R414-320-11. Eligibility Decisions and Eligibility Reviews

  (1) The Department adopts and incorporates by reference 42 CFR 435.911 and 435.912, October 1, 2013 ed., regarding eligibility determinations.

  (2) At application and review, the eligibility agency shall determine whether the individual applying for UPP enrollment is eligible for Medicaid or Refugee Medical.

  (a) An individual who qualifies for Medicaid without paying a spenddown or a Medicaid Work Incentive (MWI) premium may not enroll in the UPP program.

  (b) An individual who qualifies for Refugee Medical without paying a spenddown may not enroll in the UPP program.

  (c) An individual who must pay a spenddown or MWI premium to receive Medicaid or pay a spenddown for Refugee Medical may enroll in UPP if the individual elects not to receive Medicaid or Refugee Medical.

  (3) An individual who is open for Medicaid, Refugee Medical, PCN, or CHIP may request to enroll in the UPP program.

  (a) A new application form is not required.

  (b) The rules in Section R414-320-12 govern the effective date of enrollment.

  (c) A new income test must be completed for the individual. If the individual's income places the UPP household over the income limit for UPP, the individual is not eligible to enroll in UPP.

  (d) If the individual is moving from PCN or CHIP, the eligibility agency shall waive the open enrollment requirement if there is no break in coverage.

  (e) If the individual was previously on UPP, became eligible for Medicaid or Refugee Medical, and requests to reenroll in UPP without a break in coverage, the eligibility agency shall waive the open enrollment period and the requirement in Subsection 414-320-6(2).

  (f) If the individual is moving from Medicaid or Refugee Medical and was not previously on UPP, or there has been a break in coverage of one or more months, an adult individual must reapply during an open enrollment period.

  (g) For a PCN or CHIP individual who enrolls in an employer-sponsored health plan, the eligibility agency shall waive the requirement found in Subsection 414-320-6(2) if the change is reported within ten calendar days of signing up for coverage or within ten calendar days after coverage begins, whichever is later.

  (h) All other eligibility requirements must be met.

  (4) The eligibility agency shall process each application to a decision 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 that date is later.

  (5) 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.

  (6) 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) During these three calendar months, the eligibility agency shall waive the open enrollment period requirement and the requirement at Subsection R414-320-6(2).

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

  (7) 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 an incomplete review, the eligibility agency will process the request as a new application and waive the open enrollment period and the requirement found at Subsection R414-320-6(2).

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

  (9) The eligibility agency shall comply with the requirements of 42 CFR 435.1200(e), regarding transfer of the electronic file for the purpose of determining eligibility for other insurance affordability programs.