R414-320. Medicaid Health Insurance Flexibility and Accountability 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

R414-320. Medicaid Health Insurance Flexibility and Accountability Demonstration Waiver

R414-320-1. Authority and Purpose

Latest version.

(1) This rule is authorized by Sections 26-1-5 and 26-18-3 and allowed under Section 1115(a) of the Social Security Act.

(2) This rule establishes the eligibility requirements for enrollment and the benefits enrollees receive under the Health Insurance Flexibility and Accountability Demonstration Waiver (HIFA), which is Utah's Premium Partnership for Health Insurance (UPP).

R414-320-2. Definitions

Latest version.

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.

(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.

R414-320-3. Applicant and Enrollee Rights and Responsibilities

Latest version.

(1) The provisions of Section R414-301-4 apply to applicants and enrollees of the UPP program except that reportable changes for UPP applicants and enrollees are defined in Subsection R414-320-3(2).

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

(a) An enrollee stops paying for coverage under an employer-sponsored health plan or COBRA coverage;

(b) An enrollee changes health insurance plans;

(c) The amount of the premium that the enrollee pays for an employer-sponsored health insurance plan or COBRA coverage changes;

(d) An enrollee begins to receive coverage under, or begins to have access to Medicare or the Veteran's Administration Health Care System;

(e) An enrollee leaves the household or dies;

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

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

(h) 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 must continue to pay premiums and remain enrolled in an employer-sponsored health plan or COBRA coverage to be eligible for benefits.

(5) An eligible child may choose to enroll in his parent's or guardian's employer-sponsored health insurance plan or COBRA coverage and receive UPP benefits, or may choose direct coverage through CHIP. A child under the age of 19 may enroll in an employer-sponsored health insurance plan offered by the child's employer or COBRA coverage and UPP, or may choose direct coverage through CHIP.

R414-320-4. 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 adult applicants and enrollees of UPP.

(2) The provisions of Sections R382-10-6, R382-10-7, and R382-10-9 concerning U.S. citizenship, alien status, state residency and social security numbers apply to child applicants and enrollees.

(3) An individual who is not a U.S. citizen or national, or who does not meet the alien status requirements of Sections R414-302-3 or R382-10-6 is not eligible for any services or benefits under the UPP program.

(4) Health plans must meet the criteria of being an UPP qualified health plan.

(5) An individual must apply for the UPP program before he turns 65 years of age. Enrollment shall end effective the end of the month in which an individual turns 65 years of age.

(6) The eligibility agency only accepts applications during open enrollment periods. The eligibility agency may limit the number of individuals it enrolls.

(a) The eligibility agency may stop enrollment of new individuals at any time.

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

(i) adults with children living in the home;

(ii) adults without children living in the home, or;

(iii) other groups designated in advance by the eligibility agency consistent with efficient administration of the program.

(c) The eligibility agency may not accept applications or maintain waiting lists during a period that it stops enrollment of new individuals.

(d) A child is not subject to the open enrollment requirement to enroll in UPP.

(7) Residents of public institutions are not eligible for UPP.

(a) A child under the age of 18 is not a resident of an institution if the child is living temporarily in the institution while arrangements are being made for other placement.

(b) A child who resides in a temporary shelter for a limited period of time is not a resident of an institution.

(8) The eligibility agency may not require an applicant or enrollee for the UPP program to provide Duty of Support information. 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 UPP program.

R414-320-5. Verification and Information Exchange

Latest version.

(1) An applicant and enrollee must provide verification of eligibility factors as requested by the eligibility agency and in accordance with the provisions of Section R414-308-4.

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

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

R414-320-6. Creditable Health Coverage

Latest version.

(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.

(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.

R414-320-7. Household Composition and Income Provisions

Latest version.

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

(2) For an individual to be eligible to enroll, countable MAGI-based income for the individual's household must be equal to or less than 200% of the federal poverty guideline for the applicable household size.

R414-320-8. 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 for the upcoming certification period at the time of 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 is expected to be received or made available to the household during the upcoming certification 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 household expects to receive each month of the certification period, or an annual amount that is prorated over the certification period. The eligibility agency may use different methods for different types of income that a 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 period that 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.

R414-320-9. Assets

Latest version.

An asset test is not required for UPP eligibility.

R414-320-10. Application and Signature

Latest version.

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

(2) The eligibility agency shall reinstate an UPP case without requiring a new application if the case closes in error.

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

R414-320-11. Eligibility Decisions and Eligibility 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 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;

(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.

(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.

R414-320-12. Effective Date of Enrollment and Enrollment Period

Latest version.

(1) Subject to Section R414-320-6, and the limitations in Section R414-306-4, the effective date of enrollment in the UPP program is the first day of the application month.

(a) The effective date of enrollment for a newborn or adopted child is the date of birth or the date of adoption, if the request is made within 30 days of the date of birth or adoption.

(b) If the request to add a newborn or adopted child is made after 30 days of the date of birth or the date of adoption, enrollment is effective on the first day of the month in which the date of request occurs.

(2) An individual who is approved for the UPP program must enroll in the employer-sponsored health plan or COBRA within 30 days of receiving an approval notice from the eligibility agency.

