No. 29731 (Amendment): R414-310. Medicaid Primary Care Network Demonstration Waiver

DAR File No.: 29731
Filed: 03/26/2007, 10:12
Received by: NL

RULE ANALYSIS

Purpose of the rule or reason for the change:

This rulemaking is necessary to remove references to and the rule (Rule R414-300) for the Covered-at-Work program, which is being discontinued and replaced by a new program, Utah's Premium Partnership for Health Insurance (UPP). The UPP program is a Section 1115 demonstration program awarded to the Utah Department of Health and is described in Rule R414-320 which was effective 11/01/2006. This rule also clarifies how the agency determines the due date for verifications and the effective date of Children's Health Insurance Program (CHIP) enrollment. (DAR NOTE: The proposed repeal of Rule R414-300 is under DAR No. 29730 in this issue, April 15, 2007, of the Bulletin.)

Summary of the rule or change:

This rule is being modified throughout to delete all references to and the rules for the Covered-at-Work program. This rule defines an "employer-sponsored health plan" and outlines UPP service coverage. This rule clarifies that an individual may choose to enroll in either the UPP program or the PCN program when the cost of the least expensive employer-sponsored health insurance plan exceeds 15% of the household's gross income. This rule clarifies that all child support payments, including those for repayment of past due child support, is counted as income of a child, and describes how the agency determines the due date for verifications and the effective date of Primary Care Network (PCN) enrollment.

State statutory or constitutional authorization for this rule:

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

Anticipated cost or savings to:

the state budget:

This rule change will not affect the state budget because it is removing references to the Covered-at-Work program, which is being discontinued. State budget costs for the replacement program, Utah's Premium Partnership for Health Insurance, are described in Rule R414-320 which was adopted on 11/01/2006.

local governments:

This rule change will not affect local government because it is removing references to the Covered-at-Work program which is being discontinued.

other persons:

This rule change will not affect other persons because it is removing references to the Covered-at-Work program which is being discontinued. Costs to other persons for the replacement program are described in Rule R414-320 which was adopted on 11/01/2006.

Compliance costs for affected persons:

This rule change does not involve compliance costs to any persons because it is removing references to the Covered-at-Work program which is being discontinued. Costs to other persons for the replacement program are described in Rule R414-320 which was adopted on 11/01/2006.

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

This rule assists with the implementation of the UPP program and should not have a negative fiscal impact. David N. Sundwall, 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
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:

Gayleen Henderson or Craig Devashrayee at the above address, by phone at 801-538-6135 or 801-538-6641, by FAX at 801-538-6860 or 801-538-6099, 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:

05/15/2007

This rule may become effective on:

05/23/2007

Authorized by:

David N. Sundwall, Executive Director

RULE TEXT

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

R414-310. Medicaid Primary Care Network Demonstration Waiver.

R414-310-2. Definitions.

The following definitions apply throughout this rule:

(1) "Applicant" means an individual who applies for benefits under the Primary Care Network program[ or the Primary Care Network - Covered-at-Work program], but who is not an enrollee.

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

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

(4) "Deeming" or "deemed" means a process of counting income from a spouse or an alien's sponsor to decide what amount of income after certain allowable deductions, if any, must be considered income to an applicant or enrollee.

(5) "Department" means the Utah Department of Health.

(6) "Enrollee" means an individual who has applied for and been found eligible for the Primary Care Network program[ or the Primary Care Network - Covered-at-Work Program] and has paid the enrollment fee.

(7) "Enrollment fee" means a payment that an applicant or an enrollee must pay to the Department to enroll in and receive coverage under the Primary Care Network[ or the Primary Care Network - Covered-at-Work] program.

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

[(8)](9) "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.

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

[(10)](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.

[(11)](12) "Local office" means any Bureau of Eligibility Services or Department of Workforce Services office location, outreach location, or telephone location where an individual may apply for medical assistance.

[(12)](13) "Open enrollment means a time period during which the Department accepts applications for the Primary Care Network [or the Covered-at-Work ]program[s].

