No. 39734 (Amendment): Rule R382-10. Eligibility

(Amendment)

DAR File No.: 39734
Filed: 09/14/2015 04:24:01 PM

RULE ANALYSIS

Purpose of the rule or reason for the change:

The purpose of the change is to clarify how the Department of Workforce Services (DWS) should address reportable changes during the Children's Health Insurance Program (CHIP) review process.

Summary of the rule or change:

This amendment clarifies reportable changes and how DWS should address those changes during the CHIP review process. It also makes other technical changes.

State statutory or constitutional authorization for this rule:

• Section 26-1-5
• Title 26, Chapter 40

This rule or change incorporates by reference the following material:

• Updates 42 CFR 457.805(b), published by Government Printing Office, 10/01/2015
• Updates 42 CFR 457.340, published by Government Printing Office, 10/01/2015

Anticipated cost or savings to:

the state budget:

There is no impact to the state budget because this change only clarifies how DWS should address reportable changes during the CHIP review process.

local governments:

There is no impact to local governments because they do not fund or provide CHIP services to CHIP recipients.

small businesses:

There is no impact to small businesses because this change only clarifies how DWS should address reportable changes during the CHIP review process.

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

There is no impact to CHIP providers and to CHIP recipients because this change only clarifies how DWS should address reportable changes during the CHIP review process.

Compliance costs for affected persons:

There is no impact to a single CHIP provider or to a CHIP recipient because this change only clarifies how DWS should address reportable changes during the CHIP review process.

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

There is no impact to business because it clarifies how DWS should address reportable changes during the review process and does not affect the services of CHIP providers.

Joseph K. Miner, 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:

11/02/2015

This rule may become effective on:

11/09/2015

Authorized by:

Joseph Miner, Executive Director

RULE TEXT

R382. Health, Children's Health Insurance Program.

R382-10. Eligibility.

R382-10-4. Applicant and Enrollee Rights and Responsibilities.

(1) A parent or an adult who assumes responsibility for the care or supervision of a child may apply or reapply for CHIP benefits on behalf of a child. A child who is independent may apply on his own behalf.

(2) If a person needs assistance to apply, the person may request assistance from a friend, family member, the eligibility agency, or outreach staff.

(3) The applicant must provide verification requested by the eligibility agency to establish the eligibility of the child, including information about the parents.

(4) Anyone may look at the eligibility policy manuals located on-line or at any eligibility agency office, except at outreach or telephone locations.

(5) If the eligibility agency determines that the child received CHIP coverage during a period when the child was not eligible for CHIP, the parent, child, or legal guardian who arranges for medical services on behalf of the child must repay the Department for the cost of services.

(6) The parent or child, or other responsible person acting on behalf of a child must report certain changes to the eligibility agency.[within ten calendar days of the day the change becomes known.]

(a) The following changes are reportable within 10 calendar days of the day of the change:

( i[a]) An enrollee begins to receive coverage or to have access to coverage under a group health plan or other health insurance coverage;

( ii[b]) An enrollee leaves the household or dies;

( iii[c]) An enrollee or the household moves out of state;

( iv[d]) Change of address of an enrollee or the household; and

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

( b[7]) [The parent or child, or other responsible person acting on behalf of a child must report the following changes to the eligibility agency. These changes must be reported at a review involving enrollee participation, or within ten calendar days of the notice date that informs the enrollee of a completed ex parte review:]Certain changes are reportable as part of the review process if these changes occurred anytime during the certification period and before the 10-day notice due date in the review month. A change in the following must be reported as part of the review process for any household member:

( i[a]) [A new i]Income source;

( ii[b]) [A change in g]Gross income of $25 or more;

( iii[c]) Tax filing status;

( iv[d]) Pregnancy or termination of a pregnancy;

( v[e]) Number of dependents claimed as tax dependents;

( vi[f]) Earnings of a child;

( vii[g]) Marital status; and

( viii[h]) Student status of a child under 24 years of age.

