No. 38322 (Amendment): Rule R414-320. Medicaid Health Insurance Flexibility and Accountability Demonstration Waiver

(Amendment)

DAR File No.: 38322
Filed: 02/28/2014 01:32:51 PM

RULE ANALYSIS

Purpose of the rule or reason for the change:

The purpose of this change is to renew Utah's Premium Partnership for Health Insurance (UPP) program under the 1115 Waiver authority as recently approved by the Centers for Medicare and Medicaid Services (CMS), and to align UPP with the provisions of the Patient Protection and Affordable Care Act (ACA) relative to determining income, income and budgeting, the filing unit, and the processing of applications and reviews for Modified Adjusted Gross Income (MAGI)-based coverage groups.

Summary of the rule or change:

This amendment defines general provisions for determining countable income, best estimates of income, and the UPP filing unit that uses methodologies for MAGI-based groups. It also defines provisions for accepting and processing applications, making eligibility determinations, and for processing UPP reviews to match those used for other MAGI-based groups. 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
• Section 26-18-3

This rule or change incorporates by reference the following material:

• Updates 42 CFR 433.138(b), published by Government Printing Office, 10/01/2013
• Adds 42 CFR 435.603(c), (d), (e), (g) and (h), published by Government Printing Office, 10/01/2013
• Updates 42 CFR 435.911 and 435.912, published by Government Printing Office, 10/01/2013
• Removes 20 CFR 416, Subpart K, Appendix, published by Government Printing Office, 04/01/2010
• Removes 42 CFR 435.907 and 435.908, published by Government Printing Office, 10/01/2010

Anticipated cost or savings to:

the state budget:

The state will not incur any new costs because funding was previously approved by the legislature for this ongoing program.

local governments:

This change does not create new costs for local governments because they neither determine eligibility for the UPP program nor fund UPP services.

small businesses:

Small businesses will not incur new costs because this change does not impose new requirements or charges on business in general.

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

Medicaid providers and Medicaid recipients will not incur new costs because funding was previously approved by the legislature for this ongoing program.

Compliance costs for affected persons:

A single Medicaid provider or a Medicaid recipient will not incur new costs because funding was previously approved by the legislature for this ongoing program.

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

There is likely little impact on business but exact changes in enrollment cannot be determined at this time.

David Patton, PhD, Executive Director

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

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

Direct questions regarding this rule to:

• Craig Devashrayee at the above address, by phone at 801-538-6641, by FAX at 801-538-6099, or by Internet E-mail at [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:

04/14/2014

This rule may become effective on:

04/21/2014

Authorized by:

David Patton, Executive Director

RULE TEXT

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

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

R414-320-1. Authority and Purpose.

(1) This rule is authorized by Sections 26-1-5 and 26-18-3 and allowed under Section 1115(a) of the Social Security Act.

(2) This rule establishes the eligibility requirements for enrollment and the benefits enrollees receive under the Health Insurance Flexibility and Accountability Demonstration Waiver (HIFA), which is Utah's Premium Partnership for Health Insurance (UPP).

 

R414-320-2. Definitions.

The definitions in Section 26-40-102 and Rules R414-1 and R414-301 apply to this rule. In addition, the following definitions apply throughout this rule:

(1) "Adult" means an individual who is 19 [through 64]years of age or older.

(2) "Avenue H" means Utah's Health Marketplace where Utah employers and their employees can find information about available employer-sponsored health insurance plans, select a plan, and enroll online.

([2]3) "Best estimate" means the eligibility agency's determination of a household's income for the upcoming certification period based on past and current circumstances and anticipated future changes.

([3]4) "Children's Health Insurance Program" or (CHIP) means the program for medical benefits under the Utah Children's Health Insurance Act, Title 26, Chapter 40.

[(4) "Consolidated Omnibus Budget Reconciliation Act" or (COBRA) continuation coverage is a temporary extension of employer health insurance coverage whereby a person who loses coverage under an employer's group health plan can remain covered for a certain length of time. To receive reimbursement under Utah's Premium Partnership for Health Insurance (UPP) program, the COBRA health plan must be an UPP qualified health plan.

](5) "Creditable Health Coverage" means any health insurance coverage as defined in 45 CFR 146.113.

[(6) "Department" means the Department of Health.

(7) "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. The due process month is not counted as part of the certification period.

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

]([9]6) "Employer-sponsored health plan" means a health insurance plan offered by an employer either directly or through the Utah Health Exchange.

([10]7) "Enrollee" means an individual who applies for and is found eligible for the UPP program, and is receiving UPP benefits.

[(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.

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

]([14]8) "Open enrollment" means a period during which the eligibility agency accepts applications for the UPP program.

([15]9) "Primary Care Network" or (PCN) means the program for benefits under the Medicaid Primary Care Network Demonstration Waiver.

([16]10) "Public Institution" means an institution that is the responsibility of a governmental unit or is under the administrative control of a governmental unit.

([17]11) "Review month" means the last month of the certification period for an enrollee during which the eligibility agency redetermines the enrollee's eligibility for a new certification period.

([18]12) "UPP Qualified Health Plan" means a health plan that meets all of the following requirements:

(a) Health plan coverage includes:

(i) physician visits;

(ii) hospital inpatient services;

(iii) pharmacy services;

(iv) well child visits; and

(v) children's immunizations.

(b) Lifetime maximum benefits must be at least $1,000,000.

(c) The deductible may not exceed $2,500 per individual.

(d) The plan must pay at least 70% of an inpatient stay after the deductible.

(e) The employer contributes at least 50% of the cost of the employee's health insurance premium when the plan is offered directly through the employer. If the employer offers plans through the Utah Health Exchange, the employer must contribute at least 50% of the cost of the employee's health insurance premium for either the employer's default plan or the plan the employee selects. If the plan is a Consolidated Omnibus Budget Reconciliation Act (COBRA) [continuation]plan, the employer does not have to contribute to the premium.

(f) The plan does not cover any abortion services; or the plan only covers abortion services in the case where the life of the mother would be endangered if the fetus were carried to term or in the case of rape or incest.