[(13)](14) "Primary Care Network" or "PCN" [includes two programs under a federal waiver of Medicaid regulations. The two programs are:

(a) The Primary Care Network Program. This program provides primary care medical services to uninsured adults who do not otherwise qualify for Medicaid]means the program for benefits under the Medicaid Primary Care Network Demonstration Waiver.[, and;

(b) The Covered-at-Work Program. This program 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 that covers either the eligible employee, the eligible spouse of the employee, or both.]

[(14)](15) "Recertification month" means the last month of the eligibility period for an enrollee.

[(15)](16) "Spouse" means any individual who has been married to an applicant or enrollee and has not legally terminated the marriage.

[(16)](17) "Verifications" means the proofs needed to decide if an individual 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 the individual.

[(17)](18) "Student health insurance plan" means a health insurance plan that is offered to students directly through a university or other educational facility or through a private health insurance company that offers coverage plans specifically for students.

(19) "Utah's Premium Partnership for Health Insurance" or "UPP" means the program described in R414-320.

 

R414-310-3. Applicant and Enrollee Rights and Responsibilities.

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

(a) individuals with children under age 19 in the home;

(b) individuals without children under age 19 in the home;

(c) those enrolled in the PCN program;

(d) those enrolled in the [Covered-at-Work]UPP program;

(e) those enrolled in the General Assistance program;

(f) those that were enrolled in the Medicaid program within the last thirty days prior to the beginning of the open enrollment period; or

(g) such other group designated in advance by the Department consistent with efficient administration of the program.

(2) If a person needs help to apply, he may have a friend or family member help, or he may request help from the local office or outreach staff.

(3) Applicants and enrollees must provide requested information and verifications within the time limits given. The Department will allow the client at least 10 calendar days from the date of a request to provide information and may grant additional time to provide information and verifications upon request of the applicant or enrollee.

(4) Applicants and enrollees have a right to be notified about the decision made on an application, or other action taken that affects their eligibility for benefits.

(5) Applicants and enrollees may look at information in their case file that was used to make an eligibility determination.

(6) Anyone may look at the eligibility policy manuals located at any Department local office.

(7) An individual must repay any benefits received under the Primary Care Network program [or the Covered-at-Work program ]if the Department determines that the individual was not eligible to receive such benefits.

(8) Applicants and enrollees must report certain changes to the local office within ten calendar days of the day the change becomes known. The local office shall notify the applicant at the time of application of the changes that the enrollee must report. Some examples of reportable changes include:

(a) An enrollee in the Primary Care Network program begins to receive coverage under a group health plan or other health insurance coverage.

(b) An enrollee in the Primary Care Network program begins to have access to coverage under a group health plan or other health insurance coverage.

(c)[ An enrollee in the Covered-at-Work program no longer pays for coverage under an employer-sponsored health plan.

(d)] An enrollee in the Primary Care Network program[ or the Covered-at-Work program] begins to receive coverage under, or begins to have access to student health insurance, Medicare Part A or B, or the Veteran's Administration Health Care System.

[(e) An enrollee in the Covered-at-Work program has a change in the amount the enrollee pays for coverage under an employer-sponsored health plan.

(f)](d) An enrollee leaves the household or dies.

[(g)](e) An enrollee or the household moves out of state.

[(h)](f) Change of address of an enrollee or the household.

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

(9) An applicant or enrollee has a right to request an agency conference or a fair hearing as described in R414-301-5 and R414-301-6.

(10) An enrollee in the Primary Care Network program is responsible for paying any required co-payments or co-insurance amounts to providers for medical services the enrollee receives that are covered under the Primary Care Network program.[

(11) An enrollee in the Covered-at-Work program must continue to pay premiums and remain enrolled in the employer-sponsored health plan to be eligible for benefits.]

 

R414-310-4. General Eligibility Requirements.

(1) The provisions of R414-302-1, R414-302-2, R414-302-3, R414-302-5, and R414-302-6 apply to applicants and enrollees of the Primary Care Network program[ and the Covered-at-Work program].