( 7[8]) An applicant and enrollee may review the information that the eligibility agency uses to determine eligibility.

( 8[9]) An applicant and enrollee have the right to be notified about actions that the agency takes to determine their eligibility or continued eligibility, the reason the action was taken, and the right to request an agency conference or agency action as defined in Section R414-301-6 and Section R414-301-7.

( 9[10]) An enrollee in CHIP must pay quarterly premiums to the agency, and co-payments[,] or co-insurance amounts to providers for medical services that the enrollee receives under CHIP.

 

R382-10-10. Creditable Health Coverage.

(1) To be eligible for enrollment in the program, a child must meet the requirements of Sections 2110(b) of the Compilation of Social Security Laws.

(2) A child who is covered under a group health plan or other health insurance that provides coverage in Utah, including coverage under a parent's or legal guardian's employer, as defined in 29 CFR 2590.701-4, July 1, 2013 ed., is not eligible for CHIP assistance.

(3) A child who has access to health insurance coverage, where the cost to enroll the child in the least expensive plan offered by the employer is less than 5% of the countable MAGI-based income for the individual, is not eligible for CHIP. The child is considered to have access to coverage even when the employer only offers coverage during an open enrollment period, and the child has had at least one chance to enroll.

(4) An eligible child who has access to an employer-sponsored health plan, where the cost to enroll the child in the least expensive plan offered by the employer equals or exceeds 5% of the countable MAGI-based income for the individual may choose to enroll in either CHIP or UPP.

(a) To enroll in UPP, the child must meet UPP eligibility requirements.

(b) If the UPP eligible child enrolls in the employer-sponsored health plan or COBRA coverage, but the plan does not include dental benefits, the child may receive dental-only benefits through CHIP.

(c) If the employer-sponsored health plan or COBRA coverage includes dental, the applicant may choose to enroll the child in the dental plan and receive an additional reimbursement from UPP, or receive dental-only benefits through CHIP.

(d) A child enrolled in CHIP who gains access to or enrolls in an employer-sponsored health plan may switch to the UPP program if the child meets UPP eligibility requirements.

(5) The cost of coverage [is based upon the countable MAGI-based income for the individual's household and will ]include s the following:

(a) the premium;

(b) a deductible, if the employer-sponsored plan has a deductible; and

(c) the cost to enroll the employee, if the employee must be enrolled to enroll the child.

(6) Subject to the provisions published in 42 CFR 457.805(b), October 1, 201[3]5 ed., which the Department adopts and incorporates by reference, the eligibility agency shall deny eligibility and impose a 90-day waiting period for enrollment under CHIP if the applicant or a custodial parent voluntarily terminates health insurance that provides coverage in Utah within the 90 days before the application date. In addition, the agency may not apply a 90-day waiting period in the following situations:

(a) a non-custodial parent voluntarily terminates coverage;

(b) the child is voluntarily terminated from insurance that does not provide coverage in Utah;

(c) the child is voluntarily terminated from a limited health insurance plan;

(d) a child is terminated from a custodial parent's insurance because ORS reverses the forced enrollment requirement due to the insurance being unaffordable;

(e) voluntary termination of COBRA;

(f) voluntary termination of Utah Comprehensive Health Insurance Pool coverage; or

(g) voluntary termination of UPP reimbursed, employer-sponsored coverage.

(7) If the 90-day ineligibility period for CHIP ends in the month of application, or by the end of the month that follows, the eligibility agency shall determine the applicant's eligibility.

(a) If eligible, enrollment in CHIP begins the day after the 90-day ineligibility period ends.

(b) If the 90-day ineligibility period does not end by the end of the month that follows the application month, the eligibility agency shall deny CHIP eligibility.

(8) The Department shall comply with the provisions of enrollment after the waiting period in accordance with 42 CFR 457.340, October 1, 201[3]5 ed., which the Department adopts and incorporates by reference.