[(19) "Utah Health Exchange" or (UHE) means an internet portal where Utah employers and their employees can find information about available employer-sponsored health insurance plans, select a plan, and enroll online.

]([20]13) "Utah's Premium Partnership for Health Insurance" or (UPP) means a medical assistance program that provides cash reimbursement for all or part of the insurance premium paid by an employee for health insurance coverage through an employer-sponsored health insurance plan, including employer-sponsored health plans available under Avenue H[UHE], or COBRA [continuation]coverage that covers either the eligible employee, the eligible spouse of the employee, dependent children, or the family.

 

R414-320-3. Applicant and Enrollee Rights and Responsibilities.

(1) The provisions of Section R414-301-[3]4 apply to applicants and enrollees of the UPP program except that reportable changes for UPP applicants and enrollees are defined in Subsection R414-320-3([3]2).

(2) [Any person who meets the limitations set by the Department may apply during an open enrollment period. The open enrollment period may be limited to:

(a) adults with children living in the home;

(b) adults without children living in the home;

(c) adults enrolled in the PCN program;

(d) adults who were enrolled in the Medicaid program within the last thirty days before the beginning of the open enrollment period; or

(e) other groups designated in advance by the eligibility agency consistent with efficient administration of the program.

(3)]An applicant or enrollee must report certain changes to the eligibility agency within ten calendar days of learning of the change. The eligibility agency shall notify the applicant at the time of application of the changes that the individual must report. [Examples of r]Reportable changes include:

(a) An enrollee stops paying for coverage under an employer-sponsored health plan or COBRA [continuation]coverage;

(b) An enrollee changes health insurance plans;

(c) The amount of the premium that the enrollee pays for an employer-sponsored health insurance plan or COBRA [continuation]coverage changes;

(d) An enrollee begins to receive coverage under, or begins to have access to Medicare or the Veteran's Administration Health Care System;

(e) An enrollee leaves the household or dies;

(f) An enrollee or the household moves out of state;

(g) Change of address of an enrollee or the household; or

(h) An enrollee enters a public institution or an institution for mental diseases.

([4]3) An applicant or enrollee has a right to request an agency conference or a fair hearing as described in Sections R414-301-[5]6 and R414-301-[6]7.

([5]4) An enrollee must continue to pay premiums and remain enrolled in an employer-sponsored health plan or COBRA [continuation ]coverage to be eligible for benefits.

([6]5) An eligible child may choose to enroll in his parent's or guardian's employer-sponsored health insurance plan or COBRA [continuation]coverage and receive UPP benefits, or may choose direct coverage through CHIP. A child under the age of 19 may enroll in an employer-sponsored health insurance plan offered by the child's employer or COBRA [continuation ]coverage and UPP, or may choose direct coverage through CHIP.

 

R414-320-4. General Eligibility Requirements.

(1) The provisions of Sections R414-302-[1]3, R414-302-[2]4, R414-302-[5]7, and R414-302-[6]8 concerning United States (U.S.) citizenship, alien status, state residency, use of social security numbers, and applying for other benefits, apply to adult applicants and enrollees of UPP.

(2) The provisions of Sections R382-10-6, R382-10-7, and R382-10-9 concerning U.S. citizenship, alien status, state residency and social security numbers apply to child applicants and enrollees.

(3) An individual who is not a U.S. citizen or national, or who does not meet the alien status requirements of Sections R414-302-[1]3 or R382-10-6 is not eligible for any services or benefits under the UPP program.

(4) Health plans must meet the criteria of being an UPP qualified health plan.

(5) An individual must apply for the UPP program before he turns 65 years of age. Enrollment shall end effective the end of the month in which an individual turns 65 years of age.

(6) The eligibility agency only accepts applications during open enrollment periods. The eligibility agency may limit the number of individuals it enrolls.

(a) The eligibility agency may stop enrollment of new individuals at any time.

(b) The open enrollment period may be limited to:

(i) adults with children living in the home;

(ii) adults without children living in the home, or;

(iii) other groups designated in advance by the eligibility agency consistent with efficient administration of the program.

(c) The eligibility agency may not accept applications or maintain waiting lists during a period that it stops enrollment of new individuals.

(d) A child is not subject to the open enrollment requirement to enroll in UPP.

(7) Residents of public institutions are not eligible for UPP.

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

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

([4]8) The eligibility agency may not require an applicant or enrollee for the UPP program to provide Duty of Support information. An adult whose eligibility for Medicaid has been denied or terminated for failure to cooperate with Duty of Support requirements may not enroll in the UPP program.[An adult who is eligible for Medicaid, but fails to cooperate with Duty of Support requirements required by the Medicaid program, may not enroll in the UPP program.]

[(5) An individual who must pay a spenddown, poverty level, pregnant woman asset copayment, or MWI premium to receive Medicaid may enroll in UPP if:

(a) the individual meets UPP program eligibility criteria;

(b) the individual elects not to receive Medicaid in the month that the individual wishes to enroll in UPP; and

(c) the eligibility agency continues open enrollment under the provisions of Section R414-320-16. If the agency stops enrollment, the individual must wait for an open enrollment period to enroll in UPP.

]

R414-320-5. Verification and Information Exchange.

(1) An applicant and enrollee must provide verification of eligibility factors as requested by the eligibility agency and in accordance with the provisions of Section R414-308-4.

(2) The Department shall enter into agreements with other government agencies as outlined in Section R414-301-3.[and the eligibility agency may release information concerning an applicant or enrollee and his household to other state and federal agencies to determine eligibility for other public assistance programs.]

(3) The eligibility agency shall safeguard information about applicants and enrollees to comply with the provisions of Section R414-301-[4]5.

 

[R414-320-6. Residents of Institutions.

(1) Residents of public institutions are not eligible for the UPP program.

(2) A child under the age of 18 is not a resident of an institution if the child 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.

 

]R414-320-[7]6. Creditable Health Coverage.