(2) An individual who is not a U.S. citizen and does not meet the alien status requirements of R414-302-1 is not eligible for any services or benefits under the Primary Care Network program[ or the Covered-at-Work program].

(3) Applicants and enrollees are not required to provide Duty of Support information to enroll in the Primary Care Network program[ or the Covered-at-Work program]. An individual who would be eligible for Medicaid but fails to cooperate with Duty of Support requirements required by the Medicaid program cannot enroll in the Primary Care Network program[ or the Covered-at-Work program].

(4) Individuals who must pay a spenddown or premium to receive Medicaid can enroll in the Primary Care Network program[ or the Covered-at-Work program] if they meet the program eligibility criteria in any month they do not receive Medicaid as long as the Department has not stopped enrollment under the provisions of R414-310-16(2). If the Department has stopped enrollment, the individual must wait for an applicable open enrollment period to enroll in the PCN[ or the Covered-at-Work] program.

 

R414-310-5. Verification and Information Exchange.

(1) The provisions of [R414-307-4]R414-308-4 apply to applicants and enrollees of the Primary Care Network program[ and the Covered-at-Work program].

(2) The Department safeguards information about applicants and enrollees according to the provisions found in R414-301-4.

 

R414-310-6. Residents of Institutions.

The provisions of R414-302-4(1), (3) and (4) apply to applicants and enrollees of the Primary Care Network program[ and the Covered-at-Work program].

 

R414-310-7. Creditable Health Coverage.

(1) The Department adopts 42 CFR 433.138(b) and 435.610, 2004 ed., and Section 1915(b) of the Compilation of the Social Security Laws, in effect January 1, 2004, 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 in the Primary Care Network program[ or the Covered-at-Work program]. This includes coverage under Medicare Part A or B, student health insurance, and the Veteran's Administration Health Care System. However, an individual who is enrolled in the Utah Health Insurance Pool [(H.I.P.) ]may enroll in the Primary Care Network[ or the Covered-at-Work] program.

(3) Eligibility for the Primary Care Network program [or the Covered-at-Work program ]for an individual who has access to but has not yet enrolled in health insurance coverage through an employer or a spouse's employer will be determined as follows:

(a) If the cost of the [employer-sponsored coverage ]least expensive health insurance plan offered by the employer does not exceed [5%]15% of the household's gross income, the individual is not eligible for the Primary Care Network program[or the Covered-at-Work program].

[ (b) If the cost of the employer-sponsored coverage exceeds 5% but does not exceed 15% of the household's gross income, the individual is not eligible for the Primary Care Network program. These individuals may be eligible for the Covered-at-Work program if they choose to enroll in the employer-sponsored coverage, by the end of the month following the month in which they apply for the Covered-at-Work program.

] [(c)](b) If the cost of the [employer-sponsored coverage]least expensive health insurance plan offered by the employer exceeds 15% of the household's gross income, and the employer offers a health plan that meets the requirements of R414-320-2 (8) (a) (b) (c) (d) and (e), the individual may choose to enroll in either the Primary Care Network program or the [Covered-at-Work]UPP program unless enrollment for one of these programs has been stopped under the provisions of R414-310-16(2).[ To enroll in the Covered-at-Work program, the individual must enroll in the employer-sponsored coverage, by the end of the month following the month in which they apply for the Covered-at-Work program.]

(c) If the cost of the least expensive health insurance plan offered by the employer exceeds 15% of the household's gross income, but the employer does not offer a health plan that meets the requirements in R414-320-2 (8) (a) (b) (c) (d) and (e), the individual may only enroll in the PCN program.

(d) The 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 in the Primary Care Network [or the Covered-at-Work ]program, 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 in the Primary Care Network program[ or the Covered-at-Work program]. An individual who is eligible to enroll in the VA Health Care System, but who has not yet enrolled, may be eligible for the Primary Care Network program [or the Covered-at-Work 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 Primary Care Network program [or the Covered-at-Work program ]ends once the individual becomes enrolled in the VA Health Care System.

