us-ut/manual/dhhs/chip

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us-ut/manual/dhhs/chip — Axiom

(101-enrollee-rights)101 Enrollee Rights#

(101-enrollee-rights)(block-1)Previous Policy#

Persons who are eligible for CHIP have the right to receive correct and timely benefits. They have the right to receive proper notice if there is a change in the benefits for which they qualify. In most situations, this means the notice must be written, adequately explain the action, and sent in a timely manner. (See section 803 for more rules about notices.)

In addition, all people have the right to:

Apply for CHIP. Any applicant has the right to receive assistance from Department of Workforce Services employees.

A child living on his own may apply on his own behalf.

Be treated with dignity, courtesy and respect. This includes, but is not limited to being addressed as Mr., Mrs., Ms., or Miss; being told the name of any worker they contact; and being told clearly and courteously (verbally and in writing) which verifications and information he or she must provide.

Receive information about:

Programs and benefits: Enrollees have a right to receive information about medical programs including Medicaid, Utah’s Premium Partnership (UPP) and the Children's Health Insurance Program (CHIP). It also includes information about the benefits of those programs. Enrollees should also get information about the Federally Facilitated Marketplace (FFM) and Advanced Premium Tax Credit (APTC).

Rights and responsibilities: This includes what the enrollee agrees to when signing the application as well as agency responsibilities. The enrollee also has a right to an explanation of the agreements he makes when signing the application form.

Requirements of the program: Enrollees have the right to information about their own eligibility as well as the proofs on which we based an eligibility action. This means enrollees can see information in their case files that was used to determine their eligibility. Anyone can look at a copy of the policy manual for any programs.

Medicaid Policy Manual

CHIP

Voter Registration Information: Enrollees have the right to receive information about how to register to vote. All applicants will be asked if they wish to register to vote. If the enrollee chooses to register to vote at application or review, complete voter registration form VOT-80. Each time an enrollee reports a change of address on a form, he or she will again be given an opportunity to complete a voter registration form. If the enrollee chooses to register to vote when reporting an address change, have the enrollee complete form VOT-81. If the enrollee has questions regarding the voting process, where to vote, etc., refer to form VOT-PM-82. Staff will assist enrollees to complete the forms in the same manner as staff would assist in completing an application for benefits. At no time will staff encourage enrollees not to register to vote, to join a particular political party, or to vote in a particular manner. Staff will tell enrollees that the decision about registering to vote will not affect their eligibility for CHIP.

Look at information in their case record that the eligibility agency uses to make an eligibility determination.

Protections Guaranteed under the Constitution and Law:

Do not discriminate on the basis of race, color, religion, sex, age, national origin, political beliefs or disabling conditions.(Age of a child may affect eligibility for CHIP and/or certain Medicaid programs. However, these distinctions do not affect a person's right to apply for assistance.)Questions about ethnic background are for statistical purposes only.

Provide auxiliary aids and services free of charge, in a timely manner, to individuals with disabilities.

Provide language assistance services, free of charge, in a timely manner, to individuals with limited English proficiency.

Home Visits: If you must visit an applicant or enrollee after working hours, make an appointment. Do NOT enter an enrollee's home without his permission.

Due Process Rights:

Written notice: The enrollee has the right to be told in writing the reason for actions taken by the department which deny, reduce, or terminate his benefits, or when an application is approved.(See Section 803 for more information about time requirements for notices.)

The eligibility agency cannot close or take an adverse action without providing 10-day advance notice. This includes action taken regarding reviews and case changes. (See section 803 for exceptions to the advance notice requirements.)

Review of Decisions: The enrollee may request an agency conference to talk about his case. He may request a fair hearing any time he does not agree with an action on his case.(See Sections 120-1 and 120-3 for rules about agency conferences and fair hearings.)

(102-1-completion-of-an-application)102-1 Completion of an Application#

(102-1-completion-of-an-application)(block-1)Effective Date: March 1, 2022#

Previous Policy

1. To apply for CHIP, individuals must complete, sign, and date a medical application or the Single Streamlined Application used to apply for all Insurance Affordability programs. Applicants have several options to complete and file an application (701).

· Paper application : A paper application must be completed, signed, dated and filed at a DWS local office, the Federally Facilitated Marketplace (FFM), or an outreach location by delivering it in person, mailing it, or faxing it.

· Telephone applications : Applicants may ask to apply by telephone. When applying by phone, the agency will take the eligibility information over the phone. The applicant will have the option to complete the application over the phone in one of two ways:

o Telephonic signature: The telephonic signature will be documented and stored by the agency. A confirmation receipt documenting the telephonic application will be sent to the applicant via the communication method they have selected, or

o A copy of the completed telephonic application form can be mailed to the applicant. The applicant must sign and return the signature page in person, by mail or fax no later than the last day of the application processing period.

· Online Applications : Applicants may complete an online application through the state agency or complete the Single Streamlined Application through the FFM. When applying online, applicants may complete the online signature. The agency accepts an online signature as a legal signature of the individual applying for CHIP. The applicant can print a copy of the application, the rights and responsibilities, and other important information provided for their own records.

· FFM Account Transfers : Individuals assessed eligible for Medicaid or CHIP by the FFM will have their account transferred to the state agency for a final determination.

· Review Form : If an individual or household is currently open for public assistance, a review form may be used as an application for another type of assistance, or for a new household member. The individual must indicate on the form what type of assistance is being requested, who the household wants to cover, and the date of the request. The review form with the request must be received:

o Electronically online;

o In Person, at a DWS employment center;

o Over the phone with a telephonic signature that will be documented and stored by the agency;

o By Mail; or

o By Fax

If the individual has not previously signed a medical assistance application and completed appropriate assignment of rights and third-party liability information, the agency will send this information to the applicant to complete, sign and return. If the review closed for failure to complete the review process, the review form can be used to re-apply if received by the eligibility agency within 90 days after the closure. See section 704 .

· Verbal Request : An applicant who has a pending application for other types of assistance may make a verbal request to add CHIP to the application.

a. The applicant must make the verbal request while the application for other assistance is still pending and within 30 days of the application date of the pending application. If the 30 th day is a non-business day, the applicant has until the first business day following the 30 th day to make the verbal request. The date the applicant makes the request to add CHIP is the date of application for medical assistance.

b. If the agency has approved or denied the application for other assistance, or if it is more than 30 days after the application date, the applicant must submit a new application.

2. An unsigned application is not complete and the agency cannot determine eligibility until it receives the signature. The applicant must physically, electronically or telephonically sign no later than the last day of the application processing period or the agency will deny the application. (See section 701 -1 on filing an application and section 701-2 on how the agency sets the application date.)

3. If an application is not complete, the agency will contact the applicant and offer ways for the applicant to complete the application. The application must be completed by the end of the application processing period, or the application will be denied.

(102-2-verification)102-2 Verification#

(102-2-verification)(block-1)Effective Date: January 1, 2014#

No Previous Policy

(102-2-verification)(block-2)Verification#

The eligibility agency will use electronic data matching to verify factors of eligibility before asking the individual to provide additional information or documentation. Individuals must verify factors of eligibility when:

The information is not available electronically, or

The electronic data is not reasonably compatible with the client’s statement.

The following rules apply when asking the individual to provide verification:

The agency will give individuals a written request for verifications

Applicants and recipients will have at least 10 days from the date the agency gives or mails a request for verifications to provide the verification.

Verifications needed to complete an application must be returned no later than the last day of the application processing period.

If the due date falls on a non-business day, the individual has until the close of business on the first business day after the due date.

Verifications turned in at an outreach location at a time the outreach office is open are dated as received on that day. If verifications are turned in at an outreach location at a time when the office is closed, the date received is the last day that a staff person was at that location to receive or collect verifications.

Individuals may ask for more time to return verifications. The agency will give the individual at least 10 more days to provide the verifications if the individual asks for more time by the due date.

If the agency requests more information, the agency will allow at least 10 days for the individual to return the information. The agency will extend the application processing period as needed to give the individual time to return verifications.

If verifications are not provided on time, the agency will deny the application or close the eligibility review.

If the agency cannot give 10-day notice for an adverse action, it must continue benefits to the following month. (See Section 803 for exceptions to the advance notice requirements.)

If the applicant provides verifications within 30 days after an application has been denied, the date the verifications are received becomes the new application date. The individual does not have to complete a new application form.

If the applicant returns verifications more than 30 days after the application has been denied, the individual will have to reapply.

If a case closed for failure to complete the review, the individual has 90 days from the date of closure to return verifications without having to complete a new application.

Anytime a due date falls on a Saturday, Sunday or state holiday, the individual has until the close of business on the business day immediately following the due date to turn in verifications.

Note: If the Post Office returns a notice requesting verifications with no forwarding address, see Sec. 803-2 .

Give applicants at least 10 days from the mailing date of the request to return verifications. Applicants may request more time if they contact the agency by the due date. In that case, give applicants at least 10 more days.

If an application is incomplete, the agency will contact the applicant and offer ways for them to complete it. The application must be completed by the end of the application processing period, or it will be denied. If the application is completed by the 30th day after a denial, the new application date is the date the application is completed.

See Section 102-1 when an application is received while another application is already pending.

See Section 704 for more information on eligibility reviews.

See Section 804 for verifications needed when a change is reported.

(102-3-report-changes)102-3 Report Changes#

(102-3-report-changes)(block-1)Effective Date: January 1, 2024#

Previous Policy

This section defines what changes an individual must report and when those changes must be reported. (For information on how to treat reported changes, see section 804 .)

An individual, or an individual acting on behalf of an individual, is responsible for repaying any incorrect benefits received if the individual:

intentionally provides false information,

fails to report changes timely, or

fails to provide verification timely. (See Section 806 )

A. Reportable Changes During the Certification Period

The individual must report the following changes that occur anytime during the certification period within 10 days of the date of the change.

A member begins to receive coverage under a group health plan or other health insurance coverage.

A member begins coverage under a state employee’s group health plan due to a parent’s or legal guardian’s employment with the state.

A member leaves the household or dies.

A member or the household moves out of state.

A member or the household changes their address.

A member enters a public institution or an Institution for Mental Disease.

Change in citizenship status.

CHIP recipient becomes pregnant. See policy section 222.

CHIP recipient gives birth.

B. Reportable Changes at Review

At each review, members must report all changes that occurred during the current certification period up to the start date of the new certification period. In addition to the changes in section A, report the following changes for each household member. (See Section 804 for treatment of changes.)

Income source (new source, loss of previous source)

Gross income of $25 or more

Tax filing status

Pregnancy or termination of pregnancy

Number of dependents claimed as tax dependents

Earnings of a child

Marital status

Student status of a child under the age of 24

A member begins to have access to coverage under a health insurance plan offered by an employer.

A member gains access to coverage under a state employee’s group health plan due to a parent’s or legal guardian’s employment with the state.

C. Date of Report

The date of report is the date the individual tells the eligibility agency through an online reporting process, in person, by telephone, by fax or by mail about a change when that report is received by the close of business.

The agency will date change reports received anywhere other than an outreach location after the close of business as received on the next business day.

Change reports delivered to an outreach location at a time when the office is closed will be dated as received on the last business day that an outreach staff person was working at that location.

When an individual mails information, the business day the agency receives the mailed change report is the date of report.

D. Timely Reports

Changes reported by the due dates defined in A. and B. are considered timely.

If a due date for reporting a change falls on a Saturday, Sunday or state holiday, the individual has until the close of business on the next business day to report the change.

Change reports delivered to an outreach location at a time when the office is closed will be dated as received on the last business day that an outreach staff person was working at that location. Based on the date the change report is dated as received at an outreach location, timeliness then follows the rules in A. and B.

If the agency cannot give 10-day notice for an adverse action, it must continue benefits to the following month. See Section 803 for exceptions to advance notice requirements.

E. Verifications

Individuals who provide reports, forms, or verifications by any one of the dates listed below have provided the information on time:

· When the local office receives the information by 5:00 p.m. on the due date; or

· When the due date is on a Saturday, Sunday or State holiday, the local office receives the information by 5:00 p.m. of the first working day after the due date; or

· When the individual faxes in the information and the fax date shows it was faxed by 5:00 p.m. on the due date.

If the agency cannot give 10-day notice for an adverse action, it must continue benefits to the following month. (See Section 803 for exceptions to the advance notice requirements.)

(111-3-releasing-information-to-others)111-3 Releasing Information to Others#

(111-3-releasing-information-to-others)(block-1)Effective Date: January 1, 2014#

Previous Policy

The Department may not release enrollee information when it is to be used for a commercial or political reason. Income Match information may be released only to those parties who have access to it. (See section 111-3 #4 .)

1. Permission Granted by Applicants and Enrollees:

An applicant or enrollee can give written permission to release case record information.

Form 114AR

A. A valid permission form must include:

1) Individual’s name.

2) Individual’s Social Security number or PID number. There is an exception to this requirement if the individual has not provided a Social Security Number, and is not required to do so (i.e., someone who is not applying for benefits for themselves).

3) Individual’s date of birth.

4) Name of the person or organization to whom the individual is authorizing the release of information.

5) The purpose of releasing the information.

6) The date the release ends. It starts the date it is signed by the individual.

7) A statement as to how the individual or authorized representative can revoke the authorization.

8) A statement that explains that there is no obligation to sign the release and that CHIP eligibility will not be denied if it is not signed.

9) A statement indicating that the individual understands that once information is released, it may no longer be protected and may be re-disclosed.

10) The release must be signed and dated by whoever signed the application. If signed by someone other than the individual, describe their authority to sign.

Note: An applicant or recipient CANNOT authorize the release of Income Match Data from the case records. See 111-3 #4 below for additional information about Income Match Data.

B. There are two exceptions to obtaining permission from the enrollee before sharing information about him:

1) The reason for the request is listed in 111-3 #2, AND the request is NOT for Income Match information, AND the agency making the request has comparable rules for safeguarding its records.

2) It is an Emergency. If it is an emergency, you may release the information and then get the enrollee's permission, if the request is NOT for Income Match information, AND the agency making the request has comparable rules for safeguarding its records.

The CHIP Program Manager or his designee decides what an emergency is. Detail the nature of the emergency in the case notes.

2. Reasons You Can Release Information

With the exception of Income Match data, you may release information about CHIP enrollees when it will be used to administer medical assistance and Federal or State needs-based programs. This includes such reasons as:

A. To establish eligibility.

B. To provide related social services.

C. To assist in any investigation, prosecution, or criminal or civil proceeding connected with the administration of the CHIP program.

D. To confirm eligibility information for the current month for CHIP services.

Example: Information about a SSI recipient, spouse of an SSI recipient, or parents of an SSI recipient may be released to SSA. DO NOT require a written request from SSA. This is because SSA will use the information to administer the SSI program, which is needs‑based.

(See Section 111-3 #4 for the rules for release of Income Match data.)

3. To Whom You Can Release Information

The Department can release case record information to outside sources that must also safeguard their case record information on specific enrollees.

When an outside source requests safeguarded information, (other than the Social Security Administration, Dept. of Workforce Services or Office of Recovery Services), ask them how they are going to keep it confidential. Keep their written answer in the case record. Narrate what you did. If they cannot or will not tell you what their plan is to keep it confidential, you must not give them the information.

4. What Happens When Someone Requests Enrollee Information For A Reason Not Listed In 111-3 #2 ?

You must not release information to anyone for any reason not listed in 111-3 #2 unless the enrollee gives his permission.

If the case record gets subpoenaed by an outside source, call the CHIP Program Specialist, immediately.

The legal counsel for the Department will ask the court to disallow the information from our case records. He will cite the Federal Social Security Act and this manual material.

5. Taxpayers

There are no provisions for taxpayers to see any information from the enrollee's records .

(120-4-the-hearing)120-4 The Hearing#

(120-4-the-hearing)(block-1)Effective Date: January 1, 2023#

Previous Policy

The Department of Workforce Services, as the eligibility agency, handles all CHIP hearings.

The Hearing Officer must notify the enrollee and the local office of the time, date, place, and reason for the hearing. The agency must mail the notice at least seven days before the hearing. However, if all parties agree, the Hearing Officer may hold the hearing sooner.. The Hearing Officer may choose to schedule pre-hearing meetings as a way to clarify the issue, arrange for the exchange of documents and identify witnesses.

DWS generally schedules hearings as phone hearings. The enrollee can ask for an in-person hearing by contacting the Administrative Law Judge (ALJ) before the date of the scheduled hearing.

For hearings held in person, all parties meet at the same place for the hearing.

For a hearing held by telephone, the Hearing Officer remains in the office and conducts the hearing via telephone conference call to other locations where the parties involved in the hearing are located.

The enrollee can request an expedited hearing (processed in 7 days) which can only be granted if the enrollee can verify that the standard time for a hearing (90 days) could jeopardize their life, or ability to reach, maintain, or regain maximum function.

The ALJ, eligibility agency or enrollee can request a postponement of the hearing. The postponement cannot exceed a total of 30 days.

The request for the postponement must be made before the scheduled hearing.

The request must be made orally or in writing to the ALJ assigned to hear the case.

The party requesting the postponement must show a reasonable reason for the request.

The agency must hold the rescheduled hearing within 30 days of the original hearing date.

The enrollee may have a representative, including legal counsel.

The eligibility agency may have legal counsel.

No party to the hearing can discuss the issues pertinent to the hearing with the Hearing Officer without all interested parties either being present or subsequently informed of the content of the discussion.

Fair Hearings are not open to the public. Only the following individuals may attend:

The Hearing Officer.

Representatives, legal counsel and witnesses from the Department of Health and Human Services, Department of Workforce Services.

A transcriber, as determined by the Hearing Officer.

The applicant or enrollee, friends or relatives of the enrollee's choice, and a designated representative for the enrollee as space permits.

Cancelling a Hearing.

The applicant or enrollee must notify the Division of Adjudication or the ALJ if they want to cancel the hearing and not proceed with the appeal.

The ALJ issues a decision dismissing the appeal.

This decision has the effect of upholding the eligibility agency’s original action.

The customer has 30 days to reinstate the appeal by filing a written request for reinstatement to the Division of Adjudication.

Failure to Appear for a Fair Hearing.

If either party fails to appear at the hearing in person, by telephone or through a representative, the ALJ issues a decision based on the available evidence.

Reopening a Fair Hearing.

If either party fails to participate in the hearing, but the agency has not issued a decision, the party may request the hearing be reopened.

If the agency has issued a decision, either party that failed to participate personally may request the decision be set aside and a new hearing scheduled.

The request must be in writing and mailed, faxed or delivered to the Division of Adjudication within 10 days of the issuance of the decision.

Enrollees who requested the hearing be reopened more than 10 days after the issuance of the decision mush show good cause for not making the request within the allotted time limit.

A request made by the eligibility agency more than 10 days after the decision will not be granted.

Good Cause to Reopen a Fair Hearing.

Failure to report as instructed at the time and place of the scheduled hearing is the equivalent of failing to participate, even if the party reports at another time or place.

Good cause for failing to participate in a hearing does not include such things as:

Failure to read and follow instructions on the notice of the hearing.

Failure to arrange for personal circumstances such as transportation or child care.

Failure to arrange for receipt or distribution of mail.

Failure to delegate responsibility for participation in the hearing.

Forgetfulness.

(120-5-benefits-pending-a-hearing-decision)120-5 Benefits Pending A Hearing Decision#

(120-5-benefits-pending-a-hearing-decision)(block-1)Effective Date: July 1, 2024#

Previous Policy

When an enrollee asks for a fair hearing, the enrollee may be eligible to receive CHIP benefits while the hearing is pending. Applicants cannot receive CHIP benefits during the hearing process. Continue benefits during the hearing process for an enrollee in the following two instances.

Continue CHIP assistance if the enrollee asks for a hearing any time before the effective date of the action or by the close of business on the 10th day after the date the Notice of Decision is received, whichever is later. The date which the notice is received is considered to be 5 days after the date on the notice, unless the member can show he did not receive the notice within that 5 day period.

If the 10 th day from the date the notice of decision is received is a non-business day, the enrollee has until the close of the next business day to make the request.

At the hearing or pre-hearing conference, the Hearing Officer will determine what the actual issues are. If the Hearing Officer finds the only reason for the hearing is because of Federal or State policy or law and discontinues the fair hearing process, stop the CHIP coverage. Otherwise, continue CHIP coverage until you get the hearing decision.

If the enrollee can demonstrate that he or she did not receive the Notice of Decision in the mail, mail a new notice of decision and allow the enrollee 10 days from the date this notice is received to request the hearing and continued CHIP benefits.

Enrollee’s Requirement to Repay Continued Benefits

The enrollee must repay benefits if the hearing decision goes against the enrollee. The agency must tell the enrollee of the requirement to repay benefits pending the hearing decision.

Repayment is required even if the enrollee does not use any CHIP services while the hearing is pending. This information is part of the hearing request form.

Repayment of benefits includes all expenses paid by the CHIP agency on behalf of the enrollee including fees for a CHIP Health Plan.

How to Handle Case Changes Before the Hearing Decision

When a new change happens during the continued benefits time which requires a change in CHIP coverage, adjust the coverage holding constant whatever item is the subject of the hearing. Notify the enrollee of the effect of the change. If the new change causes the enrollee to be ineligible for CHIP coverage, stop the continued benefits giving proper notice. The enrollee has the right to ask for a new hearing on the new change and may receive continued benefits if the criteria under 120-5 are met.

Appeals

Enrollees who were receiving benefits pending the hearing decision are not entitled to continued benefits during an appeal to District Court.

When to Stop CHIP Pending the Hearing Decision

An enrollee who meets the criteria to receive benefits pending the hearing decision may choose not to receive continued benefits.

Do not provide benefits pending the hearing decision or if the applicant or enrollee says he or she does not want benefits while the hearing process goes on.