(1) The Department adopts and incorporates by reference 42 CFR 433.138(b), [2010]October 1, 2013 ed.[, which is incorporated by reference.]

(2) An applicant who is covered under a group health plan or other creditable health insurance coverage, as defined in 29 CFR 2590.701-4, [2010]July 1, 2013 ed., is not eligible for enrollment.

(3) An applicant who is covered by COBRA [continuation ]coverage may be eligible for UPP enrollment.

(4) The following requirements apply to an individual who has access to but has not yet enrolled in employer-sponsored health insurance[The eligibility agency determines UPP eligibility for an individual who has access to but has not yet enrolled in employer-sponsored health insurance coverage who meets the requirements of Subsection R414-320-2(14) as follows]:

(a) If the individual's cost for the employer-sponsored coverage offered by the employer directly, or for the employer's default plan offered through Avenue H[UHE], is less than 5% of the [household's countable gross]countable MAGI-based income for the individual's household, the individual is not eligible for the UPP program.

(b) If the individual's cost for the employer-sponsored coverage offered by the employer directly, or for the employer's default plan offered through Avenue H[UHE], equals or exceeds 5% of the [household's countable gross]countable MAGI-based income for the individual's household, the individual may enroll in UPP.

(i) An eligible child may choose enrollment in either UPP or CHIP.

(ii) If the cost of coverage exceeds 15% for an adult, the individual may enroll in either UPP or PCN. To enroll in PCN, it must be an open enrollment period and the individual must meet the PCN criteria.

(c) The cost of coverage includes a deductible if the employer-sponsored plan has a deductible.

(d) The eligibility agency will include in the cost of coverage for the spouse or dependent child, the cost to enroll the employee if the employee must be enrolled to enroll the spouse or dependent child.[For adults, if the individual's cost for the employer-sponsored coverage offered by the employer directly, or for the employer's default plan offered through UHE, exceeds 15% of the household's countable gross income, the adult may choose to enroll in UPP or may choose direct coverage through PCN if PCN enrollment continues under the provisions of Section R414-310-16.

(d) If the cost to enroll a child in the employer-sponsored coverage offered by the employer directly, or the employer's default plan offered through UHE, is greater than or equal to 5% of the household's countable gross income, a child may choose enrollment in the employer-sponsored health plan and UPP or direct coverage through CHIP.

(e)The cost of coverage includes a deductible if the employer-sponsored plan has a deductible that must be met before it will pay any claims. For a spouse or dependent child, if the employee must be enrolled to enroll the spouse or dependent child, the cost of coverage includes the cost to enroll the employee and the spouse or dependent child].

(5) An eligible individual who has access to or who is enrolled in a COBRA plan may choose to enroll in UPP and the COBRA plan if the individual's cost for the COBRA plan exceeds 5% of the [household's gross ]countable MAGI-based income for the individual's household[and the plan meets the criteria to be an UPP qualified health plan as defined in R414-320-2(16)].

(6) 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 UPP enrollment, even if the individual must wait for a Medicare open enrollment period to apply[ for Medicare benefits].

(7) An individual who is enrolled in the Veteran's Administration (VA) Health Care System is not eligible for UPP enrollment.

(a) An individual who is eligible to enroll in the VA Health Care System, but who has not yet enrolled, may be eligible for the UPP program while waiting for enrollment in the VA Health Care System to become effective. To be eligible during this waiting period, the individual must [initiate the process]apply for and take all necessary steps to enroll in the VA Health Care System.

(b) Eligibility for the UPP program ends once the individual's coverage in the VA Health Care System begins.

(8) An individual who voluntarily terminates health insurance coverage is ineligible to enroll in UPP for 90 days [after the earlier insurance ends.]from the date the coverage ends.

(a) The eligibility agency may not apply a 90-day waiting period in the following situations:

(i) The premium paid by the individual or family for coverage of the individual or family member exceeded 5% of the MAGI-based household income.

(ii) The cost of the premium paid and deductible that includes the individual for the family coverage health plan exceeds 9.5% of the MAGI-based household income.

(iii) An employer stopped offering coverage under an ESI.

(iv) Loss of coverage due to a change in employment or involuntary separation.

(v) The individual has special heath care needs as defined by the Department.

(vi) Loss of coverage due to the death or divorce of an UPP individual.

(vii) Voluntary termination of COBRA.

(viii) Voluntary termination of Utah Comprehensive Health Insurance Pool coverage.

(ix) Voluntary termination of coverage for an adult child from the parent's or guardian's ESI plan.

(x) Voluntary termination of coverage by a spouse who does not live in the same household as the UPP applicant.

(xi) Voluntary termination of coverage for a child from a non-custodial parent's ESI plan.

(xii) The individual is voluntarily terminated from insurance that does not provide coverage in Utah;

(xiii) The individual is voluntarily terminated from a limited health insurance plan;

(xiv) A child is terminated from a parent's insurance because ORS reverses the forced enrollment requirement due to the insurance being unaffordable.

[(a) For an individual to enroll in UPP, the 90-day ineligibility period must expire by the earlier of:

(i) the end of the open enrollment period during which the individual applies for UPP; or

(ii) the end of the month which follows the month that the individual applies for UPP if the open enrollment period continues.

(b) If the 90-day ineligibility period does not end by the earlier of those two dates, the eligibility agency shall deny the application.

(c) An effective date of enrollment can only occur after the 90-day ineligibility period.

]([9]b) The eligibility agency will determine the individual's eligibility at the end of the waiting period without requiring a new application.

(i) The agency may request information about changes in the individual's circumstances that may affect eligibility.

(ii) If eligible, enrollment in UPP can begin in the month in which the 90-day ineligibility period ends.[An applicant, applicant's spouse, or dependent child may be eligible for enrollment in UPP without a 90-day ineligibility period if that person discontinues coverage under a COBRA plan, the Utah Comprehensive Health Insurance Pool, or involuntarily discontinues coverage under an employer-sponsored health plan.]

