R414-310. Medicaid Primary Care Network Demonstration Waiver, R414. Health, Health Care Financing, Coverage and Reimbursement Policy, Utah Administrative Code

Utah Administrative Code (Current through November 1, 2019)

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

R414-310. Medicaid Primary Care Network Demonstration Waiver

R414-310-1. Authority and Purpose

Latest version.

(1) This rule is authorized by Sections 26-1-5 and 26-18-3. The Primary Care Network Demonstration is authorized by a waiver of federal Medicaid requirements approved by the Centers for Medicare and Medicaid Services and allowed under Section 1115(a) of the Social Security Act.

(2) The purpose of this rule is to establish eligibility requirements for enrollment under the Medicaid Primary Care Network Demonstration Waiver.

R414-310-2. Definitions

Latest version.

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

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

(2) "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.

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

(4) "Copayment and coinsurance" means a portion of the cost for a medical service for which the enrollee is responsible to pay for services received under the Primary Care Network.

(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 Avenue H.

(7) "Enrollee" means an individual who has applied for and has been found eligible for the Primary Care Network program.

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

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

(10) "Review month" means the last month of the review period for an enrollee during which the eligibility agency shall redetermine eligibility for a new review period if the enrollee completes the review process timely.

(11) "Student health insurance plan" means a health insurance plan that is offered to students directly through a university or other educational facility.

(12) "Utah's Premium Partnership for Health Insurance" or (UPP) means the program described in Rule R414-320.

R414-310-3. Applicant and Enrollee Rights and Responsibilities

Latest version.

(1) The provisions of Section R414-301-4 apply to applicants and enrollees of the PCN program except that reportable changes for PCN applicants and enrollees are defined in Subsection R414-310-3(2).

(2) An applicant or enrollee must report certain changes to the eligibility agency within ten calendar days of the day the change becomes known. The eligibility agency shall notify the applicant at the time of application of the changes that the enrollee must report. Reportable changes include:

(a) An enrollee in PCN begins to receive coverage or to have access to coverage under a group health plan or other health insurance coverage;

(b) An enrollee in PCN begins to receive coverage under, or begins to have access to student health insurance, Medicare, or the Veteran's Administration Health Care System;

(d) Changes in household composition;

(e) Changes in tax filing status;

(f) Changes in the number of dependents claimed as tax dependents;

(g) An enrollee or the household moves out of state;

(h) Change of address of an enrollee or the household; or

(i) An enrollee enters a public institution or an institution for mental diseases.

(3) An applicant or enrollee has a right to request an agency conference or a fair hearing as described in Sections R414-301-6 and R414-301-7.

(4) An enrollee in PCN is responsible for paying any required copayments or coinsurance amounts to providers for medical services that the enrollee receives that are covered under PCN.

R414-310-4. General Eligibility Requirements

Latest version.

(1) The provisions of Sections R414-302-3, R414-302-4, R414-302-7, and R414-302-8 concerning United States (U.S.) citizenship, alien status, state residency, use of social security numbers, and applying for other benefits, apply to applicants and enrollees of PCN.

(2) An individual who is not a U.S. citizen or national, or who does not meet the alien status requirements of Section R414-302-3 is not eligible for any services or benefits under PCN.

(3) An individual must be at least 19 and not yet 65 years of age to enroll in PCN.

(a) The month in which an individual turns 19 years of age is the first month that the person may enroll in PCN.

(b) An individual must apply for the PCN program before he turns 65 years of age.

(4) The eligibility agency only accepts applications during open enrollment periods. The eligibility agency limits the number it enrolls according to the funds available for the program and may stop enrollment at any time.

(a) The open enrollment period may be limited to:

(i) individuals with children under the age of 19 in the home;

(ii) individuals without children under the age of 19 in the home.

(b) The eligibility agency may not accept applications or maintain waiting lists during a period that enrollment of new individuals is stopped.

(5) The provisions of Subsection R414-302-6(1) and (4) apply to applicants and enrollees of PCN who are residents of institutions.

(6) An applicant or enrollee is not required to provide Duty of Support information to enroll in PCN. An adult whose eligibility for Medicaid has been denied or terminated for failure to cooperate with Duty of Support requirements may not enroll in the PCN program.

R414-310-5. Verification and Information Exchange

Latest version.

(1) The provisions of Section R414-308-4 regarding verification of eligibility factors apply to applicants and enrollees of PCN.