The enrollee can mark the box on the hearing request form or make the request by telephone or in person to say he does not want continued benefits.

If an enrollee who initially declined the continued benefits later says he wants to receive benefits while the hearing is still in process, confirm that the hearing is still pending. Reopen the case from that point forward. Document the request. Do not open prior months. Once a hearing decision has been made, follow that decision.

If the Hearing Officer states, in writing, that the only reason for the hearing is because of Federal or State policy or law and decides not to hold a hearing, stop CHIP coverage at that time. (The Hearing Officer decides what the issues are at the hearing or pre-hearing conference.) Otherwise, provide CHIP coverage until a hearing decision is received.

If the enrollee’s whereabouts are unknown, stop the continued benefits and send notice to the last known address. Reopen the case without requiring a new application if the enrollee contacts the office within 30 days after the closure, still wants to receive benefits pending the hearing decision, and the hearing decision is still pending. If the enrollee contacts the office more than 30 days after the case is closed, reopen the case only from that point forward if the hearing is still pending.

If another change makes the enrollee ineligible, stop the continued benefits. Send appropriate notice of the closure. (See 120-5 #3 above.)

Do not provide continued benefits during an appeal to District Court. (See Section 120-8 .)

(120-6-what-happens-during-a-fair-hearing)120-6 What Happens During a Fair Hearing#

(120-6-what-happens-during-a-fair-hearing)(block-1)Effective Date: January 1, 2023#

Previous Policy

All hearings will be conducted informally and in a way to protect the rights of the parties. The hearing may be recorded.

The ALJ considers all issues relevant to the hearing and bases the decision on the relevant evidence and policies.

All parties may testify, present evidence, and comment on the issues.

All testimony of the parties and witnesses will be given under oath or affirmation.

The ALJ will direct the order of testimony and rule on the admissibility of evidence.

The ALJ may accept oral or written evidence of any nature, whether or not conforming to the legal rules of evidence, including hearsay, and determine its relevance to the issues.

Each party to a hearing receives an adequate opportunity to be heard and present any pertinent evidence that helps prove the party’s position. Each party can know about any evidence submitted by rebut, cross-examination or otherwise.

Official records of the eligibility agency, including reports submitted in connection with any program administered by the agency or other State agency may be included in the record.

The parties, with the consent of the ALJ, may stipulate to the facts involved. The ALJ may decide the issues on the basis of such facts or may set the matter for hearing and take such further evidence as deemed necessary to determine the issues.

The ALJ makes a decision based solely on the testimony and evidence presented at the hearing.

Unless the applicant or enrollee requests a continuance, the ALJ issues a decision within 60 days of the date on which the enrollee requests the hearing.

An individual may request an expedited fair hearing (a decision issued to the individual within 7 business days of request) if they can verify that waiting the standard time for a hearing (90 days) could jeopardize their life, or ability to reach, maintain or regain maximum function.

· These circumstances must be justified with sufficient documentation and should be entered into the case record.

· If requested documentation is not received within 7 days, the request will be denied and treated as a standard fair hearing request (90-day decision).

· A decision of whether an expedited hearing will be granted will be made based on the evidence submitted. Additional information may be required to demonstrate the urgent need on a case-by-case basis.

· If the expedited hearing request is denied, the initial request will be treated as a standard fair hearing. The individual will be notified of the denial for an expedited fair hearing and allowed to request continued benefits during the appeal.

· If the Request is approved, the individual will be contacted to set up an expedited hearing.

· After the hearing, the department will issue a determination within 7 business days after receiving the initial request.

A decision of the ALJ which results in a reversal of the eligibility agency becomes final 30 days after the decision unless the Department of Health and Human Services chooses to conduct an Agency Review. (See Section 120-8 .) The DWS hearing decision may be made final in less than 30 days upon agreement of all parties. The CHIP eligibility agency will take case action within 10 calendar days from the date the decision becomes final. The ALJ may take evidence after the hearing. If more facts are found in the process, the ALJ may reopen the hearing.

(120-8-fair-hearing-decisions)120-8 Fair Hearing Decisions#

(120-8-fair-hearing-decisions)(block-1)Effective Date: July 1, 2022#

Previous Policy

1 The Department of Workforce Services (DWS) Division of Adjudications must issue a written decision to all parties involved in the hearing.

2 Send copies of the decision to the DWS Fair Hearing Team. This group is responsible to forward the decision to the individual, individual’s authorized representative and selected representatives of DWS and possibly The Department of Health and Human Services (DHHS) for review.

What Must Be Included in the Decision

A A description of the evidence that was presented.

B Finding of facts based on the evidence. The decision must be based on more than just hearsay evidence.

C Conclusions of laws and rules upon which the decision was based.

D Statement of the reason for the decision.

E Statement of action the agency must take, if any.

F Right to request an Agency Review from the DWS Division of Adjudications and how to make the request.

3 Agency Review

A DHHS, as the Single-State Medicaid Agency, is a party to all fair hearings concerning eligibility for CHIP. The DWS Division of Adjudications conducts appeals and DHHS has the right to conduct an Agency Review of CHIP hearing decisions rendered by DWS.

B The applicant or enrollee may appeal the DWS decision to DHHS. The request for agency review must be made in writing within 30 days of the mailing date of the hearing decision.

C The DWS hearing decision becomes final 30 days after the decision is sent unless DHHS will conduct an Agency Review. The DWS Division of Adjudications will conduct an Agency Review when the applicant or enrollee appeals the DWS decision, or if DHHS disagrees with the DWS decision, they will conduct an agency review.

D The DWS hearing decision may be made final in less than 30 days upon agreement of all parties.

E DHHS notifies DWS Division of Adjudications whenever it will conduct an Agency Review. The DWS hearing decision is suspended until DHHS completes their Agency Review.

F A Decision and Order on Agency Review from DHHS is reviewed a second time by the DWS Division of Adjudications, and is either agreed upon and corrected, or rejected by the DWS Division of Adjudications who’s decision is then final.

G Within 30 days of the date the Decision and Order on Agency Review was issued, the applicant or enrollee may file a petition for judicial review with the District Court. Failure to appeal a DWS Division of Adjudications hearing decision negates this right to a judicial appeal.

H Enrollees are not entitled to continued benefits pending judicial review by the District Court.

I The eligibility agency must take case action within 10 calendar days of the date the decision becomes final if the decision reverses or modifies the eligibility agency’s decision.

(201-1-screening-for-medicaid-eligibility)201-1 Screening for Medicaid Eligibility#

(201-1-screening-for-medicaid-eligibility)(block-1)Effective Date: January 1, 2014#

Previous Policy

If the child does not qualify as an SSI recipient, Parent/Caretaker Relative, Former Foster Care Child, or Pregnant Woman, use the MAGI-based income and household composition to determine Medicaid eligibility for Child Medicaid.

(201-1-screening-for-medicaid-eligibility)(block-2)Application#

If the MAGI-based income for the child is below the applicable poverty-level income limits for Child Medicaid, the child is Medicaid eligible. Complete the eligibility decision and notify the family.

If the MAGI-based income for the child is above the applicable poverty-level income limits for Child Medicaid, and not over the income limit for CHIP, determine eligibility for CHIP.

If the household income shows that the child could be eligible for a Medicaid program that will require a spenddown of excess income, or MWI premium, determine their eligibility for CHIP.

(201-1-screening-for-medicaid-eligibility)(block-3)Review#

Screen the review to determine if any of the children can qualify for Medicaid. Use the same process that you use to process an application.

Remove any child from CHIP who is eligible for Medicaid.

Proceed with the CHIP review for any child who is not eligible for Medicaid.

(201-1-screening-for-medicaid-eligibility)(block-4)Reported Changes#

Income decreases:

If the enrollee reports a decrease in income, and requests Medicaid coverage for any household member, or a new income determination, remove any child from CHIP who is eligible for Medicaid.

If the enrollee does not request Medicaid or a new income determination, continue CHIP through the end of their enrollment period. At review, redetermine Medicaid eligibility using the MAGI-based household composition and MAGI-based income amounts.

If other changes are discovered or reported during the 12 month enrollment period, determine Medicaid eligibility only when the enrollee requests a Medicaid determination, or asks for a new income determination.

Review the change to determine if the change causes an enrollee to no longer qualify for CHIP and take appropriate actions.

Remove any child from CHIP who is Medicaid eligible.

Continue the enrollee on the CHIP program through the end of their enrollment period if the reported change does not make the child eligible for Medicaid (and it also does not make the child ineligible for CHIP.) (See Sec. 703-1 for changes that can result in CHIP eligibility ending.)

(202-1-u-s-citizens)202-1 U.S. Citizens#

(202-1-u-s-citizens)(block-1)Effective Date: March 1, 2026#

Previous Policy

CHIP applicants and recipients must document U.S. Citizenship and identity for household members applying for or receiving CHIP. (See Section 202 and Table IV )

An individual is a U.S. citizen if any of the following criteria are met:

Birth in the United States. U.S. citizenship is automatic for individuals born in any of the 50 states, the District of Columbia, Puerto Rico, Guam, the Virgin Islands, the Northern Mariana Islands, American Samoa, and Swain's Island. Citizenship is verified by proof of the place of birth.

EXCEPTION: Children born in the U.S. to foreign sovereigns or diplomatic officers are not U.S. citizens because they are not subject to the jurisdiction of the United States. It should be noted that for Medicaid purposes, there is not a distinction between U.S. Citizenship and U.S. Non-citizen Nationalization.

Naturalization . Citizenship may be granted to an individual who was not born in the U.S. or one of its territories if that individual satisfies the legal requirements for naturalization.

It should be noted that for Medicaid purposes, there is not a distinction between U.S. Citizenship and U.S. Non-citizen Nationalization.

Born outside of the U.S. to a U.S. Citizen Parent . If a child is born outside of the United States to a person who is a United States citizen at the time the child is born and citizenship has been claimed, the child is also considered a U.S. citizen for CHIP purposes.

Automatic Citizenship .

Children, biological or adopted, born in a foreign country automatically become U.S. Citizens when they meet all of the following criteria at the same time on or after February 27, 2001.

At least one parent (biological or adoptive, but not a step-parent) is a U.S. Citizen either by birth or naturalization. The parent may become naturalized after the birth or adoption of a foreign born child; and

The child is under age 18. If an individual has turned 18 before February 27, 2001, or if the child turns 18 before a parent becomes a U.S. citizen, automatic citizenship does not apply; and

The child lives in the United States pursuant to a lawful admission for permanent residence and resides in the legal and physical custody of a U.S. Citizen parent. Permanent resident status could have been granted before, on or after February 27, 2001. The child must be residing with the U.S. Citizen parent on or after February 27, 2001; and

For an adopted child born outside the U.S., the adoption has been finalized either in the country from which the child is being adopted or in the United States. The adoption can take place in another country or in the U.S., and finalization may occur before, on or after February 27, 2001.

Summary : To receive automatic citizenship, the child must be the adopted or biological child of the U.S. Citizen parent, have permanent resident status in the U.S., be residing with a U.S. citizen parent and still be under age 18, on or after February 27, 2001.

When is Automatic Citizenship Effective?

The effective date for the automatic citizenship cannot be earlier than February 27, 2001. The effective date is the date when all of the criteria are true at the same time on or after February 27, 2001 . Once the individual has met the citizenship criteria, a change in circumstances does not affect citizenship status.

Proof of Citizenship.

These children will receive proof of citizenship only upon application to USCIS (formerly known as INS).

If the child does not have a Certificate of Citizenship or U.S. passport, one parent must certify on form N-6006 that the child satisfies the criteria for automatic citizenship; and

Provide documentation of the parent's citizenship and alternative documentation for the child that establishes that the child meets these requirements. Such documents need to show the child's place of birth (a birth certificate or other medical record), adoption records showing the relationship to the parent and proof of finalization either in the foreign country or the U.S., and USCIS residency status documents.

(202-2-1-lawfully-present-children)202-2.1 Lawfully Present Children#

(202-2-1-lawfully-present-children)(block-1)Effective Date: December 5, 2017#

Previous Policy

A child who does not meet the non-citizen status requirements in 202-2 , but is lawfully residing in the United States may be eligible for CHIP.

These children must meet all other eligibility factors such as state residency, age (up to 19), income and assets.

Some of these children will not have an SSN ( 211-3 ).

Do not impose a 5 year bar to children who are lawfully present.

Do not deem a sponsor’s income and assets when determining eligibility.

Verify lawfully present status at application and review.

A child is considered lawfully present if they are:

A qualified non-citizen as defined in section 202-2 who is subject to the 5 year bar but has not met the 5 year requirement;

A non-citizen in nonimmigrant status who has not violated the terms of the status under which he or she was admitted or to which he or she has changed after admission;

A non-citizen who has been paroled into the United States pursuant to section 212(d)(5) of the Immigration and Nationality Act (INA) (8 U.S.C. §1182(d)(5)) for less than 1 year, except for a non-citizen paroled for prosecution, for deferred inspection or pending removal proceedings;

A non-citizen who belongs to one of the following classes.

Non-citizens currently in temporary resident status pursuant to section 210 or 245A of the INA (8 U.S.C. §§1160 or 1255a, respectively);

Non-citizens currently under Temporary Protected Status (TPS) pursuant to section 244 of the INA (8 U.S.C. §1254a), and pending applicants for TPS who have been granted employment authorization;

Non-citizens who have been granted employment authorization under 8 CFR 274a.12(c)(9), (10), (16), (18), (20), (22), or (24);

Family Unity beneficiaries pursuant to section 301 of Pub. L. 101-649, as amended;

Non-citizens currently under Deferred Enforced Departure (DED) pursuant to a decision made by the President;

Non-citizens currently in deferred action status; or

Non-citizens whose visa petition has been approved and who have a pending application for adjustment of status;

A pending applicant for asylum under section 208(a) of the INA (8 U.S.C. § 1158) or for withholding of removal under section 241(b)(3) of the INA (8 U.S.C. § 1231) or under the Convention Against Torture who has been granted employment authorization, and such an applicant under the age of 14 who has had an application pending for at least 180 days;

A non-citizen who has been granted withholding of removal under the Convention Against Torture;

A child who has a pending application for Special Immigrant Juvenile status as described in section 101(a)(27)(J) of the INA (8 U.S.C. § 1101(a)(27)(J));

A non-citizen who is lawfully present in the Commonwealth of the Northern Mariana Islands under 48 U.S.C. § 1806(e); or

A non-citizen who is lawfully present in American Samoa under the immigration laws of American Samoa.

(202-2-qulaified-non-citizen)202-2 Qualified Non-Citizen#

(202-2-qulaified-non-citizen)(block-1)Effective Date: February 1, 2023#

Previous Policy

A qualified non-citizen is a non-citizen who is lawfully admitted for permanent residence under various sections of the Immigration and Nationality Act (INA). Not all qualified non-citizens are eligible for CHIP assistance. Some qualified non-citizens cannot receive CHIP for five years from the date they obtained qualified non-citizen status. After determining that a non-citizen is a qualified non-citizen, it is necessary to determine if the non-citizen is subject to the five-year bar. If a child is a qualified non-citizen but has not met the 5 year bar, see if the child meets the criteria in section 202-2.1 .

A. Qualified Non-Citizens

1. A non-citizen who is lawfully admitted for permanent residence under the Immigration and Nationality Act. This includes Amerasian immigrants. Proof is a U.S. Citizenship and Immigration Services (USCIS) Form I-151 or I-551 or INS Form I-94 with class codes AM1, AM2, or AM3.

2. A non-citizen who is admitted as a refugee under section 207 of the INA. Proof is a USCIS Form I-94.

3. Iraqi and Afghan immigrants who enter as Lawful Permanent residents may receive Special Immigrant status (either before or after they enter the country.) The law allows these Iraqi and Afghan Special Immigrants to be treated as refugees after their date of entry or the date they are granted this Special Immigrant status. See #3 below for the policy governing these immigrants.

4. A non-citizen who is granted conditional entry under section 203(a)(7) of the INA as in effect prior to April 1, 1980. Proof is an USCIS Form I-94 stamped "Refugee - Conditional Entry."

5. A non-citizen who is granted asylum under section 208 of the INA. Proof is an USCIS Form I-94 and a letter establishing this status.

6. A non-citizen who is paroled into the United States under section 212(d)(5) of the INA for a period of at least 1 year. Proof is an I-94 stating that he has been paroled under Section 212(d)(5) of the INA or stamped "Cuban/Haitian Entrant (Status Pending) Reviewable January 15, 1981."

7. A non-citizen whose deportation is being withheld under section 243(h) of the INA (status granted prior to September 30, 1996), or under section 241(b)(3) after September 30, 1996. Proof is an order from an immigration judge showing that deportation has been withheld. If deportation is being withheld under another section of the INA, the person is not a qualified non-citizen.

8. A non-citizen who is granted status as a Cuban and Haitian entrant (as defined in section 501(e) of the Refugee Education Assistance Act of 1980).

9. A non-citizen who is admitted as an Amerasian immigrant (these individuals may enter as refugees or lawful permanent residents.)

10. An American Indian born in Canada who is at least one-half American Indian. They are considered lawful permanent residents, but will not have USCIS documents. A statement from the tribe is acceptable verification. They are not subject to the five-year bar for eligibility.

11. Battered non-citizens, who meet the conditions set forth in §431(c) of PRWORA, as added by §501 of the Illegal Immigration Reform and Immigrant Responsibility Act of 1996, P.L. 104-208 (IIRIRA), and amended by §5571 of the Balanced Budget Act of 1997, P.L. 105-33 (BBA), and §1508 of the Violence against Women Act of 2000, P.L. 106-386. Section 431(c) of PRWORA, as amended, is codified at 8 USC 1641(c).

12. Victims of a severe form of trafficking, in accordance with §107(b)(1) of the Trafficking Victims Protection Act of 2000, P.L. 106-386.

13. A citizen of the Freely Associated (COFA) States of: the Federated States of Micronesia, the Republic of the Marshall Islands, and the Republic of Palau.

B. Application of the 5-Year Bar

Some qualified non-citizens are barred from receiving CHIP for five years from the date they obtain qualified non-citizen status. The 5-year bar applies only to immigrants who enter the country on or after August 22, 1996. Non-citizens who do not meet one of the following exemptions are not eligible for CHIP until after the 5-year bar.

1. Exceptions to the 5-Year Bar:

Resident non-citizens who have been granted certain non-citizen statuses or meet certain conditions can be eligible for CHIP and are not subject to the five-year bar regardless of their entry date. They must meet the eligibility requirement for CHIP. Resident non-citizens not subject to the 5-year bar include:

a. A non-citizen who is admitted as a refugee under section 207 of the Immigration and Nationality Act (INA).

b. A non-citizen who is granted asylum under section 208 of the INA.

c. A non-citizen whose deportation has been withheld under section 243(h) of the INA (prior to September 30, 1996) or under section 241(b)(3) of the INA (after September 30, 1996).

d. A non-citizen granted status as a Cuban and Haitian entrant as defined in section 501(e) of the Refugee Education Assistance Act of 1980.

e. A non-citizen admitted as an Amerasian immigrant.

f. An American Indian born in Canada who is at least one-half American Indian.

g. A qualified non-citizen who is a veteran with an honorable discharge from the Armed Forces of the United States. The spouse and unemancipated dependent children of the veteran may also qualify if they too are qualified non-citizens and are considered to be household members. The spouse of a deceased veteran who has not remarried may also qualify if he or she is a qualified non-citizen.

h. A qualified non-citizen who is on active duty in the Armed Forces of the United States. A person on active duty for training does not qualify under this category. The spouse and unemancipated dependent children of the person on active duty may also qualify if they are qualified non-citizens and are considered to be household members.

i. Hmong and other Highland Lao tribal peoples who have been lawfully admitted to the United States for permanent residence, and who fought on behalf of the United States during the Vietnam conflict are considered Veterans and therefore are not subject to the five-year bar on eligibility.

j. Victims of a severe form of trafficking, in accordance with §107(b)(1) of the Trafficking Victims Protection Act of 2000, P.L. 106-386.

k. Beginning December 19, 2009, Iraqi and Afghan Special Immigrants admitted to the United States for permanent residence, regardless if they received the status before December 19, 2009.

l. Legal permanent residents who first entered the country under one of the exempt categories above and who later converted to LPR status.

m. A citizen of the Freely Associated (COFA) States of: the Federated States of Micronesia, the Republic of the Marshall Islands, and the Republic of Palau.

2. Entry after August 22, 1996

Immigrants who entered the country on or after August 22, 1996 and who do not meet one of the exceptions listed above, are subject to the 5-year bar.

a. Use the actual date of entry only to determine if the 5-year bar applies. This may or may not be the date on the person's DHS Alien registration card.

b. Once you have determined that the 5-year bar applies, the non-citizen is not eligible for CHIP for five years from the date that he or she obtained qualified non-citizen status. This will be the date on the immigrant's USCIS alien registration card, which may be different from the actual date of entry.

C. Iraqi and Afghan Special Immigrants

Federal laws allow Lawful Permanent resident immigrants from Iraq and Afghanistan who are granted a Special Immigrant (SIV) status to receive the same types of benefits that refugees can receive. The special status applies to the individual and their dependent family members who enter either at the same time, or follow later.

1. Workers must always consider eligibility for other Medicaid programs or CHIP before Refugee Medical Assistance. If the Iraqi or Afghan Special Immigrant household qualifies for other Medicaid programs or CHIP, there are no time limits to eligibility, aside from the normal program rules.

2. If the Iraqi or Afghan Special Immigrant household is not eligible for other Medicaid programs or CHIP, they may receive Refugee Medical Assistance for up to 8 months from the month they enter the United States.