(6) Individuals who are full-time students and who can enroll in student health insurance coverage are not eligible to enroll in the Primary Care Network program[ or the Covered-at-Work program].

(7) The Department shall deny eligibility if the applicant or spouse has voluntarily terminated health insurance coverage within the six months immediately prior to the application date for enrollment under the Primary Care Network program[ or the Covered-at-Work program]. An applicant or an applicant's spouse can be eligible for the Primary Care Network [or the Covered-at-Work program ]if their prior insurance ended more than six months before the application date. An applicant or applicant's spouse 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 Primary Care Network[ or the Covered-at-Work] program without a six month waiting period.

(8) Notwithstanding the limitations in this section, an individual with creditable health coverage operated or financed by the Indian Health Services may enroll in the Primary Care Network program[ or the Covered-at-Work program].

(9) 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, a student health insurance plan, Medicare Part A or B, or the VA Health Care System.

(10) 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 in the program.

 

R414-310-8. Household Composition.

(1) The following individuals are included in the household when determining household size for the purpose of computing financial eligibility for the Primary Care Network Program[ or the Covered-at-Work program]:

(a) the individual;

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

(c) any 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) 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.

 

R414-310-9. Age Requirement.

(1) An individual must be at least 19 and not yet 65 years of age to enroll in the Primary Care Network program[ or the Covered-at-Work program].

(2) The month in which an individual's 19th birthday occurs is the first month the person can be eligible for enrollment in the Primary Care Network program[ or the Covered-at-Work program].

(a) If the individual could qualify for Medicaid in that month without paying a spenddown or premium, the individual cannot enroll in the Primary Care Network [or Covered-at-Work ]program until the following month.

(b) the individual could enroll in the Children's Health Insurance Program and it is an open enrollment period for CHIP for that month, the individual cannot enroll in the Primary Care Network program[ or the Covered-at-Work program] until the following month.

(3) The benefit effective date for the Primary Care Network program[ or the Covered-at-Work program] cannot be earlier than the date of the 19th birthday.

(4) The individual's 65th birthday month is the last month the person can be eligible for enrollment in the Primary Care Network program[ or the Covered-at-Work program].

 

R414-310-10. Income Provisions.

(1) To be eligible to enroll in the Primary Care Network program[ or the Covered-at-Work program], a household's countable gross income must be equal to or less than 150% of the federal non-farm poverty guideline for a household of the same size. An individual with income above 150% of the federal poverty guideline is not allowed to spend down income to be eligible under the Primary Care Network program[ or the Covered-at-Work program]. 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.

(2) Any income in a trust that is available to, or is received by a household member, is countable income.

(3) Payments received from the Family Employment Program, Working Toward Employment program, refugee cash assistance or adoption support services as authorized under Title 35A, Chapter 3 are countable income.

(4) 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.

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

(6) 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 certification period.

(7) Needs-based Veteran's pensions are counted as income. Only the portion of a Veteran's Administration check to which the individual is legally entitled is countable income.

(8) Child support[ payments received by a parent in the household which is in repayment of past due child support is counted as income for the parent. Current child support] payments received for a dependent child living in the home are counted as that child's income.

(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 which 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) Supplemental Security Income and State Supplemental payments are countable income.

(11) Income, unearned and earned, shall be deemed from an alien's sponsor, and the sponsor's spouse, if any, when the sponsor has signed an Affidavit of Support pursuant to Section 213A of the Immigration and Nationality Act on or after December 19, 1997. Sponsor deeming will end when the alien becomes a naturalized U.S. citizen, or has worked 40 qualifying quarters as defined under Title II of the Social Security Act or can be credited with 40 qualifying work quarters. Beginning after December 31, 1996, a creditable qualifying work quarter is one during which the alien did not receive any federal means-tested public assistance.