(3) If the applicant does not enroll in the employer-sponsored health insurance plan or COBRA within 30 days of the date that the eligibility agency sends the UPP approval notice, the eligibility agency shall deny the application.

(4) The Department may not reimburse the enrollee for premiums before the effective date of enrollment and not before the month in which the enrollee pays a health insurance or COBRA premium. The enrollee must verify the premium payment.

(5) The effective date of enrollment for an individual moving directly from Medicaid, PCN, or CHIP is the first day of the month after eligibility for Medicaid, PCN, or CHIP ends.

(6) The effective date of reenrollment in UPP after the eligibility agency completes the periodic review, is the first day of the month after the review month, or the first day after the due process month. Subsection R414-320-11(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.

(7) An individual who becomes eligible for UPP is enrolled for a 12-month certification period that begins with the first month of eligibility.

(8) The eligibility agency shall end eligibility before the end of a 12-month certification period for any of the following reasons:

(a) The individual turns 65 years of age;

(b) An enrolled child turns 19 years of age and was covered by the parent's or guardian's health insurance plan;

(d) The individual becomes covered by VA Health Insurance, or fails to apply for VA health system coverage when potentially eligible;

(e) The individual is determined eligible for Medicaid when the household requests a new eligibility determination for any household member;

(f) The individual dies;

(g) The individual moves out of state or cannot be located; or

(h) The individual enters a public institution or an Institution for Mental Disease.

(9) The eligibility agency shall end eligibility if an adult enrollee discontinues enrollment in employer-sponsored insurance or COBRA. The enrollee may switch to the PCN program if the enrollee meets PCN eligibility requirements.

R414-320-13. Change Reporting and Benefit Changes

Latest version.

(1) Enrollees are required to report changes to the eligibility agency as defined in Subsection R414-320-3(2).

(a) The eligibility agency shall determine the effect of the change and make the appropriate change in the enrollee's eligibility.

(b) The eligibility agency shall send proper notice of changes in eligibility.

(2) An enrollee who fails to report changes or return verification timely must repay any overpayment of benefits for which the enrollee is not eligible to receive.

(3) An eligible household may request enrollment for an individual not enrolled in UPP; the application date for the individual is the date of the request.

(a) A new application form is not required.

(b) The eligibility agency determines the individual's eligibility for UPP in accordance with Section R414-320-11.

(c) The eligibility agency shall determine the effective date of enrollment for individuals in accordance with Section R414-320-12.

(d) The eligibility agency shall waive the requirement found in Subsection R414-320-6(2) if the individual is a newborn or adopted child, and the request to add the child is made within 30 days of the date of birth or adoption.

(e) 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.

(f) All other eligibility requirements must be met.

(4) If an eligible household requests a new eligibility determination for any household member during the certification period, the eligibility agency shall determine if any enrolled household member is eligible for Medicaid coverage.

(a) An enrollee who is eligible for Medicaid coverage without a cost is no longer eligible for UPP.

(b) An enrollee who must meet a spenddown or MWI premium to receive Medicaid and chooses not to meet the spenddown or MWI premium may remain on UPP.

R414-320-14. Notice and Termination

Latest version.

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

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

(3) The eligibility agency shall end an individual's enrollment if the individual fails to complete the periodic review process on time.

(4) The eligibility agency shall notify an enrollee in writing at least ten days before the effective date of an action adversely affecting the enrollee's eligibility. The notice must include:

(a) the action to be taken;

(b) the reason for the action;

(d) the applicant's or enrollee's right to a hearing;

(e) how an applicant or enrollee may request a hearing; and

(f) the applicant or enrollee's right to represent himself, or use legal counsel, a friend, relative, or other spokesperson.

(5) The eligibility agency need not give ten-day notice of termination if:

(a) the enrollee is deceased;

(b) the enrollee moves out-of-state and is not expected to return; or

R414-320-15. 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 an 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 the UPP program for which the individual is not eligible must repay the Department for the cost of the benefits that he receives.

(3) 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 that the enrollee is not eligible to receive the benefits.

R414-320-16. Benefits

Latest version.

(1) The UPP program shall provide cash reimbursement to enrollees.

(2) The reimbursement may not exceed the amount that the enrollee pays toward the cost of the employer-sponsored health plan, employer-sponsored plans selected through UHE, or COBRA continuation coverage.

(3) The UPP program may reimburse an adult up to $150 each month.

(4) The UPP program may reimburse a child up to $120 each month for medical coverage. The UPP program will pay the child an additional $20 if the child elects to enroll in employer-sponsored dental coverage.

(a) When the employer-sponsored insurance does not include dental benefits, a child may receive cash reimbursement up to $120 for the medical insurance cost and may receive dental-only benefits through CHIP.

(b) When the employer also offers employer-sponsored dental coverage, the applicant may choose to enroll a child in the employer-sponsored dental coverage, in which case, the UPP program will pay the child an additional $20. The enrollee may also choose to only enroll the child in the employer-sponsored health insurance and UPP, and not enroll the child in the employer-sponsored dental coverage, in which case the child may receive dental-only benefits through CHIP.