No. 37879 (Amendment): Rule R382-10. Eligibility

(Amendment)

DAR File No.: 37879
Filed: 08/01/2013 05:31:57 PM

RULE ANALYSIS

Purpose of the rule or reason for the change:

The purpose of this amendment is to comply with provisions of the Patient Protection and Affordable Care Act, the purpose of this change is to implement the interface and exchange of information with the Federally Facilitated Marketplace (FFM).

Summary of the rule or change:

This amendment includes requirements for the setup of an electronic interface with FFM, which implements the eligibility process for assessing whether individuals are eligible for medical assistance programs or are eligible to enroll in insurance and receive advanced premium tax credits. It also adds new definitions related to health care reform provisions.

State statutory or constitutional authorization for this rule:

• Pub. L. No. 111-148
• Title 26, Chapter 40

This rule or change incorporates by reference the following material:

• Adds 42 CFR 457.348 and 42 CFR 457.350, published by Government Printing Office, 10/01/2012
• Updates Sections 2110(b) and (c) of the Compilation of Social Security Laws, published by Social Security Administration, 01/01/2013

Anticipated cost or savings to:

the state budget:

Some administrative costs are associated with the implementation of this process. Nevertheless, these costs are minimal and there is no data to determine them at this time.

local governments:

There is no impact to local governments, as they do not make eligibility determinations for Medicaid.

small businesses:

This amendment does not impose any new costs or requirements on small businesses because they do not make eligibility determinations for the Medicaid program.

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

This amendment does not impose any new costs or requirements on Medicaid providers and on Medicaid recipients because it does not affect Medicaid services. These changes are solely about interactions between the Medicaid agency and the FFM to implement the eligibility process.

Compliance costs for affected persons:

This amendment does not impose any new costs or requirements on a single Medicaid provider or on a Medicaid recipient because it does not affect Medicaid services. These changes are solely about interactions between the Medicaid agency and the FFM to implement the eligibility process.

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

Minimal impact on business--This will enhance data exchange between Agency and FFM.

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
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:

09/16/2013

This rule may become effective on:

10/01/2013

Authorized by:

David Patton, Executive Director

RULE TEXT

R382. Health, Children's Health Insurance Program.

R382-10. Eligibility.

R382-10-2. Definitions.

(1) The Department adopts and incorporates by reference the definitions found in Sections 2110(b) and (c) of the Compilation of Social Security Laws, in effect January 1, 201[1]3.

(2) The Department adopts the definitions in Section R382-1-2. In addition, the Department adopts the following definitions:

(a) "American Indian or Alaska Native" means someone having origins in any of the original peoples of North and South America (including Central America) and who maintains tribal affiliation or community attachment.

(b) "Best estimate" means the eligibility agency'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) "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 CHIP.

(e) "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.

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

(g) "Employer-sponsored health plan" means health insurance that meets the requirements of Subsection R414-320-2(9).

(h) "Federally Facilitated Marketplace" (FFM) means the entity individuals can access to enroll in health insurance and apply for assistance from insurance affordability programs such as Advanced Premium Tax Credits, Medicaid and CHIP.

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

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

([j]k) "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.

(l) "Modified Adjusted Gross Income" (MAGI) means the income determined using the methodology defined in 42 CFR 435.603(e).

([k]m) "Presumptive eligibility" means a period of time during which a child may receive CHIP benefits based on preliminary information that the child meets the eligibility criteria.

([l]n) "Quarterly Premium" means a payment that enrollees must pay every three months to receive coverage under CHIP.

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

([n]p) "Utah's Premium Partnership for Health Insurance" or "UPP" means the program described in Rule R414-320.

([o]q) "Verification" means the proof needed to [decide if]determine whether a child meets the eligibility criteria to be enrolled in the program. Verification may include [hard copy] documents in paper format[such as a birth certificate], electronic records from computer match systems[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.

 

R382-10-5. Verification and Information Exchange.

(1) The provisions of Section R414-308-4 apply to applicants and enrollees of CHIP.

(2) The Department and the eligibility agency shall safeguard applicant and enrollee information in accordance with Section R414-301-4.

(3) The Department or the eligibility agency may release information concerning applicants and enrollees and their households to other state and federal agencies to determine eligibility for other public assistance programs.

(4) The Department adopts and incorporates by reference 42 CFR 457.348, 457.350, and 457.380, October 1, 2012 ed.

(5) The Department shall enter into an agreement with the Centers for Medicare and Medicaid Services (CMS) to allow the FFM to screen applications and reviews submitted through the FFM for CHIP eligibility.

(a) The agreement must provide for the exchange of file data and eligibility status information between the Department and the FFM as required to determine eligibility and enrollment in insurance affordability programs, and eligibility for advance premium tax credits and reduced cost sharing.

(b) The agreement applies to agencies under contract with the Department to provide CHIP eligibility determination services.

([4]6) The Department and the eligibility agency shall release information to the Title IV-D agency and Social Security Administration to determine benefits.

[(5) The Department and the eligibility agency may verify information by exchanging information with other public agencies as described in 42 CFR 435.945, 435.948, 435.952, 435.955, and 435.960.

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KEY: children's health benefits

Date of Enactment or Last Substantive Amendment: [April 1, 2012]2013

Notice of Continuation: May 9, 2013

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

 

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