(9[a]) An individual is eligible to enroll in UPP if the individual's prior health insurance coverage expires before the end of the calendar month that follows the month in which he applies for UPP, and the individual has access to another employer-sponsored health insurance plan that meets the criteria of an UPP qualified health plan.[

(b)] The UPP enrollment date must be after the prior health insurance coverage ends.

[(10) An applicant, applicant's spouse, or dependent child can be eligible for the UPP program if his earlier insurance ended more than 90 days before the application date.

]([11]10) An eligible individual with access to an employer-sponsored health plan who also has creditable health coverage operated or financed by Indian Health Services may enroll in the UPP program[ to receive reimbursement for his employer-sponsored health plan].

[(12) The individual must enroll in an UPP qualified health plan either with an employer-sponsored health plan or a COBRA continuation health plan within 30 days of the date of the approval notice to enroll in UPP.

(13) Individuals must report at application and review 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 or parent's employer, Medicare Part A or B, the VA Health Care System, or COBRA continuation coverage.

(14) The eligibility agency shall deny an application or review if the applicant or enrollee fails to respond to questions about health insurance coverage for any individual that the household seeks to enroll or recertify.

]

R414-320-[8]7. Household Composition and Income Provisions.

(1) The Department determines household composition and countable household income according to the provisions in R414-304-5.[The following individuals are included in the household when determining household size for the purpose of computing financial eligibility for the UPP program:

(a) The individual;

(b) The individual's spouse living with the individual;

(c) All children of the individual or the individual's spouse who are under age 19 and living with the individual; and

(d) An unborn child if the individual is pregnant, or if the applicant's legal spouse who lives in the home is pregnant.]

(2) For an individual to be eligible to enroll, countable MAGI-based income for the individual's household must be equal to or less than 200% of the federal poverty guideline for the applicable household size.[The eligibility agency shall determine household composition for an eligible child in accordance with Subsection R382-10-11(1).

(3) A household member who is temporarily absent for schooling, training, employment, medical treatment or military service, or who will return home to live within 30 days from the date of application is considered part of the household.

(4) Any household member who is defined in Subsection R414-320-8(1) or Subsection R414-320-8(2) who is not a U.S. citizen or national, or who is not a qualified resident alien is included in the household size. The eligibility agency shall count that individual's income the same way that it counts the income of a U.S. citizen, national, or a qualified resident alien.

 

R414-320-9. Age Requirement.

(1) An individual must be under age 65 to be eligible for UPP and must enroll in the UPP program before he turns 65 years of age.

(2) The eligibility agency shall deny eligibility if it does not receive an application before an individual turns 65 years of age.

 

R414-320-10. Income Provisions.

(1) For an individual to be eligible to enroll, gross countable household income must be equal to or less than 200% of the federal non-farm poverty guideline for a household of the same size.

(2) All gross income, earned and unearned, received by the individual and the individual's spouse is counted toward household income, unless this section specifically describes a different treatment of the income. The eligibility agency shall use the countable gross income of parents who live with a child to determine the child's eligibility. The agency may not count any income that it excludes under Section R414-320-10.

(3) Any income in a trust that a household member receives becomes the income of the individual for whom it is received. The income is countable if the eligibility agency counts that individual's income to determine eligibility.

(4) The eligibility agency shall count as income payments that a household member receives from the Family Employment program, Working Toward Employment program, or from refugee cash assistance or adoption support services as authorized under Title 35A, Chapter 3, Employment Support Act.

(5) The eligibility agency shall count rental income. The eligibility agency may deduct the following expenses:

(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) The eligibility agency shall count as income cash contributions from non-household members unless the parties sign a written agreement to repay the funds.

(7) The eligibility agency shall count as income the interest earned from payments under a sales contract or a loan agreement to the extent that the individual continues to receive these payments during the certification period.

(8) The eligibility agency shall count as income needs-based veteran's pensions. Nevertheless, the agency counts only the portion of a Veteran's Administration check to which the individual is legally entitled. Any portion of the payment for another family member counts solely as that family member's income.

(9) The eligibility agency shall count solely as the child's income the child support payments that a parent receives for a dependent child when that child lives in the home.

(10) The eligibility agency may only count in-kind income when a non-household member provides goods or services to an individual in exchange for services that the individual performs.

(11) The eligibility agency shall count as income supplemental security income and state supplemental payments.

(12) The eligibility agency may not count income that is excluded under 20 CFR 416 Subpart K, Appendix, 2010 edition, which is incorporated by reference.

(13) The eligibility agency may not count as income payments that are prohibited under other federal laws from being counted to determine eligibility for federally-funded medical assistance programs.

(14) The eligibility agency may not count as income death benefits to the extent that the funds are spent on the deceased person's burial or last illness.

(15) The eligibility agency may not count as income a bona fide loan that an individual contracts in good faith and endorses in writing to repay.

(16) The eligibility agency may not count as income child care assistance under Title XX.

(17) The eligibility agency may not count as income reimbursements of Medicare premiums that an individual receives from the Social Security Administration.

(18) The eligibility agency may only count earned and unearned income of an eligible child who is under 19 years of age when the child is the head of the household. When the applicant or enrollee's spouse is under the age of 19, the agency may only count the spouse's earned and unearned income when the spouse under the age of 19 is the head of the household. The eligibility agency shall count income of a spouse over age 19.

(19) The eligibility agency may not count as income educational income, such as educational loans, grants, scholarships, and work-study programs. The individual must verify enrollment in an educational program.

(20) The eligibility agency may not count reimbursements for employee work expenses incurred by an individual.

(21) The eligibility agency may not count the value of food stamp assistance.

(22) The eligibility agency may not count income paid by the U.S. Census Bureau to a temporary census taker to prepare for and conduct the census.]

 

R414-320-[11]8. Budgeting.

(1) The Department shall apply the MAGI-based budgeting methodology defined at 42 CFR 435.603(c), (d), (e), (g) and (h), October 1, 2013 ed., which it adopts and incorporates by reference.[Subject to the limitations in Subsection R414-320-10(19), the eligibility agency shall count the gross income of the individual and the individual's spouse, or of an eligible child's parents to determine the eligibility of the applicant or enrollee, unless the income is excluded under this rule. The eligibility agency shall deduct from the gross income only those expenses that are required to make income available to the individual.]

