No. 29872 (Amendment): R382-1. Benefits and Administration

DAR File No.: 29872
Filed: 04/26/2007, 04:15
Received by: NL

RULE ANALYSIS

Purpose of the rule or reason for the change:

The State Plan for the Children's Health Insurance Program (CHIP) was changed in July 2006. This rulemaking is necessary to update the rule so that it correctly reflects the State Plan.

Summary of the rule or change:

This change corrects the reference to the section in the State Plan where benefits are described. It also clarifies that in order to receive CHIP benefits, children must enroll in one of the managed care organizations that contracts with the Department of Health.

State statutory or constitutional authorization for this rule:

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

This rule or change incorporates by reference the following material:

Section 6.2 of the State Plan for the Children's Health Insurance Program, July 1, 2005 ed.; and Section 8 of the State Plan for the Children's Health Insurance Program, July 1, 2005 ed.

Anticipated cost or savings to:

the state budget:

There is no budget impact because this amendment only reflects changes in the State Plan.

local governments:

There is no budget impact because local governments do not fund or provide CHIP benefits.

other persons:

There is no budget impact because this amendment only reflects changes in the State Plan.

Compliance costs for affected persons:

There are no compliance costs because this amendment only reflects changes in the State Plan.

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

These technical changes to the rule to conform to the Medicaid state plan should not have a fiscal impact on business. 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
Children's Health Insurance Program
CANNON HEALTH BLDG
288 N 1460 W
SALT LAKE CITY UT 84116-3231

Direct questions regarding this rule to:

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

Interested persons may present their views on this rule by submitting written comments to the address above no later than 5:00 p.m. on:

06/14/2007

This rule may become effective on:

06/22/2007

Authorized by:

David N. Sundwall, Executive Director

RULE TEXT

R382. Health, Children's Health Insurance Program.

R382-1. Benefits and Administration.

R382-1-1. Authority and Purpose.

This rule implements the Children's Health Insurance Program under Title XXI of the Social Security Act, as adopted in the state under Title 26, Chapter 40 of the Utah Code. It is authorized by Section 26-40-103.

 

R382-1-3. Nature of Program and Benefits.

(1) The Children's Health Insurance Program provides reimbursement to medical providers for services rendered to a child who meets the eligibility requirements and application requirements of R382-10. The Children's Health Insurance Program provides limited benefits as described in this rule. The Department provides reimbursement coverage under the program only for benefits and levels of coverage for each program benefit:

(a) as provided in rule governing the Children's Health Insurance Program;

(b) as described and limited in [the Attachment B benefit plan]Section 6.2 of the State Plan for the Children's Health Insurance Program, [1998]July 1, 2005 ed., which is adopted and incorporated by reference, and all applicable laws and rules[;].

[ (c) to the extent that it has agreed to reimburse providers with whom it contracts to provide services; and

(d) as limited in provider manuals that form part of its contracts with providers.

] (2) The Children's Health Insurance Program is not health insurance. A relationship with the Department as the insurer and the enrollee as the insured is not created under the program.

 

R382-1-4. Limitation of Abortion Benefits.

Abortion is a covered benefit only if necessary to save the life of the mother.

 

R382-1-5. Providers.

[(1) The Department shall reimburse only providers who contract with the Department to provide services under the program.

(2) ]The Department [may ]requires a child to enroll in [a health maintenance organization or other]one of the managed care organizations that contracts with the Department under the program.

 

R382-1-6. Reimbursement.

(1) The Department shall reimburse only for benefits as limited in [provider manuals that form part of ]its contracts with [providers]the managed care organizations.[

(2) The Department shall reimburse providers according to the fee schedule or schedules that are made part of its contracts with providers.]

([3]2) Payment for services by the [Department]contracted managed care organization and enrollee co-payment, if any, constitutes full payment for services. A provider may not bill or collect any additional monies for services rendered[ pursuant to a contract to provide services under the Children's Health Insurance Program].

 

R382-1-7. Cost Sharing.

A provider may require an enrollee to pay a co-payment equal to that listed in Section 8 of the State Plan for the Children's Health Insurance Program, July 1, [1998 ]2005 ed., which is adopted and incorporated by reference.

 

R382-1-8. Grievances and Appeals.

(1) An applicant or enrollee may request an agency conference at any time to resolve a problem without requesting an agency action under the Utah Administrative Procedures Act.

(a) Agency conferences may be held at the discretion of the Department.

(b) A representative authorized in writing may participate in the agency conference.

(c) The Department may conduct an agency conference by telephone if the applicant or enrollee does not object.

(2) The enrollee, the enrollee's parent(s), or representative authorized in writing by the enrollee or the enrollee's parent(s) may request an agency action. An applicant, the applicant's parent(s), or representative authorized in writing by the applicant or the applicant's parent(s) may request an agency action.

(a) Any request for agency action must be in writing clearly stating a desire to commence an agency proceeding, delivered or mailed to the Department, Department of Workforce Services, or the local [Bureau of Eligibility Services]eligibility [O]office. The request must be mailed within 90 days of the Department's action or initial decision.

(b) Proceedings pursuant to requests for agency action under the Children's Health Insurance Program are designated as formal proceedings.

(c) An applicant's or enrollee's authorized representative may participate in the administrative proceedings before the Department.

(d) The Department may conduct the administrative proceeding, including any hearings, telephonically or by other similar means if the applicant or enrollee does not object.

(e) The enrollee may choose not to accept the continued benefits that the Department offers pending an administrative decision.

(f) The Department need not conduct a hearing if the sole issue is one of state or federal law or policy.

(3) [A enrollee enrolled in a health maintenance organization or other managed care organization that contracts with the Department under the program to provide services]Enrollees must exhaust [his ]grievance remedies with the [health maintenance organization or other ]managed care organization before [he]they can request an agency action.

 

KEY: children's health benefits[*]

Date of Enactment or Last Substantive Amendment: [July 14, 1998]2007

Notice of Continuation: June 9, 2003

Authorizing, and Implemented or Interpreted Law: 26-1-5; 26-40-103