R414-320-2. Definitions

  The definitions in Section 26-40-102 and Rules R414-1 and R414-301 apply to this rule. In addition, the following definitions apply throughout this rule:

  (1) "Adult" means an individual who is 19 years of age or older.

  (2) "Avenue H" means Utah's Health Marketplace where Utah employers and their employees can find information about available employer-sponsored health insurance plans, select a plan, and enroll online.

  (3) "Best estimate" means the eligibility agency's determination of a household's income for the upcoming certification period based on past and current circumstances and anticipated future changes.

  (4) "Children's Health Insurance Program" or (CHIP) means the program for medical benefits under the Utah Children's Health Insurance Act, Title 26, Chapter 40.

  (5) "Creditable Health Coverage" means any health insurance coverage as defined in 45 CFR 146.113.

  (6) "Employer-sponsored health plan" means a health insurance plan offered by an employer either directly or through the Utah Health Exchange.

  (7) "Enrollee" means an individual who applies for and is found eligible for the UPP program, and is receiving UPP benefits.

  (8) "Open enrollment" means a period during which the eligibility agency accepts applications for the UPP program.

  (9) "Primary Care Network" or (PCN) means the program for benefits under the Medicaid Primary Care Network Demonstration Waiver.

  (10) "Public Institution" means an institution that is the responsibility of a governmental unit or is under the administrative control of a governmental unit.

  (11) "Review month" means the last month of the certification period for an enrollee during which the eligibility agency redetermines the enrollee's eligibility for a new certification period.

  (12) "UPP Qualified Health Plan" means a health plan that meets all of the following requirements:

  (a) Health plan coverage includes:

  (i) physician visits;

  (ii) hospital inpatient services;

  (iii) pharmacy services;

  (iv) well child visits; and

  (v) children's immunizations.

  (b) Lifetime maximum benefits must be at least $1,000,000.

  (c) The deductible may not exceed $2,500 per individual.

  (d) The plan must pay at least 70% of an inpatient stay after the deductible.

  (e) The employer contributes at least 50% of the cost of the employee's health insurance premium when the plan is offered directly through the employer. If the employer offers plans through the Utah Health Exchange, the employer must contribute at least 50% of the cost of the employee's health insurance premium for either the employer's default plan or the plan the employee selects. If the plan is a Consolidated Omnibus Budget Reconciliation Act (COBRA) plan, the employer does not have to contribute to the premium.

  (f) The plan does not cover any abortion services; or the plan only covers abortion services in the case where the life of the mother would be endangered if the fetus were carried to term or in the case of rape or incest.

  (13) "Utah's Premium Partnership for Health Insurance" or (UPP) means a medical assistance program that provides cash reimbursement for all or part of the insurance premium paid by an employee for health insurance coverage through an employer-sponsored health insurance plan, including employer-sponsored health plans available under Avenue H, or COBRA coverage that covers either the eligible employee, the eligible spouse of the employee, dependent children, or the family.