No. 34560 (Amendment): Rule R382-1. Benefits and Administration

(Amendment)

DAR File No.: 34560
Filed: 04/07/2011 04:26:32 PM

RULE ANALYSIS

Purpose of the rule or reason for the change:

The purpose of this amendment is to add and update definitions in the rule text, update incorporations by reference, clarify when the Department may cover an abortion, and modify procedures for agency conferences and administrative hearings in accordance with state and federal law.

Summary of the rule or change:

This amendment adds and updates definitions in the rule text, updates incorporations by reference, clarifies when the Department may cover an abortion, and modifies procedures for agency conferences and administrative hearings. These changes clarify the procedures that govern Medicaid eligibility, clarify the appeal process through managed care organizations, and specify that the Department of Workforce Services is the agency that conducts fair hearings. This amendment also makes other stylistic changes.

State statutory or constitutional authorization for this rule:

• Title 26, Chapter 40

This rule or change incorporates by reference the following material:

• Updates Section 6.2 of the State Plan for the Children's Health Insurance Program, published by Division of Medicaid and Health Financing, 04/17/2009
• Updates Section 8 of the State Plan for the Children's Health Insurance Program, published by Division of Medicaid and Health Financing, 04/17/2009

Anticipated cost or savings to:

the state budget:

The Department does not anticipate any impact to the state budget because this amendment only clarifies fair hearing procedures and the appeal process for the Children's Health Insurance Program (CHIP). This amendment neither increases nor decreases services for CHIP clients, and it does not affect client eligibility.

local governments:

The Department does not anticipate any impact to local governments because they do not fund or provide CHIP services and do not determine client eligibility.

small businesses:

The Department does not anticipate any impact to small businesses because this amendment only clarifies fair hearing procedures and the appeal process under CHIP. This amendment neither increases nor decreases services for CHIP clients, and it does not affect client eligibility.

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

The Department does not anticipate any impact to CHIP providers and to CHIP clients because this amendment only clarifies fair hearing procedures and the appeal process under this program. This amendment neither increases nor decreases services for CHIP clients, and it does not affect client eligibility.

Compliance costs for affected persons:

The Department does not anticipate any compliance costs for a single CHIP provider or any out-of-pocket expenses for a single CHIP client because this amendment only clarifies fair hearing procedures and the appeal process under this program. This amendment neither increases nor decreases services for CHIP clients, and it does not affect client eligibility.

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

As this proposed rule neither increases nor decreases services no fiscal impact on business is expected. Clarification of the fair hearing and appeals process should assist business with compliance.

W. 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
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:

05/31/2011

This rule may become effective on:

06/07/2011

Authorized by:

W. David Patton, Executive Director

RULE TEXT

R382. Health, Children's Health Insurance Program.

R382-1. Benefits and Administration.

R382-1-1. Authority and Purpose.

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

 

R382-1-2. Definitions.

The definitions found in Title 26, Chapter 40 apply to this rule. In addition,

(1) "Applicant" means a child under the age of 19 on whose behalf an application has been made [an application ]for benefits under the Children's Health Insurance Program (CHIP), but who is not an enrollee.

(2) "Department" means the Utah Department of Health.

(3) "Enrollee" means a child under the age of 19 who has applied for and has been found eligible for benefits under CHIP.

 

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

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

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

(b) as described and limited in Section 6.2 of the State Plan for the Children's Health Insurance Program, [July 1, 2005]April 17. 2009 ed., which is adopted and incorporated by reference[, and all applicable laws and rules].

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

 

R382-1-4. Limitation of Abortion Benefits.

[Abortion is a covered benefit only if necessary to save the life of the mother]The Department may only cover abortion in accordance with the provisions of 42 U.S.C. Sec. 1397ee.

 

R382-1-5. Providers.

The Department requires a child to enroll in one of the managed care organizations (MCO) that contracts with the Department under the program.

 

R382-1-6. Reimbursement.

(1) The Department shall reimburse only for benefits as limited in its contracts with the [managed care organizations]MCOs.

(2) Payment for services by the contracted [managed care organization]MCO and enrollee co-payment, if any, constitutes full payment for services. A provider may not bill or collect any additional monies for services rendered.

 

R382-1-7. Cost Sharing.

A provider may require an enrollee to pay a co-payment equal to that listed in Section 8 of the State Plan for the Children's Health Insurance Program, [July 1, 2005]April 17, 2009 ed., which is adopted and incorporated by reference.

 

R382-1-8. [Grievances]Agency Conferences, Fair Hearings and Appeals.

(1) An applicant or enrollee may request an agency conference in accordance with Section R414-301-5 at any time to resolve a problem without requesting an agency action under the Utah Administrative Procedures Act (UAPA).

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

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

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

] (2) The applicant or enrollee, [the enrollee's] parent[(s)], legal guardian, or authorized representative [authorized in writing by the enrollee or the enrollee's parent(s)] may request an agency action, also called a fair hearing, if he disagrees with an agency decision regarding the individual's eligibility. [An applicant, the applicant's parent(s), or representative authorized in writing by the applicant or the applicant's parent(s) may request an agency action.]The request for a fair hearing must be in accordance with the provisions and time limits of Section R414-301-6.

(3) The Department of Workforce Services (DWS) shall conduct fair hearings on eligibility in accordance with the provisions of Section R414-301-6.

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

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

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

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

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

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

] ([3]4) If an enrollee disagrees with a decision of the MCO regarding a covered benefit or service, the enrollee may appeal the decision through the MCO.

(a) An [E]enrollee[s] must exhaust grievance remedies with the [managed care organization]MCO before [they can]he request s an agency action from the Department.

(b) The enrollee may file an appeal with the Department if the enrollee disagrees with the MCO's resolution. The enrollee must file the appeal within 60 days of the date that the MCO sends the resolution notice.

(c) The Department shall conduct a review of the MCO's decision in accordance with the provisions of 42 CFR 438.408 and issue a final decision to the enrollee and the MCO.

(d) The Department shall conduct all appeals in accordance with UAPA.

(e) The enrollee may continue to receive benefits if the enrollee meets the conditions of 42 CFR 438.420.

 

KEY: children's health benefits, fair hearings

Date of Enactment or Last Substantive Amendment: [July 1, 2007]2011

Notice of Continuation: May 30, 2008

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

 

---