(2) The Department shall safeguard information about applicants and enrollees to comply with the provisions of Section R414-301-5.

(3) The Department shall enter into agreements with other government agencies as outlined in Section R414-301-3.

R414-310-6. Creditable Health Coverage

Latest version.

(1) The Department adopts and incorporates by reference 42 CFR 433.138(b) and 435.610, October 1, 2015 ed., and Section 1915(b) of the Compilation of the Social Security Laws, in effect January 1, 2016.

(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).

(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.

R414-310-7. Household Composition and Income Provisions

Latest version.

(1) The eligibility agency determines household composition and countable household income according to the provisions in R414-304-5.

(2) For an individual to be eligible to enroll in PCN, countable MAGI-based income for the individual must be equal to or less than 95% of the federal poverty guideline for the applicable household size.

R414-310-8. Budgeting

Latest version.

(1) The Department shall apply the MAGI-based budgeting methodology defined at 42 CFR 435.603(c), (d), (e), (g) and (h), October 1, 2013 ed., which it adopts and incorporates by reference.

(2) The eligibility agency determines an individual's eligibility prospectively at application and at each review for continuing eligibility.

(a) The eligibility agency determines prospective eligibility by using the best estimate of the household's average monthly income that the agency expects the household to receive or to become available to the household during the upcoming review period.

(b) The eligibility agency shall include in the best estimate, reasonably predictable income expected to be received during the review period, such as seasonal income, contract income, income received at irregular intervals, or income received less often than monthly. The income will be prorated over the review period to determine an average monthly income.

(3) Methods of determining the best estimate are income averaging, income anticipating, and income annualizing. The eligibility agency may use a combination of methods to obtain the best estimate. The best estimate may be a monthly amount that the agency expects the household to receive each month of the review period, or an annual amount that is prorated over the review period. The eligibility agency may use different methods for different types of income that the same household receives.

(4) The eligibility agency determines farm and self-employment income by using the individual's most recent tax return forms or other verification the individual can provide. If tax returns are not available, or are not reflective of the individual's current farm or self-employment income, the eligibility agency may request income information from the most recent time period during which the individual had farm or self-employment income. The eligibility agency shall deduct the same expenses from gross income that the Internal Revenue Service allows as self-employment expenses to determine net self-employment income, if those expenses are expected to occur in the future.

(5) The eligibility agency may request additional information and verification about how a household is meeting expenses if the average household income appears to be insufficient to meet the household's living expenses.

R414-310-9. Assets

Latest version.

An asset test is not required for PCN eligibility.

R414-310-10. Application and Signature

Latest version.

(1) The provisions of Section R414-308-3 apply to PCN applicants, except for paragraph (9), (10) and the three months of retroactive coverage.

(2) A Medicaid or CHIP recipient may make a request during the open enrollment period for the agency to determine the individual's eligibility for PCN without completing a new application.

(3) The eligibility agency shall reinstate a medical case without requiring a new application if the agency closes the case in error.

(4) An applicant may withdraw an application for PCN any time before the eligibility agency completes an eligibility decision on the application.

R414-310-11. Eligibility Decisions and Reviews

Latest version.

(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 is eligible for Medicaid, Refugee Medical or CHIP.

(a) An individual who qualifies for Medicaid or Refugee Medical without paying a spenddown or for Medicaid Work Incentive (MWI) without paying an MWI premium may not enroll in PCN.

(b) An applicant who is eligible for Medicaid, Refugee Medical or CHIP during the application month, or a Medicaid, Refugee Medical or CHIP recipient who requests PCN enrollment during an open enrollment period, may enroll in PCN in accordance with Subsection R414-310-12(1).

(3) An individual open on Medicaid, Refugee Medical or UPP may request to enroll in PCN.

(a) A new application form is not required.

(b) The rules in Section R414-310-12 govern the effective date of enrollment.

(c) If the individual is moving from UPP, the eligibility agency shall waive the open enrollment requirement if there is no break in coverage.

(d) If the individual is moving from Medicaid or Refugee Medical, the eligibility agency shall waive the open enrollment period if the individual was previously on PCN, became eligible for Medicaid or Refugee Medical, and requests to reenroll in PCN without a break in coverage.

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

(f) All other eligibility requirements must be met.

(4) The eligibility agency shall complete an eligibility determination for each application 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;

(d) the applicant does not respond to requests for information within the 30-day application period or by the verification due date, if the verification 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.

(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) The eligibility agency shall waive the open enrollment requirement during these three calendar months.

