Utah Admin. Code 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.
Notes
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