for CHIP. Coverage cannot begin in a month that the child is otherwise eligible for medical assistance.

(3) If the eligibility agency receives an application during the first four days of a month, the agency shall allow a grace enrollment period that begins no earlier than four days before the date that the agency receives a completed and signed application. 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 may not pay for any services that the individual receives before the effective enrollment date.

(4) If a child determined eligible for a presumptive eligibility period files an application in accordance with the requirements of Section 1920A of the Social Security Act and is determined eligible for regular CHIP based on that application, the effective date of CHIP enrollment is the first day of the month of application or the first day of the month in which the presumptive eligibility period began, if later.

(a) The four-day grace period defined in Subsection R382-10-1[8]7(3) applies if the applicant meets that criteria and the child was not eligible for any medical assistance during such time period.

(b) Any applicable CHIP premiums apply beginning with the month regular CHIP coverage begins, even if such months are the same months as the CHIP presumptive eligibility period.

(5) For a family who 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 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 R382-10-1[8]7(3).

(6) The effective date of enrollment for a new certification period after the review month is the first day of the month after the review month, if the review process is completed by the end of the 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 if the review process is completed by the end of the due process month. The enrollee must complete the review process and continue to be eligible to be reenrolled in CHIP at review.

 

R382-10-1[9]8. Enrollment Period.

(1) Subject to the provisions in Subsection R382-10-1[9]8(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) 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 the quarterly premium.

(3) The presumptive eligibility period ends on the earlier of:

(a) the day the eligibility agency makes an eligibility decision for medical assistance based on the child's application when that application is made in accordance with the requirements of Section 1920A of the Social Security Act; or

(b) the last day of the month following the month in which a presumptive eligibility period begins if an application for medical assistance is not filed on behalf of the child by the last day of such month.

(4) [The month that a child turns 19 years of age is the last month that the child may be eligible for CHIP, including CHIP presumptive eligibility coverage.

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

(5) The agency shall redetermine eligibility if a family reports a decrease in income and requests a redetermination during the certification period. A decrease in the premium is effective as follows:

(a) The premium change is effective the month of report if income decreased that month and the family provides timely verification of income;

(b) The premium change is effective the month following the report month if the decrease in income is for the following month and the family provides timely verification of income;

(c) The premium change is effective the month in which verification of the decrease in income is provided, if the family does not provide timely verification of income.

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

 

R382-10-[20]19. 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.

(d) The agency shall charge the family the lowest premium amount when the family has two or more children, and those children qualify for different quarterly premium amounts.

(2) The eligibility agency shall end CHIP coverage and assess a $15 late fee to a family who does not pay its quarterly premium by the premium due date.

(3) The agency may reinstate coverage [when any of the following events occur:

(a) The]if 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]4) A child is ineligible for CHIP for three months if CHIP is terminated for failure to pay the quarterly premium. The child must reapply at the end of the three months. If eligible, the agency shall approve eligibility without payment of the past due premiums or late fee.[A family whose CHIP coverage ends and who reapplies within one year for coverage must pay any outstanding premiums and late fees before the children can be re-enrolled.]

([4]5) The eligibility agency may not charge the household a premium during a due process month associated with the periodic eligibility review.

([5]6) The eligibility agency shall assess premiums that are payable each quarter for each month of eligibility.

 

R382-10-2[1]0. Termination and Notice.

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

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

(3) Notices under Section R382-10-2[1]0 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, use legal counsel, a friend, relative, or other spokesperson.

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

(a) the child is deceased;

(b) the child moves out-of- state and is not expected to return;

(c) the child enters a public institution or an institution for mental diseases; or

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

 

R382-10-2[2]1. Case Closure or Withdrawal.

(1)  The eligibility agency shall 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 before the eligibility agency makes a decision on the application.

(2) The eligibility agency shall comply with the requirements of 42 CFR 457.350(i), regarding transfer of the electronic file for the purpose of determining eligibility for other insurance affordability programs.

 

KEY: children's health benefits

Date of Enactment or Last Substantive Amendment: [October 1, ]2013

Notice of Continuation: May 9, 2013

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

 

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