No. 38210 (Emergency Rule): Rule R414-310. Medicaid Primary Care Network Demonstration Waiver

DAR File No.: 38210
Filed: 12/31/2013 10:46:59 AM

RULE ANALYSIS

Purpose of the rule or reason for the change:

The purpose of this change is to extend the Primary Care Network (PCN) under the 1115 Waiver authority as recently approved by the Centers for Medicare and Medicaid Services (CMS) and to align PCN with the provisions of the Patient Protection and Affordable Care Act (ACA) in regards to determining income, budgeting of income, 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 rule defines the general provisions for determining the countable income, best estimates of income, and the filing unit for the Primary Care Network which will follow the methodologies used for MAGI-based groups. The rule defines the provisions for accepting and processing applications, making eligibility determinations and processing reviews for PCN to match those used for other MAGI-based groups. The rule also makes changes to comply with the new requirements of the 1115 Demonstration Waiver which includes reducing the income limit to 100% Federal Poverty Level (FPL), eliminating the annual enrollment fee, and eliminating the 12-month certification period so that PCN will be month-to-month eligibility. It also updates incorporations and makes other needed technical changes.

Emergency rule reason and justification:

Regular rulemaking procedures would place the agency in violation of federal or state law.

Justification: The Department's 1115 Waiver authority for PCN was set to expire 12/31/2013. The Department has been in negotiations with CMS to extend this waiver authority and received approval in December. As part of the approval, the Department must modify the eligibility criteria to align with MAGI methodologies from ACA, reduce the income limit to 100% FPL, and have PCN be on a month-to-month eligibility process.

State statutory or constitutional authorization for this rule:

• Section 26-1-5
• Section 26-18-3

This rule or change incorporates by reference the following material:

• Updates 42 CFR 431.206, 42 CFR 431.210, 42 CFR 431.211, 42 CFR 431.213, 42 CFR 431.214, and 42 CFR 435.919, published by Government Printing Office, 10/01/2013
• Updates 42 CFR 435.911 and 42 CFR 435.912, 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 433.138(b) and 42 CFR 435.610, published by Government Printing Office, 10/01/2013
• Removes 20 CFR 416 Subpart K, Appendix, published by Government Printing Office, 10/01/2010
• Removes 42 CFR 435.907 and 42 CFR 435.908, published by Government Printing Office, 10/01/2010
• Updates Section 1915(b) of the Compilation of the Social Security Laws, published by Social Security Administration, 01/01/2013

Anticipated cost or savings to:

the state budget:

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

local governments:

This change does not create a cost for local governments because they do not determine PCN eligibility.

small businesses:

This change will not cost small businesses anything because they do not determine eligibility for PCN, and this does not impose any changes on businesses.

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

Individuals with income under 100% FPL will not incur any new costs as this rule continues the PCN program for these individuals. Individuals with income above 100% FPL will be transitioned off of the PCN program and instructed about how they can apply for insurance through the Federally Facilitated Marketplace and about the potential that they may qualify for Advanced Premium Tax Credits. Data is not available to determine the aggregate cost for these individuals as the Department cannot predict how much each individual might receive in Advanced Premium Tax Credits nor how much private insurance might cost.

Compliance costs for affected persons:

An individual with income above 100% FPL could incur some costs to purchase private insurance; however, those costs may be offset with the availability of Advanced Premium Tax Credits from the federal government.

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

Subsidies may increase the number of individuals enrolled in private health insurance plans.

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]

This rule is effective on:

01/01/2014

Authorized by:

David Patton, 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 definitions in Rules R414-1 and R414-301 apply to this rule. In addition, the following definitions apply throughout this rule:

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

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

(4) "Copayment and coinsurance" 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.

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

(6) ["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.

(7) "Department" means the Department of Health.

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

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

([10]7) "Enrollee" means an individual who has applied for and has been found eligible for the Primary Care Network program[ and has paid the enrollment fee].

[(11) "Enrollment fee" means a payment that an applicant or an enrollee must pay to the eligibility agency to enroll in and receive coverage under the Primary Care Network program.

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

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

(14) "Income averaging" means a process of using a history of past and current income and averaging it over a determined period of time to represent future income.

]([15]8) "Open enrollment" means a period during which the eligibility agency accepts applications for the Primary Care Network program.

([16]9) "Primary Care Network" or (PCN) means the program for benefits under the Medicaid Primary Care Network Demonstration Waiver.

(10[7]) "[Recertification]Review month" means the last month of the certification period for an enrollee during which the eligibility agency shall redetermine eligibility for a new certification period if the enrollee completes the [recertification]review process timely.

