Medicaid Policy
Medicaid Policy
Determining the Cost of Coverage
The cost of coverage is the amount the employee is required to pay, over and above any contribution from the employer, to enroll himself or his spouse in the employer-sponsored health insurance coverage.
Consider only the cost to enroll the individual who is applying for UPP benefits. If both spouses and/or children are applying for benefits, consider the cost of coverage for each person separately.
If the spouse or children of the employee cannot be enrolled unless the employee is enrolled, include the cost of the employee’s coverage when determining the cost of coverage for the spouse.
Consider an unborn the same as a child when determining the cost of coverage.
Use the family cost of coverage from the Form 116M when there are two or more children in the household, including unborn children. If there is only one child or one unborn, use the employee + child cost of coverage.
If the plan has a deductible, add the monthly amount of the deductible to the monthly cost of the premium.
Deductibles are typically annual amounts and will need to be divided by 12 before adding them to the individual’s cost of coverage.
Count the ‘individual’ or ‘single’ deductible amount to the policy holder and the ‘family’ amount to anyone else in the household.
Compare the cost of coverage to the individual’s monthly countable income after any applicable 5% disregard is applied to determine the correct percentage.
APPLICANTS
Employer-Sponsored Health Insurance
An applicant may be eligible for UPP when an employer offers health insurance that meets the requirements for an “UPP Qualified Health Plan” (See Section 1003-1), but a period of time must pass before employees, their spouses, or dependent children are eligible to enroll.
No benefit may be paid until the employer-sponsored health insurance premium has been paid.
Eligibility for UPP is a ‘qualifying event’ for health plans in Utah.
The “qualifying event date” is the date of application and allows an employee to enroll in their employer-sponsored health insurance outside of the open enrollment period.
The applicant must enroll within 30 days from the date they receive the notice.
Determining Eligibility When the Individual Has Access to Employer-Sponsored Health Insurance
Eligibility for individuals who have access to but who have not yet enrolled in employer-sponsored health insurance coverage, and have had at least one chance to enroll, will be determined as follows:
If the cost of the employer-sponsored least expensive medical plan for that individual is less than 5% of the individual’s countable income after any applicable 5% disregard is applied, the individual is not eligible for UPP.
When the cost of the employer-sponsored least expensive medical plan for a child equals or exceeds 5% of the individual’s countable income after any applicable 5% disregard is applied, the child may enroll in UPP or CHIP. If the individual chooses UPP, he or she must enroll in the employer-sponsored coverage within 30 days of the written approval or deny the application. If the individual chooses CHIP, add the child(ren) to CHIP coverage.
COBRA Coverage
Applicants who have paid their COBRA premiums and are currently receiving COBRA coverage through an UPP Qualified Health Plan may be eligible for UPP.
UPP benefits would begin the month of application. No retroactive benefits are allowed. (See 1003-1 for acceptable COBRA plans)
When an applicant is offered COBRA coverage through an UPP Qualified Health Plan but a period of time must pass before they can enroll, they may be approved for UPP.
However, no UPP benefit may be paid until a COBRA premium has been paid.
When an applicant is enrolled in COBRA and an employer-sponsored health insurance plan becomes available:
The applicant must switch to the employer-sponsored coverage if the cost of employer-sponsored coverage exceeds 5% of the individual’s countable income after any applicable 5% disregard is applied.
The applicant is not eligible for UPP if the cost of employer-sponsored coverage does not exceed 5% of the individual’s countable income after any applicable 5% disregard is applied.
It does not matter whether or not he or she chooses to enroll in the new employer-sponsored coverage or if the other plan is considered an 'UPP Qualified Health Plan'. (See Section 1003-1)
RECIPIENTS
When an UPP recipient or other household member begins new employment during the certification period and the new employer offers a health insurance plan; or their current employer changes health plans; or they have a COBRA "qualifying event" and are offered COBRA coverage; determine continued eligibility as follows.
Employer-Sponsored Plan Available
If the UPP recipient chooses to enroll in the new employer-sponsored coverage the change must be reported within 10 days of either the day the recipient signs up or the date coverage begins, whichever is later, with the new health insurance plan.
They may then end the first plan without being subject to an ineligibility period.
The new plan must meet all the UPP requirements including being an 'UPP Qualified Health Plan' (see 1003-1), and the cost of coverage must exceed 5% of the individual’s countable income after any applicable 5% disregard is applied.
Do a new best estimate of the individual’s current income to determine the cost of coverage.
Do not do a new income eligibility determination until the next regularly scheduled recertification.
If the recipient does not report coverage within 10 days of either the day the recipient signs up or the date coverage begins with the new employer-sponsored health insurance plan, the individual cannot continue on UPP. End the UPP coverage as soon as you receive information that the recipient has coverage in the new employer-sponsored health insurance plan.
If the recipient chooses not to enroll in the new employer-sponsored coverage he may remain on UPP under his current health plan until the end of the current certification period. At the next regular recertification all factors of eligibility must be re-determined including income eligibility, access to the employer-sponsored coverage and the cost of the coverage.
COBRA Coverage Available
If the UPP recipient has a COBRA qualifying event and chooses to enroll in the COBRA coverage, take the following action if they:
Report the change within 10 days from either the day the recipient signs up or the date COBRA coverage begins, whichever is later.
Adjust the UPP reimbursement amount. The new COBRA coverage must meet “UPP Qualified Health Plan” requirements except for the 50% employer contribution. (See Section 1003-1)
Do not do a new income eligibility determination until the next regularly scheduled recertification.
Fail to report the change within 10 days from either the day the recipient signs up or the date COBRA coverage begins, whichever is later.
Do not adjust the UPP reimbursement amount.
Continue UPP benefits at the same reimbursement amount until the next month a change can be made using the 10-10-10 reporting rules.
Do not do a new income eligibility determination until the next regularly scheduled recertification.
If the UPP recipient has a qualifying event and the individual chooses not to enroll in the COBRA coverage, close UPP and determine eligibility for Medicaid or CHIP.
Link to Definitions 1003-1
Link to Certification Periods 1008