(12) Income that is defined in 20 CFR 416 Subpart K, Appendix, 2004 edition, which is incorporated by reference, is not countable.

(13) Payments that are prohibited under other federal laws from being counted as income to determine eligibility for federally-funded medical assistance programs are not countable.

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

(15) 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.

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

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

(18) Earned and unearned income of a child who is under age 19 is not counted if the child is not the head of a household.

(19) 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.

(20) Reimbursements for employee work expenses incurred by an individual are not countable income.

(21) The value of food stamp assistance is not countable income.

 

R414-310-11. Budgeting.

This section describes methods that the Department uses to determine the household's countable monthly or annual income.

(1) The gross income of all household members is counted in determining the eligibility of the applicant or enrollee, unless the income is excluded under this rule. Only expenses that are required to make an income available to the individual are deducted from the gross income. No other deductions are allowed.

(2) The Department 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 Department multiplies the weekly amount by 4.3 to obtain a monthly amount. The Department multiplies income paid biweekly by 2.15 to obtain a monthly amount.

(3) The Department shall determine an individual's eligibility prospectively for the upcoming certification period at the time of application and at each recertification for continuing eligibility. The Department 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. The Department prorates income that is received less often than monthly over the certification 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) Methods of determining the best estimate are income averaging, income anticipating, and income annualizing. The Department 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 certification period, or an annual amount that is prorated over the certification period. The Department may use different methods for different types of income received in the same household.

(5) The Department determines farm and self-employment income by using the individual's most recent tax return forms. If tax returns are not available, or are not reflective of the individual's current farm or self-employment income, the Department may request income information from the most recent time period during which the individual had farm or self-employment income. The Department 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 Department may exclude more than 40% if the individual can demonstrate that the actual expenses were greater than 40%. The Department deducts the same expenses from gross income that the Internal Revenue Service allows as self-employment expenses.

(6) The Department 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 Department 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.

 

R414-310-12. Assets.

There is no asset test for eligibility in the Primary Care Network program[ or the Covered-at-Work program].

 

R414-310-13. Application Procedure.

(1) The Department adopts 42 CFR 435.907 and 435.908, 2004 ed., which are incorporated by reference. The Department shall maintain case records as defined in R414-308-8[01].

(2) The applicant must complete and sign a written application or complete an application on-line via the Internet to enroll in the Primary Care Network program[ or the Covered-at-Work program].

(a) The Department accepts any Department-approved application form for medical assistance programs offered by the state as an application for the Primary Care Network program[ or the Covered-at-Work program]. The local office eligibility worker may require the applicant to provide additional information that was not asked for on the form the applicant completed, and may require the applicant to sign a signature page from a hardcopy medical application form.

(b) If an applicant cannot write, he must make his mark on the application form and have at least one witness to the signature. A legal guardian or a person with power of attorney may sign the application form for the applicant.

(c) An authorized representative may apply for the applicant if unusual circumstances prevent the individual from completing the application process himself. The applicant must sign the application form if possible.

(3) The [date of ]application date is the [day]date the agency receives a signed application form [is received by the]at a local office by 5:00 p.m. on a business day. This applies to paper applications delivered in person or by mail, paper applications sent via facsimile transmission, and electronic applications sent via the internet. If a local office receives an application after 5:00 p.m. on a business day, the date of application is the next business day.

(4) The application date for applications delivered to an outreach location is as follows:

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

(b) If the application is delivered at a time when the outreach office is closed, including being closed for weekends or holidays, the date of application is the last business day that a staff person from the state agency was available to receive or pick up applications from the location.

(5) The due date for verifications needed to complete an application and determine eligibility is 5:00 p.m. on the last day of the application period.

([4]6) If an applicant has a legal guardian, a person with a power of attorney, or an authorized representative, the local office shall send decision notices, requests for information, and forms that must be completed to both the individual and the individual's representative, or to just the representative if requested or if determined appropriate.

([5]7) The Department shall reinstate a medical case without requiring a new application if the case was closed in error.