3. If an Iraqi or Afghan Special Immigrant household loses eligibility under a regular Medicaid program or CHIP before the end of the 8 months, convert the household to Refugee Medical Assistance for the balance of the 8 months.

4. Iraqi and Afghan Special Immigrants are LPR's, not refugees. However, effective December 19, 2009, they will be treated as qualified non-citizens and no longer be subject to the 5-year bar. It does not matter if they received the Special Immigrant status before December 19, 2009.

5. An infant, born to a woman eligible for Medicaid on the date of birth under this provision, is a U.S. citizen and eligible for the one year of continued coverage.

D. Afghan Parolees

1. In addition to the Special Immigrant Visa (SIV) holders mentioned in C., other Afghan evacuees will receive the Special Immigrant (SI/SQ) Parolee or the Humanitarian (non-SI/SQ) Parolee status. Like the SIV holders, those individuals with either parolee status will be eligible for full Medicaid benefits if they meet all other eligibility factors.

2. Workers must always consider eligibility for other Medicaid programs or CHIP before Refugee Medical Assistance. If the Iraqi or Afghan Special Immigrant household qualifies for other Medicaid programs or CHIP, there are no time limits to eligibility, aside from the normal program rules.

3. If the parolee is not eligible for other Medicaid programs or CHIP, they may receive Refugee Medical Assistance for up to 8 months from the month they enter the United States.

4. If a parolee household loses eligibility under a regular Medicaid program or CHIP before the end of the 8 months, convert the household to Refugee Medical Assistance for the balance of the 8 months.

E. Ukrainian Nationals

Ukrainians who have been displaced by Russia’s February 24, 2022 invasion and fled Ukraine may be eligible for CHIP based on their immigration status. These individuals may be granted a range of lawful non-citizen statuses, including parole, temporary protected status (TPS), immigrant and nonimmigrant visas, and refugee or asylee.

1. Parolees:

· Ukrainian nationals who enter the United States as parolees on or between February 24, 2022 and September 30, 2023 are eligible for CHIP, without a five-year waiting period, if they meet all other eligibility requirements.

· Ukrainian nationals who are paroled into the U.S. after September 30, 2023, and are the spouse or child of a parolee described above, or who is the parent, legal guardian, or primary caregiver of a parolee described above who is determined to be an unaccompanied child may also be eligible for Medicaid if they meet all other eligibility requirements.

2. Temporary Protected Status (TPS)

· Ukrainians granted TPS, and Ukrainians who have pending applications for TPS and who have been granted employment authorization are not considered “qualified non-citizens” for purposes of CHIP, and thus are not eligible for CHIP, unless they are:

i. a child under age 19, or

ii. a pregnant individual.

· The TPS designation is effective April 19, 2022, and will remain in effect for 18 months, through October 19, 2023.

(202-citizenship-and-non-citizen-status-requirements)202 Citizenship and Non-Citizen Status Requirements#

(202-citizenship-and-non-citizen-status-requirements)(block-1)Effective Date: August 1, 2022#

Previous Policy

A. Eligibility Requirement for CHIP

Individuals eligible to receive CHIP benefits include the following.

1. U. S. citizens. See Section 202-1 .

2. Qualified non-citizens. See Section 202-2 .

3. SSI recipients living in the U.S. on August 22, 1996 and meeting the criteria for one of the grand-fathered SSI recipient non-citizen groups. See Section 329 of the Medicaid manual.

4. Lawfully Present Children. See section 202-2.1 .

(All others may only receive emergency Medicaid services, described in Section 205-6 of Medicaid policy.)

B. Proof of Citizenship, Qualified Non-citizens and Identity

1. U.S. Citizens must document their Citizenship and Identity. Always determine first if the individual meets a citizenship exemption. (See below and Table IV ) Verify citizenship and identity through electronic data sources before asking for verification from the customer. If an electronic interface runs before determining an exemption, document in the case file which exemption the individual meets.

2. Applicants : Do not delay or deny benefits when an individual declares to be a US Citizen or US National or qualified non-citizen, and there is no evidence that contradicts their claim.

If otherwise eligible, provide CHIP coverage and give the member reasonable time to provide the documentation.

o “Reasonable time” is defined as (at least) 95 days from the date verification is requested.

o A member needs to either provide the documentation by the end of the time-frame given, or provide proof they are working to obtain the documentation. Give more time to members who show a good faith effort to provide the documentation.

o If the member has been given reasonable time and does not provide the documentation or proof they are working on obtaining it, remove the member from the CHIP coverage with proper notice.

3. Citizenship/Identity Documentation Exemptions

The following individuals are EXEMPT and do not have to meet the Cit/ID documentation requirement. If the individual loses an exempt status they must meet the Cit/ID requirement at their next scheduled review.

o SSI recipients and those in an SSI Protected group

o SS-DI recipients

o Medicare recipients

o Children in receipt of Title IV-B or Title IV-E Subsidized Adoption Assistance

o Children in receipt of Title IV-B or Title IV-E Foster Care Payments

o Qualifying non-citizens*

o Members only eligible for Emergency Medicaid

o Household members who are not receiving Medicaid or CHIP benefits

4. Children who received deemed newborn eligibility: When a child receives deemed newborn coverage, the child’s citizenship and identity is verified. No additional verification is required.

a. A child receives deemed newborn eligibility when the mother was eligible and received Medicaid at the time of the child’s birth.

o Make a collateral contact with the applicable State Medicaid agency to verify the claim that the child received deemed newborn coverage.

o Once the agency has verification of the child's eligibility under the deemed newborn eligibility, the child never has to provide Cit/ID documentation again.

C. Documentation Requirements

1. States must obtain satisfactory documentary evidence of an applicant’s or recipient’s, citizenship and identity. Verify citizenship/identification and non-citizen status through electronic data sources first before requesting any documents from the customer.

o Table IV (Charts 1, and 2) outlines acceptable Citizenship documentation.

o Chart 3 on Table IV describes the acceptable sources of identity documentation.

o States are allowed to match with the States Verification and Exchange System (SVES) via the Social Security Administration (SSA) interface. A match satisfies the citizenship and identity requirement. See #2 below for additional information.

o States are allowed to match with the State Vital Statistics to obtain birth verification.

o When an individual born in Utah does not have an original birth certificate, do an electronic search for birth years that have been computerized. For years that have not been computerized, they are to submit a Form 125 to Utah State Vital Records to obtain verification that a birth record is on file with the state.

2. SCHIP-I

a. SCHIP-I verifies information regarding the person's claim of US citizenship or nationality.

i. The individual's name, SSN and date of birth compares with data in the SSA Master File of SSN Holders (Numident).

ii. The interface is daily and responses are received the next day.

iii. Two responses are possible: positive and no match with SSA records.

b. A positive response satisfies the Citizenship and Identity requirement. See Table IV , Chart 1.

i. The data submitted is consistent with SSA records.

ii. No additional information is required from the individual.

c. An inconsistency or no match response indicates the data submitted to SSA does not match. (IE, misspelled name, incorrect SSN, incorrect DOB or incorrect citizenship declaration.)

i. The agency first makes a reasonable effort to identify and resolve the cause of the inconsistency. For example, typographical or other clerical error.

ii. When an inconsistency is identified and corrected, resubmit the request.

iii. When an inconsistency is not found by the agency, OR if the second request result is the same, the individual has 95 days to provide proper citizenship documentation.

o The 95 days starts with the date on the notice.

o CHIP benefits remain open during the 95 day verification period.

o If the case closes for any reason during the 95 day verification period, the 95 days continues to run.

o Once the 95 day verification period has expired, it cannot be extended or repeated.

iv. If proper citizenship documentation has not been provided by the end of the 95 day verification period, remove the individual from coverage at the end of the month for which 10-day notice can be given.

(203-1-determining-residency)203-1 Determining Residency#

(203-1-determining-residency)(block-1)Effective Date: June 1, 2026#

Previous Policy

Use the following guidelines to determine if an individual is a Utah resident.

1. Living in the State . The person must be physically present in the state or temporarily absent to be a resident of Utah.

a. A resident need not have a permanent residence or a fixed address.

Example: An individual who is residing in an emergency shelter or stays temporarily in other people’s houses.

b. Temporary absences after a person has been residing in Utah do not affect residency, if the individual intends to return to Utah when the reason for the temporary absence is accomplished. Reasons for temporary absences may include schooling, medical care, visits, temporary employment, military service, or temporary religious or other volunteer services such as the Peace Corps.

c. Do not deny or terminate CHIP because of a temporary absence if the person intends to return to Utah, unless another state has decided the person is a resident in that state for the purpose of CHIP eligibility.

If the National Change of Address (NCOA) data source shows an out of state address, follow the steps in 803-2 . If there is a PARIS match from another state, follow the steps in 706-1 .

d. To decide if the absence is temporary, you may need to find out if:

i. the absence is for a specific period-of-time,

ii. the person is maintaining their home in Utah, or

iii. other factors exist that indicate the person intends to return to Utah when the reason for the absence ends.

e. For someone who has recently moved to Utah, see Section 203-6 .

2. Duration . Residency does not require a person to be in the State for a specific period-of-time before becoming a resident. The person may declare intent to be a resident effective with the first day they arrived in Utah.

3. Reason for living in Utah . Consider the reason why the individual is in Utah, except to the extent that the reason may indicate that the individual is not in Utah voluntarily or is in Utah only temporarily. If the individual is in Utah involuntarily or temporarily, they do not meet Utah residency requirements.

For example:

An individual from Arizona is visiting or traveling through the state, and is arrested for a crime and jailed. This individual is not in the state voluntarily and is not a state resident.

An individual from Nevada is in Utah to give their baby up for adoption and intends to move back to Nevada after the baby is born. This individual is in the stat temporarily and is not a state resident.

4. Citizenship . Citizenship is not relevant to the determination of state residency. A non-citizen may be a Utah resident even if his immigration status is temporary. Non-citizens may have dual intent - intent to remain in the U.S. if permitted to stay and intent to leave if Department of Homeland Security requires them to leave.

5. Intent . An individual who is capable of expressing intent may do so on the application form. Unless there is an indication that the person does not meet residence requirements, accept the applicant's statement. See Section 203-2 for information on "Who is Capable of Expressing Intent" and Section 203-5 for "Factors Indicating No Intent to Reside in Utah". If other factors indicate a conflict, the applicant’s statement of intent must be verified.

Example: Bill came to Utah and has been living here for 3 months. He applied for medical benefits and stated he is a resident of Utah. SNAP benefits are open in Idaho. Since another state is providing benefits intent is not clear and needs to be verified.

6. Residents of Public Institutions such as Jails or Prisons .

a. An individual residing in a public institution such as a jail or prison is a resident of Utah if the person was a resident before being placed. An individual who lived in another state, but was arrested and placed in jail in Utah is not a Utah resident.

b. If another state places the person in a public institution in Utah, the individual is not a Utah resident. Residency does not change from the previous state. (See Sec. 203-5 and 203-6 )

c. State residency does not change when an individual in a public institution goes directly to a hospital for an inpatient stay.

7. Residents of other institutions .

a. Any individual placed in an institution by another state is a resident of that state. This includes individuals from another state placed in a Utah nursing home or hospital. (Sec. 203-5 )

b. A competent individual who leaves an institution after having been placed by another state is a resident of the state in which the individual is physically located.

c. For residents of an institution who are not placed by another state, see sec. 203-4 .

8. Individuals receiving a State Supplementary Payment (SSP). An individual of any age who receives an SSP is a resident of the state paying the SSP. If an individual receiving an SSP from another state moves to Utah, see Sec. 203-5 .

9. Individuals receiving Title IV-E payments. An individual of any age who receives federal payments for foster care or adoption assistance under Title IV-E is a resident of the state in which the individual lives. A Title IV-E eligible child will receive Utah Medicaid. A IV-E eligible foster child placed in another state by Utah will receive Medicaid from the state in which the child is placed. Utah will continue to make the IV-E foster care payment. A IV-E eligible child with a Utah Adoption Assistance Agreement who moves to another state will receive Medicaid from the state in which the child resides.

10. Cases of disputed residency between two states . If an individual has come to Utah from anther state, and the two states cannot resolve which state is the person's state of residency, the individual is a resident of the state in which the individual is physically located.

(203-4-determining-residency-for-individuals-under-21)203-4 Determining Residency for Individuals Under 21#

(203-4-determining-residency-for-individuals-under-21)(block-1)Effective Date: November 1, 2017#

Previous Policy

(203-4-determining-residency-for-individuals-under-21)(block-2)Individuals Under Age 21 Not Residing in an Institution#

T itle IV-E and State Supplemental Payment Recipients ( 203-1 ).

Individual not receiving Title IV-E or SSP payments. If the individual is able to state intent and is emancipated (by age, court order or marriage), the individual is a resident of Utah if he or she lives in the state voluntarily and meets one of the following two criteria:

Intends to reside, including without a fixed address; or

Entered Utah with a job commitment or to seek employment, whether or not they are currently working. See 203-6 for individuals just moving to Utah.

The state of residence of an individual under age 21 who is not institutionalized and who does not meet the criteria in 1 or 2, is:

The state where the individual resides, including without fixed address, when the individual does not reside with a parent or caretaker relative; or

The state of residency of the parent or caretaker relative with whom the individual resides ( 203-5 ).

If the parents are unable to claim Utah residency due to the requirements of their nonimmigrant status, and they request Medicaid for their citizen children, they may claim Utah residence for those children.

(203-4-determining-residency-for-individuals-under-21)(block-3)Individuals Living in Institutions#

For the purposes of this section, an "institution" is an establishment that furnishes food, shelter and some treatment or services to 4 or more persons unrelated to the proprietor. A "wilderness camp" could be an institution if it provides food, shelter (even tents) and some treatment or services to 4 or more teens unrelated to the proprietor.

An institutionalized individual under age 21 who is not emancipated is a resident of the State:

Where the parent (or legal guardian, if parental rights have been terminated) is living at the time of placement; or

Where the parent (or legal guardian, if parental rights have been terminated) who filed the application is living; or

Where the person who applied for medical assistance on the child's behalf is living, if the child has been abandoned by his parents and no legal guardian has been appointed, if the child is institutionalized in that same state.

An individual residing in an institution who is under age 21, capable of stating intent, and emancipated or married, is a resident of the state in which the individual is living with the intent to reside.

(203-4-determining-residency-for-individuals-under-21)(block-4)Non-IV-E Foster Care and Adoption Assistance#

Foster child not receiving IV-E Foster Care assistance:

When another state places a foster child in Utah and the child is receiving non-IV-E foster care, the child cannot receive Utah CHIP. The state making the placement is responsible to provide CHIP for the child.

Child With Adoption Assistance But Not IV-E Eligible:

When a non-IV-E child with an adoption assistance agreement originating from another state moves to Utah, the child is eligible for Utah Medicaid and should not be opened on CHIP if the state originating the adoption assistance agreement is a member of the Interstate Compact on Adoption and Medical Assistance (ICAMA).

If the state is not a member of ICAMA, the child is not eligible for medical assistance in Utah. The state making the payment is responsible to provide medical assistance for the child. Refer to Medicaid Section 355 for the ICAMA list. If the state originating the adoption assistance agreement is not on the ICAMA list, the eligibility worker should verify that the state is not a member of ICAMA by contacting the originating state or the Utah ICAMA administrator. States join periodically and the list could be outdated.

(203-5-factors-indicating-no-intent-to-reside-in-utah)203-5 Factors Indicating No Intent to Reside in Utah#

(203-5-factors-indicating-no-intent-to-reside-in-utah)(block-1)Effective Date: December 5, 2017#

Previous Policy

An individual’s actions and actual circumstances may be a more accurate and persuasive expression of intent than the individual’s statement.

A. Ownership of an Exempt Home in Another State

If an individual owns a home in another state and claims that the home is his residence, or because an institutionalized individual intends to return to that home, do not accept that individual’s statement of intent to reside in Utah.

B. Employment in Another State

If an individual is employed in another state and does not make a reasonable claim that he resides in Utah even though he works out-of-state, do not accept that individual’s statement of intent to reside in Utah. Do not accept the individual’s statement of intent to reside in Utah as long as he is on temporary leave from a job in another state. If the individual cannot make a reasonable claim that he maintains residency in Utah even though working in another state, the individual is not a Utah resident.

C. Temporary Visit

If an individual has come to Utah for a temporary purpose and intends to leave within a foreseeable period of time, when that temporary purpose will be accomplished, then do not accept that individual’s statement of intent to reside in Utah. (See Sections 203-1 and 203-4 )

D. Placement by another State

An individual placed in a Utah institution by an agency of another state is not a Utah resident. For the purposes of this section, an “institution is an establishment that furnishes food, shelter, and some treatment or services to 4 or more persons unrelated to the proprietor.

1. Placement . Placement is more than just providing information or assisting an individual in locating an institution in another state. Placement requires a state agency to have authority to act on behalf of the individual. An individual is not “placed” by a state agency if he is capable of expressing intent and independently decides to come to Utah.

2. Agency of a State . An agency of a state includes an entity recognized under the laws of that state as being under contract with that state, as well as any governmental agency of that state.

3. Reason for Placement in Utah . The state other than Utah also retains responsibility for an individual when placement is made in Utah because the other state lacks a sufficient number of appropriate facilities to provide services to its residents.

E. People Receiving a State Supplemental Payment

When a person receives a State Supplemental Payment (SSP), the state making the payment is the state of residence.

1. Choosing to Reside in Utah. A person may choose to become a Utah resident by stating that he or she intends to live in the state or entered with a job commitment or seeking employment, and by asking the Social Security Administration to transfer all State Supplemental benefits to the Utah address. (This usually means the individual must contact Social Security to submit a change of residency.) If the person chooses to transfer the State Supplemental benefits to Utah and states the intent to reside in Utah, that person may be a Utah resident even though he received an SSP from another state.

2. 4-Day Grace Period ( 701-2 ) A person receiving an SSP from another state may not decide retroactively to reside in Utah. You can approve coverage in the 4-day grace period only if evidence shows that the person was in the state during that time period with the intent to reside in Utah. Before approving coverage for the 4-day grace period, require the person to take immediate steps to change the SSP to Utah, if it has not been changed already.

(203-6-moving-from-state-to-state)203-6 Moving From State to State#

(203-6-moving-from-state-to-state)(block-1)Effective Date: January 1, 2014#

Previous Policy

Moving to Utah.

An individual who moves to Utah from another state with the intent to become a Utah resident can receive CHIP in Utah even if the other state provided CHIP for the month of application. If the individual received a State Supplemental Payment from the other state, see Section 203-5 , #5.

An individual is not a Utah resident until he or she arrives in Utah.

An individual is not a Utah resident while en route to Utah from another state.

Other family members do not become Utah residents until they arrive in Utah, too.

The effective date for Utah CHIP cannot begin until the day the individual becomes a Utah resident.

Institutionalized individuals from other states.

An individual placed in a Utah institution by another state, or an agency acting on behalf of another state, is a resident of the placing state. This includes placement in a public institution in Utah such as a jail or prison. When such individual is taken from the public institution and admitted to a hospital for an inpatient stay, the individual's state of residency does not change.

When a competent individual is no longer a resident of an institution, the state of residence is the state where the individual is living with the intent to reside. If the individual is not competent when he leaves the facility, the state of residence is where the individual is physically present.

The eligibility agency cannot deny CHIP to an institutionalized individual, except for someone placed by an agency of the other state, on the grounds that the individual did not establish residence in Utah before entering the institution, if the individual meets the defined residency rules.

Moving Out of Utah

When an individual moves out of Utah, consider him a Utah resident through the end of the month in which he moved out of Utah.

After an un-emancipated person is found to meet Utah residency requirements, his eligibility is not affected by a change of residency on the part of his parents, legal guardian or the person who applied for medical assistance on his behalf. If the individual remains in Utah, he is a Utah resident.

(204-2-what-is-a-public-non-medical-institution)204-2 What is a Public Non-Medical Institution?#

(204-2-what-is-a-public-non-medical-institution)(block-1)Effective Date: June 1, 2025#

Previous Policy

A. Definition

Non-medical institutions include jails, prisons, and community residence facilities. Other institutions may also be non-medical. CHIP policy differs for residents of public or private non-medical institutions.

B. Residents of Private Non-Medical Institutions

Residents of private non-medical institutions can receive CHIP if they meet all other factors of eligibility.

C. Residents of Public Non-Medical Institutions

A public non-medical institution is an institution that is the responsibility of a governmental unit or that is under the administrative control of a governmental unit. Residents of some public, non-medical institutions are not eligible for CHIP. Individuals living in the following institutions may be eligible for CHIP if all other factors or eligibility are met. See 604 for suspending benefits for incarcerated individuals. Residents of a public non-medical institution who are within 30 days of release may be eligible for pre-release services.

1. A community residence facility. An eligible community residence facility must meet the following requirements:

a. Designed for and actually serving 16 or fewer individuals;

b. Cannot be located on the grounds of or adjacent to an ineligible institution; and

c. Must operate primarily as a facility that provides other services the residents need. Such as:

o social services;

o help with personal living activities;

o training in socialization and life skills; or

o occasional or incidental medical or remedial care.

2. A halfway house. An eligible halfway house must meet following the requirements:

a. Residents of the facility must have freedom of movement and association as outlined according to the following tenets:

o Residents are not precluded from working outside the facility;

o Residents can use community facilities ‘at will’, such as libraries, grocery stores, recreation areas, or schools; and

o Residents can seek health care treatment in the community to the same extent as other CHIP enrollees in the state.

b. ‘At will’ includes Facility operational rules or “house rules”. For example, the facility may be locked or closed during certain hours of the day, residents may be required to report in during certain times, or sign in and out, etc.

