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Utah Administrative Code (Current through November 1, 2019) |
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R382. Health, Children's Health Insurance Program |
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R382-1. Benefits and Administration |
| R382-1-1. Authority and Purpose |
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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. It is authorized by Section 26-40-103. |
| R382-1-2. Definitions |
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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 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 |
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(1) CHIP provides reimbursement to medical providers for the services they render to a child who meets the eligibility and application requirements of Rule R382-10. 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 CHIP; (b) as described and limited in Section 6.2 of the State Plan for the Children's Health Insurance Program, April 17. 2009 ed., which is adopted and incorporated by reference. (2) CHIP is not health insurance. A relationship with the Department as the insurer and the enrollee as the insured does not exist under this program. |
| R382-1-4. Limitation of Abortion Benefits |
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The Department may only cover abortion in accordance with the provisions of 42 U.S.C. Sec. 1397ee. |
| R382-1-5. Providers |
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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 |
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(1) The Department shall reimburse only for benefits as limited in its contracts with the MCOs. (2) Payment for services by the contracted 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 |
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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, April 17, 2009 ed., which is adopted and incorporated by reference. |
| R382-1-8. Agency Conferences, Fair Hearings and Appeals |
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(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). (2) The applicant or enrollee, parent, legal guardian, or authorized representative may request an agency action, also called a fair hearing, if he disagrees with an agency decision regarding the individual's eligibility. 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. (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 enrollee must exhaust grievance remedies with the MCO before he requests 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. |