No. 39102 (Amendment): Rule R382-10. Eligibility

(Amendment)

DAR File No.: 39102
Filed: 01/30/2015 03:36:22 PM

RULE ANALYSIS

Purpose of the rule or reason for the change:

The purpose of this change is to implement by rule provisions of the Patient Protection and Affordable Care Act, which allow for an ex parte review under the Children's Health Insurance Program (CHIP).

Summary of the rule or change:

This amendment includes reportable change requirements and outlines the process for treating reportable changes after an ex parte review. It also defines "ex parte" and makes other technical changes.

State statutory or constitutional authorization for this rule:

• Pub. L. No. 111-148
• Section 26-1-5
• Section 26-18-3

This rule or change incorporates by reference the following material:

• Updates Subsections 2110(b) and (c) of the Compilation of Social Security Laws, published by Social Security Administration, 01/01/2015

Anticipated cost or savings to:

the state budget:

There is no impact to the state budget because this amendment only clarifies reportable change requirements under CHIP.

local governments:

There is no impact to local governments because they neither fund nor provide CHIP services to CHIP recipients.

small businesses:

There is no impact to small businesses because this amendment only clarifies reportable change requirements under CHIP.

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

There is no impact to CHIP providers and to CHIP recipients because this amendment only clarifies reportable change requirements under CHIP.

Compliance costs for affected persons:

There is no impact to a single CHIP provider or to a CHIP recipient because this amendment only clarifies reportable change requirements under CHIP.

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

This amendment has no impact on business because it makes no additional requirements on care providers or enrollees.

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:

03/17/2015

This rule may become effective on:

04/01/2015

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 Subsections 2110(b) and (c) of the Compilation of Social Security Laws, in effect January 1, 201[3]5.

(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" (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 a health insurance plan offered by an employer either directly or through Utah's Health Marketplace (Avenue H).

(h) "Ex parte review" means a review process the agency conducts without contacting the recipient for information as defined in 42 CFR 457.343.

([h]i) "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.

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

([j]k) "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.

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

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

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

 

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 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.  The following changes are [R]reportable:[changes include:]

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

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

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

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

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

(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:

(a) A new income source;

(b) A change in gross income of $25 or more;

(c) Tax filing status;

(d) Pregnancy or termination of a pregnancy;

(e) Number of dependents claimed as tax dependents;

(f) Earnings of a child;

(g) Marital status; and

(h) Student status of a child.

([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, co-payments, or co-insurance amounts to providers for medical services that the enrollee receives under CHIP.

 

R382-10-17. Effective Date of Enrollment and Renewal.

(1) Subject to the limitations in Section R414-306-6, Section R382-10-10, and the provisions in Subsection R414-308-3(7), the effective date of CHIP enrollment is the first day of the application month.

(2) If the eligibility agency receives an application during the first four days of a month, the agency shall allow a grace enrollment period that begins no earlier than four days before the date that the agency receives a completed and signed application.

(a) If the eligibility agency allows a grace enrollment period that extends into the month before the application month, the days of the grace enrollment period do not count as a month in the 12-month enrollment period.

(b)  During the grace enrollment period, the individual must receive medical services, meet eligibility criteria, and have an emergency situation that prevents the individual from applying. The Department may not pay for any services that the individual receives before the effective enrollment date.

(3) For a family who has a child enrolled in CHIP and who adds a newborn or adopted child, the effective date of enrollment is the date of birth or placement for adoption if the family requests the coverage within 30 days of the birth or adoption. If the family makes the request more than 30 days after the birth or adoption, enrollment in CHIP will be effective beginning the first day of the month in which the date of report occurs, subject to the limitations in Section[s] R414-306-6, Section R382-10-10 , and the provisions of Subsection R382-10-17(2).

(4) The effective date of enrollment for a new certification period after the review month is the first day of the month after the review month, if the review process is completed by the end of the review month. If a due process month is approved, the effective date of enrollment for a renewal is the first day of the month after the due process month if the review process is completed by the end of the due process month. The enrollee must complete the review process and continue to be eligible to be reenrolled in CHIP at review.

 

R382-10-18. Enrollment Period.

(1) Subject to the provisions in Subsection R382-10-18(2), a child determined eligible for CHIP [enrollment ]receives 12 months of coverage that begins with the effective month of enrollment.[If the eligibility agency allows a grace enrollment period that extends into the month before the application month, the days of the grace enrollment period do not count as a month in the 12-month enrollment period.]

(2) CHIP coverage may end 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) fails to respond to a request to verify access to employer-sponsored health coverage;

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

([e]g) enters a public institution or an institution for mental diseases; or

([f]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:

(a) The agency shall re-determine eligibility when it receives a change report 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.

([3]5) Certain changes affect an enrollee's eligibility during the 12-month certification period.

(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 calendar days of enrolling, or within ten calendar days of when coverage begins, whichever is later. The employer-sponsored plan must meet UPP criteria.

(b) If income decreases, the enrollee may report the income and request a redetermination. 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.

([4]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 is effective as follows:

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

(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) 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: [November 1, 2014]2015

Notice of Continuation: May 9, 2013

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

 

---