3. Home Confinement, also known as “house arrest,” “ankle monitor,” or “electronic monitoring.” If the conditions of home confinement fit the definition of freedom of movement described in 2.a. and b., the individual is eligible for Medicaid.

4. A child already on CHIP and in jail, prison or in secure care with Juvenile Justice and Youth Services (JJYS)

a. If a child is in jail, prison or in secure care with JJYS and is within 30 days of release.

(220-1-definitions)220-1 Definitions#

(220-1-definitions)(block-1)Effective Date: January 1, 2014#

Previous Policy

The following definitions apply to terms used in this section and throughout this policy manual.

1. “COBRA coverage” is a temporary extension of employer health insurance coverage whereby a person who loses coverage under the employer’s group health plan can remain covered for a certain length of time. The person is usually required to pay both the employee and the employer share of the premium, with up to an additional 2% for administrative costs.

2. “Enrolled” means a person is signed up for and receiving health insurance coverage.

3. “Group health plan” is an employee welfare benefit plan that provides medical care to employees or their dependents directly or through insurance, reimbursement, or otherwise.

4. “Health insurance coverage or plan” means a benefit plan offered by a health insurance issuer which provides for coverage of medical care under any hospital or medical service plan contract, or health maintenance organization contract. The coverage may be a group plan or an individual insurance plan. A health insurance issuer is a company licensed to sell insurance under state law.

5. “Limited coverage plans” are insurance plans which only provide medical care for a single type of service or specific disease, under special or specific circumstances, or where the medical care is secondary to the primary purpose of the insurance. Examples of limited coverage plans are found in Sec. 220-3 .

6. “Medical care” means amounts paid for the diagnosis, cure, mitigation, treatment or prevention of disease, or amounts paid for the purpose of affecting any structure or function of the body; transportation primarily for and essential to medical care; and amounts paid for insurance covering medical care.

7. “Open enrollment periods” are times a person may enroll in a health insurance plan if he or she did not enroll at the earliest possible time.

8. “Waiting period” is a period of time that must pass before an individual who is enrolled in an insurance plan can receive coverage for services under the plan. For example, the individual may enroll in the insurance plan on their first day of employment, but coverage under the policy does not start until the first day of the next month.

A waiting period is not a period of time that an employer requires the person to be employed before they are allowed to enroll in a group health insurance plan. For example, an employer requires their employees to work for them for six months before they are eligible to enroll in the insurance. (See section 220-9 for information about CHIP eligibility during this time.)

(220-4-access-to-employer-sponsored-health-insurance)220-4 Access to Employer-Sponsored Health Insurance#

(220-4-access-to-employer-sponsored-health-insurance)(block-1)Effective Date: July 1, 2024#

Previous Policy

The following conditions must be considered in determining access to health insurance and eligibility for CHIP enrollment.

Access to Employer-Sponsored Health Insurance:

A child is NOT eligible for enrollment in CHIP if the cost to enroll the child is less than 5% of the MAGI-based countable income for the individual’s household after any applicable 5% disregard is applied .

A child has access if the plan provides coverage for dependents and the custodial parent or the legal guardian could enroll the child in the plan.

Consider the child to have access to coverage even if the employer offers coverage only during an open enrollment period.

Cost of Coverage:

To determine the cost, find out how much the employee is required to pay to enroll the child, or children, in the health plan. If the children cannot be enrolled unless the employee is enrolled and the employee must pay for his coverage, include the cost of his coverage. 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.

Next, compare the total cost to the individual’s countable income after any applicable 5% disregard has been applied . If the cost of the insurance is less than 5% of the individual’s countable income after any applicable 5% disregard has been applied , the child is not CHIP eligible. If the cost of the insurance is 5% or more of the individual’s countable income after any applicable 5% disregard has been applied , the child is CHIP and possibly UPP eligible. If eligible for both programs, allow the parent to choose the best program for their family.

Example #1: Jerry Jones has 2 children under 19. He is on salary and receives $2,000 per month. His employer offers health insurance coverage. Jerry must pay $40 per month for employee only coverage. The cost for him and his family coverage is $80 per month. He must also pay a $3,000 deductible.

5% of Monthly Income Monthly Deductible Total Cost of Coverage $2,000 /mo $3,000 /yr $80 /premium X .05 / 12 +$250 /deductible = $100 = $250 = $330

The cost of coverage is more than 5% of Jerry’s income; therefore, the children do not have access to health insurance coverage.

Example #2: Mary Evans has 3 children under 19. She is on salary and receives $3,000 per month. Her employer offers health insurance coverage. The employer pays all of Mary’s cost for employee only coverage but Mary must pay $100 per month for family coverage. She must also pay a $500 deductible.

5% of Monthly Income Monthly Deductible Total Cost of Coverage $3,000 /mo $500 /yr $100 /premium X .05 / 12 + $41.67 /deductible = $150 = $41.67 = $141.67

The cost of coverage is less than 5% of Mary’s income; therefore, the children have access to health insurance coverage and are not eligible for CHIP.

“Cafeteria" or "Flexible Benefit" Plans.

Some employers may allow a certain dollar amount per employee to “purchase” various kinds of benefits, including health insurance. Each employee has some discretion in how to use his “benefits.” For example, an employer may allow a certain amount each month that could be used to purchase group health insurance for dependents, additional life insurance, long-term disability benefits, etc.

If the employee receives these funds and is allowed to use them to purchase health insurance , and the employer offers a group health plan, decide whether the cost of the group health plan is 5% or more of the individual’s countable income after any applicable 5% disregard is applied . If the cost is less than 5% of the individual’s countable income after any applicable 5% disregard is applied , the child has access. It does not matter whether or not the employee has chosen to use the funds in that manner.

If an employer pays cash to employees with the intent that the employees privately purchase individual health insurance, the funds paid by the employer are simply counted as income.

In some instances, employees may choose to defer some income from gross pay to be used to reimburse the employee for out-of-pocket medical expenses. This type of benefit is usually called a “flex-plan” or “flexible spending plan.” This is different than funds the employer makes available to the employee to purchase health insurance. Do not deduct deferred income for medical expenses from the employee’s wages.

First Opportunity to Enroll.

Access to enroll in an employer-sponsored health insurance plan may only be available during an open enrollment period.

Applicants . If an applicant could enroll their children in employer-sponsored health insurance except it is not an open enrollment period, the child is still considered to have access to coverage and is NOT eligible for CHIP if: The child has had at least one chance to enroll, and the cost to the employee to enroll the child in the least expensive employer-sponsored health insurance plan is less than 5% of the individual’s monthly countable income after any applicable 5% disregard is applied .

Within 30 days of application the applicant will have their first opportunity to enroll and the cost to the employee to enroll the child in the least expensive employer sponsored health insurance plan is less than 5% of the individual's countable income after any applicable 5% disregard is applied .

Recipients . If a household currently enrolled in CHIP reports that a parent or the enrollee has obtained employment, request information regarding employer-sponsored health insurance. If the least expensive employer-sponsored health insurance plan costs less than 5% of the individual’s countable income after any applicable 5% disregard is applied AND they must wait for the next open enrollment period before they can enroll their children, the children may stay enrolled in CHIP until they either enroll the children or until the current certification period expires.

Exception: If access to an affordable health insurance plan is discovered as part of an ex parte review process, the eligiblity agency ends benefits in the first month in the new certification period that proper notice can be given. See 703-1

At the end of the review period, the CHIP enrollment must be discontinued. It does not matter whether or not there are any further enrollment period restrictions.

If the least expensive employer-sponsored health insurance plan costs 5% or more of the individual's monthly countable income after any applicable 5% disregard is applied , the children may stay enrolled in CHIP.

If they choose to enroll in the employer coverage, discontinue CHIP at the end of the month in which proper notice can be given and consider the family for UPP.

To move from CHIP to UPP, the enrollee has 10 days to report enrollment in the insurance coverage from the date the child is signed up or the date coverage begins, whichever is later.

Qualifying Events for Employer-Sponsored Health Insurance

Regardless of when the employer’s open enrollment period is scheduled, an employer-sponsored health plan offering coverage for dependents must allow 30 days to enroll new dependents when the following qualifying events occur:

When a covered individual marries, the spouse and any dependent step-children may enroll;

When a new baby is born to a covered individual;

When a child is “placed” for adoption with a covered individual. (Placed for adoption is when the child is initially placed in a home for the purpose of adoption, even though the adoption will not be finalized for several months.)

When a spouse loses coverage under his or her employer’s plan, and had not enrolled in the other spouse's coverage because he or she was covered under a different plan.

If a household with an open CHIP case requests to enroll a new child on CHIP, determine if the child could be enrolled in any employer-sponsored health insurance plan and the cost to enroll the child is less than 5% of the individual’s countable income after any applicable 5% disregard is applied . If so, the child is not eligible for CHIP enrollment. (The countable income used to determine CHIP eligibility is the Best Estimate used at the time of current certification.)

(220-5-health-insurance-coverage-through-a-non-custodial-parent)220-5 Health Insurance Coverage through a Non-Custodial Parent#

(220-5-health-insurance-coverage-through-a-non-custodial-parent)(block-1)Effective: June 1, 2012#

Previous Policy

Out of State Coverage

If a parent who lives or works in another state has enrolled a child in his or her insurance plan coverage but the plan does not provide coverage or provides only limited coverage in Utah, the child may be enrolled in CHIP.

For example, the parent lives in Arizona and the child can only receive medical services in Arizona, or the insurance only covers emergency room visits in Utah, the child may be enrolled in CHIP.

However, if the plan provides coverage in Utah (does not have to be as comprehensive as CHIP covered services), the child is not eligible to enroll.

ORS Medical Support Enforcement

When a non-custodial parent has been court ordered to provide medical insurance coverage for a child, but has not enrolled the child in a health insurance plan, the child may be eligible for CHIP enrollment.

Tell the applicant about the medical support services available through ORS (Office of Recovery Services). If the applicant would like ORS assistance, give them a non public assistance packet and the address of the local ORS office where they can apply for services.

ORS will not automatically notify you if they are able to enforce the medical support order, so tell the applicant that he must report within 10 days if the child becomes enrolled in a health insurance plan.

Close the case with proper notice if you receive information that the child has been enrolled in a health insurance plan.

ORS may force enrollment in insurance under a National Medical Support Notice (NMSN) for the non-custodial and/or custodial parent. If the cost of insurance premium exceeds 5% of the gross monthly income of the obligated parent, the obligated parent may contest the NMSN based on a mistake of fact. If a parent successfully contests the action to enroll the children in the parent's insurance, ORS will notify the employer to discontinue enrollment and withholding of insurance premiums for the children. The child is then terminated from the insurance and the child is NOT subject to the 90 day sanction. (See 220-8 #2).

(222-pregnancy-and-postpartum)222 Pregnancy and Postpartum#

(222-pregnancy-and-postpartum)(block-1)222 Pregnancy and Postpartum#

Effective Date: January 1, 2024

No Previous Policy

A. Eligibility

A CHIP eligible member who is pregnant at application or becomes pregnant during their certification period is protected from most changes in circumstance through the duration of their pregnancy and a 12-month postpartum period.

Once the agency has been notified of a pregnancy for a covered CHIP member, only review for Medicaid eligibility for that member at the member’s request.

The first month of the 12-month postpartum period is the month after the pregnancy ends.

If the covered CHIP member becomes pregnant again during their postpartum period, their eligibility extends through the subsequent pregnancy and postpartum period.

This does not apply to a member covered by State CHIP after age 19.

A CHIP member who is eligible for the 12-month postpartum period cannot have a reduction in coverage group.

Can move from CHIP plan C to CHIP plan B.

Can move from State CHIP to CHIP plan B or C.

Can not move from CHIP plan B to CHIP plan C during pregnancy or postpartum period.

Can move from CHIP plan B or C to State CHIP due to a loss of citizenship status.

B. Exceptions to the Extended Pregnancy and Postpartum Eligibility

The only changes in circumstance (i.e. age, access or enrollment in insurance, income, etc.) that allow a CHIP eligible member who is pregnant or in the 12 month postpartum period to terminate are:

The member requests voluntary termination;

The member ceases to be a state resident;

The agency determines that eligibility was determined incorrectly at the most recent determination or redetermination of eligibility because of agency error or fraud, abuse, or perjury attributable to the individual;

The member dies;

The member is eligible for Medicaid and requests to move programs;

Enrollment in another insurance.

Changes in citizenship status. A child who loses citizenship status can be moved to State CHIP even if the member has reached 19 years of age at the time of the loss. A child who gains citizenship status must be moved to Medicaid or CHIP plan B or C.

(400-1-joint-custody-and-temporary-absence)400-1 Joint Custody and Temporary Absence#

(400-1-joint-custody-and-temporary-absence)(block-1)Effective Date: March 1, 2026#

Previous Policy

A. Joint Custody

Physical living arrangements of a child determines in which household the child should be included. This is true even when a parent claims to have joint custody of the child. A child residing in the home more than 50% of the time must be included in that household, despite custody agreements or court orders.

1. Eligibility is not based solely on a court order awarding custody. On a case-by-case basis, consider the actual circumstances about where the child lives.

2. A child’s physical living arrangement is where the child returns to after a temporary absence or visitation to the other parent.

3. When living arrangements show the child is living 50% of the time in each parent’s household, include the child in the household of the parent who applies first and is found eligible.

· If both parents apply on the same day, they may decide together in which household to include the child.

4. When both parents claim they have physical custody of the child more than 50% of the time, refer for an investigation. The investigator will make the decision based on the household circumstances.

5. If there is an actual change of residence of a CHIP recipient (physical custody of a child changed from one parent's CHIP household to another parent's CHIP household), the parents may decide if they want the child to remain on the current CHIP case until the end of the 12-month certification period; or begin a new eligibility determination/enrollment period with the other parent. When moving the child to a new case, do not overlap CHIP eligibility months. Open the new CHIP case the month after the other CHIP case closed. See section 804-4 .

B. Temporary Absence

When a child is in the Division of Child and Family Services (DCFS) or Juvenile Justice and Youth Services (JJYS) custody, the child is not considered temporarily absent.

An individual is temporarily absent if: The individual lives away from home because of work, education, medical care, military service, vacation, incarceration or some other temporary purpose (example: volunteer services for a church or the Peace Corps) and The individual intends to return to the home when the reason for the absence ends.

There is no time limit for a temporary absence as long as the family member intends to return to the home. If the absent family member changes their intent so that they do not intend to return, they are no longer temporarily absent. They are no longer a member of the household at the point that their intent changes or if there are factors conflicting with Utah Residency, see 203-1 . If there are factors conflicting with Utah Residency see 203-1 . If a baby born in the hospital remains institutionalized for medical reasons, and disability has been established beginning with the month of birth, the child is considered an institutionalized person, and not temporarily absent. (Refer to Nursing Home Medicaid in Section 327 of the manual for information on institutionalized children.)

Regardless of tax filing status, when a member is an incarcerated individual of a public institution such as a jail or prison, take the client’s statement that the individual is temporarily absent.

Exception: If the incarcerated individual is a child and the parent’s rights have been terminated, they are not considered temporarily absent.

(400-income-standards-and-household-composition)400 Income Standards and Household Composition#

(400-income-standards-and-household-composition)(block-1)Effective Date: November 1, 2021#

Previous Policy

A. Introduction

1. To qualify for CHIP, individuals must meet an income requirement. Section 400 covers the steps in determining an individual's household composition and temporary absence, whose income and what income counts in the eligibility determination, deeming income from other household members, excluded income types, and income deductions.

2. This section includes the income methodologies for MAGI-based Medicaid groups.

B. Section 400 Organization

To qualify for CHIP, individuals must meet an income test requirement. The policies in section 400 cover the steps in determining;

· The household size and composition, including temporary absence;

· Policy about whose income must be counted to determine eligibility;

· The calculation of MAGI Methodology;

· The types of income, including unearned income and earned income;

· Income exclusions;

· Income deductions; and

· Budgeting concepts and methods.

C. Worker Requirements

(400-income-standards-and-household-composition)(block-2)The Department prohibits employees of the Departments of Human Services, Workforce Services, or Health from advising or encouraging applicants for, or recipients of, public assistance programs to terminate employment or otherwise reduce income to qualify for an assistance program. This does not mean employees cannot tell applicants or recipients about the Medicaid spenddown program and the ways to reduce or meet the medical excess with medical bills to receive Medicaid coverage.#

Workers can explain eligibility policies, tell individuals how we decide if someone is eligible for Medicaid, explain what income deductions an individual receives, and answer questions a individual asks about policies. (See 461-5 for rules on medical bills.)

If the individual has expenses and not enough income to cover the expenses, the individual must verify how they are meeting their expenses ( 731-1 ).

(401-1-the-magi-household)401-1 The MAGI Household#

(401-1-the-magi-household)(block-1)Effective Date: June 1, 2025#

Previous Policy

A . General Rules

The first step to determine CHIP eligibility using the MAGI-based rules is to build the household for each applicant or recipient. The household composition rules follow federal tax rules, and in some cases, relationship rules.

· The MAGI household is determined based on whether the applicant or recipient expects to file a federal tax return or not, and whether the person can be claimed as a dependent by another tax filer.

· The MAGI household of a spouse of a tax filer is determined based on whether they file a joint return, and if filing separately, who the spouse can claim as dependents.

· The MAGI household size for children of the applicant or recipient depends on whether the children are claimed as dependents by a tax filer, who is claiming them, who they live with, and the relationships with household members.

· The MAGI household of other dependents of a tax filer is based on the relationships of the people those dependents live with.

· The MAGI household for individuals who will neither file a tax return nor be claimed as a dependent by another tax filer will be determined based on the relationships of the people living in the household.

B. Applicant and Recipient Requirements

1. An applicant or recipient must declare whether they intend to file a federal tax return for the year in which CHIP eligibility is being determined, and whether the person can be claimed as a dependent by another tax filer.

2. If the individual expects to file a tax return and cannot be claimed as a dependent, the individual must state:

a. Who he expects to claim as dependents and the relationships of those individuals whom he is claiming,

b. Who lives in the home and the relationship to those individuals, and

c. Anticipated changes in the coming tax year.

3. If a tax filer expects to claim a relative who is not a dependent child or who is an unrelated individual, the tax filer may need to verify the reason that person can be claimed as a dependent if the information the agency receives conflicts with the client's statement.

4. If an applicant does not intend to file a tax return, the individual must declare who lives in the home and the relationship of those individuals.

5. Household size is determined separately for each individual applying for benefits.

(401-2-tax-filer-s-magi-household)401-2 Tax Filer's MAGI Household#

(401-2-tax-filer-s-magi-household)(block-1)Effective Date: November 1, 2021#

Previous Policy (401-2 was previously found in 230-2 as of November 1, 2021)

A. Definitions

The following definitions apply for MAGI households.

1. "Child" means a biological, adopted or stepchild.

2. "MAGI household" means the household size and composition for someone whose CHIP eligibility is determined using the MAGI methodology.

3. "Parent" means a biological, adoptive or step parent.

4. "Sibling" means a biological, adoptive, half-sibling, or step-sibling who meets the age limits, and school attendance requirement if applicable.

5. "Tax Household" means the number of individuals included on a tax filer's tax return for whom the tax filer can claim personal exemptions.

B. Tax household rules

The MAGI household follows tax rules about who is part of the household with some exceptions.

The following information defines who can be counted in a tax filer's tax household. This is to help establish an understanding of the tax rules about households which will be the basis for how to build the MAGI household for CHIP.

1. The tax filer. This is the individual who is applying for CHIP and states an intent to file a tax return, and is not being claimed as a dependent by another tax filer.

2. The spouse of a tax filer is included in the tax household if the couple files a joint return. In essence, they are both filers.

Note : Spouses living together are always included in each other’s MAGI household for CHIP even if the couple does not file a joint return), which is discussed in section C below. Unmarried couples are not allowed to file a joint tax return. (See common-law marriage policy in C.2.)

3. Dependent individuals are people for whom a tax filer may claim an exemption and they include:

a. Qualifying child. To be a qualifying child for the purpose of claiming a tax exemption, the child must:

· Be under age 19, or age 19 through 23 and enrolled in school full-time, or be a child of any age who is permanently and totally disabled. If the individual says he can claim the disabled child, accept the client's statement.

· Not have provided 50% of his own support. The child may be claimed by the parent he lives with, or in some cases by the non-custodial parent.

· Be the tax filer's son, daughter, stepchild, foster child, brother, sister, half-brother, half-sister, stepbrother, stepsister, or a descendent of any of them. An adopted child is treated as the tax filer's child, including a child placed for adoption with the tax filer. (Tax law makes no distinction between children who are adopted and those who are still in the adoption process.)

o Be younger than either the tax filer or the tax filer's spouse.

o Live with the tax filer more than half of the year (some exceptions apply for temporary absence, children who were born or who died during the year, and when parents are divorced.)

b. A qualifying relative or unrelated person who lives with the tax filer the whole year and is someone who:

· Is a relative of the filer or the filer's spouse, or is an unrelated person; and

· Cannot be the tax filer's qualifying child or a qualifying child of another taxpayer, (so a child who does not meet the criteria to be a qualifying child may be claimed as a dependent relative); and

· Is not expected to have income in excess of the income limit for dependents ( 404-2 ); and

· The tax filer expects to provide more than 50% of the person's support.

c. A qualifying relative who does not live with the tax filer, meets the other criteria in 3.b., and is one of the following relatives:

· child or descendant of child, including a foster child;

· brother or sister;

· parent or grandparent including step parent, but not foster parent;

· niece or nephew;

· aunt or uncle;

· in-laws: son, daughter, mother, father, brother or sister.

d. Death or divorce does not change relationships that were established by marriage.

C. MAGI CHIP Household ("MAGI Household") for tax filers

The MAGI household for a tax filer is determined by following tax rules about household composition with some modifications. To determine the MAGI household for a child living with a parent, build the MAGI household of the tax filer parent first.