(2) [The eligibility agency determines 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 eligibility agency multiplies the weekly amount by 4.3 to obtain a monthly amount. The eligibility agency multiplies income paid biweekly by 2.15 to obtain a monthly amount.

(3)]The eligibility agency determines an individual's eligibility prospectively for the upcoming certification period at the time of application and at each review for continuing eligibility.

(a) The eligibility agency 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 certification period.

(b) The eligibility agency shall include in the best estimate, reasonably predictable income expected to be received during the review period, such as seasonal income, contract income, income received at irregular intervals, or income received less often than monthly. The income will be prorated over the review period to determine an average monthly income.[The eligibility agency prorates income that is received less often than monthly over the certification period to determine an average monthly income. The eligibility agency may request earlier years' tax returns as well as current income information to determine a household's income.]

([4]3) Methods of determining the best estimate are income averaging, income anticipating, and income annualizing. The eligibility agency may use a combination of methods to obtain the best estimate. The best estimate may be a monthly amount that the household expects to receive each month of the certification period, or an annual amount that is prorated over the certification period. The eligibility agency may use different methods for different types of income that a household receives.

([5]4) The eligibility agency determines farm and self-employment income by using the individual's most recent tax return forms or other verification 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 eligibility agency may request income information from the most recent period that the individual had farm or self-employment income. [The eligibility agency deducts 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 eligibility agency may exclude more than 40% if the individual can demonstrate that the actual expenses were greater than 40%.]The eligibility agency shall deduct[s] the same expenses from gross income that the Internal Revenue Service allows as self-employment expenses to determine net self-employment income, if those expenses are expected to occur in the future.

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

(7) The eligibility agency may request additional information and verification about how a household is meeting expenses if the average household income appears to be insufficient to meet the household's living expenses.

]

R414-320-[12]9. Assets.

[There is no]An asset test is not required for UPP eligibility[ in the UPP program].

 

R414-320-10[3]. Application and Signature[Procedure].

(1) [The Department adopts 42 CFR 435.907 and 435.908, 2010 ed., which are incorporated by reference.

(2) The applicant must complete and sign a written application or complete an application on-line to enroll in the UPP program.] The provisions of Section R414-308-3 apply to applicants of the UPP program, except for paragraph (9), (10) and the three months of retroactive coverage.

([3]2) The eligibility agency shall reinstate an UPP case without requiring a new application if the case closes in error.

([4]3) An applicant may withdraw an application any time before the eligibility agency completes an eligibility decision on the application.

[(5) If an eligible household requests enrollment for a new household member, the application date for the new household member is the date of the request. A new application form is not required. However, the household shall provide the information necessary to determine eligibility for the new member, including information about access to creditable health insurance.

(a) The effective date of enrollment in UPP for the new household is defined in Section R414-320-15. Coverage continues through the end of the certification period.

(b) The eligibility agency may not require a new income test to add the new household member for the months remaining in the certification period.

(c) A household may add a new member only during an open enrollment period under Section R414-320-16. A child is not subject to the open enrollment period.

(d) The eligibility agency shall consider income of the new member at the next scheduled review.

]

R414-320-11[4]. Eligibility Decisions and Eligibility Reviews.

(1) The Department adopts and incorporates by reference 42 CFR 435.911 and 435.912, October 1, 2013[0] ed., regarding eligibility determinations.[which are incorporated by reference.]

(2) [When an individual applies for UPP,]At application and review, the eligibility agency shall determine whether the individual applying for UPP enrollment is eligible for Medicaid.

(a) An individual who qualifies for Medicaid without paying a spenddown[, a poverty level, pregnant woman asset copayment, ] or an MWI premium cannot enroll in the UPP program.[If the individual appears to qualify for Medicaid, but additional information is required to determine eligibility for Medicaid, the applicant must provide additional information requested by the eligibility worker. The eligibility agency shall deny the application if the individual does not provide the requested information.]

(b) An individual who must pay a spenddown or MWI premium to receive Medicaid may enroll in UPP if the individual elects not to receive Medicaid.[If the individual must pay a spenddown, a poverty-level, pregnant woman asset copayment or an MWI premium to qualify for Medicaid, the individual may choose to enroll in the employer-sponsored health insurance and the UPP program. The individual may enroll in UPP only during an open enrollment period, except that a child is not subject to an open enrollment period, and must meet all the eligibility criteria.

(c) At each review for UPP reenrollment, the eligibility agency shall decide whether the enrollee is eligible for Medicaid. If the individual qualifies for Medicaid without a spenddown, a poverty-level, pregnant woman asset copayment or an MWI premium, the individual cannot reenroll in the UPP program. If the individual appears to qualify for Medicaid, the applicant must provide additional information requested by the eligibility worker. The eligibility agency shall deny the review if the individual does not provide the requested information.]

(3) An individual who is open for Medicaid, PCN or CHIP may request to enroll in the UPP program.

(a) A new application form is not required.

(b) The rules in Section R414-320-12 govern the effective date of enrollment.

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

(d) If the individual is moving from PCN or CHIP, the eligibility agency shall waive the open enrollment requirement if there is no break in coverage.

(e) If the individual was previously on UPP, became eligible for Medicaid, and requests to reenroll in UPP without a break in coverage, the eligibility agency shall waive the open enrollment period and the requirement in Subsection 414-320-6(2).

(f) If the individual is moving from Medicaid and was not previously on UPP, or there has been a break in coverage of one or more months, an adult individual must reapply during an open enrollment period.

(g) For a PCN or CHIP individual who enrolls in an employer-sponsored health plan, the eligibility agency shall waive the requirement found in Subsection 414-320-6(2) if the change is reported within ten calendar days of signing up for coverage or within ten calendar days after coverage begins, whichever is later.

(h) All other eligibility requirements must be met.

