No. 27050 (Amendment): R382-10. Eligibility

DAR File No.: 27050
Filed: 04/01/2004, 08:23
Received by: NL

 

RULE ANALYSIS

Purpose of the rule or reason for the change:

This rulemaking is needed to change application provisions for the Children's Health Insurance Program (CHIP) coverage. This change will allow children who lose Medicaid eligibility because they have reached the maximum age limit of the program or are no longer deprived of parental support, to apply for CHIP without waiting for the next open enrollment period. It also describes the quarterly premium charged to CHIP enrollees and the consequences for nonpayment. It also makes other minor corrections and clarifications.

 

Summary of the rule or change:

In Section R382-10-2, adds a definition for the quarterly premium an enrollee must pay to receive CHIP coverage. In Section R382-10-16, allows a child who loses Medicaid coverage because the child has reached the maximum age limit for the program to apply for CHIP without waiting for the next open enrollment period and allows a child who loses Medicaid coverage because the child is no longer deprived of parental support to apply for CHIP without waiting for the next open enrollment period. In Section R382-10-17, increases the maximum number of days in which a CHIP eligibility determination must be made from 30 to 45 days from the date of the application. In Section R382-10-19, clarifies that applicants may apply for CHIP by FAX during an open enrollment period. In Section R382-10-20, adds language to include failing to pay a quarterly premium as a reason for an eligible child to lose CHIP coverage prior to the end of the 12-month enrollment period. In Section R328-10-21, puts into rule a premium process allowed by federal law that was implemented in 2002, families with income above 100% of the federal poverty level pay this premium. Penalties for nonpayment of premium are also specified.

 

State statutory or constitutional authorization for this rule:

Title 26, Chapter 40; Section 26-40-103; and Title XXI of the Social Security Act

 

Anticipated cost or savings to:

the state budget:

We anticipate approximately 56 new CHIP enrollees per month as a result of the changes to Section R382-10-16. There is no net effect to the state budget because these enrollees would otherwise be enrolled during the open enrollment period. By allowing these new enrollees to become eligible each month, the time between open enrollments may increase. Since 2002, premium payments have been collected so there will be no change as a result of this rule. About 4,200 enrolled families with income between 150% and 200% of the federal poverty level pay the $25 quarterly premium and 5,200 families with income between 100% and 150% of the federal poverty level pay the $13 quarterly premium, for a total of $690,400.

 

local governments:

The change to allow enrollment in CHIP after loss of Medicaid coverage will have some positive fiscal impact to local governments that provide health care. However, the amount of the impact is uncertain and difficult to quantify.

 

other persons:

We anticipate approximately 56 new CHIP enrollees per month as a result of the changes to Section R382-10-16. This will have a positive impact on these families but the amount is impossible to quantify. Families in CHIP will continue to pay the quarterly premium now in effect, about 4,200 enrolled families pay the $25 quarterly premium and 5,200 families pay the $13 quarterly premium, for a total of $690,400.

 

Compliance costs for affected persons:

Since 2002, premium payments have been required. This rule will not change the premium. A family with income between 150% and 200% of the federal poverty level pays the $25 quarterly premium and a family with income between 100% and 150% of the federal poverty level pays the $13 quarterly premium.

 

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

This rulemaking will allow children who lose Medicaid eligibility because they have reached the maximum age limit of the program or are no longer deprived of parental support, to apply for CHIP without waiting for the next open enrollment period. It also describes the quarterly premium charged to CHIP enrollees and the consequences for nonpayment. There will be a positive impact on medical providers that serve this population by allowing eligibility to continue without interruption. Scott D. Williams, MD, Executive Director

 

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

Health
Children's Health Insurance Program
CANNON HEALTH BLDG
288 N 1460 W
SALT LAKE CITY UT 84116-3231

 

Direct questions regarding this rule to:

Gayleen Henderson at the above address, by phone at 801-538-6135, by FAX at 801-538-6860, 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:

05/17/2004

 

This rule may become effective on:

05/18/2004

 

Authorized by:

Scott D. Williams, Executive Director

 

 

RULE TEXT

R382. Health, Children's Health Insurance Program.

R382-10. Eligibility.

R382-10-1. Authority.

This rule sets forth the eligibility requirements for coverage under the Children's Health Insurance Program. It is authorized by Title 26, Chapter 40.

 

R382-10-2. Definitions.

(1) The Department adopts the definitions found in Sections 2110(b) and (c) of the Social Security Act as enacted by Pub. L. No. 105-33 which are incorporated by reference in this rule.

(2) The following additional definitions also apply:

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

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

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

(d) "Department" means the Utah State Department of Health.

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

(f) "Income anticipating" means a process of using current facts regarding rate of pay, number of working hours, and expected changes to anticipate future income.