A tax filer's household can include individuals who are not typically included in a CHIP household, such as children age 19-23. That is because the MAGI household follows tax rules about who is included in the MAGI household size. Therefore, it is possible for the CHIP household to include a foster child, an adult child, or a dependent person who is not the spouse or child of the tax filer. In addition, dependents claimed by a tax filer may not always live with the tax filer.

1. MAGI Household size for a tax filer.

a. To determine the MAGI household size for an applicant or recipient who expects to file a federal tax return and cannot be claimed as a dependent by another tax filer, use his tax household size (section B) with the following additions. (If the filer is a child who lives with parents who will not file a tax return, see section 402-3 .)

i. Include a spouse living with the tax filer who is not part of the tax household because the spouse is filing a separate return or is not filing a return.

· If the couple files a joint return, the spouse is already counted in the tax household and therefore is counted in the MAGI household.

· Married couples that are permanently separated, not living together, and filing a joint tax return, will be treated as non-tax filers. The MAGI household will not include the absent spouse ( 402-3 ).

ii. Include the expected number of unborn children of anyone being counted in the tax filer's MAGI household who is pregnant at the time of application or the eligibility review period.

Example : John, age 23, attends the university full time. He lives with his mother, Jessica, and his 17 year old sister, Chris who is pregnant. John works 15 hours per week, earning minimum wage. His mother provides more than 50% of his support. She claims John and Chris as qualifying children on her taxes. Jessica's MAGI household includes herself, John, Chris and Chris' unborn child. Jessica is able to claim them as dependents for the purposes of determining her Medicaid household.

Example : Mary is applying for medical services. She has three children: Vanessa, a 19 year old full-time college student, Trudy age 15 and Miriam age 17. Vanessa works 20 hours per week, earning minimum wage. Her mother states she provides more than 50% of Vanessa's support. Mary can claim Vanessa as her dependent. Mary's MAGI household includes herself, Vanessa, Trudy and Miriam. Due to the amount that she earns, Vanessa will be expected to be required to file a tax return. Her income will count as part of the household income ( 404-2 ).

b. Accept the client's statement about filing a tax return.

c. Accept the client's statement about a pregnancy and the expected number of unborn children.

d. Accept the client's statement about dependents he expects to claim unless the agency has information that conflicts with the client's statement.

i. If the agency has information that does not reasonably compare with the client's statement about claiming someone as a dependent, ask the tax filer for information supporting their statement.

ii. If the tax filer cannot establish a reasonable explanation of why someone can be claimed as a dependent, do not count that person in the tax filer's MAGI household.

Example : If the tax filer claims an unrelated person as a dependent, but that person's income exceeds (or is expected to exceed) the limit for a dependent, do not count that person in the tax filer's MAGI household.

2. MAGI Household size for the spouse of a tax filer.

Spouses living together are always included in each other's MAGI household for CHIP, even if the couples do not file a joint return. Build the MAGI household for the spouse of a tax filer if the spouse could be eligible for CHIP.

a. Joint filers who live together .

If a married couple files a joint tax return, the MAGI household for the tax filer's spouse is the same as the MAGI household for the tax filer.

b. Separate filers who live together.

i. The MAGI household for a spouse who files a separate tax return includes:

· Both spouses (who are filing separate returns);

· The number of dependents the individual expects to claim as exemptions on his own return;

· The expected number of unborn children of anyone included in the individual's MAGI household.

ii. If a spouse is living with his parent who is claiming him as a dependent child, follow rules for children of a tax filer.

iii. If a spouse will not be claimed on a joint return with his spouse, will not be claimed as a dependent by another tax filer, and will not file a return himself, follow the rules for non-filers to determine the spouse's MAGI household ( 402-3 ).

iv. Utah does not recognize common law marriages unless they have received a certificate from a court, in which case, they are married.

v. If an unmarried couple states they are filing taxes jointly, and declare a common-law marriage, we will treat them as non-tax filers.

· Utah will allow a couple to file a joint tax return in they entered into a common-law marriage in a state that recognized such relationships and who later moved to Utah.

· Take the client's statement unless the agency has conflicting information.

3. MAGI household of children of a tax filer

Build the household separately for each child living with the applicant tax filer based on the situation for each child. Children in the same household may have different MAGI household sizes.

When divorced or separated parents have joint custody, determine the child's residence based on section 402-1 . The child's MAGI household will be determined based on where the child lives and the following rules.

4. If the child meets the criteria of being a qualifying child and lives with only two parents who file a joint return and claim an exemption for the child, the child's MAGI household size is the same as the parents' MAGI household size with one addition:

· If the child is married and also lives with his spouse, include the child's spouse in the child's MAGI household size.

5. If the child meets the criteria of being a qualifying child and lives with only one parent who claims the child on her tax return, the child's MAGI household is the same as the parent's MAGI household size with one addition:

· If the child is married and also lives with his spouse, include the child's spouse in the child's MAGI household size.

6. If the child meets the criteria of a being a qualifying child and lives with two parents, but the parents will not file a joint tax return, then the MAGI household size of that child will follow non-tax filer rules ( 402-3 ).

7. A child could live with two biological (or adoptive) parents and a step-parent (someone married to one of the biological parents). In this case, the biological parents will not be filing a joint return. Determine the child’s MAGI household following non-tax filer rules.

8. If the child meets the criteria of a being a qualifying child and lives with one parent, but a non-custodial parent will claim the child on his or her tax return, then the MAGI household size of the child will follow non-tax filer rules ( 402-3 ).

9. Child Applicant

A child who meets the age criteria to be a qualifying child of a tax filer may apply for CHIP on her own if she does not live with her parents. If she expects to be permanently absent from her parents’ home, the agency will not consider her as her parents’ tax dependent to determine her eligibility.

i. If she expects to file her own tax return, use the applicable rules to build her MAGI household.

· If she expects to file her own tax return, use tax filer rules.

· If she does not expect to file her own tax return, use non-tax filer rules ( 402-3 ).

ii. Only count the individuals income and that of anyone who is included in their MAGI household if applicable.

10. MAGI household for other dependents of a tax filer

To determine the MAGI household size of someone claimed as a dependent of a tax filer who is not the spouse or dependent child of the filer, follow the rules for non-tax filers. Other dependents include a qualifying child who is not the tax filer's child or qualifying relative. This includes a child placed for adoption before the adoption is finalized. Utah Code does not recognize the adopting parent as a legal parent until the process is complete. Therefore, we will treat the dependent as a not tax filer ( 402-3 ).

(401-3-non-tax-filer-s-magi-household)401-3 Non-Tax Filer’s MAGI Household#

(401-3-non-tax-filer-s-magi-household)(block-1)Effective Date: November 1, 2021#

Previous Policy (401-3 was previously found in 230-3 as of November 1, 2021)

A. Non-Tax Filer Household

1. A non-tax filer is someone who states they do not intend to file a tax return and do not expect to be claimed as a dependent by someone else for the tax year in which the eligibility agency is making an eligibility determination. Accept the client's statement that they do not intend to file a tax return and does not expect to be claimed as a dependent by someone else.

2. The MAGI household for a non-tax filer is based on who lives together and the relationships of those individuals. These rules apply to the non-tax-filer, the non-filer's family, and to certain individuals claimed as a dependent.

The non-tax filer rules apply to:

a. A child applicant who meets the age criteria not living parents and who does not expect to file a tax return nor be claimed as a dependent by any other tax filer;

b. A child who meets the age criteria in section 210 and who lives with:

· Parent(s) who do not expect to file a tax return, whether or not the child will file taxes.

· One parent but is claimed as a tax dependent by a non-custodial parent.

· Both parents (biological or adoptive), and is claimed by one parent, but the parents do not file a joint return.

· One parent that plans to file a tax return with their estranged spouse and the couple is permanently separated. The estranged spouse will not be included in the MAGI household.

· A child who is placed with a tax filer for adoption.

o Whose adoption has not yet been finalized before the court; and

o Whose adopting parents are claiming them as a tax dependent.

3. A child who is claimed as a tax dependent by someone other than a spouse or legal parent, regardless of whether the person will file a tax return of their own.

B. MAGI Household for Children who must use Non-Filer Rules

The MAGI household size for a child living in a situation described in A.2., will follow non-tax filer rules to determine the MAGI household size.

1. To determine the MAGI household size, include the following individuals living with the child:

· The child;

· All parents of the child;

· All siblings of the child who are

o Under age 19; or

o Age 19 or 20 and enrolled in school full-time.

· The number of expected unborn children of anyone included in the household who is pregnant;

· If the child is married, the spouse of the child; and

· Any children of the child or child's spouse who meet the age criteria in c.

2. Temporary absence rules apply ( 402-1 ).

Household chart for non-filer households (people who live together)

Children under age 19 who live with non-filer parent Children under age 19 who do not live with parents, and do not file taxes on their own · Child · Child · Parents · Spouse of child if married · Siblings of child who meet age criteria · Children of the individual or spouse who meet the age criteria · Spouse of child if married · Siblings of child who meet the age criteria · Expected number of unborn of anyone included in the household who is pregnant · Expected number of unborn of anyone included in the household who is pregnant · Children of the individual or spouse who meet the age criteria

(413-4-ownership-of-income)413-4 Ownership of Income#

(413-4-ownership-of-income)(block-1)Effective Date: November 1, 2021#

No Previous Policy

Determine if income belongs to a child, a parent, or someone else in the individual's family. Count income as belonging to the person for whom the income is paid. The income of a child’s parents is deemed to the child for eligibility purposes.

A. Income from Trusts

1. Trusts Established Before August 11, 1993

If the trust was set up before August 11, 1993, and has not been amended after that date, do not count the money as both income and an asset in the same month.

a. Medicaid Disqualifying Trusts:

i. If the maximum potential disbursement from the trust is counted as an asset, any payments actually received are NOT countable income.

ii. If the sole beneficiary of the trust is a resident of an institution for the care of the mentally retarded AND the trust was established before April 7, 1986, do not count the trust as an asset. Trust payments received by the individual must be counted as unearned income.

b. Other Trusts:

i. If the trust does not meet the criteria of being a Medicaid Disqualifying Trust, decide if the trust is countable as an asset. If the trust counts as an asset, do not count payments made from the trust as income.

ii. If the trust does not count as an asset, count payments made from the trust to the individual as income. If a child or a parent receives income from a trust, read the trust agreement carefully. If the trust agreement explains who owns the income, accept the terms of the trust agreement.

If the trust agreement does not specify the amount of payments for each person and the payer does not divide the income, then count income as follows:

· If the payment is made in one person's name, count the income as belonging to that person.

· If the payment is made in the names of both a parent and the spouse, count ½ of the payment for each of them.

2. Trusts Established On or After August 11, 1993

a. A trust set up on or after August 11, 1993 can count as an asset and payments made from the trust can count as income in the same month.

b. Count payments made from the trust to, or for the benefit of, the child or a parent, as income in the month the payment is made.

i. If the payment is made in one person's name or for one person's benefit, count the payment as income for that person.

ii. If the payment is made in both names or for the benefit of both, count ½ for each of them, unless the trust has specific provisions to do otherwise.

iii. Payments for the benefit of a child count as income if CHIP policy counts such benefits as income.

e. Count payments made from the trust to a third party, not for the benefit of the child, as a transfer of an asset.

B. Other Income

In most cases, income belongs to the person in whose name it is given. Follow the MAGI Income deeming policies found in 411-1. The following types of income are less common situations for CHIP.

1. Social Security, Railroad Retirement, and Black Lung benefits belong to the person for whom the payment is made even when the payments are sent to a guardian or representative payee.

2. Pensions, or retirement benefits, See section 415-3.

3. Income issued in the name of the child's legal guardian or conservator, or a child's representative payee for the benefit of the child is income for the child. Follow the policy in 411-1 and 440-5 to determine countable income.

4. When income is issued in more than one name, or when the individual states that some of the income is for another family member, find out how much income belongs to the individual and how much belongs to any other persons by contacting the person or agency making the payment. If that person or agency divides the income, accept ownership of the income according to the division made.

(413-6-what-is-not-income)413-6 What is Not Income?#

(413-6-what-is-not-income)(block-1)Effective Date: April 1, 2023#

Previous Policy

Some payments or benefits an individual receives are not income and therefore are never counted as part of the individual's income to determine eligibility. Payments and benefits that are not income include:

1. Medical and Social Services, Related Cash and In-Kind Items as follows:

a. From a governmental agency that provides medical or social services:

· cash for medical or social services is not income (this does not include payments under TANF, VA, BIA or similar income assistance)

· in-kind medical or social services items (including food or shelter)

b. From non-governmental agencies. Payments received as sickness and injury benefits may or may not count, depending on the source.

· Payments from the following sources are exempt:

o Black Lung benefit payments,

o Federal Employee’s Compensation Act (FECA), taxable amounts include payments received under FECA as continuation of pay for up to 45 days while a claim is being decided,

o Qualified Indian Health Care benefits,

o Compensatory damages received for physical injury or sickness,

o Benefits received under an accident or health insurance policy

o Disability benefits received for loss of income or earning capacity as a result of injuries under a no-fault care insurance policy.

o Payments received for permanent loss or loss of use of a part or function of the body, or for permanent disfigurement. This compensation must be based only the injury and not on the period of absence from work.

o Reimbursement for medical care may be exempt, unless it is received as an advance reimbursement or loan for future medical expenses from an employer without regard to whether the individual suffered a personal injury, sickness, or incurred medical expenses.

· Payments from the following sources are not exempt:

o Payments received as sick pay under the Railroad Unemployment Insurance Act,

o Payments from FECA (see above) received as a continuation of pay for up to 45 days while a claim is being decided,

o Payments received as an advance reimbursement or loan for future medical expenses from an employer without regard to whether the individual suffered a personal injury, sickness, or incurred medical expenses,

o Reimbursements received under an employer's plan for expenses incurred before the plan was established are included in income.

2. Personal Services such as mowing the lawn, shopping, baby-sitting, housecleaning, or other similar services, which are done sporadically, without the intent to establish a self-employment business, and render nominal amounts of money.

3. Rebates, refunds, or return of money already paid is not income when received. Rebates do not include a return on an investment, such as dividends on a business interest.

4. Amounts refunded from taxes already paid.

5. Credit life or credit disability insurance payments because these payments are made directly to the loan or mortgage company. The value of food or shelter received as a result (i.e., the credit life pays the mortgage while someone is disabled).

6. Proceeds from a bona fide loan agreement that the individual is expected to repay. However, if the person lending the money receives interest, the interest received is income.

a. For Educational Loans see 403-7 .

b. Reverse equity mortgages . Reverse equity mortgages are loans to the homeowner. The monies received are not income in the month of receipt. Under reverse equity mortgages, homeowners may borrow money against the value of their home and receive a lump sum payment, or monthly payments for a certain period of time. The mortgage holder will hold a lien on the property until repayment is made. Repayment can be when: 1) the house is sold; 2) the house is turned over to the mortgage holder; or 3) the owners die and repayment is taken from the settlement of the estate.

c. The proceeds received from a loan become a countable resource in the month following the month of receipt, if retained. This includes the proceeds from a home equity loan or a reverse equity mortgage.

7. Payment of a person's bills by a third party is not income.

8. Replacement of income that was lost or stolen.

9. An owed payment to the individual is not income if they return the un-cashed check or otherwise repay the money received in error.

10. Weatherization assistance (i.e., insulation, storm doors or windows, etc.).

11. Certain non-cash items are not income if the item will become a wholly or partially excluded non-liquid resource the following month. For example, a individual in a wheelchair receives a van with a wheelchair lift paid for by donations raised by his church. This is the individual's only vehicle and is excluded the month after he receives it.

12. Certain Employee benefits. Payments made by employers on behalf of employees that are not earnings and are not available to meet food or shelter costs are not income. For example, payments to a retirement plan (not including a nonqualified plan), medical insurance and FICA taxes paid by the employer.

13. TPL. Payments from a medical insurance policy are not income to the individual if they are paid directly to medical providers or collected by the Office of Recovery Services as a third party liability.

(415-1-examples-of-unearned-income)415-1 Examples of Unearned Income#

(415-1-examples-of-unearned-income)(block-1)Effective Date: November 1, 2021#

Previous Policy (415-1 was previously found in 402-1 as of November 1, 2021)

Types of Unearned Income

1. Pensions and annuities include Railroad Retirement, Social Security, Black Lung benefits, Civil Service, private pensions, retirement funds, and investment annuities. When an individual qualifies for and receives periodic payments from a retirement plan, pension, or annuity, the payments are counted as income, not a conversion of an asset. When a pension or retirement account has been divided by a Qualified Domestic Relations Order, refer to 415-3 for treatment as income.

2. Disability benefits such as Social Security Disability Insurance, Workers Compensation, long-term disability insurance from an employer, and paycheck insurance. See 417-17 for excluded disability payments

3. Survivor's benefits from Social Security, Railroad Retirement, VA, etc. See 440-4 for how to consider Worker's Compensation.

4. Needs-based income such as Supplemental Security Income or Family Employment Program benefits. See 417-17 for needs-based payments

5. Unemployment compensation; Strike and union benefits . See 417-20 for disaster related unemployment compensation.

6. VA benefits . See 415-2 .

7. Child support and alimony . For child support, see the rules in 415-5.

8. Rental income and payments for the use of real or personal property. See 415-4 for rules on how to count this income.

9. Sales contracts . See 4 15-8 .

10. Payments to replace lost or destroyed property . See 415-9 .

11. Interest earned on loans made by the individual. If the individual has borrowed money, see 417-12 .

12. Inheritances . See 421 for lump sum policy.

13. Life insurance benefits and other death benefits. See 417-6 and 421 for exclusions.

14. Personal injury settlements . See 415-12 .

15. Medical insurance payments made directly to an individual. If the payment is not a refund for expenses the individual has already paid, or the payment from the medical insurance will not be collected by the Office of Recovery Services (ORS) as a third-party liability, the amount received is income to the individual. This includes payments from a long-term care insurance partnership policy made directly to the individual if it is not a reimbursement of paid expenses or will not be collected by ORS.

16. Educational assistance and college work-study. See the rules in 415-6 .

17. Tribal fund payments . See 417-14 and 415-13 .

18. Cash gifts , contributions, and church assistance. See the rules in 415-7 and 417 .

· For items received from medical or social service agencies that are not income, see 413-7 .

· Deposits to joint checking and/or savings accounts by a non-household member, including guardian, conservator, or representative payee accounts. See 413-5 .

19. Interest and dividends . See 415-7 .

20. Certain royalties paid for the use of property or natural resources. See 415-11 . If the royalties are received as part of self-employment or in connection with the publication of the individual's work see 419 .

21. Unearned Income in kind does not count as income.

22. Deferred Income and Other Deductions from Income. Deferred income is income that is received later than the normal payment date.

a. If an individual is supposed to be receiving unearned income, but says that the payments are being withheld, or deferred, for some reason, see 415-3 .

b. If wages or salaries are being deferred, see 419-1 .

23. Payments from a trust . How to count income from a trust is covered under 417-2 , which covers when payments must be counted as income.

24. Certain business income . Income received by a limited partner of a Partnership; income received from an S Corp when the individual is not actively engaged in the business; dividends received by a member of a Limited Liability Company which is being taxed as a corporation; and dividends received by a stockholder in a Corporation. See 413-6 for more information.

25. Prizes, winnings or awards. See 440-4 for treatment of Lottery and Gambling Winnings.

(415-3-when-the-entitlement-amount-differs-from-the-payment-amount)415-3 When the Entitlement Amount Differs from the Payment Amount#

(415-3-when-the-entitlement-amount-differs-from-the-payment-amount)(block-1)Effective Date: November 1, 2021#

No Previous Policy

Where an unearned income source amount differs from the actual payment amount, use the following criteria to determine what unearned income is countable:

1. Civil Service benefits .

If a Civil Service recipient is divorced, the divorce decree may award a portion of the Civil Service benefits to the spouse. This is because the laws governing Civil Service benefits allow a spouse who meets certain criteria, to receive a portion of benefits under a domestic support order from the divorce court. The Civil Service office has a formula for calculating the benefit amount for the spouse. Upon receiving the order, Civil Service will determine the amount to be paid to the spouse, and begin sending a check directly to the spouse. The benefit amount for the Civil Service recipient will be decreased by that amount. Count only the amount of Civil Service benefits the individual is entitled to receive after the division has been made.

2. Other Pension or Retirement Income

a. Divided Between Divorced Spouses.

When a married couple divorces, pension or retirement funds may be divided between them under a Qualified Domestic Relations Order (QDRO). A QDRO transfers an interest in one individual's pension plan, profit-sharing plan or other retirement investment plan to another individual, usually divorcing spouses. The person who has the interest in the retirement plan is called the participant because that person is the one eligible to receive benefits from the retirement plan. The person who will receive an interest in the retirement plan through the QDRO is called the "alternate payee." An alternate payee could be someone other than a former spouse, such as a child of the participant.

b. When a pension or retirement fund is divided by a QDRO, count as unearned income only the monthly benefit amount awarded to the individual. Request a copy of the divorce decree, or QDRO document, if it is separate. Do not deduct amounts taken out of the individual's benefit amount for things like health insurance or taxes, if any.

(415-12-personal-injury-and-tpl-settlements)415-12 Personal Injury and TPL Settlements#

(415-12-personal-injury-and-tpl-settlements)(block-1)Effective Date: November 1, 2021#

No Previous Policy

General Requirements

Sometimes an individual may receive payments under a personal injury settlement or from a third party such as an insurance company. The payment, or payments, counts as income in the month received. Certain expenses are usually deducted from the total settlement amount before the individual receives payment. To determine how these payments count, see 440-4.