[(3) To enroll in UPP, the individual must meet enrollment criteria during an open enrollment period under the provisions of Section R414-320-16, except that a child is not subject to open enrollments.

](4) The eligibility agency shall [complete a determination of eligibility or ineligibility for]process each application to a decision 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 dies;

(c) the applicant cannot be located; or

(d) the applicant does not respond to requests for information within the 30-day application period or by the verification due date, if that date is later.

(5) The eligibility agency shall complete a periodic review of an enrollee's eligibility for medical assistance in accordance with the requirements of 42 CFR 435.916.[at least once every 12 months. The periodic review is a review of eligibility factors that may be subject to change. The eligibility agency uses available, reliable sources to gather necessary information to complete the review.]

(a) The agency may request a recipient to contact the agency to complete the eligibility review.

(b) The agency shall provide the recipient a written request for verification needed to complete the review.

(c) The agency shall provide proper notice of an adverse decision.

(d) If the agency cannot provide proper notice of an adverse decision, the agency extends eligibility to the following month to allow for proper notice.

(6) If a recipient fails to respond to a request to complete the review or fails to provide all requested verification to complete the review, the eligibility agency shall end eligibility effective the end of the month for which the agency sends proper notice to the recipient.

(a) If the recipient contacts the agency to complete the review or returns all requested verification within three calendar months of the closure date, the eligibility agency shall treat such contact or receipt of verification as a new application. The agency may not require a new application form.

(b) The application processing period applies to this request to reapply.

[(6) The eligibility agency may ask the enrollee to respond to a request to complete the review process. The eligibility agency shall end the enrollee's eligibility effective at the end of the review month if the enrollee fails to respond to the request. The eligibility agency shall treat a response from the enrollee to complete the review or reapply as a new application if the enrollee responds to the review request or reapplies by the end of the month immediately following the review month. The application processing period applies for this new request for coverage.

(a) The eligibility agency may ask the enrollee for verification to redetermine eligibility.

] ([b]c) Eligibility can begin in the month the client contacts the agency to complete the review if all verification is received within the application processing period.

(d) If the recipient fails to return the verification timely, but before the end of the three calendar months, eligibility becomes effective the first day of the month in which all verification is provided and the individual is found eligible.[Upon receiving verification, the eligibility agency shall redetermine eligibility and notify the enrollee. The agency shall send a denial notice to the enrollee if the enrollee fails to return verification within the application processing period or if the agency determines that the enrollee is ineligible.]

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

([d]f) During these three calendar months, the eligibility agency shall waive the open enrollment period requirement and the requirement at Subsection R414-320-6(2).[The eligibility agency shall waive the open enrollment period requirement and the requirement found at Subsection R414-320-7(2) if the enrollee completes the review process or reapplies in the calendar month immediately following the effective closure date.]

([e]g) If the enrollee does not respond to the request to complete a review for UPP during the three calendar months immediately following the review closure date, the enrollee must reapply for UPP and meet all eligibility criteria.[The new certification period begins the day after the closure date if the enrollee becomes eligible.

(7) The eligibility agency may request verification from the enrollee if the enrollee responds to the review request during the review month.

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

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

(8) The eligibility agency shall determine eligibility and notify the enrollee of its decision if the enrollee responds to the review request on time and provides all verification by the verification due date.

(a) The eligibility agency shall send proper notice of an adverse decision when the decision affects eligibility for the month that follows the review month.

(b) The eligibility agency shall extend eligibility to the due process month when the agency does not send proper notice of an adverse change. The eligibility agency shall send proper notice of the adverse decision that becomes effective the first of the month after the due process month.

(9) The eligibility agency shall extend eligibility to the due process month if the enrollee responds to the review request during the review month and the verification due date is during the due process month. The enrollee must provide all verification by the verification due date.

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

(b) The eligibility agency shall end eligibility effective the end of the month in which it sends proper notice of the closure date if the enrollee does not provide all requested verification by the verification due date.

(c) The eligibility agency shall treat the date that it receives all verification as a new application date if the enrollee returns all verification after the verification due date and before the effective closure date. The agency shall determine the enrollee's eligibility and notify the enrollee.

(d) The eligibility agency shall waive the open enrollment period during the due process month, and for a reapplication received before the effective closure date. The eligibility agency also waives the requirement found at Subsection R414-320-7(2) if the enrollee completes the review or reapplies before the effective closure date.

(e) The eligibility agency may not continue eligibility while it makes an eligibility determination. If the agency determines that an enrollee is eligible, the new certification date for the application is the day after the effective closure date.

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

([11]7) If the individual files a new application or makes a request to reenroll within the calendar month that follows the effective closure date, when the closure is for a reason other than an incomplete review, [T]the eligibility agency will process the request as a new application and[shall] waive the open enrollment period and the requirement found at Subsection R414-320-[7]6(2)[if an enrollee reapplies in the calendar month immediately following the effective closure date].

([12]8) The enrollee must reapply if the case closes for one or more calendar months for any reason other than an incomplete review.[and must meet all eligibility criteria.]

(9) The eligibility agency shall comply with the requirements of 42 CFR 435.1200(e), regarding transfer of the electronic file for the purpose of determining eligibility for other insurance affordability programs.

 

R414-320-12[5]. Effective Date of Enrollment[, Change Reporting] and Enrollment Period.

(1) Subject to Section[s] R414-320-[7]6,[R414-320-9 and R414-320-16] and the limitations in Section R414-306-[6]4, the effective date of enrollment in the UPP program is the first day of the application month.

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

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

(2) An individual who is approved for the UPP program must enroll in the employer-sponsored health plan or COBRA[continuation coverage] within 30 days of receiving an approval notice from the eligibility agency.[Eligibility for UPP is a qualifying event and employers must allow the individual to enroll in the health insurance plan upon approval.]

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

([2]4) The Department may not reimburse the enrollee for premiums before the effective date of enrollment and not before the month in which the enrollee pays a health insurance or COBRA premium[that the enrollee verifies to the eligibility agency]. The enrollee must verify the premium payment.

