R414-320-6. Creditable Health Coverage

  (1) The Department adopts and incorporates by reference 42 CFR 433.138(b), October 1, 2015 ed.

  (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, 2015 ed., is not eligible for enrollment.

  (3) An applicant who is covered by COBRA coverage may be eligible for UPP enrollment.

  (4) An adult is not eligible for UPP 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 UPP.

  (5) The following requirements apply to an individual who has access to but has not yet enrolled in employer-sponsored health insurance:

  (a) If the individual's cost for the employer-sponsored coverage offered by the employer directly, or for the employer's default plan offered through Avenue H, is less than 5% of the countable MAGI-based income for the individual's household, the individual is not eligible for the UPP program.

  (b) If the individual's cost for the employer-sponsored coverage offered by the employer directly, or for the employer's default plan offered through Avenue H, equals or exceeds 5% of the countable MAGI-based income for the individual's household, the individual may enroll in UPP.

  (i) An eligible child may choose enrollment in either UPP or CHIP.

  (ii) If the cost of coverage exceeds 15% for an adult, the individual may enroll in either UPP or PCN. To enroll in PCN, it must be an open enrollment period and the individual must meet the PCN criteria.

  (c) The cost of coverage includes a deductible if the employer-sponsored plan has a deductible.

  (d) The eligibility agency will include in the cost of coverage for the spouse or dependent child, the cost to enroll the employee if the employee must be enrolled to enroll the spouse or dependent child.

  (6) An eligible individual who has access to or who is enrolled in a COBRA plan may choose to enroll in UPP and the COBRA plan if the individual's cost for the COBRA plan exceeds 5% of the countable MAGI-based income for the individual's household.

  (7) An individual who could enroll in Medicare is not eligible for UPP enrollment, even if the individual must wait for a Medicare open enrollment period to apply.

  (8) An individual who is enrolled in the Veteran's Administration (VA) Health Care System is not eligible for UPP enrollment.

  (a) An individual who is eligible to enroll in the VA Health Care System, but who has not yet enrolled, may be eligible for the UPP program while waiting for enrollment in the VA Health Care System to become effective. To be eligible during this waiting period, the individual must apply for and take all necessary steps to enroll in the VA Health Care System.

  (b) Eligibility for the UPP program ends once the individual's coverage in the VA Health Care System begins.

  (9) An individual who voluntarily terminates health insurance coverage is ineligible to enroll in UPP for 90 days from the date the coverage ends.

  (a) The eligibility agency may not apply a 90-day waiting period in the following situations:

  (i) The premium paid by the individual or family for coverage of the individual or family member exceeded 5% of the MAGI-based household income.

  (ii) The cost of the premium paid and deductible that includes the individual for the family coverage health plan exceeds 9.5% of the MAGI-based household income.

  (iii) An employer stopped offering coverage under an ESI.

  (iv) Loss of coverage due to a change in employment or involuntary separation.

  (v) The individual has special heath care needs as defined by the Department.

  (vi) Loss of coverage due to the death or divorce of an UPP individual.

  (vii) Voluntary termination of COBRA.

  (viii) Voluntary termination of coverage through the Federally Facilitated Marketplace.

  (ix) Voluntary termination of coverage for an adult child from the parent's or guardian's ESI plan.

  (x) Voluntary termination of coverage by a spouse who does not live in the same household as the UPP applicant.

  (xi) Voluntary termination of coverage for a child from a non-custodial parent's ESI plan.

  (xii) The individual is voluntarily terminated from insurance that does not provide coverage in Utah;

  (xiii) The individual is voluntarily terminated from a limited health insurance plan;

  (xiv) A child is terminated from a parent's insurance because ORS reverses the forced enrollment requirement due to the insurance being unaffordable.

  (b) The eligibility agency will determine the individual's eligibility at the end of the waiting period without requiring a new application.

  (i) The agency may request information about changes in the individual's circumstances that may affect eligibility.

  (ii) If eligible, enrollment in UPP can begin in the month in which the 90-day ineligibility period ends.

  (10) An individual is eligible to enroll in UPP if the individual's prior health insurance coverage expires before the end of the calendar month that follows the month in which he applies for UPP, and the individual has access to another employer-sponsored health insurance plan that meets the criteria of an UPP qualified health plan. The UPP enrollment date must be after the prior health insurance coverage ends.

  (11) An eligible individual with access to an employer-sponsored health plan who also has creditable health coverage operated or financed by Indian Health Services may enroll in the UPP program.