1. If the settlement is being received because the person was injured and the individual has been receiving CHIP, report the settlement to the Office of Recovery Services as soon as you become aware that the individual may be receiving a settlement. ORS may place a lien against the settlement to recoup expenses that have been paid on behalf of the individual. If you do not learn of the settlement until after the payment has been made, immediately report this to ORS.

2. For CHIP, the following expenses can be deducted from the total settlement before counting the settlement as income. Other expenses may be deductible. Request a copy of the court documents, or settlement agreement to determine the amounts that can be deducted. Contact the BEP Program Specialist if you need help deciding what can be deducted.

· Legal fees and attorney expenses incidental to getting the settlement.

· Court fees associated with the lawsuit or settlement.

· Medical expenses not already covered by insurance or Medicaid that will be paid directly to the provider under the settlement agreement.

· A lien against the settlement for expenses CHIP has already paid on behalf of the individual.

3. Generally, the court or settlement agreement will show the exact amounts to be paid out for the above expenses, and the remaining amount that will be paid to the individual. If the court or settlement agreement specifically indicates that other payments will be paid out before any payments are made to the individual, we may be able to deduct those expenses, too. An example may include payments to someone who has provided personal care and assistance to the injured individual. However, if you are not sure whether some expenses should be allowed as a deduction before counting the remainder as income, contact a BEP Program Specialist.

4. When a worker learns that an individual will be receiving a settlement, make sure ORS knows about the settlement. ORS may be able to place a lien against the settlement for CHIP expenses paid on behalf of the individual.

(417-14-payments-to-american-indians-alaska-natives)417-14 Payments to American Indians/Alaska Natives#

(417-14-payments-to-american-indians-alaska-natives)(block-1)Effective Date: January 1, 2023#

Previous Policy

A. Payments to American Indians/Alaska Natives

1. Exclude from income:

a. Money received by American Indians/Alaska Natives that are derived from ownership interest in rents, leases, royalties or usage rights related to the extraction of natural resources resulting from the exercise of federally protected rights. These may be paid to individual Indians or as per capita payments paid by the tribe. Natural resources include things such as minerals, oil, natural gas, coal, timber, plants, animals or fish. Also exclude from income per capita payments that the Secretary of the Interior or an Indian tribe distributes when the Secretary held the funds in trust. This includes Golden Age and Senior Retirement payments made by the Ute Indian Tribe.

b. Tribal money paid to the Ute Indian Tribe is reported on an account known as the "IIM Account" (Individual Indian Money). (Other tribes may also use IIM accounts.) Money paid to these accounts may include per capita payments, oil and mineral Leases, and income from individual interests in lands or resources held by the tribal member. Per capita payments paid to the account are exempt when the funds were held in trust by the Secretary of the Interior. Funds held in trust include interest and investment income earned on the funds while they are in trust. The source of funds in IIM accounts (Individual Indian Money) must be verified by customer statement, or by their response on Attachment A, unless one of the sources is identified as countable in 415-13 . If additional information is required, workers must attempt to contact the member directly prior to requesting IIM account verification.

c. Payments received under the Individual Indian Account Settlement Litigation, Pub. L. 111-291. (IIM)

d. Payments made under the Alaska Native Claims Settlement Act, Public Law 92-203.

e. Payments made under the Maine Implementing Act and the Maine Indian Claims Settlement Fund, Section 9 of Public Law 96-240.

f. Tribal benefits received by the following Indian tribes under section 5 of Public Law 94-114:

TRIBE RESERVATION Bad River Band of the Lake Superior Tribe of Chippewa Indians of Wisconsin Bad River Blackfeet Tribe Blackfeet Cherokee Nation of Oklahoma Cheyenne River Sioux Tribe Cheyenne River Crow Creek Sioux Tribe Crow Creek Lower Brule Sioux Tribe Lower Brule Devils Lake Sioux Tribe Fort Trotten Fort Belknap Indian Community Fort Belknap Assiniboine and Sioux Tribes Fort Peck Lac Courte Oreilles Band of Lake Superior Chippewa Indians Lac Courte Oreilles Keweenaw Bay Indian Community L'Anse Minnesota Chippewa Tribe White Earth Navajo Nation Navajo Ogallala Sioux Tribe Pine Ridge Rosebud Sioux Tribe Rosebud Shoshone Bannock Tribes Fort Hall Standing Rock Sioux Tribe Standing Rock

B. Special Payments to American Indians/Alaska Natives

1. Exclude from income, money received by American Indians/Alaska Natives that are derived from ownership interest in rents, leases, royalties or usage rights related to the extraction of natural resources resulting from the exercise of federally protected rights. These may be paid to individual Indians or as per capita payments paid by the tribe. Natural resources include things such as minerals, oil, natural gas, coal, plants, animals or fish. Also exclude from income per capita payments the Secretary of the Interior or an Indian Tribe distributes when the Secretary held the funds in trust. This includes Golden Age and Senior Retirement payments made by the Ute Indian Tribe. Tribal money paid to the Ute Indian Tribe is reported on an account known as the “IIM Account” (Individual Indian Money.) (Other tribes may also use IIM accounts.) IIM accounts will be verified by customer statement. Money paid to these accounts may include per capita payments, Oil and Mineral Leases, and income from Individual Interests in lands or resources held by the tribal member. Per capita payments paid to the account are exempt when the funds were held in trust by the Secretary of the Interior.

2. Funds held in trust include interest and investment income earned on the funds while they are in trust.

3. Do not exclude per capita payments that tribes distribute from funds not held in trust by the Secretary. Examples are revenues from tribal run businesses such as:

· Tribal managed gambling,

· Sales of items not held in trust, or

· Storage of nuclear waste on tribal lands.

4. Exclude payments received under the Individual Indian Account Settlement Litigation, Pub. L. 111-291.

5. Payments made under the Alaska Native Claims Settlement Act, Public Law 92-203.

6. Payments made under the Maine Implementing Act and the Maine Indian Claims Settlement Fund, Section 9 of Public Law 96-240.

7. Tribal benefits received by the following Indian tribes under section 5 of Public Law 94-114:

TRIBE RESERVATION Bad River Band of the Lake Superior Tribe of Chippewa Indians of Wisconsin Bad River Blackfeet Tribe Blackfeet Cherokee Nation of Oklahoma Cheyenne River Sioux Tribe Cheyenne River Crow Creek Sioux Tribe Crow Creek Lower Brule Sioux Tribe Lower Brule Devils Lake Sioux Tribe Fort Trotten Fort Belknap Indian Community Fort Belknap Assiniboine and Sioux Tribes Fort Peck Lac Courte Oreilles Band of Lake Superior Chippewa Indians Lac Courte Oreilles Keweenaw Bay Indian Community L'Anse Minnesota Chippewa Tribe White Earth Navajo Tribe Navajo Ogallala Sioux Tribe Pine Ridge Rosebud Sioux Tribe Rosebud Shoshone Bannock Tribes Fort Hall Standing Rock Sioux Tribe Standing Rock

8. Monies received by American Indians/Alaska Natives that are derived from ownership interest in rents, leases, royalties or usage rights related to the extraction of natural resources resulting from the exercise of federally protected rights are not counted as income. This applies, regardless of the tribe to which the American Indian/Alaska Native belongs.

· Count as income any monies paid by the tribe from funds that are not held in trust by the Secretary of the Interior. This includes payments from the proceeds of tribal run businesses.

· Count as income any money received by an individual American Indian/Alaska Native derived from the production of goods or services or the sale of natural resources from privately held lands that are not excluded tribal lands or federally protected ownership interests.

9. Tribal or Bureau of Indian Affairs (BIA) General Assistance Payments and TANF payments follow the MAGI-based household income rules and are exempt.

(417-18-employment-and-volunteer-program-payments)417-18 Employment and Volunteer Program Payments#

(417-18-employment-and-volunteer-program-payments)(block-1)Effective Date: November 1, 2021#

No Previous Policy

A. The Corporation for National and Community Services (CNCS)

1. Definition:

The Corporation for National and Community Service (CNCS) administers a number of national and community service programs including AmeriCorps*VISTA, and the National Senior Volunteer Corporation and Domestic Volunteer Services programs which were formerly funded under the ACTION agency.

2. Unless presented with evidence to the contrary, consider that payments from the following programs are stipends or reimbursement for expenses and do not count as income for CHIP.

· ACE (Section 418 of Public Law 93-113.)

· Nutrition Program for the Elderly

· Retired Senior Volunteers Program (RSVP)

· SCORE

· Senior Companion Program

· Senior Health Aides

· The Foster Grandparent Program

· University Year for ACTION (UYA)

· AmeriCorps*VISTA (formerly just VISTA-Volunteers in Service to America) Do not confuse this with the AmeriCorps program described in 417-4. Checks should say AmeriCorps*VISTA when it is for the volunteer service.

3. Do not count interest earned on retained payments under these programs.

B. Benefits Received Under the Older American’s Act of 1965 that are not in the Form of Wages

(417-18-employment-and-volunteer-program-payments)(block-2)3. Payments that are stipends or reimbursement for expenses are not countable income CHIP.#

4. In addition, interest earned on excluded funds paid under the Older Americans Act does not count as income. Some types of programs include:

· health services;

· nutrition services;

· legal assistance; and

· Community service employment (i.e. Easter Seals).

5. Use documents in the individual's possession or contact with the provider or local council on aging to determine whether a wage or salary is paid. If the payment is not a wage or salary do not count the income.

(417-18-employment-and-volunteer-program-payments)(block-3)7. If the individual says the payments are made under the Workforce Innovation and Opportunity Act (WIOA), request verification of the funding source from the agency making payments ( 420-8 ).#

C. Americorps State and National Program and Americorps National Civilian Community Corps

(417-19-reparations-payments)417-19 Reparations Payments#

(417-19-reparations-payments)(block-1)Effective Date: November 1, 2021#

No Previous Policy

A. German Reparation Payments; Payments to Victims of Nazi Persecution

1. The German government has several provisions in place to make payments to various groups of individuals who were subjected to Nazi persecution.

2. The most recent provision was passed in July 2000.

a. Under this law, the German government in conjunction with a number of German companies set up a foundation to make payments to people who were slave or forced laborers under the Nazis.

b. The foundation is called "Remembrance, Responsibility and the Future."

3. Exempt Income

Do not count as income any payments from the German government or this foundation made to victims of Nazi persecution.

a. Payments may be monthly or just a one-time lump sum.

b. In absence of supporting evidence or conflicting information, accept the individual's signed statement of the source of such income.

c. Do not count interest earned on retained funds as income.

B. Japanese-American, Japanese-Canadian, and Aleutian Restitution Payments

Do not count the following payments as income.

1. Restitution payments made by the U.S. Government or the Canadian Government to individual Japanese-Americans, Japanese- Canadians, or their survivors and Aleuts who were interned or relocated during World War II.

2. Interest earned on retained restitution payment funds.

C. Payments to Certain Persons Captured and Interned by North Vietnam

1. Do not count payments made by the Department of Defense to an individual who was captured and interned by North Vietnam when that payment is made under Section 657 of the National Defense Authorization Act (P.L. 104-201).

2. If the individual is deceased, the payment can be made to a surviving spouse, or to surviving children.

a. The payment is a one-time payment of $40,000.

b. $2,000 can be added for each year that the person's confinement exceeded 20 years up to a total payment of $50,000.

3. Do not count interest earned on retained funds as income.

D. Payments to Filipino Veterans of World War II

1. Do not count compensation payments made under the American Recovery and Reinvestment Act of 2009 to eligible Filipino veterans of World War II.

E. Austrian Social Insurance Payments

(417-19-reparations-payments)(block-2)1. Do not count Austrian Social Insurance payments received by individuals because they were a victim of Nazi persecution (i.e.: were imprisoned, unemployed, or forced to flee Austria) during the period of March 1933 - May 1945. If a person states he or she receives Austrian Social Insurance Payments based on having been a victim of Nazi persecution, accept the signed statement from the person and do not count the payment as income. Do not count interest earned on retained funds as income.#

F. Netherland WUV Payments to Victims of Persecution

(417-20-settlements-disaster-relief-payments)417-20 Settlements/Disaster Relief Payments#

(417-20-settlements-disaster-relief-payments)(block-1)Effective Date: November 1, 2021#

No Previous Policy

A. Payments under the National Flood Insurance Program

Do not count any assistance provided under a program for flood mitigation activities with respect to a property the individual owns. Interest earned on any retained funds is also excluded from income.

B. Agent Orange Settlement Payments

1. Agent Orange settlement payments made in connection with the case of In re Agent Orange Product Liability Litigation come from a fund created by manufacturers of Agent Orange who agreed to pay into a settlement fund.

a. Payments began in March 1989.

b. Qualifying veterans will receive at least one payment a year for the life of the program.4.

c. Qualifying survivors of deceased veterans will receive a single lump sum payment.

2. Excluded Income

a. Do not count Agent Orange settlement payments as income.

b. Do not count interest earned on retained funds as income.

3. Countable Income

a. Current monthly VA payments to the veteran or surviving spouse (pensions or compensation) may be based on a disability caused by exposure to Agent Orange; however, such payments are not from the Agent Orange Settlement and are countable income.

b. If the payments are made on behalf of or to a disabled child of a veteran who was exposed to Agent Orange, See 417-20 (Disaster Relief Funds).

C. Radiation Exposure Compensation Trust Fund Payments

1. Do not count payments made by the U.S. Government to individuals exposed to radiation during atmospheric nuclear testing in Nevada.

a. These may be referred to as 'down winders' payments or Radiation Exposure Compensation Trust Fund Payments .

2. Do not count payments made to uranium mine workers including surface mine workers and transporters who were exposed to high doses of uranium ore.

3. Do not count interest earned on retained funds as income.

D. Disaster Relief Funds

1. Disaster Relief and Emergency Assistance Act

a. Exclude from income, funds received under the federal Disaster Relief and Emergency Assistance Act or other assistance provided under a federal statute because of a catastrophe which is declared a major disaster by the President of the United States (i.e. disaster related Unemployment Compensation).

b. Exclude as income any interest earned on these funds.

c. Also exclude from income, funds received from a State or local government, or a disaster assistance organization, when paid to an individual due to a major disaster as ordered by the President.

2. Federal Pandemic Unemployment Compensation

a. The CARES act, issued on March 27, 2020, allows for people who might not otherwise be eligible for unemployment compensation to receive payments, by including, among other things, provisions for temporary coverage of individuals who have exhausted their entitlement to regular unemployment compensation and who are self-employed or have limited recent work history. These unemployment compensation payments will be countable for all Medicaid programs

b. It also provides individuals who are collecting unemployment compensation benefits with an additional $600 in Federal benefits per week for weeks of unemployment ending on or before July 31, 2020. These additional payments will be excluded income in determining all Medicaid programs.

E. Settlements Paid to Hemophilia Patients (and others) Infected with HIV

1. A number of class action suits were settled on behalf of people with hemophilia who became infected with HIV from blood products received between 1978 and 1985.

2. The settlement also covers spouses and children who became infected with HIV.

3. The companies involved agreed to make settlement payments to people in this class or to certain heirs of such persons in the event such person is deceased. The original class action suit is called "Susan Walker v. Bayer Corporation, et al," 96-C-5024 (N.D. Ill.)

4. Excluded income

Payments in the settlement of a class action lawsuit made to a person with hemophilia infected with HIV, or to a person infected by a person with hemophilia with HIV, or to an heir of such person are not counted as income.

F. Energy Employees Occupational Illness Compensation Program (EEOICP)

1. The EEOICP makes lump sum payments and reimbursement of medical expenses to employees of the Department of Energy (DOE) or of private companies under contract with DOE, who suffer from specific diseases because of their work in the nuclear weapons industry, and designated beryllium workers. Survivors of these employees may also receive payments.

2. There are two parts to this law, Part B and Part E. Each one has different effective dates, illness criteria and medical/compensation allowances.

a. Part B is effective July 31, 2001 and includes compensation of:

i. $150,000 for a covered employee or his or her survivors, and

ii. $50,000 for a covered uranium worker or his or her survivors who previously received $100,000 compensation under the Radiation Exposure Compensation Act.

b. Part E is effective October 28, 2004, and includes variable compensation up to $250,000 based on wage loss, medical expenses, impairment, and survivorship.

· Eligible individuals may include those exposed to toxic substances such as solvents, chemicals, acids, and metals, in addition to those exposed to radiation.

3. Policy for Treatment of Payments

c. Exclude from income, lump sum payments made under the EEOICP, including reimbursement for medical expenses received by the affected employee or by a survivor.

d. Some individuals who receive a payment under EEOICP may also receive a payment under the Radiation Compensation Act.

e. Exclude from income, interest earned on retained funds.

4. Verify the EEIOCP Payment

a. Review Department of Labor (DOL) documents the individual has, or

b. Contact the local DOL district office. A list of the DOL district offices and telephone numbers is included on the DOL website:

https://www.dol.gov/agencies/whd/contact/local-offices .

G. Victim's Compensation Payments

1. Do not count as income, payments made from a fund established by a state to aid victims of a crime.

2. Interest earned on retained funds does not count as income.

(419-1-sources-of-earned-income)419-1 Sources of Earned Income#

(419-1-sources-of-earned-income)(block-1)Effective Date: November 1, 2021#

No Previous Policy

A. Sources of earned income include (but are not limited to):

Most taxable earned income is countable for CHIP ( 440-4 ) .

1. Wages and salaries. This includes holiday, sick and vacation pay that the employer pays. Payments to employees paid on a contractual basis that is not self-employment are treated like wages or salaries. (See 440-4 about deductions for health insurance premiums.)

a. Wage advances are counted as income when received, not when the paycheck is received showing a deduction for the advance.

b. Deferred wages are wages that are received later than their normal payment date. Examples of wages that may be deferred include vacation pay, dismissal or severance pay, back pay, bonuses, etc.

i. If the deferred wages are taxable income and will be received sometime during the certification period, count the income as part of the individual's income. Prorate the amount over the certification period.

ii. If an individual's wages are deferred by depositing them into a 401K account, or into a non-taxable account like a Health Savings Account, those wages would not be counted in the household taxable income.

2. Commissions.

3. Tips as reported by the individual. Do not count allocated tips as income. The allocated amount is the amount reported by the employer to IRS based on gross receipts of the business.

4. Training incentive payments and work allowances. Determine the source of the payments to decide if it is counted as income.

5. Profits received from self-employment, including earnings over a period of time for which payment is received at one given time. Examples include payment to independent contractors, poultry raised for sale or bought for resale. (See 413-6 for information about types of businesses; and 419-3 for information about determining countable self-employment income.)

6. Capital gains received from the sale or transfer of assets used in self-employment. This includes gains received from the sale of (a) farmland or depreciable farm equipment; (b) livestock held for breeding, sport or dairy purposes; (c) securities; (d) real estate; or (e) other investment property.

7. Rental Income. Rental income is countable income ( 415-4 and 419-3 ).

8. Severance Pay includes the cash out of holiday, vacation, and sick pay received when a person terminates a job. Treat severance pay as terminated income, not as a lump sum ( 421 ).

9. AmeriCorps and the National Civilian Community Corps . CNCS also administers the AmeriCorps program and the new National Civilian Community Corps (NCCC) program. AmeriCorps includes community service projects such as educational programs, environmental activities and disaster relief. The NCCC program is a residential service program for young adults aged 18-24 who participate in various community service projects. Some payments are earned income; others are unearned income in-kind. Count payments from either of these programs as follows:

a. Living allowance stipend. Count as earned income for all Family-related Medicaid program, both the MAGI-based groups and the medically needy groups.

· As of 9/1/2008, this income is exempt for aged, blind and disabled programs.

b. Educational award after completion of service. An individual may receive an educational award that would be paid directly to an educational institution or to a loan-holder to pay off an educational loan.

· For CHIP, the educational award does not count as income if it is used to cover educational expenses.

· In some cases, the individual may choose to receive an alternative award equal to one-half of the educational award. It is paid directly to the individual. If an individual receives the alternative award as a cash payment, count it as earned income.

c. Food and Shelter. Any in-kind food and shelter benefits received are exempt for aged, blind and disabled and all Family-related Medicaid programs ( 413-1 ).

(419-2-income-received-from-a-business)419-2 Income Received from a Business#

(419-2-income-received-from-a-business)(block-1)Effective Date: November 1, 2021#

No Previous Policy

Income received by an individual from a business may be considered as self-employment income, wages as an employee, or unearned income depending upon the form of business and the individual’s relationship to the business. The following policy explains the different forms of business:

A. Sole Proprietorship

A sole proprietorship is an unincorporated business owned by one individual. The owner has sole control and responsibility of the business; receives all the profits; and is legally liable for all the debts of the business. The owner of a sole proprietorship is self-employed. See 419-3 for information about how to determine countable income.

B. Partnerships

A partnership is an association of two or more people. A partnership can be created by a verbal or written contract between the individuals. There are three types of partnerships, a General Partnership, a Limited Partnership, and a Limited Liability Partnership. The income received from a partnership is either self-employment or unearned income depending on whether the individual is a general partner or a limited partner. The income tax form, Schedule K-1 (Partner’s Share of Income, Credits, Deductions, etc.) which the partner receives from the partnership will show whether the individual is a general partner or a limited partner.

1. General Partnership : Each partner jointly owns the business, shares in the profits and losses, and is personally liable for all the debts of the business. There may or may not be a written partnership agreement. The income a general partner receives from the partnership is self-employment income. See 419-3 for information about how to determine countable income.

