Utah Admin. Code R382-10-15 - Application and Eligibility Reviews

(1) The department conducts application and eligibility reviews in accordance with 42 CFR 457.330, 457.340, 457.343, and 457.348.

(2) Section R414-308-3 applies to applicants for CHIP, except for Subsection R414-308-3(9) and except for the three months of retroactive coverage.

(3) An individual can apply without having an interview.

(4) The eligibility agency may interview an applicant, a member, the parents or spouse, and any adult who assumes responsibility for the care or supervision of the child to resolve discrepancies or to gather information that cannot be obtained otherwise.

(5) The eligibility agency shall complete a periodic review of a member's eligibility for CHIP medical assistance in accordance with 42 CFR 457.343.

(6)

(a) If a member fails to respond to a request for information to complete the review during the review month, the agency shall end the member's eligibility effective at the end of the review month and send proper notice to the member.

(b) If the member responds to the review or reapplies within three calendar months of the review closure date, the eligibility agency shall treat the response as a new application without requiring the member to reapply. The application processing period then applies for this new request for coverage.

(c) If the member is determined eligible based on this reapplication, the new certification period begins the first day of the month that the member contacts the agency to complete the review if verification is provided within the application processing period.

(i) Under these circumstances, the four -day grace period may apply.

(ii) If the member fails to return verification within the application processing period, or if the member is determined ineligible, the eligibility agency shall send a denial notice to the member.

(d) The eligibility agency may not continue eligibility while it makes a new eligibility determination.

(7) Except as defined in Subsection R382-10-15(5), the member must reapply for CHIP if the member's case is closed for one or more calendar months.

(8) If the eligibility agency sends proper notice of an adverse decision during the review month, the agency shall change eligibility for the month that follows.

(9) If the eligibility agency does not send proper notice of an adverse change for the month that follows, the agency shall extend eligibility to that month. The eligibility agency shall send proper notice of the effective date of an adverse decision.

(10) If the member responds to the review in the review month and the verification due date is in the month that follows, the eligibility agency shall extend eligibility to the month that follows. The member must provide verification by the verification due date.

(a) If the member provides requested verification by the verification due date, the eligibility agency shall determine eligibility and send proper notice of the decision.

(b) If the member does not provide requested verification by the verification due date, the eligibility agency shall end eligibility effective at the end of the month that the eligibility agency sends proper notice of the closure.

(c) If the member returns verification after the verification due date and before the effective closure date, the eligibility agency shall treat the date it receives verification as a new application date. The eligibility agency shall determine eligibility and send a notice to the member.

(11) The eligibility agency may not continue eligibility while it determines eligibility. The new certification date for the application is the day after the effective closure date if the member is found eligible.

(12) The eligibility agency shall provide ten-day notice of case closure if the member is determined to be ineligible or if the member fails to provide verification by the verification due date.

(13) If eligibility for CHIP enrollment ends, the eligibility agency shall review the case for eligibility under any other medical assistance program without requiring a new application. The eligibility agency may request additional verification from the household if there is insufficient information to determine eligibility.

(14) An applicant must report at application and review whether any of the children in the household for whom enrollment is being requested have access to or are covered by a group health plan, other health insurance coverage, or a state employee's health benefits plan.

(15) The eligibility agency shall deny an application or review if the member fails to respond to questions about health insurance coverage for any children for whom the household seeks to enroll or renew in the program.

Notes

Utah Admin. Code R382-10-15

Amended by Utah State Bulletin Number 2014-22, effective 11/1/2014 Amended by Utah State Bulletin Number 2024-14, effective 7/1/2024