(9) A child with creditable health coverage operated or financed by Indian Health Services is not excluded from enrolling in CHIP.

(10) A child who has access to state-employee health insurance as defined in 42 CFR 457.310 is not eligible for CHIP assistance.

 

R382-10-18. Enrollment Period and Benefit Changes.

(1) Subject to the provisions in Subsection R382-10-18(2), a child determined eligible for CHIP receives 12 months of coverage that begins with the effective month of enrollment.

(2) CHIP coverage may end or change before the end of the 12-month certification period if the child:

(a) turns 19 years of age[before the end of the 12-month enrollment period];

(b) moves out of the state;

(c) becomes eligible for Medicaid;

(d) leaves the household;

(e) is not eligible, or is eligible for a different plan due to a change described in Subsection R382-10-4(6)(b);[fails to respond to a request to verify access to employer-sponsored health coverage;]

(f) begins to be covered under a group health plan or other health insurance coverage;

(g) gains access to state-employee health benefits as defined in 42 CFR 457.310;

( h[g]) enters a public institution or an institution for mental disease ;[s; or]

(i) fails to respond to a request to verify access to employer-sponsored health coverage;

(j) fails to respond to a request to verify reportable changes as described in Subsection R382-10-4(6)(b); or

( k[h]) does not pay the quarterly premium.

[(3) The agency shall take the following actions on changes reported after an ex parte review is completed:

] ( 3[a]) The agency [shall]evaluates changes and may re-determine eligibility when it receives a change report as described in Subsection R382-10-4(6). If the agency requests verification of the change, the agency shall give the client at least 10 days to provide verification. The agency shall provide proper notice of an adverse action.[before the ten-day notice deadline in the review month;

(b) The agency shall process the reported change according to Subsections R382-10-18(5), (6) and (7) if the agency receives a change report after the ten-day notice deadline in the review month.

(4) If the agency cannot complete an ex parte review, the agency shall complete a regular review by requesting updated information from the client. The agency will act on all reported changes to re-determine eligibility up to the point of approving a new certification period. Subsections R382-10-18(5), (6) and (7) apply to changes reported after the regular review has been completed.]

( 4[5]) [Certain changes affect an enrollee's eligibility during the 12-month certification period.]If a client reports a change that occurs during the certification period and requests a redetermination, the agency shall re-determine eligibility.

(a) If an enrollee gains access to health insurance under an employer-sponsored plan or COBRA coverage, the enrollee may switch to UPP. The enrollee must report the health insurance within [ten]10 calendar days of enrolling, or within [ten]10 calendar days of when coverage begins, whichever is later. The employer-sponsored plan must meet UPP criteria.

(b) If the change would cause an adverse action, eligibility shall remain unchanged through the end of the certification period.

( c[b]) [If income decreases, the enrollee may report the income and request a redetermination.]If the change results in a better benefit, the agency shall take the following actions:

(i) If the change makes the enrollee eligible for Medicaid, the eligibility agency shall end CHIP eligibility and enroll the child in Medicaid.

[(c) If income increases during the certification period, eligibility remains unchanged through the end of the certification period.

] ( ii[6]) [The agency shall re-determine eligibility if a family reports a decrease in income and requests a redetermination during the certification period. A decrease in the premium]If the change results in a lower premium, the decrease is effective as follows:

( A[a]) The premium change is effective the month of report if income decreased that month and the family provides timely verification of income;

( B[b]) The premium change is effective the month following the report month if the decrease in income is for the following month and the family provides timely verification of income;

( C[c]) The premium change is effective the month in which verification of the decrease in income is provided, if the family does not provide timely verification of income.

( 5[7]) Failure to make a timely report of a reportable change may result in an overpayment of benefits and case closure.

 

KEY: children's health benefits

Date of Enactment or Last Substantive Amendment: [ April 1, ]2015

Notice of Continuation: May 9, 2013

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

 

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