2. Limited Partnership: A business owned by at least one or more general partners who manage the business and one or more limited partners. The general partner or partners are responsible for the management of the company and are personally liable for all the debts of the business. The income a general partner receives from the partnership is self-employment income. See 419-3 for information about how to determine countable income.

a. The income a limited partner receives from a partnership is unearned income and must be reported on his or her individual income tax return.

b. To determine the countable unearned income, request a copy of the Schedule K-1 (Partner’s Share of Income, Credits, Deductions, etc.) from the partnership and the individual’s Schedule E (Supplemental Income and Loss), which they file with their personal income tax return. Count the amount from line 32 of the Schedule E as unearned income.

Note : If the Schedule E includes income from more than one business and there is a loss, do not deduct a loss from one source from any others.

3. Limited Liability Partnership (LLP): A business set up like a general partnership except that the partners are granted limited liability. Usually, a Limited Liability Partnership is set up by individuals who are in professions such as law, medicine and accounting. The partners aren’t personally liable for the malpractice or debts of the other partners or for the debts of the LLP. An LLP is formed by filing an application for Limited Liability Partnership with the Utah Division of Corporations and Commercial Code. The income a general partner in an LLP receives from the partnership is self-employment income. See 419-3 for information about how to determine countable income. The income a limited partner receives from a partnership is unearned income and must be reported on his or her individual income tax return. Follow the policy in 401-2 #2B to determine countable income.

C. Limited Liability Company (LLC)

A Limited Liability Company is formed by filing articles of organization with the Utah Division of Corporations and Commercial Code. The individual members of a Limited Liability Company are not personally liable for the debts of the company.

Profits of a Limited Liability Company are either taxed to each member similar to those of a partnership or are taxed as a corporation. The Articles of Organization, the Operating Agreement, or their income tax forms will give you this information. If the LLC is being taxed as a partnership, follow the policy for partnership income. If the company is being taxed as a corporation, the income is received in the form of dividends and is countable unearned income.

D. Corporations

A corporation is formed by a transfer of money, property, or both by prospective shareholders in exchange for capital stock in the corporation. If money is exchanged for stock, no gain or loss is realized by the shareholder or corporation. The stock received by the shareholder has a basis equal to the money transferred to the corporation by the shareholder. All corporations are divided into two groups: S Corporations which have elected Subchapter S treatment, and C Corporations, which encompass all other corporations.

1. S Corporation : A small business corporation formed and operated under a state’s general corporation law. It is like any other corporation, except that it is treated like a sole proprietorship or a partnership for federal income tax purposes. The S corporation files an “information” tax return to report its income and expenses, but it is not separately taxed. Instead the income and expenses of the corporation are divided among it’s shareholders, based upon the percentage of stock of the corporation that they own, who then report them on their own income tax returns (Schedule E, Supplemental Income & Loss.)

If the individual is actively engaged in the business, the income is self-employment income. See 419-3 for information about how to determine countable income.

Note : Check the information reported on their Schedule E, Supplemental Income & Loss to determine whether or not the individual is actively engaged in the business. If the income is listed as Non-passive Income (#28 h), the individual is actively engaged in the business. If it is listed as Passive Income (#28 g), they are not actively engaged in the business.

If the individual is not actively engaged in the business, the income received is countable unearned income. The individual will receive a Schedule K-1 from the S Corp which they then use to complete Schedule E to file with their personal income tax return. Count the amount from line 31 on the form Schedule E, as unearned income.

Note : If the Schedule E includes income from more than one business, do not deduct a loss from one source from any other source.

2. C Corporation: A C corporation is treated by law as a legal entity. The owners of a corporation are the stockholders or shareholders. The C Corporation reports its income and expenses on a corporation income tax return and is taxed on its profits at corporation income tax rates. Dividends when paid, are taxed to stockholders who report them as income. Dividends paid to a stockholder are countable unearned income when they are received.

A stockholder of a corporation may also be an employee of the corporation. If the stockholder is an employee, count the wages as earned income when they are received.

E. Independent Contractors

(419-3-self-employment-income)419-3 Self-Employment Income#

(419-3-self-employment-income)(block-1)Effective Date: February 1, 2023#

Previous Policy

A. Definition

1. A self-employed individual actively earns income directly from his own business, trade or profession, rather than as salary or wages from an employer. A self-employed individual may be the sole owner of a business; a general partner in a partnership; a member of a Limited Liability Company being taxed as a partnership; or a shareholder in an S Corp who is actively engaged in the operation of the business. (See 419-2 for an explanation of these types of businesses).

2. A self-employed farmer actively earns income from operating a farm for profit either as owner or tenant. A farm includes stock, dairy, poultry, fish, bee, fruit, or truck farms. It also includes plantations, ranches, nurseries, or orchards.

3. An individual is not self-employed if the business is incorporated; if the individual is a limited partner in a Limited Partnership or in a Limited Liability Partnership; or if the individual is a member (owner) of a Limited Liability Company which files federal income taxes as a corporation. In these situations, any earned income actually received by the individual as an employee of the business is countable wages. Dividends or the share of profit from the company reported by the individual on his individual income tax is countable unearned income.

4. Generally a person is considered self-employed if the person:

o Carries on a trade or business as a sole proprietor or an independent contractor.

o Is a member (other than just a limited partner) of a partnership that carries on a trade or business.

o Is otherwise in business for himself or herself (including a part-time business)

5. Self-employment income may include income from rental properties if the person is in the business of renting property. See 415-4 for more information about rental income.

B. Countable Self-Employment Income

An individual’s countable self-employment income from a business depends on the type of business and the individual’s relationship to the business.

1. Sole Proprietor (See 419-2 ) If the individual is the sole owner of the business, the individual’s countable self-employment income is the profit from a business or farm. Profit is the total gross earnings minus allowable business expenses.

2. General Partner (See 419-2) If the individual is a general partner, the individual’s self-employment income is his share of the total profit from the partnership. Read the partnership agreement to determine their share of the profits and divide the profits according to the agreement. If no partnership agreement exists, divide the profits equally among all general partners.

3. Shareholder in an S Corporation (See 419-2): If the individual is a shareholder in an S Corporation and is actively engaged in the business, the individual’s self-employment income is his share of the profits. An individual who is a shareholder in an S Corporation but is not actively engaged in the business is not self-employed. Their share of the profits is countable unearned income.

4. Member of a Limited Liability Company (LLC) Filing Federal Taxes as a Partnership (See Section 419-2 ): If the individual is a member of a Limited Liability Company which files federal taxes as a partnership and the individual is a general partner, the individual’s self-employment income is his share of the profit.

If the individual is a limited partner, he is not self-employed. Any income he receives for services he performs are countable wages. Any dividends paid to him from the LLC are countable unearned income. (Follow the rules in 419-2 to determine countable income)

C. How to Determine Countable Self-Employment Income

In general, self-employment income must be annualized. This means that the total profit expected to be received for a full year must be averaged to determine monthly countable self-employment income.

1. Count the countable self-employment or business income reported by the individual. If tax information match data from the Internal Revenue Service is available, use that information to make the reasonable compatibility test. If the client's statement of income is reasonably compatible with the available electronic income match data, do not request verification from the individual. See section 440-5 for information regarding reasonable compatibility.

2. When the client's statement and the available electronic match data is not reasonably compatible, request further verification from the individual. The following methods can be used to determine self-employment income.

a. Tax returns and applicable schedules or related forms. The individual’s most recent income tax return can be used to determine the countable profit from self-employment or farming if the income on the tax return is representative of the current self-employment income and circumstances. (See 419 ).

b. Income and expense records. Records of gross income and business expenses can be used to determine countable self-employment income. Use records provided by the individual, which may include ledgers, checks, receipts, or another type of bookkeeping system to calculate countable self-employment income. Calculate the gross income (in cash or in-kind) received or available to the individual and then deduct the allowable business or farm expenses. Do not include money earned but not yet received. Do not count any income twice. Only request receipts if the individual has no other record keeping system for expenses.

(419-3-self-employment-income)(block-2)Deduct the actual business expenses reported by the individual from the gross self-employment income. Refer to paragraph C.2. of this section to determine self-employment income and expenses. See section 419-3 for a list of allowable business expenses.#

B . Deducting Losses from a Self-Employment Business

When an individual is self-employed, they can deduct a loss in the current year from other earned income.

1. First determine the amount of the loss from the self-employment business. (Refer to 419-2 to determine self-employment income.)

2. If the information about income and expenses of the self-employment business shows that the business is losing money in the current year, and this is expected to continue into future months, calculate the monthly amount of the loss.

3. When using the prior year's tax forms to determine the loss, document why the loss is expected to continue in the current year.

4. The individual may need to provide more current verification of business income and expenses to justify that the loss is expected to continue.

5. Deduct this anticipated loss from the other earned income such as wages, income from another self-employment business, or from the spouse's earned income.

6. The deduction of a loss from self-employment can only be deducted from other earned income. It cannot be deducted from unearned income.

(419-4-self-employment-expenses)419-4 Self-Employment Expenses#

(419-4-self-employment-expenses)(block-1)Effective Date: June 1, 2024#

Previous Policy

General Information

Accept the individual's ledgers, other bookkeeping system or tax return as verification of the allowable expenses. Only request receipts if the individual has no other record keeping system for expenses. Some expenses the individual may claim as business expenses are not allowed as deductions. They include:

· The cost of purchasing income-producing real estate and capital assets such as equipment, machinery and other durable goods, including payments on the principal of a loan to purchase capital goods;

· Expenses and net losses from previous periods;

· Federal, state and local income taxes;

· Money set aside for the individual's retirement. For MAGI programs, however, allow contributions to SEP, SIMPLE and Qualified Plans as self-employment expenses.

· Other work related personal expenses such as transportation to and from work or personal entertainment expenses;

· Repayment on the principal of a bank loan; and

· Debts from a previous business, including bankruptcy payments

1. Self-Employment Expenses (Non-Farm)

a. Advertising - Amounts paid for advertising and promotional fees.

b. Bad Debts - Bad debts are mainly the result of credit sales to customers. They can also be the result of loans to suppliers, individuals, employees, or distributors. A bad debt may be claimed if the income that the debt represents is definitely known to be worthless.

c. Car and Truck Expenses -

i. Mileage Expenses. If the vehicle is used for personal use and for the business, the individual must declare the percentage of mileage used for business. Allow the same percentage of all expenses related to the vehicle.

o Standard Mileage Rate : Rather than using actual expenses, the individual may choose a standard mileage rate of 67 cents a mile for vehicle expenses. In order to use the standard rate, the individual must have owned the vehicle and used the standard mileage rate for the first year it was placed in service. If the vehicle was leased they must have used the standard mileage rate for the entire lease period. (The standard rate is not allowed if the car is used for hire or if they operate two or more cars at the same time.)

o Not Using Standard Mileage Rate: For those who do not use the standard mileage rate, the business portion of expenses for gasoline, oil, repairs, insurance, tires, parking fees, rental fees, garage rent, license plates, etc. are allowable. Also allow a deduction for vehicle registration, prorated for 12 months.

ii. Principal Payments: Do not allow a deduction for payment on the principal for the purchase of the vehicle. Do not allow a deduction for a payment for leasing the vehicle if the payment may also be applied towards purchase of the vehicle. Do not allow costs of driving the car or truck between home and the main regular workplace.

d. Commissions and Fees

e. Depletion - Depletion is the using up of natural resources by mining, quarrying, drilling or felling. Individuals who have an economic interest in mineral property or standing timber may deduct the cost of using up those natural resources

f. Depreciation - Depreciation is the annual deduction allowed to recover the cost or other basis of business or investment property which has a useful life beyond one year. It includes improvements made to lease business property. Stock in trade, inventories, or land are not depreciable.

g. Employee benefit programs - Contributions to employee benefit programs that are not a part of a pension or profit sharing plan. Examples are accident and health plans, group-term life insurance, and dependent care assistance programs. Do not allow these expenses for contributions made into these plans for the self-employed individual.

h. Insurance - Premiums paid for insurance related to the trade or business. This includes fire, theft, flood or other similar insurance, merchandise and inventory insurance, and liability insurance.

i. Interest - Interest paid to banks or other financial institutions for a mortgage on real property used in the business that is not the individual’s home or the home of any partner in the business. Do not allow a deduction for bills owed but not paid. Do not deduct interest paid or accrued on debts allocable to investment property. Do not allow any deduction for payment on the principal for any land or business. If the property being purchased is a vehicle, see the rules for Car and Truck Expenses above.

i. Business Use of a Home - Not Day Care

If the business is operated in a home of the individual or the individual's partner, determine the percentage of the home that is used regularly and exclusively for business purposes. Do not include any part of the home that is used for both living space and for business. Allow the same percentage of the costs associated with the home.

ii. Business Use of a Home - Day Care

If the day care business is operated in a home of the individual or the individual's partner, determine the percentage of the home that is used on a regular basis for business purposes. It is not necessary for any portion of the home to be used exclusively for business. Allow the same percentage of the costs associated with the home.

j. Legal and Professional services - Legal and professional fees that are ordinary and necessary expenses directly related to operating the business. The cost of tax advice and preparation of the tax forms related to the business are included.

k. Office Expenses - Expenses paid as operating costs of an office. Do not include purchases of office furniture or equipment (these are capital expenditures.)

l. Pension and profit sharing plans - Contributions made to pension, profit-sharing, or annuity plans for employees of the business. Do not include contributions made for the self-employed individual.

m. Rent or leases - Amounts paid for the use of property rented or leased for the business.

n. Repairs and Maintenance - Amounts paid for repairs and maintenance to property that does not add to the value or increase the life of the property. Do not deduct amounts spent to restore or replace property (these are capital expenses.)

o. Supplies - Supplies and materials used in the business. Do not include inventory that is maintained for sale.

p. Taxes and licenses - Taxes paid by the business. This includes state and local sales taxes imposed on the individual as the seller of goods or services; real estate and personal property taxes on business assets; licenses and regulatory fees for the trade or business paid each year to state or local governments; Social Security and Medicare taxes paid to match required withholding from the employees’ wages; federal unemployment taxes; and federal highway use taxes.

o Do not allow federal income taxes, including the individual’s self-employment tax; taxes assessed to pay for improvements, such as paving and sewers; State and local sales taxes on property purchased for use in the business; and other taxes and license fees not related to the business.

q. Travel, meals, and entertainment - Expenses for lodging and transportation connected with overnight travel, if they are directly related to or associated with the active conduct of the trade or business. Do not allow expenses paid or incurred for a facility (such as a yacht or hunting lodge) used for any activity usually considered entertainment, amusement or recreation. Do not deduct amounts paid or incurred for membership dues in any club organized for business, pleasure, recreation or other social purpose. This includes country clubs, golf and athletic clubs, airline and hotel clubs.

r. Utilities - Utility expenses for the trade or business

i. Business not in a Home

All utility payments made, including telephone, are allowable deductions for a business that is not run in the individual's home or the home of any partner in the business. The payment is an allowable deduction in the month the payment is made.

ii. Business in the home of a individual or individual's Partner

If the business is operated in the home of the individual or the individual's partner, determine the percentage of the home that is used on a regular basis for business purposes. Allow the same percentage of the utility costs, except for the telephone, associated with the home.

If there is more than one telephone in the home, allow the full amount paid for any additional telephone (s) listed in the phone book as business phones. If there is only one telephone or if no additional phone is listed in the phone book as a business phone, allow deductions only for specific telephone calls identified by the individual as business calls. Allow the deductions in the month the bill is paid.

s. Wages - Wages paid to employees of the business. Do not include salaries or wages paid to the self-employed individual.

t. Other Expenses - Donations to business organizations, licenses and regulatory fees, subscriptions to trade or professional publications.

2. Farm Expenses

a. Car and Truck Expenses - If the vehicle is used for personal use and for farming, the individual must declare the percentage of mileage used for farming. Allow the same percentage of all expenses related to the vehicle.

i. Standard Mileage Rate - Rather than using actual expenses, the individual may choose a standard mileage rate of 67 cents a mile for vehicle expenses. In order to use the standard rate, the individual must have owned the vehicle and used the standard mileage rate for the first year it was placed in service. If the vehicle was leased they must have used the standard mileage rate for the entire lease period. (The standard rate is not allowed if the car is used for hire or if they operate two or more vehicles at the same time, such as fleet operations.)

ii. For those who do not use the standard mileage rate, the business portion of expenses for gasoline, oil, repairs, insurance, tires, parking fees, rental fees, garage rent, license plates, etc. are allowable. Also allow a deduction for vehicle registration, prorated for 12 months.

Do not allow a deduction for payment on the principal for the purchase of the vehicle. Do not allow a deduction for a payment for leasing the vehicle if the payment may also be applied towards purchase of the vehicle.

b. Chemicals

c. Conservation Expenses - Deductible soil and water conservation expenses generally are those that are paid to conserve soil and water or to prevent erosion of land used for farming. These expenses include (but are not limited to) the cost of leveling, grading and terracing, contour furrowing, the construction, control, and protection of diversion channels, drainage ditches, earthen dams, watercourses, outlets and ponds, the eradication of brush, and the planting of windbreaks. This deduction may not exceed 25% of the gross income from farming.

d. Custom Hire (Machine Work) - Amounts paid for custom hire or machine work (the machine operator furnished the equipment). Do not include amounts paid for rental or lease of equipment that the farmer operated himself.

e. Depreciation - Depreciation is the annual deduction allowed to recover the cost or other basis of buildings, cars and trucks, machinery, and other farm equipment which have a useful life beyond one year. It includes improvements made to leased business property. Depreciation on the home, furniture or other personal items, land, livestock bought or raised for resale, or other property in inventory are not depreciable.

f. Employee Benefits - Contributions made to employee benefit programs that are not an incidental part of a pension or profit-sharing plan. Examples are accident and health plans, group-term life insurance, and dependent care assistance programs. Do not deduct any contributions made on behalf of the farmer to an accident and health plan or for group-term life insurance.

g. Feed Purchases - Expenses for feed that was consumed by the livestock in the current year, including prepaid farm supplies. Prepaid farm supplies are amounts paid during the tax year for feed, seed, fertilizer, and similar farm supplies not used or consumed during the year. Prepaid farm supplies do not include any amount paid for farm supplies on hand at the end of the tax year that would have been consumed if not for a fire storm, flood, or casualty, disease, or drought. Deduct the expense for prepaid farm supplies that does not exceed 50% of the other deductible farm expenses in the year of payment.

h. Fertilizers and lime - Cost of fertilizer, lime, and other materials applied to farm land to enrich neutralize or condition it.

i. Freight and Trucking - Costs of freight and trucking. Do not include the cost of transportation incurred in purchasing livestock held for resale.

j. Gasoline, fuel and oil - Cost of gasoline, fuel and oil used for farming.

k. Insurance - Premiums paid for farm business insurance. Do not deduct amounts credited to a reserve for self-insurance or premiums paid for a policy that pays for the farmer’s lost earnings due to sickness or disability.

l. Interest - Interest paid to banks or other financial institutions for a mortgage on farmland or other obligations incurred in the farm business. If the proceeds of a loan are used for more than one purpose (for example, personal and business), allocate the interest on that loan to each use. Only allow the portion of the interest payment that is the farm expense.

m. Labor Hired - Amounts paid for farm labor. Do not deduct amounts paid to the owner of the farm. Allow reasonable wages or other compensation paid to the children or the spouse of the farmer if a true employer-employee relationship exists. Do not deduct wages paid to hired help for the construction of new buildings or other items.

n. Pension and Profit-Sharing Plans - Contributions made to employee pension, profit-sharing, or annuity plans for employees of the farm. Do not include contributions made for the self-employed farmer.

o. Rent or Lease Payments - Business portion of the rental cost for rented or leased vehicles, machinery, or equipment. Do not deduct rent for property which the farmer will receive equity in or title to.

p. Repairs and Maintenance - Amounts paid for repairs and maintenance of farm buildings, machinery, and equipment. This includes the cost of tools of short life or minimal cost, such as shovels and rakes. Do not deduct repairs or maintenance on the farmer’s home.

q. Seeds and Plants Purchased - Costs of seeds and plants purchased for further development and cultivation before sale. Do not deduct the purchase price and seeds and young plants for Christmas trees and timber.

r. Storage and warehousing - Costs for storage and warehousing.

s. Supplies purchased - Costs of supplies and materials used in the farming. Do not include inventory that is maintained for sale.

t. Taxes - Taxes paid by the Farm. This includes real estate and personal property taxes on the farm business assets, Social Security and Medicare taxes paid to match what was required to be withheld from farm employees’ wages, federal unemployment taxes, and federal highway use taxes.

Do not deduct federal income taxes, including self-employment tax; estate and gift taxes; taxes assessed for improvements such as paving and sewers; taxes on the home or personal use property and state and local sales taxes on property purchased for use in the farm business; or other taxes not related to the farm business.

u. Utilities - Amounts paid for gas, electricity, water, etc., for business use on the farm. Do not include personal utilities. Do not deduct the base rate (including taxes) of the first telephone line into the farmer’s residence, even if used for business.

v. Veterinary, Breeding, and Medicine - Veterinary, breeding and medicine costs.

w. Other Expenses - Other necessary farm expenses such as advertising office supplies, cost of qualified clean-fuel vehicle property, legal and professional fees, etc. Do not include fines or penalties paid to a government for violating any law.

Note : You may allow expenses for business use of the home only if the home is used exclusively and regularly for the administrative or management activities of the farm and there is no other fixed location where the farmer can conduct these activities. If part of the home is used for business, determine the percentage of the home that is used regularly and exclusively for business purposes. Allow the same percentage of the expenses association with the home. These expenses include utilities, deductible mortgage interest, real estate taxes, and casualty and theft losses.

(435-1-definitions)435-1 Definitions#

(435-1-definitions)(block-1)Effective Date: November 1, 2021#

No Previous Policy

Definitions

The following definitions apply to policy on budgeting income.

