No. 40296 (Amendment): Section R414-310-6. Creditable Health Coverage

(Amendment)

DAR File No.: 40296
Filed: 04/04/2016 03:23:01 PM

RULE ANALYSIS

Purpose of the rule or reason for the change:

The purpose of this change is to eliminate the sanction period for the Primary Care Network (PCN) when terminating health coverage through the Federally Facilitated Marketplace (FFM).

Summary of the rule or change:

This amendment aligns PCN with the Children's Health Insurance Program and Utah's Premium Partnership for health insurance when PCN eliminates the sanction period for terminating health coverage through FFM.

State statutory or constitutional authorization for this rule:

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

This rule or change incorporates by reference the following material:

• Updates 42 CFR 433.138(b) and 435.610, published by Government Printing Office, 10/01/2015
• Updates Section 1915(b) of the Compilation of the Social Security Laws, published by Social Security Administration, 01/01/2016

Anticipated cost or savings to:

the state budget:

There is no impact to the state budget because this amendment neither increases nor decreases the number of individuals who become eligible for PCN.

local governments:

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

small businesses:

There is no impact to small businesses because this amendment neither increases nor decreases the number of individuals who become eligible for PCN.

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

There is no impact to PCN providers and to PCN recipients because this amendment neither increases nor decreases the number of individuals who become eligible for PCN.

Compliance costs for affected persons:

There is no impact to a single PCN provider or to a PCN recipient because this amendment neither increases nor decreases the number of individuals who become eligible for PCN.

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

There is no fiscal impact on business because the amendment does not change the number of recipients eligible for PCN.

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
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]

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:

05/31/2016

This rule may become effective on:

06/07/2016

Authorized by:

Joseph Miner, Executive Director

RULE TEXT

R414. Health, Health Care Financing, Coverage and Reimbursement Policy.

R414-310. Medicaid Primary Care Network Demonstration Waiver.

R414-310-6. Creditable Health Coverage.

(1) The Department adopts and incorporates by reference 42 CFR 433.138(b) and 435.610, October 1, 201[3]5 ed., and Section 1915(b) of the Compilation of the Social Security Laws, in effect January 1, 201[3]6.

(2) An applicant who is covered under a group health plan or other creditable health insurance coverage as defined in 29 CFR 2590.701-4, July 1, 2013 ed., is not eligible for enrollment in PCN. This includes coverage under student health insurance and the Veteran's Administration Health Care System.

(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) An individual is not eligible for PCN if the individual becomes eligible for Refugee Medical without a spenddown as defined in Section R414-303-10. An individual who is eligible for Refugee Medical with a spenddown may choose to enroll in either Refugee Medical or PCN.

(4) 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 is not eligible for PCN 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, does not exceed 15% of the countable MAGI-based income for the individual's household.

(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.

(c) The eligibility agency considers the individual to have access to coverage if the individual has had at least one opportunity to enroll

(5) An individual who voluntarily terminates health insurance coverage is ineligible to enroll in PCN for 180 days from the date the coverage ended. The eligibility agency may not apply a 180-day ineligibility period in the following situations:

(a) Voluntary termination of COBRA.

(b) Voluntary termination of coverage through the Federally Facilitated Marketplace due to the loss of Advanced Premium Tax Credits (APTC)[Utah Comprehensive Health Insurance Pool coverage].

(6) To be eligible to enroll in PCN, the 180-day ineligibility period must end by the earlier of the following dates or the eligibility agency shall deny the application:

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

(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.

(c) Enrollment in PCN may not begin before the 180-day ineligibility period ends.

 

KEY: Medicaid, primary care, demonstration

Date of Enactment or Last Substantive Amendment: [February 1, 2015]2016

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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