(11[8]) "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 Health Exchange" or (UHE) means an internet portal for Utah employers and their employees where the employees can find information about available employer-sponsored health insurance plans, select a plan and enroll online.

]( 12[20]) "Utah's Premium Partnership for Health Insurance" or (UPP) means the program described in Rule R414-320.

 

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

(1) The provisions of Section R414-301-[3]4 apply to applicants and enrollees of the PCN program except that reportable changes for PCN applicants and enrollees are defined in Subsection R414-310-3([3]2).

(2) [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) an individual with children under the age of 19 in the home;

(b) an individual without children under the age of 19 in the home;

(c) an individual who is enrolled in the PCN program;

(d) an individual who is enrolled in the UPP program;

(e) an individual who is enrolled in the General Assistance program;

(f) an individual who is enrolled in the Medicaid program within 30 days before the open enrollment period begins; or

(g) any group that the Department designates in advance to be 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 the day the change becomes known. The eligibility agency shall notify the applicant at the time of application of the changes that the enrollee must report. [Some examples of r]Reportable changes include:

(a) An enrollee in PCN begins to receive coverage or to have access to coverage under a group health plan or other health insurance coverage;

(b) An enrollee in PCN 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;

(c) Changes in household income;

(d) Changes in household composition[An enrollee leaves the household or dies];

([d]e) An enrollee or the household moves out of state;

([e]f) Change of address of an enrollee or the household; or

([f]g) 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 in PCN is responsible for paying any required copayments or coinsurance amounts to providers for medical services that the enrollee receives that are covered under PCN.

 

R414-310-4. 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 applicants and enrollees of PCN.

(2) An individual who is not a U.S. citizen or national, or who does not meet the alien status requirements of Section R414-302-[1]3 is not eligible for any services or benefits under PCN.

(3) An individual must be at least 19 and not yet 65 years of age to enroll in PCN.

(a) The month in which an individual turns 19 years of age is the first month that the person may enroll in PCN.

(b) An individual must enroll in the PCN program before he turns 65 years of age.

(c) Enrollment shall end effective the end of the month in which an individual turns 65 years of age.

(4) The eligibility agency only accepts applications during open enrollment periods. The eligibility agency limits the number it enrolls according to the funds available for the program and may stop enrollment at any time.

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

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

(ii) individuals without children under the age of 19 in the home.

(b) The eligibility agency may not accept applications or maintain waiting lists during a period that enrollment of new individuals is stopped.

(5) The provisions of Subsection R414-302-6(1) and (4) apply to applicants and enrollees of PCN who are residents of institutions.

([3]6) An applicant or enrollee is not required to provide Duty of Support information to enroll in PCN. 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 PCN 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 PCN.

(4) An individual who must pay a spenddown or premium to receive Medicaid can enroll in PCN if:

(a) the individual meets PCN program eligibility criteria in any month that the individual does not receive Medicaid; and

(b) the Department does not stop enrollment under the provisions of Subsection R414-310-16(2). If the Department stops enrollment, the individual must wait for an open enrollment period to enroll in the PCN program.]

 

R414-310-5. Verification and Information Exchange.

(1) The provisions of Section R414-308-4 regarding verification of eligibility factors apply to applicants and enrollees of PCN.

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

(3) The Department shall enter into agreements with other government agencies as outlined in section R414-301-3.

 

[R414-310-6. Residents of Institutions.

The provisions of Subsection R414-302-4(1) and (4) apply to applicants and enrollees of PCN.

 

]R414-310-[7]6. Creditable Health Coverage.

(1) The Department adopts and incorporates by reference 42 CFR 433.138(b) and 435.610, [2010]October 1, 2013 ed., and Section 1915(b) of the Compilation of the Social Security Laws, in effect January 1, 2013[2011, which are incorporated by reference.]

(2) An applicant[Subject to Subsection R414-310-7(10), an individual] 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., [at the time of application ]is not eligible for enrollment in PCN. This includes coverage under [Medicare Part A or B, ]student health insurance[,] and the Veteran's Administration Health Care System.[ Nevertheless, a]

(a) An individual who is enrolled in the Utah Health Insurance Pool or who can receive health coverage through Indian Health Services may enroll in PCN.

(b) An individual who could enroll in Medicare is not eligible for enrollment in PCN, even if the individual must wait for a Medicare open enrollment period to apply.