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

[(3) If the applicant does not enroll in the employer-sponsored health insurance or COBRA continuation coverage that meets the requirements of Subsection R414-320-2(14) within 30 days of the date that the eligibility agency sends the UPP approval notice, DWS shall deny the application. The individual may reapply during another open enrollment period, except that a child is not subject to the open enrollment period.

(4) The effective date of enrollment for a newborn or newly adopted child is the date of birth or the date that the child is placed for adoption if the newborn or newly adopted child is enrolled in the employer-sponsored health insurance or COBRA continuation coverage and the family requests UPP coverage within 30 days of the birth or placement for adoption. If the family makes the request after 30 days of the birth or placement for adoption, enrollment becomes effective on the first day of the month in which the date of report occurs.

(a) The requirement found at Subsection R414-320-7(2) does not apply if the request for UPP enrollment occurs during such 30 days.

(b) If the request for UPP enrollment is made more than 30 days after the date of birth or date of placement for adoption, the child must meet the requirements of Section R414-320-7.

(5) An enrollee may request to add a spouse to UPP coverage during the certification period.

(a) If the spouse had previous UPP coverage, but became eligible for Medicaid or PCN, the enrollee may add the spouse to UPP without waiting for an open enrollment period. Eligibility for the spouse becomes effective the month after coverage for Medicaid or PCN ends if there is no break in coverage. A spouse moving back to UPP from Medicaid may reenroll in UPP even if the spouse is enrolled in the employer-sponsored health insurance at the time of request and there is no break in coverage between Medicaid and UPP.

(b) If the spouse did not have previous UPP coverage, but is moving directly from PCN to UPP coverage, the effective date of enrollment is the first day of the month after PCN ends. The spouse does not have to wait for an open enrollment period. If the spouse is not moving directly from PCN to UPP coverage, the spouse may enroll in UPP during an open enrollment period. The eligibility agency shall determine the effective date of enrollment in accordance with Subsection R414-320-15(1).

(6) An enrollee may request to add a dependent child to UPP coverage during the certification period.

(a) If the child had previous UPP coverage, but became eligible for Medicaid or CHIP, the effective date of enrollment is the first day of the month after Medicaid or CHIP ends if there is no break in coverage.

(b) If the child is not moving from another medical assistance program to UPP, the eligibility agency shall determine the effective date of enrollment in accordance with Subsection R414-320-15(1).

(c) If the child is a newborn or has recently been placed for adoption with the enrollee, the provision in Subsection R414-320-15(4) applies.

] ([7]6) The effective date of reenrollment in UPP after the eligibility agency completes the periodic [eligibility]review, is the first day of the month after the review month, or the first day after the due process month. [The eligibility agency shall complete the review as described in Subsection R414-320-14(8) or (9), and the enrollee must continue to meet eligibility criteria.]Subsection R414-320-11(5) defines the effective date of reenrollment when the enrollee completes the review process in the three calendar months after the case is closed for incomplete review.

([8]7) An individual who becomes eligible for UPP is enrolled for a 12-month certification period that begins with the first month of eligibility.[If the enrollee completes the review process and continues to be eligible, the recertification period continues for an additional 12 months, except that the eligibility agency may not count a due process month associated with a review in the new 12-month recertification period.]

([9]8) The eligibility agency shall end eligibility before the end of a 12-month certification period for any of the following reasons:

(a) The individual turns 65 years of age;

(b) An enrolled child turns 19 years of age and was covered by the parent's or guardian's health insurance plan;

(c) The individual becomes entitled to receive Medicare;

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

(e) The individual dies;

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

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

([10]9) The eligibility agency shall end eligibility if an adult enrollee discontinues enrollment in employer-sponsored insurance or COBRA[continuation coverage].[

(a)] The enrollee may switch to the PCN program [for the rest of the certification period]if the enrollee meets PCN eligibility requirements.[discontinues enrollment in employer-sponsored insurance involuntarily and does not enroll in COBRA continuation coverage, or if the individual discontinues COBRA coverage voluntarily or involuntarily. The individual must meet the PCN income test.

(b) The enrollee must notify the eligibility agency within ten calendar days after the enrollee's insurance coverage ends to be eligible to switch to PCN outside of an open enrollment period.

(c) The eligibility agency shall complete a new eligibility determination and the individual must pay a PCN enrollment fee for the new 12-month certification period if the change occurs in the last month of the UPP certification period.

(11) When the enrollee reports other changes, the eligibility agency shall determine the effect of the change and make the appropriate change in the enrollee's eligibility. The eligibility agency shall send proper notice of changes in eligibility. The agency may end eligibility if the enrollee fails to report changes within ten calendar days. Other changes that may affect eligibility or benefits occur when:

(a) an enrollee changes health insurance plans or has a COBRA qualifying event; or

(b) the amount of the premium changes that the enrollee pays for an employer-sponsored health insurance plan or COBRA continuation coverage.

(12) An enrollee who fails to report changes or return verification timely must repay any overpayment of benefits for which the enrollee is not eligible to receive.

(13) A child enrolled in UPP may discontinue employer-sponsored health insurance or COBRA continuation coverage and UPP, and move to direct coverage under CHIP at any time during the certification period without any ineligibility period.

(14) An individual who is enrolled in PCN or CHIP and who enrolls in an employer-sponsored health plan or COBRA continuation coverage may switch to the UPP program. The individual must report to the eligibility agency within ten calendar days of signing up for an employer-sponsored plan or COBRA continuation coverage, or within ten days after coverage begins, whichever is later.

(a) The eligibility agency shall add the individual for the rest of the certification period if the household has an open UPP case.

(b) The eligibility agency shall approve a new 12-month certification period if the household does not have an open UPP or PCN case. If the household has an open PCN case, eligibility under UPP continues through the end of the PCN certification period.

(15) If an UPP case closes for any reason, other than to become covered by another Medicaid program, PCN or CHIP, and remains closed for one or more calendar months, the individual must submit a new application to the eligibility agency during an open enrollment period to reapply, except that a child is not subject to the open enrollment period. The individual must meet all the requirements of a new applicant.