([6]8) The Department shall continue enrollment without requiring a new application if the case was closed for failure to complete a recertification or comply with a request for information or verification:

(a) if the enrollee complies before the effective date of the case closure or by the end of the month immediately following the month the case was closed; and

(b) the individual continues to meet all eligibility requirements.

([7]9) An applicant may withdraw an application for the Primary Care Network program[ or the Covered-at-Work program] any time before the Department completes an eligibility decision on the application.

([8]10) The applicant shall pay an annual enrollment fee to enroll in the Primary Care Network Program[ or Primary Care Network - Covered-at-Work Program] once the local office has determined that the individual meets the eligibility criteria for enrollment.

(a) Coverage does not begin until the Department receives the enrollment fee.

(b) The enrollment fee covers both the individual and the individual's spouse if the spouse is also eligible for enrollment in the Primary Care Network [or the Primary Care Network - Covered-at-Work ]Program.

(c) The enrollment fee is required at application and at each recertification.

(d) The enrollment fee must be paid to the local office in cash, or by check or money order made out to the Department of Health or to the Department of Workforce Services.

(e) The enrollment fee for an individual or married couple receiving General Assistance from the Department of Workforce Services is $15. The enrollment fee for an individual or couple who does not receive General Assistance but whose countable income is less that 50 percent of the federal poverty guideline applicable their household size is $25. The enrollment fee for any other individual or married couple is $50.

(f) The Department may refund the enrollment fee if it decides the person was ineligible for the program; however, the Department may retain the enrollment fee to the extent that the individual owes any overpayment of benefits that were paid in error on behalf of the individual by the Department.

([9]11) If an eligible household requests enrollment for a spouse, the application date for the spouse 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 spouse, including information about access to creditable health insurance, including Medicare Part A or B, student health insurance, and the VA Health Care System.

(a) Coverage or benefits for the spouse will be allowed from the date of request or the date an application is received through the end of the current certification period.

(b) A new enrollment fee is not required to add a spouse during the current certification period.

(c) A new income test is not required to add the spouse for the months remaining in the current certification period.

(d) A spouse may be added only if the Department has not stopped enrollment under section R414-310-16.

(e) Income of the spouse will be considered and payment of the enrollment fee will be required at the next scheduled recertification.

 

R414-310-14. Eligibility Decisions and Recertification.

(1) The Department adopts 42 CFR 435.911 and 435.912, 2004 ed., which are incorporated by reference.

(2) When an individual applies for PCN[ or the Covered-at-Work program], the local office shall determine if the individual is eligible for Medicaid. An individual who qualifies for Medicaid without paying a spenddown or a premium cannot enroll in the Primary Care Network[ or the Covered-at-Work] 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. Failure to provide the requested information shall result in the application being denied.

(a) If the individual must pay a spenddown or premium to qualify for Medicaid, the individual may choose to enroll in the PCN[ or the Covered-at-Work ]program if it is an open enrollment period[ for those programs], and the individual meets all the applicable criteria for eligibility. If the PCN [or the Covered-at-Work programs ]program [are]is not in an enrollment period, the individual must wait for an open enrollment period.

(b) At recertification for PCN[ or the Covered-at-Work program], the local office shall first review eligibility for Medicaid. If the individual qualifies for Medicaid without a spenddown or premium, the individual cannot be reenrolled in the PCN[ or Covered-at-Work] program. If the individual appears to qualify for Medicaid, the applicant must provide additional information requested by the eligibility worker. Failure to provide the requested information shall result in the application being denied.

(3) To enroll, the individual must meet the eligibility criteria for enrollment in the Primary Care Network program[ or the Covered-at-Work program], pay the enrollment fee, and it must be a time when the Department has not stopped enrollment under section R414-310-16.[ An applicant for the Covered-at-Work program must be able to enroll in his or her employer-sponsored health insurance by the end of the month following the application month to be eligible for the Covered-at-Work program. Otherwise, eligibility will be denied, and the individual may reapply during another open enrollment period.]