(c) An individual who is eligible to enroll in the VA Health Care System, but who has not yet enrolled, may be eligible for PCN as long as the individual applies for and takes all necessary steps to enroll. Eligibility for PCN ends once the individual's coverage in the VA Health Care System begins.

(d) Individuals who are full-time students and who can enroll in student health insurance coverage are not eligible to enroll in PCN.

(3) [The eligibility agency determines PCN eligibility for an]An individual who has access to but has not yet enrolled in employer-sponsored health insurance coverage through an employer or a spouse's employer [as follows:]is not eligible for PCN if[

(a) If] the individual's cost for the least expensive health insurance plan offered by the employer directly, or for the employer's default plan offered through Avenue H[UHE], does not exceed 15% of the household's countable [gross]MAGI-based income[ as defined in this rule, the individual is not eligible for PCN].

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

(b) The eligibility agency will include in the cost of coverage for the spouse, the cost to enroll the employee, if the employee must be enrolled to enroll the spouse.

[(b) If the individual's cost for the least expensive health insurance plan offered by the employer directly, or for the employer's default plan offered through UHE, is 5% or more of the household's countable gross income, the individual may enroll in the employer-sponsored health insurance plan and the UPP program during an UPP open enrollment period. The employer-sponsored health plan must meet the requirements of Subsection R414-320-2(18).

(c) If the individual's cost for the least expensive health insurance plan offered by the employer, or for the employer's default plan offered through UHE, exceeds 15% of the household's countable gross income, the individual may choose to enroll in either PCN or the UPP program. The following conditions apply:

(i) to enroll in UPP, the employer-sponsored health insurance plan the individual enrolls in, or the plan the employee selects through UHE, must meet the requirements of Subsection R414-320-2(18); and

(ii) enrollment for the program that the individual chooses to enroll in has not been stopped under the provisions of Subsections R414-310-16(2) or R414-320-16(2).

(d) If none of the plans offered by the employer, either directly or through UHE, meet the requirements of Subsection R414-320-2(18), and the individual's cost to enroll exceeds 15% of the household's countable gross income, the individual may only enroll in the PCN program during a PCN open enrollment period.

]([4]c) The eligibility agency considers the individual to have access to coverage [even when the employer only offers coverage during an open enrollment period, ]if the individual has had at least one opportunity to enroll[, or if the first opportunity to enroll occurs within 30 days of either the date of application or the first day of the recertification month].

[(5) 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. If the employee must be enrolled to enroll the spouse, the cost of coverage for the spouse includes the cost to enroll the employee and the spouse.

(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 enrollment in PCN, even when 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 enrollment in PCN. An individual who is eligible to enroll in the VA Health Care System, but who has not yet enrolled, may be eligible for PCN 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 PCN ends once the individual's coverage in the VA Health Care System begins.

(8) Individuals who are full-time students and who can enroll in student health insurance coverage are not eligible to enroll in PCN.

]([9]4) An individual who voluntarily terminates health insurance coverage is ineligible to enroll in PCN for six months from the date the coverage ended.[after the date that the earlier health insurance ends.]  The eligibility agency shall not apply a six-month ineligibility period in the following situations:

(a) Voluntary termination of COBRA.

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

(5) To be eligible to enroll in PCN, the six-month ineligibility period must end by the earlier of the following dates or the eligibility agency shall deny the application:

([i]a) the last day of the open enrollment period during which the individual applies for PCN; or

([ii]b) the last day of the month that follows the month in which the individual applies for PCN, if the open enrollment period does not expire before that following month ends.

[(b) If the six-month ineligibility period does not end by the earlier of the dates mentioned in Subsection R414-310-7(9)(a)(i) or (ii), the eligibility agency shall deny the application.

](c) Enrollment in PCN may not begin before[The effective date of enrollment in PCN must be after] the six-month ineligibility period ends.

[(10) An applicant or applicant's spouse who voluntarily discontinues health insurance coverage under a Consolidated Omnibus Budget Reconciliation Act (COBRA) plan or under the State Health Insurance Pool, or who is involuntarily terminated from an employer-sponsored health plan may be eligible for PCN without a six-month ineligibility period.

(a) An individual is eligible to enroll in PCN if the individual's health insurance coverage expires before the end of the calendar month that follows the month in which he applies for PCN.

(b) The PCN enrollment date must be after health insurance coverage ends.

(11) Notwithstanding the limitations in Section R414-310-7, an individual with creditable health coverage operated or financed by Indian Health Services may enroll in PCN.

(12) An individual 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.

(13) The eligibility agency shall deny an application or recertification 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 in the program.