(g) If the enrollee does not respond to the request to complete the review for PCN during the three calendar months immediately following the review closure date, the enrollee must reapply for PCN 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 incomplete review, the eligibility agency shall waive the open enrollment period and process the request as a new application.

(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.

R414-310-12. Effective Date of Enrollment and Enrollment Period

Latest version.

(1) Subject to the limitations in Sections R414-306-4 and R414-310-6, the effective date of PCN enrollment is the first day of the application month with the following exceptions:

(a) An applicant may be eligible for PCN if the applicant applies during an open enrollment period and will turn 19 before the end of the month in which open enrollment ends.

(i) Enrollment in PCN may not begin before an individual turns 19 years of age.

(ii) If an applicant qualifies for Medicaid or CHIP in the application month, enrollment in PCN begins the month after eligibility for Medicaid or CHIP ends.

(b) If the individual is moving from UPP, the effective date of enrollment is the first day after the health insurance coverage ends.

(c) If the individual is moving from Medicaid, or is eligible for Medicaid in the application month or the month following the application month, the effective date of enrollment is the first day of the month after Medicaid coverage ends. To enroll in PCN, Medicaid eligibility must end by the end of the month following the application month.

(2) The effective date of reenrollment for PCN after the eligibility agency completes the periodic review is the first day after either the review month or due process month. Subsection R414-310-11(5) defines the effective date of reenrollment when the enrollee completes the review process in the three calendar months after the case is closed for incomplete review.

(3) The eligibility agency shall end eligibility for any of the following reasons:

(a) the individual turns 65 years of age;

(b) the individual enrolls in a health coverage plan as defined in Subsection 414-310-6(2);

(c) the individual gains access to an employer-sponsored health plan that meets the requirements of Subsection R414-310-6(2);

(d) a change in income or household composition results in the individual exceeding the income limit;

(e) the individual dies;

(f) the individual moves out of state or cannot be located; or

(g) the individual enters a public institution or an Institution for Mental Disease.

(4) An enrollee who gains access to or enrolls in an employer-sponsored health plan may switch to the UPP program if the enrollee meets UPP eligibility requirements.

R414-310-13. Change Reporting and Benefit Changes

Latest version.

(1) Unless otherwise stated, the provisions in Section R414-308-7 apply to the PCN program.

(2) Reportable changes are defined in Subsection R414-310-3(2).

(3) For a decrease in income, the following provisions apply:

(a) If a change is already anticipated in a best estimate of income, the eligibility agency may only re-determine eligibility if the enrollee requests a redetermination of benefits.

(b) If a change is not anticipated, the agency shall re-determine eligibility.

(c) If a change makes the enrollee eligible for Medicaid, the effective date of the change is the first day of the month of report, if the change is verified timely.

(d) If a change is not verified timely, the change is effective on the first day of the month the change is verified.

(4) If an enrollee requests enrollment for a spouse, the application date for the spouse is the date of the request, and the following provisions apply:

(a) The eligibility agency does not require a new application;

(b) Eligibility is determined in accordance with Section R414-310-11;

(d) The applicant must meet all other eligibility requirements.

R414-310-14. Notice and Termination

Latest version.

(1) The Department adopts and incorporates by reference 42 CFR 431.206, 431.210, 431.211, 431.213, 431.214, and 435.919, October 1, 2013 ed.

(2) The eligibility agency shall notify an applicant or enrollee in writing of the eligibility decision made on the application or the review.

(3) The eligibility agency shall end an individual's enrollment upon enrollee request or upon discovery that the individual is no longer eligible.

R414-310-15. Improper Medical Coverage

Latest version.

(1) Improper medical coverage occurs when:

(a) an individual receives medical assistance for which the individual is not eligible, including benefits that the individual receives pending a fair hearing or during an undue hardship waiver if the enrollee fails to act as required by the eligibility agency;

(b) an individual receives a benefit or service that is not part of the benefit package for which the individual is eligible;

(d) the Department pays too much or too little for medical assistance benefits on behalf of an eligible individual.

(2) An individual who receives benefits under PCN for which the individual is not eligible must repay the Department for the cost of the benefits that the individual receives.

(3) An alien and the alien's sponsor are jointly liable for benefits that an individual receives for which the individual is not eligible.

(4) An overpayment of benefits includes all amounts paid by the Department for medical services or other benefits on behalf of an enrollee, or for the benefit of the enrollee during a period in which the enrollee is not eligible to receive the benefits.