(4) The local office shall complete a determination of eligibility or ineligibility for each application unless:

(a) the applicant voluntarily withdraws the application and the local office sends a notice to the applicant to confirm the withdrawal;

(b) the applicant died; or

(c) the applicant cannot be located; or

(d) the applicant has not responded to requests for information within the [30]45 day application period or by the date the eligibility worker asked the information or verifications to be returned, if that date is later.

(5) The enrollee must recertify eligibility at least every 12 months.

(6) The local office eligibility worker may require the applicant, the applicant's spouse, or the applicant's authorized representative to attend an interview as part of the application and recertification process. Interviews may be conducted in person or over the telephone, at the local office eligibility worker's discretion.

(7) The enrollee must complete the recertification process and provide the required verifications by the end of the recertification month.

(a) If the enrollee completes the recertification, continues to meet all eligibility criteria and pays the enrollment fee, coverage will be continued without interruption.

(b) The case will be closed at the end of the recertification month if the enrollee does not complete the recertification process and provide required verifications by the end of the recertification month.

(c) If an enrollee does not complete the recertification by the end of the recertification month, but completes the process and provides required verifications by the end of the month immediately following the recertification month, coverage will be reinstated as of the first of that month if the individual continues to be eligible and pays the enrollment fee.

(8) The eligibility worker may extend the recertification due date if the enrollee demonstrates that a medical emergency, death of an immediate family member, natural disaster or other similar cause prevented the enrollee from completing the recertification process on time.

 

R414-310-15. Effective Date of Enrollment and Enrollment Period.

(1) The effective date of enrollment in the Primary Care Network program is the day that a completed and signed application[ or an on-line application] is received by the local office as defined in R414-310-13(3) and R414-310-13(4)(a) and (b) and the applicant meets all eligibility criteria, including payment of the enrollment fee. The Department shall not provide any benefits or pay for any services received before the effective enrollment date.

(2) [The effective date of enrollment in the Covered-at-Work program cannot be before the month in which the applicant pays a premium for the employer-sponsored health insurance and is determined as follows:

(a) The effective date of enrollment is the date an application is received and the person is found eligible, including payment of the enrollment fee, if the applicant enrolls in and pays the first premium for the employer-sponsored health insurance in the application month.

(b) If the applicant will not pay a premium for the employer-sponsored health insurance in the application month, the effective date of enrollment is the first day of the month in which the applicant pays a premium for the employer-sponsored health insurance. The applicant must enroll in the employer-sponsored health insurance no later than the end of the month following the month the application is received. The applicant must be determined eligible and pay the enrollment fee for the Covered-at-Work program.

(c) If the applicant cannot enroll in the employer-sponsored health insurance by the end of the month immediately following the application month, the application shall be denied and the individual will have to reapply during another open enrollment period.

(3) ]The effective date of re-enrollment for a recertification in the Primary Care Network program [or the Covered-at-Work program ]is the first day of the month after the recertification month, if the recertification is completed as described in R414-310-14(7).

[(4)](3) If the enrollee does not complete the recertification as described in R414-310-14(7), and the enrollee does not have good cause for missing the deadline, the case will remain closed and the individual may reapply during another open enrollment period.

[(5)](4) An individual found eligible for the Primary Care Network program [or the Covered-at-Work program ]shall be eligible from the effective date through the end of the first month of eligibility and for the following 12 months. If the enrollee completes the [redetermination]recertification process in accordance with R414-310-14(7) and continues to be eligible, the recertification period will be for an additional 12 months beginning the month following the recertification month. Eligibility could end before the end of a 12-month certification period for any of the following reasons:

(a) the individual turns age 65;

(b) the individual becomes entitled to receive student health insurance, Medicare, or becomes covered by Veterans Administration Health Insurance;

(c) the individual dies;

(d) the individual moves out of state or cannot be located;

(e) the individual enters a public institution or an Institute for Mental Disease.