]

R414-310-8. Household Composition and Income Provisions.

(1) The eligibility agency 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 PCN:

(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 the age of 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 in PCN, countable MAGI-based income for the individual must be equal to or less than 100% of the federal poverty guideline for the applicable household size.[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.]

[(3) Any household member defined in Subsection R414-310-8(1) 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 counts that individual's income the same way that it counts the income of a U.S. citizen, national, or qualified resident alien.

]

[R414-310-9. Age Requirement.

(1) An individual must be at least 19 and not yet 65 years of age to enroll in PCN.

(2) The month in which an individual turns 19 years of age is the first month that the person may enroll in PCN. The effective date of enrollment for an applicant who meets the eligibility criteria for PCN and who turns 19 or 65 years of age is defined in Section R414-310-15.

 

R414-310-10. Income Provisions.

(1) To be eligible to enroll in PCN, 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 PCN. 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 may not count any income that is excluded under this section.

(2) The eligibility agency shall treat any income in a trust that is available to, or is received by a household member as income of the person for whom it is received. It is countable income if the eligibility agency counts that person's income to determine eligibility.

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

(4) 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.

(5) The eligibility agency shall count as income cash contributions made by non-household members unless the parties have a signed written agreement for repayment of the funds.

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

(7) 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 that is for other family members counts as that family member's income.

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

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

(10) The eligibility agency shall count as income Supplemental Security Income and State Supplemental payments.

(11) The eligibility agency shall count as income, unearned and earned income that is 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 after December 18, 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. 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) The eligibility agency may not count as income payments that are 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 as income 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 must repay and that the individual has contracted in good faith without fraud or deceit, and genuinely endorsed in writing for repayment.

(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 individual's spouse who is under 19 years of age when that spouse is the head of the household.

(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 as income reimbursements for employee work expenses incurred by an individual.

(21) The eligibility agency may not count as income 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.

 

]R414-310-9[11]. 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 limitation in Subsection R414-310-10(18), the eligibility agency counts the gross income of all household members to determine the eligibility of the applicant or enrollee, unless the income is excluded under this rule. The agency only deducts required expenses from the gross income to make an income available to the individual. No other deductions are allowed.]

(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 and 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 [recertification]review for continuing eligibility.

(a) The eligibility agency determines prospective eligibility by using the best estimate of the household's average monthly income that the agency expects the household to receive or to become available to the household during the upcoming certification period.

(b) The eligibility agency shall include in the best estimate, reasonably predictable income changes, such as seasonal income or contract income, to determine the average monthly income expected to be received during the certification period.

(c) 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 agency expects the household 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 the same household receives.

(5) 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 time period during which 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.

[(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.

]

R414-310-10[2]. Assets.

[There is no]An asset test is not required for PCN eligibility[ in PCN].

 

R414-310-11[3]. Application and Signature[Procedure].

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

(2) To enroll in PCN, the applicant must complete and sign a written application or complete an online application during an open enrollment period.] The provisions of Section R414-308-3 apply to PCN applicants , except for paragraph (9), (10) and the three months of retroactive coverage.

[(a) The eligibility agency shall review an application to determine eligibility for the PCN program if the application is pending approval when the open enrollment period begins.

(b) An applicant must follow the provisions of Section R414-310-14 to reapply for each recertification.

](2) A Medicaid or CHIP recipient may make a request during the open enrollment period for the agency to determine the individual's eligibility for PCN without completing a new application.

(3) The eligibility agency shall reinstate a medical case without requiring a new application if the agency closes the case in error.

(4) An applicant may withdraw an application for PCN any time before the eligibility agency completes an eligibility decision on the application.

[(5) An applicant or enrollee must pay an annual enrollment fee for each 12-month recertification period to enroll in PCN. Upon the eligibility agency determining that the individual meets the eligibility criteria for enrollment, the individual must pay the enrollment fee when he applies and recertifies for PCN.

(a) An applicant must pay the enrollment fee within 30 days of the date on the notice that approves enrollment.

(b) To reenroll after the individual recertifies, the individual must pay the enrollment fee within 30 days of the date on the notice that approves enrollment, or by the end of the month that follows the review month, whichever is longer.

(c) The eligibility agency does not require an American Indian or Alaska Native to pay an enrollment fee. This enrollment fee waiver applies to both the individual and the spouse if both are enrolled and at least one of them is an American Indian or Alaska Native. If only one spouse is enrolled in PCN and is not an American Indian or Alaska Native, that spouse must pay the enrollment fee to enroll in PCN.