(16) If an UPP case closes because the enrollee is eligible for another Medicaid program, PCN or CHIP, the individual may reenroll in UPP if there is no break in coverage between the programs, even when the eligibility agency stops enrollment under Subsection R414-320-16(2).

(a) The individual may reenroll during the current 12-month certification period for UPP, PCN or CHIP. The eligibility agency may not require the individual to complete a new application or have a new income eligibility determination.

(b) The individual may still reenroll in UPP if the previous 12-month certification period has ended and the individual is moving from Medicaid. The individual must meet eligibility and income guidelines for the new certification period.

(c) If there is a break in coverage of one or more calendar months between programs, the individual must reapply during an open enrollment period, except that a child is not subject to the open enrollment period.

(d) If the individual reapplies in the month immediately following the closure, the eligibility agency waives the open enrollment period and the provision in Subsection R414-320-7(2). The individual must meet all other UPP requirements.

(17) The eligibility agency shall end eligibility effective at the end of the month in which the agency sends proper notice if the agency requests verification of a reported change and the enrollee fails to return the verification. The eligibility agency shall treat the verification as a new application if the enrollee returns the verification within one calendar month after the effective closure date. The eligibility agency shall waive the open enrollment period, and if the enrollee is eligible, continue eligibility for the rest of the certification period. The eligibility agency shall send a denial notice to the enrollee if the enrollee is ineligible.

(18) An enrollee may request a Medicaid determination of eligibility when there is a change of income during the certification period.

(a) The eligibility agency shall end UPP enrollment and change the enrollee's coverage to Medicaid if the enrollee asks for a Medicaid determination and the reported change makes the enrollee eligible for Medicaid without cost.

(b) If the enrollee asks for a Medicaid determination and the reported change makes the enrollee eligible for Medicaid with a spenddown, MWI premium or a poverty level, pregnant woman asset copayment, the enrollee may choose to remain on UPP.]

 

R414-320-13[6]. Change Reporting and Benefit Changes[Open Enrollment Period.]

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

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

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

(2) An enrollee who fails to report changes or return verification timely must repay any overpayment of benefits for which the enrollee is not eligible to receive.

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

(a) A new application form is not required.

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

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

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

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

(f) All other eligibility requirements must be met.

(4) An enrollee may request a Medicaid determination of eligibility when there is a change of income during the certification period.

(a) The eligibility agency shall end UPP enrollment and change the enrollee's coverage to Medicaid if the enrollee asks for a Medicaid determination and the reported change makes the enrollee eligible for Medicaid without cost.

(b) If the enrollee asks for a Medicaid determination and the reported change makes the enrollee eligible for Medicaid with a spenddown or MWI premium, the enrollee may choose to remain on UPP.

[(1) The eligibility agency accepts applications for enrollment at times when sufficient funding is available to justify enrollment of more individuals. The eligibility agency limits the number it enrolls according to the funds available for the program.

(2) The eligibility agency may stop enrollment of new individuals at any time based on availability of funds.

(3) The eligibility agency may not accept applications or maintain waiting lists during a period that it stops enrollment of new individuals.

(4) A child is not subject to the open enrollment requirement to enroll in UPP.

]

R414-320-14[7]. Notice and Termination.

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

(2) The eligibility agency shall end an individual's enrollment upon enrollee request or upon discovery that the individual is no longer eligible.

(3) The eligibility agency shall end an individual's enrollment if the individual fails to complete the periodic review process on time.

(4) The eligibility agency shall notify an enrollee in writing at least ten days before [taking a proposed]the effective date of an action adversely affecting the enrollee's eligibility. The notice must include:

(a) the action to be taken;

(b) the reason for the action;

(c) the regulations or policy that support an adverse action;

(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 or enrollee's right to represent himself, or use legal counsel, a friend, relative, or other spokesperson.

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

(a) the enrollee is deceased;

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

(c) the enrollee enters a public institution or institution for mental disease.

 

R414-320-15[8]. Improper Medical Coverage.

(1) Improper medical coverage occurs when:

(a) an individual receives medical assistance for which the individual is not eligible, including benefits that an individual receives pending a fair hearing or during an undue hardship waiver if the enrollee fails to act as required by the eligibility agency;

(b) an individual receives a benefit or service that is not part of the benefit package for which the individual is eligible;

(c) an individual pays too much or too little for medical assistance benefits; or

(d) the Department pays too much or too little for medical assistance benefits on behalf of an eligible individual.

(2) An individual who receives benefits under the UPP program for which the individual is not eligible must repay the Department for the cost of the benefits that he receives.

(3) An overpayment of benefits includes all amounts paid by the Department for medical services or other benefits on behalf of an enrollee or for the benefit of the enrollee during a period that the enrollee is not eligible to receive the benefits.

 

R414-320-16[9]. Benefits.

(1) The UPP program shall provide cash reimbursement to enrollees.

(2) The reimbursement may not exceed the amount that the enrollee pays toward the cost of the employer-sponsored health plan, employer-sponsored plans selected through UHE, or COBRA continuation coverage.

(3) The UPP program may reimburse an adult up to $150 each month.

(4) The UPP program may reimburse a child up to $120 each month for medical coverage. The UPP program will pay the child an additional $20 if the child elects to enroll in employer-sponsored dental coverage.

(a) When the employer-sponsored insurance does not include dental benefits, a child may receive cash reimbursement up to $120 for the medical insurance cost and may receive dental-only benefits through CHIP.

(b) When the employer also offers employer-sponsored dental coverage, the applicant may choose to enroll a child in the employer-sponsored dental coverage, in which case, the UPP program will pay the child an additional $20. The enrollee may also choose to only enroll the child in the employer-sponsored health insurance and UPP, and not enroll the child in the employer-sponsored dental coverage, in which case the child may receive dental-only benefits through CHIP.

 

KEY: CHIP, Medicaid, PCN, UPP

Date of Enactment or Last Substantive Amendment: [October 1, 2012]2014

Notice of Continuation: October 13, 2011

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

 

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