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

(h) "Local office" means any Bureau of Eligibility Services office location, outreach location, or telephone location where an individual may apply for medical assistance.

(i) "Quarterly Premium" means a payment that enrollees must pay every 3 months to receive coverage under CHIP.

(j) "Renewal month" means the last month of the eligibility period for an enrollee.

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

 

R382-10-16. Application and Renewal.

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

(1) The applicant must complete and sign a written application to become enrolled in the program.

(2) The Department accepts 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 during open enrollment periods in person, through the mail, by fax, or online.

(4) A family who has a child enrolled in CHIP, may enroll a new child born to or adopted by a household member without waiting for the next open enrollment period.

(5) A child who loses Medicaid coverage because he or she has reached the maximum age limit and does not qualify for any other Medicaid program without paying a spenddown, may enroll in CHIP without waiting for the next open enrollment period.

(6) A child who loses Medicaid coverage because he or she is no longer deprived of parental support and does not qualify for any other Medicaid program without paying a spenddown, may enroll in CHIP without waiting for the next open enrollment period.

(7) The Department may interview applicants, the applicant's parents, and any adult who has assumed responsibility for the care or supervision of the child to assist in determining eligibility.

([6]8) If eligibility for CHIP enrollment ends, the Department shall review the case for eligibility under any other medical assistance program without requiring a new application. The Department may request additional verification from the household if there is insufficient information to make a determination.

 

R382-10-17. Eligibility Decisions.

(1) The Department must determine eligibility for CHIP within [30]45 days of the date of application. If a decision can not be made in [30]45 days because the applicant fails to take a required action and requests additional time to complete the application process, or if circumstances beyond the Department's control delay the eligibility decision, the Department shall document the reason for the delay in the case record. The Department must inform the applicant of the status of the application and the time frame for completing the application process.

(2) The Department may not use the time standard as a waiting period before determining eligibility, or as a reason for denying eligibility because the Department has not determined eligibility within that time.

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

(a) the applicant voluntarily withdrew the application and the Department sent a notice to the applicant to confirm the withdrawal;

(b) the applicant died; or

(c) the applicant can not be located or has not responded to requests for information within the 30 day application period.

(4) The Department must redetermine eligibility at least every 12 months.

(5) At application and renewal, the Department must determine if any child applying for CHIP enrollment is eligible for coverage under Medicaid. A child who is eligible for Medicaid coverage is not eligible for CHIP. A child who must meet a spend-down to receive Medicaid and chooses not to meet the spenddown can be enrolled in CHIP.

 

R382-10-19. Open Enrollment Period.

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

(a) The Department shall notify the public of the open enrollment period 10 days in advance through a newspaper of general circulation.

(b) During an open enrollment period, the Department accepts applications in person, through the mail, by fax, or online. The Department sorts applications according to the date received. When an application is received through the mail, the date of receipt is the date of the postmark. When an application is submitted online, the date of receipt is the date of electronic transmission. If the applications received on a day exceed the number of openings available, the Department shall randomize all applications for that day and select the number needed to fill the openings.

(c) The Department will not accept applications prior to the open enrollment date, except as provided in R382-10-16.

 

R382-10-20. Enrollment Period.

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

(2) A child eligible for CHIP enrollment receives 12 months of coverage unless the child turns 19 years of age before the end of the 12-month enrollment period, moves out of the state, becomes eligible for Medicaid, begins to be covered under a group health plan or other health insurance coverage, [or] enters a public institution, or does not pay his or her quarterly premium. The month a child turns 19 years of age is the last month the child is eligible for CHIP.

 

R382-10-21. 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 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 $13.00.

(c) A family with countable income greater than 150% and up to 200% of the federal poverty level must pay a quarterly premium of $25.00.

(2) A family who does not pay its quarterly premium by the premium due date will be terminated from CHIP. Coverage may be reinstated when any of the following events occur:

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

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

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

(3) A family who was terminated from CHIP who reapplies within one year of the termination date, must pay any outstanding premiums before the children can be re-enrolled.

 

R382-10-[21]22. Termination and Notice.

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

(2) The Department shall notify an enrollee in writing ten days before taking a proposed action adversely affecting the enrollee's eligibility.

(3) Notices under this section 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;

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

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

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

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

(a) the child is deceased;

(b) the child has moved out of state and is not expected to return;

(c) the child has entered a public institution; or

(d) the child has enrolled in other health insurance coverage, in which case eligibility may cease immediately and without prior notice.

 

R382-10-[22]23. Case Closure or Withdrawal.

The department shall terminate a child's enrollment upon enrollee request or upon discovery that the child is no longer eligible. An applicant may withdraw an application for CHIP benefits any time prior to approval of the application.

 

KEY: children's health benefits

[January 5], 2004

Notice of Continuation June 10, 2003

26-1-5

26-40