Medicaid Policy
Medicaid Policy
UPP Applicants and Termination of Coverage
Voluntary Termination of Coverage
With some exceptions, an individual is not eligible for a period of 90 days if he or she has:
Voluntarily terminated health insurance coverage; OR
Voluntarily changed a comprehensive health insurance plan to a limited health plan within 90 days of the date of application is not eligible for UPP.
The period of ineligibility is 90 days from the date the insurance coverage ended. Individuals may be eligible beginning the 91st day after the date the prior insurance coverage ended. If an application was received during the 90-day waiting period, the individual is not required to reapply when the waiting period ends.
Exceptions to the 90-day sanction period:
Voluntary termination of COBRA coverage.
Voluntary termination of coverage by a parent for an adult child.
Voluntary termination of coverage by a spouse who does not live in the same household as the UPP applicant.
Voluntary termination of a child’s coverage by a non-custodial parent.
Voluntary termination of a limited health plan.
Voluntary termination of a FFM plan.
Voluntary termination of an ESI plan because the individual is no longer eligible for the Adult Expansion program with premium reimbursement (348-3).
Voluntary termination of insurance when the premium paid that includes the UPP individual exceeds 5% of the monthly individual countable income after any applicable 5% disregard is applied.
If the best estimate using the current income shows the cost is less than 5% of the monthly individual countable income after any applicable 5% disregard is applied and the customer disagrees, the customer may submit verifications of the income at the time the insurance was terminated to verify that the cost did exceed 5% at that time.
Voluntary termination of insurance when the cost of the premium and deductible that includes the UPP individual exceeds 9.5% of the monthly individual countable income after any applicable 5% disregard is applied.
If the best estimate using the current income shows the cost is less than 9.5% of the monthly individual countable income after any applicable 5% disregard is applied and the customer disagrees, the customer may submit verifications of the income at the time the insurance was terminated to verify that the cost did exceed 9.5% at that time.
Individuals are determined eligible for APTC’s through the FFM because employer sponsored insurance is determined unaffordable.
Coverage was lost due to the death or divorce of an UPP individual.
The UPP individual has special healthcare needs. An individual with special health care needs is defined as follows. Client statement is accepted. Please contact the Department of Health and Human Services policy specialist with any questions.
An individual who is at risk for chronic physical, developmental, behavioral, or emotional conditions and who requires health and related services of a type or amount beyond that generally required by individuals. An individual with special health care needs includes but is not limited to an individual who:
is blind or disabled
is eligible for SSI
is in Foster Care or other type of out-of-home placement
Is receiving Foster Care assistance or adoption assistance
Involuntary Termination of Coverage
There is no 90-day sanction period for an applicant who is involuntarily terminated from health insurance coverage.
Some examples include:
An employer terminates the group health plan for all employees.
The employer stopped offering coverage of dependents.
An applicant has been terminated from a job or has quit a job, and loses health insurance coverage as a result.
The applicant is not required to purchase any available COBRA coverage.
An applicant whose FFM plan is involuntarily terminated.
UPP Recipients and Termination of Coverage
Voluntary Termination
When a recipient voluntarily terminates employer-sponsored health insurance coverage or COBRA coverage and does not enroll in another employer-sponsored or COBRA plan, he is no longer eligible for UPP.
Children losing UPP coverage may be enrolled in CHIP (220-8).
Involuntary Termination
There is no 90-day sanction period for a recipient who is involuntarily terminated from health insurance coverage.
UPP recipients, who involuntarily lose their employer-sponsored or COBRA health insurance coverage, and do not enroll in another employer-sponsored or COBRA plan are no longer eligible for UPP.
Children losing coverage may be enrolled in CHIP.