[(6) If an individual on the Covered-at-Work program voluntarily discontinues enrollment in employer-sponsored insurance coverage, eligibility for the Covered-at-Work program ends. If the enrollment in employer-sponsored insurance is discontinued involuntarily and the individual notifies the local office within 10 calendar days of when the insurance ends, the individual may switch to the PCN program for the remainder of the certification period.

(7)](5) An individual enrolled in the Primary Care Network program loses eligibility when the individual enrolls in any type of group health plan or other creditable health insurance coverage including an employer-sponsored [coverage]health plan, except under the following circumstances:

(a) An individual who gains access to or enrolls in an employer-sponsored health plan may switch to the [Covered-at-work]UPP program if the individual [reports to]notifies the local office [within 10 calendar days of enrolling in an employer-sponsored plan,]before the coverage in the employer-sponsored health plan begins, and if the requirements defined in R414-310-7(3)(b)[ or (c)] are met.

(b) An individual who enrolls in the Utah Health Insurance Pool (H.I.P.) does not lose eligibility in the Primary Care Network.

[(8) An enrollee in the Primary Care Network who reports within 10 days that he or she has gained access to enroll in employer-sponsored coverage may either switch to the Covered-at-Work program. To switch to Covered-at-Work, the following requirements must be met:

(a) The requirements of R414-310-7(3) must be met.

(b) The individual must enroll in the employer-sponsored coverage and begin paying premiums for the insurance.

(9)](6) If a Primary Care Network[ or Covered-at-Work] case closes for any reason, other than to become covered by another Medicaid program, and remains closed for one or more calendar months, the individual must submit a new application to the local office during an enrollment period to reapply. The individual must meet all the requirements of a new applicant including paying a new enrollment fee.

[(10)](7) If a Primary Care Network [or Covered-at-Work ]case closes because the enrollee is eligible for another Medicaid program, the individual may reenroll in the Primary Care Network[ or the Covered-at-Work] program if there is no break in coverage between the programs, even if the State has stopped enrollment under R414-310-16(2).

(a) If the individual's 12-month certification period has not ended, the individual may reenroll for the remainder of that certification period. The individual is not required to complete a new application or have a new income eligibility determination. The individual must continue to meet the criteria defined in R414-310-7. The individual is not required to pay a new enrollment fee for the months remaining in the current certification period.

(b) If the 12-month certification period from the prior enrollment has ended, the individual may still reenroll in the Primary Care Network[ or the Covered-at-Work] program. However, the individual must complete a new application, meet eligibility and income guidelines, and pay a new enrollment fee 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 for the Primary Care Network[ or the Covered-at-Work] program.[

(11) Lifetime eligibility for benefits under the Covered-at-Work program is limited to 60 months for each enrollee.]

 

R414-310-16. Enrollment Limitation.

(1) The Department shall limit enrollment in the Primary Care Network program[ and the Covered-at-Work program].

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

(3) The Department and local offices shall not accept applications nor maintain waiting lists during a time period that enrollment of new individuals is stopped.

(4) If enrollment has not been stopped, individuals may apply for the Primary Care Network program[ or the Covered-at-Work program].

(5) An individual who becomes ineligible for Medicaid, or who must pay a spenddown or premium for Medicaid, but who was not previously enrolled in the Primary Care Network[ or Covered-at-Work] program, may apply to enroll in the Primary Care Network[ or the Covered-at-Work] program if the State has not stopped enrollment under R414-310-16(2). If enrollment has been stopped, the individual must wait for an open enrollment period to apply.

 

R414-310-18. Improper Medical Coverage.

(1) An individual who receives benefits under the Primary Care Network program [ or the Covered-at-Work program] for which he is not eligible is responsible to repay the Department for the cost of the benefits received.

(2) An alien and the alien's sponsor are jointly liable for benefits received for which the individual was not eligible.

(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 time period that the enrollee was not actually eligible to receive such benefits.

 

KEY: Medicaid, primary care, covered-at-work, demonstration

Date of Enactment or Last Substantive Amendment: [December 16, 2004]2007

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