(d) Coverage may only become effective when the eligibility agency receives the enrollment fee. The provisions of Section R414-310-15 determine the effective date of enrollment. The eligibility agency shall deny enrollment if the individual does not pay the enrollment fee timely.

(e) The enrollment fee covers both the individual and the individual's spouse if the spouse is also eligible for enrollment in PCN.

(f) The applicant or enrollee must pay the enrollment fee to DWS in cash, by debit or credit card, or by check or money order made out to DWS.

(g) The enrollment fee for an individual or married couple receiving General Assistance from DWS is $15. The enrollment fee for an individual or couple who does not receive General Assistance but whose countable income is less than 50% of the federal poverty guideline applicable to their household size is $25. The enrollment fee for any other individual or married couple is $50.

(h) DWS may refund the enrollment fee if it decides that the person is ineligible for the program; however, DWS may retain the enrollment fee to the extent that the individual owes any overpayment of benefits that DWS pays in error on behalf of the individual.

(6) If an eligible household requests enrollment for a spouse, the application date for the spouse is the date of the request. The eligibility agency may not require a new application form; however, the household must provide requested information to determine eligibility for the spouse. The household must provide information about access to creditable health insurance that includes Medicare Part A or B, student health insurance, and the VA Health Care System.

(a) The effective date of enrollment to add a spouse to an open PCN case is defined in Section R414-310-15. Coverage continues through the end of the certification period.

(b) The eligibility agency may not require a new enrollment fee to add a spouse during the certification period.

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

(d) An eligible household may only add a spouse if DWS does not stop enrollment under Subsection R414-310-16(2).

(e) The eligibility agency shall count income of the spouse and require payment of the enrollment fee at the next scheduled recertification.

]

R414-310-12[4]. Eligibility Decisions and [Recertification]Reviews.

(1) The Department adopts and incorporates by reference 42 CFR 435.911 and 435.912, October 1, 2013[2010] ed., regarding eligibility determinations[which are incorporated by reference].

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

(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 PCN.[ An applicant who turns 19 years of age during the application month and qualifies for Medicaid or CHIP during that month may enroll in PCN the following month in accordance with Section R414-310-15.]

(b) An applicant who is eligible for Medicaid or CHIP during the application month, or a Medicaid or CHIP recipient who requests PCN enrollment during an open enrollment period, may enroll in PCN in accordance with Subsection R414-310-13(1).

[(b) If the individual appears to qualify for Medicaid, or CHIP, but additional information is required to make that determination, the applicant must provide additional information requested by the eligibility worker. The eligibility agency shall deny the application if the individual fails to provide the requested information.

(3) If the individual qualifies for Medicaid and PCN, but must pay a spenddown, poverty-level, pregnant woman asset copayment or MWI premium to qualify for Medicaid, the individual may choose to enroll in the PCN program. If the PCN program is not in an enrollment period, the applicant may choose to enroll in Medicaid and wait for an open enrollment period to reapply for PCN.

(a) PCN does not cover prenatal or delivery services for a pregnant woman.

(b) PCN does not provide long-term care services in a medical institution or under a home and community-based waiver.

(4) To enroll, the individual must meet the eligibility criteria for enrollment in PCN, pay the enrollment fee, and enroll during an open enrollment period under Section R414-310-16.

]([5]3) The eligibility agency shall complete a determination of eligibility[ or ineligibility] for each application 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 the verification date is later.

([6]4) 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.

(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.

(e) If the enrollee is determined eligible during the due process month, the eligibility agency shall waive the open enrollment requirement.

(5) 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.

(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.

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

(f) The eligibility agency shall waive the open enrollment requirement during these three calendar months.

(g) If the enrollee does not respond to the request to complete the review for PCN during the three calendar months immediately following the review closure date, the enrollee must reapply for PCN and meet all eligibility criteria.

(6) 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 incomplete review, the eligibility agency shall waive the open enrollment period and process the request as a new application.

(7) The enrollee must reapply if the case closes for one or more calendar months for any reason other than an incomplete review.

(8) The eligibility agency shall comply with the requirements of 42 CFR 457.350(i), regarding transfer of the electronic file for the purpose of determining eligibility for other insurance affordability programs.[Upon determining that the applicant is eligible for PCN and upon receiving payment of the enrollment fee, the eligibility agency shall enroll the individual in PCN for a 12-month certification period. The eligibility agency shall end enrollment after the 12-month certification period.

(7) The eligibility agency shall provide an enrollee the opportunity to reenroll for a new 12-month certification period when the certification period is near completion.

