No. 29250: R414-320-7. Creditable Health Coverage

DAR File No.: 29250
Filed: 11/28/2006, 12:00
Received by: NL

RULE ANALYSIS

Purpose of the rule or reason for the change:

This change complies with the Standard Terms and Conditions of the Section 1115 Demonstration Waiver program approved by the Centers for Medicare and Medicaid Services.

Summary of the rule or change:

Subsection R414-320-7(2) removes language that allows an individual enrolled in employer-sponsored health insurance for less than 60 days to be eligible for the Section 1115 Demonstration Waiver program.

State statutory or constitutional authorization for this rule:

Sections 26-18-3 and 26-1-5

Anticipated cost or savings to:

the state budget:

There are minimal savings in state and federal dollars because this rule limits enrollment in the demonstration waiver program. Nevertheless, there is insufficient data to quantify dollar amounts.

local governments:

There is no budget impact because local governments do not fund demonstration waiver programs.

other persons:

There is a minimal loss of revenue to providers and an out-of-pocket expense to Medicaid clients who do not qualify for the demonstration waiver program. Nevertheless, there is insufficient data to quantify dollar amounts.

Compliance costs for affected persons:

There is a minimal loss of revenue to a single provider and an out-of-pocket expense to a single Medicaid client who does not qualify for the demonstration waiver program. Nevertheless, there is insufficient data to quantify dollar amounts.

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

The federally-approved state plan provision will not allow an individual enrolled in employer-sponsored health insurance for less than 60 days to be eligible for the Section 1115 Demonstration Waiver program. This emergency rule keeps Utah in compliance with federal requirements. David N. Sundwall, MD, Executive Director

Emergency rule reason and justification:

Regular rulemaking procedures would cause an imminent budget reduction because of budget restraints or federal requirements.place the agency in violation of federal or state law.

This change is necessary to comply with federal requirements. Non-compliance results in the loss of federal funds for this waiver program and a budget reduction for Medicaid clients.

The full text of this rule may be inspected, during regular business hours, at the Division of Administrative Rules, or at:

Health
Health Care Financing, Coverage and Reimbursement Policy
CANNON HEALTH BLDG
288 N 1460 W
SALT LAKE CITY UT 84116-3231

Direct questions regarding this rule to:

Craig Devashrayee or Gayleen Henderson at the above address, by phone at 801-538-6641 or 801-538-6135, by FAX at 801-538-6099 or 801-538-6860, or by Internet E-mail at [e-mail] or [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:

This rule is effective on:

11/28/2006

Authorized by:

David N. Sundwall, Executive Director

RULE TEXT

R414. Health, Health Care Financing, Coverage and Reimbursement Policy.

R414-320. Medicaid Health Insurance Flexibility and Accountability Demonstration Waiver.

R414-320-7. Creditable Health Coverage.

(1) The Department adopts 42 CFR 433.138(b), 2005 ed., which are incorporated by reference.

(2) An individual who is covered under a group health plan or other creditable health insurance coverage, as defined by the Health Insurance Portability and Accountability Act of 1996 (HIPAA), [at the time of application ]is not eligible for enrollment[ if they have been enrolled for less than 60 days at the time of application].

(3) Eligibility for an individual who has access to but has not yet enrolled in employer-sponsored health insurance coverage will be determined as follows:

(a) If the cost of the employer-sponsored coverage does not exceed 5% of the household's gross income, the individual is not eligible for the HIFA program.

(b) For adults, if the cost of the employer-sponsored coverage exceeds 15% of the household's gross income the adult may choose to enroll in the HIFA program or may choose direct coverage through the Primary Care Network program if enrollment has not been stopped under the provisions of R414-310-16.

(c) A child may choose enrollment in HIFA or direct coverage under the CHIP program if the cost of the employer sponsored coverage is more than 5% of the household's gross income.

(d) An individual is considered to have access to coverage even if the employer offers coverage only during an open enrollment period.

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

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

(6) The Department shall deny eligibility if the applicant, spouse, or dependent child has voluntarily terminated health insurance coverage within the 90 days immediately prior to the application date for enrollment under the HIFA program.

(a) An applicant, applicant's spouse, or dependent child can be eligible for the HIFA program if their prior insurance ended more than 90 days before the application date.

(b) An applicant, applicant's spouse, or dependent child who voluntarily discontinues health insurance coverage under a COBRA plan, or under the state Health Insurance Pool, or who is involuntarily terminated from an employer's plan may be eligible for the HIFA program without a 90 day waiting period.

(7) An individual with creditable health coverage operated or financed by the Indian Health Services may enroll in the HIFA program.

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

(9) The Department shall deny an application or recertification if the applicant or enrollee fails to respond to questions about health insurance coverage for any individual the household seeks to enroll or recertify.

 

KEY: Medicaid, PCN, CHIP

Date of Enactment or Last Substantive Amendment: November 28, 2006

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