Utah Admin. Code R414-320-2 - Definitions
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) "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.
(3)
"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.
(4) "Creditable Health
Coverage" means any health insurance coverage as defined in
45 CFR
146.113.
(5) "Employer-sponsored health plan" means a
health insurance plan offered by an employer either directly or through the
Utah Health Exchange.
(6)
"Enrollee" means an individual who applies for and is found eligible for the
UPP program, and is receiving UPP benefits.
(7) "Open enrollment" means a period during
which the eligibility agency accepts applications for the UPP
program.
(8) "Primary Care Network"
or (PCN) means the program for benefits under the Medicaid Primary Care Network
Demonstration Waiver.
(9) "Public
Institution" means an institution that is the responsibility of a governmental
unit or is under the administrative control of a governmental unit.
(10) "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.
(11) "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.
(c) The deductible may not exceed $4,000 per
individual.
(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.
(12) "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.
Notes
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