(a) The recertification is a reapplication to determine whether the enrollee is eligible to enroll in a new 12-month certification period.

(b) The eligibility agency shall notify the enrollee that PCN benefits end after the 12-month certification period.

(c) The eligibility agency shall inform the enrollee of the necessary steps to complete the recertification.

(8) At each recertification, the eligibility agency shall determine whether the enrollee is eligible for Medicaid. The individual may not reenroll in PCN if the individual qualifies for Medicaid without a cost. If the individual appears to qualify for Medicaid, the individual must provide additional information requested by the agency. The eligibility agency shall deny recertification if the individual fails to provide the requested information.

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

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

(b) The application processing period is based on the date that the enrollee contacts the eligibility agency to complete the recertification.

(c) The eligibility agency shall determine eligibility if the enrollee provides all verification by the verification due date or by the end of the application processing period. The agency shall either approve a new 12-month certification period pending payment of the enrollment fee or deny eligibility for a new certification period. The eligibility agency shall notify the enrollee of its decision.

(10) If the enrollee fails to respond to the request for recertification during the recertification month or does not provide all verification within the application processing period after responding timely to the recertification request, the enrollee may reapply in the calendar month that follows the effective closure date, without waiting for an open enrollment period.

(a) The enrollee must reapply by responding to the recertification request and providing all requested verification; or by filing a new application before the end of the month that follows the recertification month.

(b) The application processing period is based on the date that the enrollee contacts the eligibility agency to complete the recertification, provides all requested verification, or reapplies during such month.

(c) The benefits become effective upon the enrollee paying the required enrollment fee if the eligibility agency approves an enrollee for a new 12-month certification period.

(d) The eligibility agency shall notify the enrollee if the agency does not approve an enrollee for the new certification period.

(11) The enrollee must wait for the next open enrollment period to reapply for PCN if the enrollee fails to complete the recertification process as defined in Subsection R414-310-14(9) or (10).]

 

R414-310-13[5]. Effective Date of Enrollment[, Change Reporting] and Enrollment Period.

(1) Subject to the limitations in Section[s R414-306-6 and] R414-310-[7]6, the effective date of PCN enrollment is the first day of the application month[ in which the eligibility agency receives an application] with the following exceptions:

(a) Enrollment in PCN may not begin before an individual turns 19 years of age.

(b) Enrollment in PCN begins the first day of the month after Medicaid eligibility ends when an applicant qualifies for Medicaid in the application month or the month immediately following the application month. To enroll in PCN, Medicaid eligibility must end by the end of the month following the application month.

(c) If an applicant turning 19 years of age during the open enrollment month is eligible for Medicaid without cost or is eligible for CHIP, enrollment in PCN begins the first day of the month after Medicaid or CHIP eligibility ends.

[(a) An applicant who turns 19 years of age during the application month and before the end of the open enrollment period in the application month is enrolled in PCN as follows:

(i) The eligibility agency shall enroll the applicant in Medicaid if the applicant qualifies for Medicaid during the application month without cost. In this instance, enrollment in PCN becomes effective for the month that follows the application month if the applicant neither qualifies for Medicaid nor qualifies without cost and chooses not to pay for Medicaid during that following month;

(ii) The eligibility agency shall enroll the applicant in CHIP if the applicant qualifies for enrollment in CHIP during the application month. Enrollment in PCN then becomes effective for the following month;

(iii) If the applicant is not eligible for Medicaid without cost and is not eligible for CHIP in the application month, enrollment in PCN becomes effective in the application month, but no earlier than when the applicant turns 19 years of age;

(iv) The applicant is not eligible for PCN if the applicant turns 19 years of age after the open enrollment period.

(b) An otherwise eligible applicant who turns 65 years of age during the application month and applies before age 65 may enroll in PCN, which coverage becomes effective as defined in Subsection R414-310-15(1). The applicant is not eligible for PCN if the applicant is eligible for Medicaid without cost in the application month. The eligibility agency shall end enrollment effective the end of the month in which the applicant turns 65 years of age.

(c) The eligibility agency shall deny enrollment to an individual if the individual applies for PCN on or after the date the individual turns 65 years of age.

]([d]2) Subject to the limitations in Section R414-310-1 3[5] and the open enrollment requirement, the effective date of enrollment for the spouse of an enrollee is the first day of the month in which the enrollee requests to add the spouse.

[(2) The eligibility agency shall enroll an applicant who meets all eligibility criteria and pays the enrollment fee for a 12-month certification period that begins with the first month of enrollment. The applicant must pay the enrollment fee before any benefits for a 12-month certification period become effective. The Department may not provide any benefits or pay for any services that an applicant receives before the effective date of enrollment.

](3) The effective date of reenrollment for PCN [recertification]after the eligibility agency completes the periodic review is the first day after the review month or the due process month. R414-310-12(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.[, if the recertification is completed as described in either Subsection R414-310-14(9) or (10). The enrollee must continue to meet all eligibility criteria and pay the enrollment fee timely before benefits become effective for the new 12-month certification period.]

(4) 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) the individual enrolls in a health coverage plan as defined in Subsection 414-310-6(2)[becomes a full-time student who is entitled to receive student health insurance, becomes entitled to or eligible to enroll in Medicare, or becomes covered by Veterans Administration Health Insurance];

(c) the individual gains access to an employer-sponsored health plan that meets the requirements of R414-310-6(2);

(d) a change in income or household composition results in the individual exceeding the income limit;

([c]e) the individual dies;

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

([e]g) the individual enters a public institution or an Institution for Mental Disease.

[(5) The eligibility agency shall end PCN enrollment when the individual enrolls in any type of group health plan or other creditable health insurance coverage including an employer-sponsored health plan. The eligibility agency shall continue PCN eligibility through the end of the certification period if the individual gains access to an employer-sponsored health plan but does not enroll in the plan.

]([6]5) An enrollee who gains access to or enrolls in an employer-sponsored health plan may [choose to enroll in the employer-sponsored health plan and ]switch to the UPP program.

(6) An individual enrolled in UPP may switch to the PCN program if the employer-sponsored health plan ends involuntarily, or if COBRA coverage ends and there is no break in coverage between UPP and PCN.

(a) 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 an open enrollment period.

(b) Enrollment in PCN is effective the day after the other health insurance ends.

[(a) The individual must notify the eligibility agency within ten calendar days of enrolling in the plan or within ten days after coverage begins, whichever is longer, to switch to UPP.

(b) The requirements defined in Subsection R414-310-7(3)(b) or (c) must be met except that the individual does not have to enroll in UPP during an open enrollment period.

(c) The eligibility agency continues the current certification period without doing a new income determination when a PCN enrollee switches to UPP.

(7) The eligibility agency shall determine if an enrollee who gains access to an employer-sponsored health plan during the certification period but does not enroll in such plan may reenroll in PCN at the next recertification as follows:

(a) The individual is not eligible to reenroll in PCN for a new 12-month certification period if the enrollee has access to an employer-sponsored health plan that costs less than 15% of the enrollee's countable gross income at the next recertification;

(b) The enrollee may choose to switch to UPP if the enrollee can enroll in the employer-sponsored health plan upon recertifying, and the plan meets the requirements of Subsection R414-310-7(3)(b) or (c) and costs 5% or more of the enrollee's countable gross income. The enrollee does not have to wait for an UPP open enrollment period and must enroll in the employer-sponsored health plan to switch to UPP.

(c) The enrollee may reenroll in PCN if the cost exceeds 15% of the enrollee's countable gross income.

(8) An individual who enrolls in the Utah Health Insurance Pool does not lose PCN eligibility.

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

(10) The individual may file a new application or make a request to the eligibility agency to reenroll if a PCN case closes for any reason.

(a) The individual must file a new application or make a request to reenroll within the calendar month that follows the effective closure date;

(b) The eligibility agency shall process the request as a new application. The agency shall waive the open enrollment period and determine whether the individual is still eligible for PCN;

(c) The eligibility agency shall continue eligibility through the end of the current certification period if the agency determines that the individual is eligible for PCN;

(d) The eligibility agency shall approve the individual for a new certification period if the certification period has ended when the agency determines that the individual continues to be eligible. The individual must pay the enrollment fee timely for the new 12-month certification period;

(e) The eligibility agency shall deny the request to reenroll and send a notice to the individual if the agency determines that the individual is not eligible for PCN.

(11) The eligibility agency shall determine eligibility for PCN if a Medicaid-eligible recipient reports a change during a PCN enrollment month that makes the recipient ineligible for Medicaid or causes a spenddown. The effective date of enrollment for PCN is the day after the Medicaid case closes if the agency determines that the recipient is eligible for PCN and the recipient pays the enrollment fee timely.

(12) If a PCN case closes for any reason, other than to become covered by another Medicaid or UPP program, and remains closed for one or more calendar months, the individual must submit a new application to the eligibility agency during an enrollment period to reapply. The individual must meet all the requirements of a new applicant including paying a new enrollment fee.

(13) If a PCN case closes because the enrollee is eligible for another Medicaid program or UPP, the individual may request to reenroll in PCN if there is no break in coverage between the programs, even if the eligibility agency ends open enrollment under Subsection R414-310-16(2).

(a) If the individual's 12-month PCN certification period, or 12-month UPP certification period, has not ended, the individual may reenroll for the rest 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 Section R414-310-7. The individual is not required to pay a new enrollment fee for the months remaining in the certification period.

(b) If the 12-month certification period from the earlier enrollment has ended and the individual is moving from Medicaid to PCN, the individual may still reenroll in PCN. The individual must meet eligibility and income guidelines, and pay a new enrollment fee for the new 12-month certification period.

(14) If the eligibility agency requests verification of a reported change and the enrollee fails to return the verification, the eligibility agency shall end eligibility effective the end of the month in which the agency sends proper notice. The eligibility agency shall treat the receipt of verification as a new application if the enrollee returns the verification within one calendar month after the effective closure date.

(a) The eligibility agency shall waive the open enrollment period and continue eligibility for the rest of the certification period if the agency determines that the enrollee is eligible for PCN.

(b) The eligibility agency shall send a denial notice to the enrollee if the agency determines that the enrollee is not eligible for PCN.

(15) A change in income during the certification period does not make the enrollee ineligible for PCN for the months remaining in the current certification period; however, the individual may request the eligibility agency make a Medicaid determination of eligibility.

(a) The eligibility agency shall change coverage to Medicaid and end PCN enrollment if the enrollee requests a Medicaid determination of eligibility and the reported change makes the enrollee eligible for Medicaid without cost.

(b) The enrollee may choose to remain on PCN through the end of the certification period if the enrollee requests a Medicaid determination of eligibility and the reported change makes the enrollee eligible for Medicaid with a spenddown or MWI premium.]

 

R414-310-14[6]. Change Reporting and Benefit Changes.[Enrollment Limitation.]

(1) Enrollees are required to report changes defined in Subsection 414-310-3(2) to the eligibility agency.

(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) If a PCN case closes because the enrollee is eligible for Medicaid or UPP, the individual may request to reenroll in PCN if there is no break in coverage between the programs.

(a) The eligibility agency may not require a new application form.

(b) The eligibility agency shall waive the open enrollment requirement.

(c) The individual must meet all eligibility criteria.

(4) If an enrollee requests enrollment for a spouse, the application date for the spouse is the date of the request. The eligibility agency may not require a new application form.

(a) The household must provide requested information to determine eligibility for the spouse, including information about access to creditable health insurance.

(b) The spouse can only be added during an open enrollment period unless the spouse was previously included in PCN and is moving directly from Medicaid or UPP. The effective date of enrollment is defined in Section R414-310-15.

(5) If the eligibility agency requests verification of a reported change and the enrollee fails to return the verification by the due date, the eligibility agency shall end eligibility effective the end of the month in which the agency sends proper notice.

[ (1) The eligibility agency shall limit enrollment in PCN.

(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 enrollment of new individuals is stopped.

(4) If enrollment is not stopped, an individual may apply for PCN.

(5) An individual who becomes ineligible for Medicaid or CHIP, or who must pay a spenddown, poverty level, pregnant woman asset copayment or MWI premium for Medicaid, but who was not previously enrolled in PCN, may apply to enroll in PCN if the eligibility agency does not stop enrollment under Subsection R414-310-16(2). If the agency stops enrollment, the individual must wait for an open enrollment period to apply.

]

R414-310-15[7]. Notice and Termination.

(1) The Department adopts and incorporates by reference 42 CFR 431.206, 431.210, 431.211, 431.213, 431.214, and 435.919, October 1, 2013[0] ed.[, which are incorporated by reference.]

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

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

[ The eligibility agency shall end enrollment after the 12-month certification period. An enrollee may reenroll for a new 12-month certification period without waiting for an open enrollment period by completing the recertification process, or by reapplying before the last day of the month that follows the effective closure date.

]

R414-310-16[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 the 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 PCN for which the individual is not eligible must repay the Department for the cost of the benefits that the individual receives.

(3) An alien and the alien's sponsor are jointly liable for benefits that an individual receives for which the individual is not eligible.

(4) 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 in which the enrollee is not eligible to receive the benefits.

 

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

Date of Enactment or Last Substantive Amendment: January 1, 2014

Notice of Continuation: June 4, 2012

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

 

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