1. Benefit Month : The calendar month, or partial month, for which the medical eligibility is approved.

2. Prospective Budgeting : A process of determining countable income for the benefit month based on anticipated income expected to be received during that month or during the upcoming certification period.

3. Best Estimate : A calculation of the household's anticipated income, deductions and size during the certification period in all benefit months based on the most current information available. Use this estimate to figure the eligibility and spenddown amounts for each month in the certification period.

4. Anticipating Income : Determining monthly income through a history of past or current knowledge of circumstances and applying those circumstances to future periods. Income that has no history can be anticipated if verification shows the individual will receive this income, such as a signed job offer or employment contract, showing employment dates and expected amount of earnings.

5. Averaging Income : Determining monthly income from an average of income received or expected to be received over a pre-determined period of time. This method is particularly useful for hourly workers whose weekly hours fluctuate.

6. Annualized Income : Determining income for an amount of time by using income from a like season, year, or contract period that is representative of future income. Income can be annualized over 12 months or less, depending on the circumstances of the individual.

7. Stable Income : Income that does not vary in either amount or frequency of receipt such as a set monthly salary.

8. Fluctuating Income : Income that varies in amount or frequency of receipt. This income must be averaged or anticipated.

9. Contract Income : Income received for services or work under a contractual agreement. This income may be received in installments over a specified period, or it may be paid at the end of the period covered by the contractual agreement.

10. Recurring Income Received Less Often than Monthly : Income that is paid quarterly, semi-annually, or annually. For example, military summer camp pay, and bonus and incentive income.

(435-2-determine-a-best-estimate-of-income)435-2 Determine a Best Estimate of Income#

(435-2-determine-a-best-estimate-of-income)(block-1)Effective Date: November 1, 2021#

No Previous Policy

A. Introduction

1. In the MAGI-based methodology, choose the method to determine the best estimate of each source of income an individual expects to receive during the certification period.

Income may be averaged, anticipated, or annualized depending on the type of income, the history of receiving it, or expected future changes.

a. Stable Income: If an individual receives stable, ongoing income, prorate the expected amount over the 12 month certification period to arrive at a monthly amount.

o If the individual is paid monthly, bi-monthly, every week or every other week, determine the average income to be received each pay period.

o Multiply the average by the number of pay periods in the certification period.

o Then divide the total by 12 months to arrive at a monthly amount.

b. New Income :

o If an individual has started a new job during the application month, request verification of the income and pay schedule. An employer statement may be the best way to request verification. Determine the pay schedule and the average income per pay period.

o If the individual has a job offer, but has not started, find out when the job is expected to begin. If income will not be received before the application processing deadline, make an eligibility determination based on the current situation.

· Set a task to request income verification after the new job is expected to begin.

· Adjust eligibility accordingly for the remainder of the certification period upon receiving verification of the new source of income.

o An individual reports receiving a new job offer. He does not have a start date.

· Set a task to request income verification after the new job is expected to begin.

o If a new income source is reported or discovered at review, request the needed verifications. Base the estimate on when the new income source starts (if the individual has not already started to receive income from the new source) following similar process as with an applicant who will have new income.

o Once you have sufficient verification, determine the best estimate as follows:

· If the individual will be paid monthly, bi-monthly, every week or every other week, determine the average income to be received each pay period.

· Multiply the average by the number of pay periods remaining in the certification period based on when the first check is received.

· Then divide the total by 12 months to arrive at a monthly amount.

Example- James applied on March 30 for himself and his family for benefits to start in March. He reports he will start a new job on April 1. He is paid every two weeks on Fridays. He will receive his first check on April 19th. He will only receive 1 check in April. He works 40 hrs/wk, earning $11.00/hr. He will receive 23 checks in the certification period because he had no income in March and only 1 check in April.

· Best estimate of income = $880 x 23 = $20,240/12 = $1,686.67/month

· Monthly countable new income = $1,686.67

c. Anticipating Infrequent Income: Anticipate infrequent income only when there is a history of the payments, and the individual expects to continue receiving the income. Prorate the income over the certification period, and add the prorated amount to the monthly income. An example is taxable interest income. It may be received monthly, quarterly or annually. Prorate the amount over the 12-month certification period and count 1/12 in each month.

d. Terminated Income: If an individual will receive income during the certification period that has terminated , determine the total expected terminated income and divide by 12 months to arrive at the monthly average amount to be received during the certification period.

Example- John has been laid off from his employment. He says he can't afford his COBRA coverage and wants to see if he can qualify his family for Medicaid. His company gave him a severance check for $5,000, and he received only one pay check of $1,500 in the application month, which is his last check. There is no other income.

o Best estimate of income = $6,500/12 = $541.67

o Monthly countable terminated income = $541.67

o John's HH size is 3 and so he qualifies for PCR coverage. His children qualify for Child Medicaid.

e. Seasonal Income: If an individual expects to receive temporary, seasonal, contract or other infrequent income, prorate the income over the certification period.

When prorating temporary, seasonal or infrequent income, total the amount expected to be received during the certification period. Then divide it by 12 to determine the monthly amount.

Example (seasonal) - For the past 5 years, John has worked as a ski instructor for 6 months of the year at $1000/month. He also works for a landscaping company during the other 6 months and earns $2000/month wages.

· Best estimate Ski Instructor = 6 months x $1000/month = $6000/12 months = $500/month

· Best estimate Landscaping = 6 months x $2000/month = $12,000/12 months = $1000/month

· Total countable income: $500 + $1000 = $1500/month

Example (temporary) - Jack was laid off and is now receiving unemployment. His weekly checks are $350 and he has 15 weeks of unemployment remaining as of the first day of the application month. Since this income will end, prorate it over the certification period. This will factor in the zero income months. Add the monthly amount to any other income the individual or household has.

· Best estimate Unemployment = $350/week x 15 weeks = $5250/12 months = $437.50/month

· Total countable Unemployment income $437.50/month.

f. Self-employment . If an individual is self-employed, determine the expected annual income the individual expects to receive from the self-employment work. Divide the annual amount by 12 to determine the average monthly income.

· Find out expected gross income and expected expenses when calculating the expected net income. See 419-2 and 419-3 for self-employment policy.

· If the self-employment is new, make the most reasonable estimate of what the individual expects to receive during the certification period.

2. Use the total monthly amount of income expected to be received to conduct a reasonable compatibility test and to determine eligibility for the certification period.

3. Reasonable compatibility : Determine if the reported income is reasonably compatible with electronic verification sources. The reasonable compatibility test compares the best estimate of countable income the agency derives based on the client's statement with the best estimate of countable income derived from available electronic income sources. Compare those amounts against the income limit for CHIP. Deduct any allowed expenses from both the client statement of income and the electronic source of income before doing the reasonable compatibility test.

a. If both the client's statement and the electronic income match are at or below the CHIP income limit, the individual is eligible.

b. If both the client statement and the electronic income match are above the CHIP income limit, the individual is ineligible for CHIP.

c. If one income amount is above and one income amount is below the CHIP income limit, request additional verification from the individual. Sec. 705 .

d. Eligibility for CHIP group C allows a 5% of FPL disregard when determining eligibility. Refer to 440-5 .

e. If electronic income information is unavailable, use other methods to verify the individual's income.

If an individual claims no income, or income is insufficient to meet basic needs, ask the individual how she is meeting basic living expenses (shelter, food, utilities, etc.)

B. Documentation and Changes

Document the method of determining the best estimate.

Refer to Section 804-5 when a change has occurred that results in the best estimate needing to be changed.

(435-budgeting-income)435 Budgeting Income#

(435-budgeting-income)(block-1)Effective Date: November 1, 2021#

No Previous Policy

A. General Budgeting Concepts

Budgeting is the process of determining a best estimate of income an individual or household will receive during the certification period. Medicaid rules require the agency to use the individual's current circumstances to determine eligibility.

1. Use prospective budgeting for CHIP. "Prospective" budgeting means that we use information about the individual's current circumstances, as well as historical information, or known future changes to project what income the individual or household will receive during the certification period.

2. Use the methods of anticipating, averaging or annualizing income to determine an appropriate prospective estimate.

o The method used to determine the best estimate depends on the type of income, the frequency of receipt, the individual’s earnings history and any known anticipated changes in circumstances.

o Determine the best method to use based upon the individual's history and current circumstances.

3. Consider the following factors to determine the best estimate of income.

o What income is the individual currently receiving or expecting to receive in the future months?

o Does the individual expect any predictable changes during the certification period? For example, will the individual's rate of pay change at a specific future date?

o What are the individual's historical patterns such as recurring income, a quarterly or annual bonus, or regular seasonal income that will continue in the future? For example, a individual working as a school aide for 9 months a year who also does yard maintenance work in the summer.

B. The Budgeting Process

1. Determine a best estimate of income the individual expects to receive during the whole certification period to arrive at a monthly amount.

o Deductions are limited to those allowed under tax rules. Remember to look for infrequent income, such as taxable interest income.

o Once the best estimate is determined for the certification period, it remains fixed unless the agency receives information about a change in income. See section 804-5 for reported income changes.

2. These rules apply to any family members whose income must be counted based on the MAGI methodology.

3. When budgeting self-employment income, determine the expected net annual income.

o Use prior year tax forms or current income and expense ledgers to determine the income and business expenses only if they are reflective of the individual's current business income and expenses.

o Tax forms show past income, so ask the individual if current income and expenses are different.

o Current ledgers, accounting statements or upcoming work contracts a individual has secured may be a more accurate way to verify current circumstances, especially during the first few years someone is self-employed.

o Subtract from gross income the actual or anticipated business expenses allowed under IRS rules. The individual must identify and verify income and expenses. Individuals may expect to have some expenses even if they have not incurred them yet. In this case, the client's statement may be the only way to verify.

o Prorate the annualized income over 12 months to determine a monthly amount.

o Some other types of income such as contract or commission income may also need to be annualized. See 419-2 and 419-3 for more information on self-employment.

(440-3-income-for-magi-methodology)440-3 Income for MAGI Methodology#

(440-3-income-for-magi-methodology)(block-1)Effective Date: April 1, 2023#

Previous Policy

A. Income Based on Tax Rules

To determine the MAGI income, count taxable income that is used to determine an individual or couple's gross taxable income. In addition, certain types of income that are not taxable have to be added to the gross taxable income, and some types of income a person receives do not count in the MAGI-based income methodology.

B. Countable Income

1. Types of taxable income : The following types of income count as income for tax purposes and compose the gross income on an individual's tax return.

a. Wages, salaries, tips which include, but not limited to ( 419 & 419-4):

o Sick and vacation pay which is paid by the employer;

o Temporary census income; and

o Earned in-kind benefits such as housing provided by an employer that are part of the individual's taxable income from earnings.

b. Taxable interest

c. Ordinary dividends

d. Taxable refunds, credits, or offsets of state and local income taxes

e. Alimony received

f. Business (i.e.: self-employment) income (or loss as per IRS rules-IRS Schedule C or C-EZ) [If additional verification from the individual is required, see Sec. 419-2 ] This includes the sale of bodily fluids such as plasma, breast milk, ect.

g. Capital gains (or loss) (This can be from sale of stocks, bonds, real property such as a home, or other personal property not used for business)

h. Other gains (or losses) (IRS form 4797, generally for business property, rental property, farmland, and livestock sold)

i. IRA distributions (taxable amount)

j. Pensions and annuities (taxable amount if different than gross)

k. Rental real estate income, royalties, partnerships, S corporations (from IRS Schedule E)

l. Farm income (or loss) (from IRS Schedule F)

m. Unemployment insurance

n. Social Security benefits (the taxable portion, if any)

o. Other income (as defined by IRS) These may include:

o Prizes, winnings or awards,

o Alaska Permanent Funds dividends,

o Cash contributions. See section 415-7 for restrictions on counting cash gifts or contributions as income.

o Taxable amounts from certain educational savings accounts or health savings accounts, etc.

o Some of these sources may be reported to the individual on an IRS1099-MISC form and could be lump sums that only count in the month received.

2. Add-Back income : To determine the MAGI-based income for CHIP eligibility, some income types must be added to the individual's gross taxable income even though it is not taxable.

a. The portion of Social Security benefits that was not taxable (in many cases, this will be the full amount of the Social Security benefits.)

b. Non-taxable interest income (such as interest earned on municipal bonds)

c. Foreign earned income that was excluded from taxable income.

C. Additional Requirements for CHIP

3. Lump sum payments are countable for CHIP eligibility, but only in the month the payment is received. (Some types of lump sum income are excluded from countable income. Sec. 411 )

4. Count educational income that is used for living expenses or other non-educational related expenses.

5. Certain income of American Indians/Alaska Natives is excluded from income. (See 417-14 )

The gross countable income will be the sum of the taxable income, plus any add backs, and any lump sum or countable educational income.

See Sections 419-4 and 417 for income that does not count for MAGI-Based programs and for treatment of various other types of income.

(440-4-specific-treatment-of-income-for-magi-based-programs)440-4 Specific Treatment of Income for MAGI-Based Programs#

(440-4-specific-treatment-of-income-for-magi-based-programs)(block-1)Effective Date: December 1, 2022#

Previous Policy

A. Income that does not count

Follow the income exemptions as defined in 417 for MAGI-based programs except as noted in this section. The following items are also excluded as income to determine the MAGI-based household income unless otherwise noted.

1. Veteran's benefits (compensation and pensions) defined in 403-2 do not count to determine the MAGI-based household income. Veteran's benefits such as Aid and Attendance, Homebound Care payments, and payments for unusual medical expenses do not count as income. VA educational income for the veteran or family members, including subsistence amounts is not countable.

2. Child support payments do not count whether they are current or arrears. (415-5)

3. Social Security benefits received by a dependent child do not count as income unless the child's income is required to be counted. See 440-3 for when a child's income must count.

4. Federal Tax refunds. Refunds of federal taxes including refundable credits are not counted as income.

5. State and Local Tax Refunds. Only count state or local tax refunds when that amount must be reported as taxable income on the individual's tax return form.

6. Educational income such as scholarships, awards or fellowship grants used for tuition, fees, books, supplies, or other educational expenses. Educational loans are not considered income.

o Count only the amounts used, or that will be used, for living and other non-educational expenses.

o Work study income that the individual reports as wages on the individual's tax return is countable income.

7. Hostile Fire Pay. When an individual is on active military duty serving in a combat zone, the full amount of the person's military pay can be excluded from taxable income. In this case, the income is not countable for the MAGI-based determination of income of that individual. See 419-4 .

8. Pre-tax deductions. If the individual is eligible for Medicaid without deducting pre-tax deductions, it is not necessary to verify these amounts. If the individual is not eligible without deducting them, request verification of the allowable deductions to determine the countable income. If you do not receive the verifications, determine the eligibility without the allowable deductions.

Pre-tax deductions may include:

· Health Insurance premium payments, including pre-tax premium payments for medical, dental or vision plans

· Health Savings Account contributions (including flexible spending accounts)

· Retirement contributions

· Child Care Flex Account contributions

9. Payments to replace property. See 415-9 for policy on how to count payments to replace or repair property.

10. Payments defined in 403-11 . Do not count as income funds received under the provisions defined in this section.

11. Sponsored aliens. Follow policy in 425-2 for MAGI-based households when the sponsor is not the spouse or parent of the alien. If the sponsor is the spouse or parent of the alien, follow the MAGI-based income rules.

12. In-Kind, Unearned Income is not countable. See 413-6.

13. Workers' Compensation- Payments made to an employee or his dependents under a workers' compensation law are exempt as income for the MAGI—based programs.

14. ABLE Accounts. Exclude ABLE account deposits, interest earnings and dividend earnings.

15. Discharged Student Loan Debt.

a. Student loan debt can be discharged if the student dies or becomes disabled. The debt holder may be the student, or a parent.

b. The discharged debt does not count as income for the MAGI-income determination.

16. Parent Mentor Stipends

Nominal amounts paid as a stipend to a parent mentor are excluded from income. The disregard of parent mentor income applies only in the case of parent mentors

working with a grantee organization.

B. Treatment of other sources of income

1. Deposits to Joint Accounts 403-15 .

· Deposits to a joint checking account made by a non-household member do not count as income to the individual.

· Direct deposits of the individual's earnings are countable income.

· Cash gifts deposited to a individual's account for the individual's benefit count only as defined in #4 below.

· Payments from a trust fund, or from other countable sources deposited into a trust account for the individual's benefit count as income of the individual.

2. Excluded Income under 403-4 .

Treat income types defined in 403-4 section B. the way they are treated in that subsection with the following exceptions;

· State and local tax refunds are counted if the tax filer must claim that amount on his or her tax return.

· Supplemental Security Income, State Supplement payments, financial assistance paid under the TANF program or General Assistance program, or Refugee Cash Assistance do not count. However, other income of such household members counts if that individual's income is required to be counted.

· Income from any of the sources defined in 403-4 that are paid in the form of wages, and that the individual would have to report as earned income on a federal tax return is counted for the MAGI-based income determination (even if the individual does not expect to file a tax return.)

· People with a PASS plan. Taxable earned income of an individual who has a PASS plan are countable income if that person's income must be counted in the MAGI determination,

· Food and Shelter. The value of food or shelter paid by an employer that the individual must report as taxable income is countable.

3. Net rental income. Count the net amount of rental income a person receives. The net amount is the gross amount minus the allowable expenses ( 403-5 ).

4. Cash Gifts. All cash received by a tax dependent FROM a tax filer is countable unearned income if all the following apply.

· The cash is received from the tax filer who is claiming the individual on their taxes;

· The individual is not the spouse or child of the tax filer; and

· The average, recurring cash is more than $300.00 per month.

5. Inheritances. Count only the amount of an inheritance that an individual must include as income on his or her tax return. This includes proceeds from life insurance or other death benefits. (Most inheritances do not count as income to the person who inherits the funds.)

6. Interest or dividends. These are countable income for MAGI as shown in 450-1 . Interest earned from a sales contract would be countable income as well.

7. Royalties. Individuals must report the net amount of royalties they earn which may come from the sale of natural resources, literary, artistic or musical works, etc.

8. Personal Injury and TPL Settlements. If any portion of a settlement has to count as income and is paid in a lump sum payment, the payment only counts as income in the month received.

· If an individual receives a payment that is to reimburse medical costs, the amount received is not countable.

· If the person suffered a personal injury, and receives a settlement amount that is to account for pain and suffering, that amount is also not countable.

· If the person did not suffer a personal injury and receives a payment for emotional distress, that portion is countable income and is reported as "Other Income."

· If any portion of a settlement is to repay lost wages, that amount is countable income because the person would have to report it as wages on a tax return.

· If a person receives punitive damages, that portion is taxable and is reported as "Other Income."

9. Sickness and Injury Benefits (Including short-term and long-term disability insurance):

a. Premiums- Pre-tax insurance premiums made partially or completely by an employer are excluded from the employee’s income.

b. Sickness and Injury Payments-

i. When an employer pays for an illness or injury insurance plan, and the premiums were not counted as part of the employee’s income, the payments the employee receives are counted as countable income.

ii. If the employee paid the full amount of the plan (had to include the premium amount in their gross income), the payments the employee receives are not counted as income.

iii. If both the employee and the employer paid for the plan, only the percentage of the amount the employee receives, that is equivalent to the employer’s portion of the premium, will be counted as income to the employee.

Example: The employee pays $25 and the employer pays $75 per month toward the premium for a Short-Term Disability insurance plan. The employee normally makes $4000 gross income per month. The employee gets injured and they need to start using the policy. The insurance policy pays the employee 50% of their regular income: $2000 per month. Since the employer contributed 75% of the insurance premiums monthly, 75% of 2000.00, or 1500.00 would count as the individual’s short-term disability income.

iv. Car Insurance Payments - Disability benefits received for loss of income or earning capacity as a result of injuries under a no-fault car insurance policy are not counted as income.

v. Accidental Death and Dismemberment Payments - Do not count as income compensation received for the following:

· loss of a body part or

· loss of use or function of the body or

· for permanent disfigurement.

10. Self-employment income. Count the individual's net self-employment income. This is the gross self-employment income minus the business expenses allowed by the IRS ( 405-3 ).

· If the individual must provide verification of self-employment income because there is no electronic match data or the electronic match data is not reasonably compatible with the client's statement, verify both the gross self-employment income and the business expenses.

· Accept the individual's ledgers, other bookkeeping system or tax return as verification of the allowable expenses. Only request receipts if the individual has no other record keeping system for expenses.

· The MAGI-based methodology cannot use the 40% deduction from gross income to account for business expenses.

11. Sale of Native American or Alaska Native Significant Items. Exclude payments resulting from the sale of items that have unique religious, spiritual, traditional or cultural significance to Native Americans or Alaska Natives. This exclusion applies to:

· Individuals who make and sell the above mentioned items as a means of self-employment.

· Individuals who own and sell the items but do not make them.

· The exclusion does not apply to the wages of employees of retail establishments who sell significant Native American items.

12. Alimony Payments.

Refer to 403-6 for policy regarding alimony income.

13. Lottery and Gambling Winnings.

a. Count qualified lottery and gambling winnings received as a lump sum as income of the person who receives the winnings using the following formula:

· Count winnings less than $80,000 in the month received;

· Count winnings of $80,000 but less than $90,000 as income over two months, with an equal amount counted in each month; and

· For every additional $10,000 add one month to the period over which total winnings are divided, and count as income in equal installments.

b. Count as income the full amount of the winnings in the month of receipt for all other household members, but do not count in future months.

c. Count the value of "non-cash" winnings like a car or boat, as income in the month received.

d. Before ending someone's eligibility, we must inform them of the opportunity to enroll in a plan through the Exchange, as well as the date when they will no longer be ineligible for Medicaid due to receipt of these winnings.

e. Hardship exemption: if an individual claims that the proration of the lottery winnings will present a hardship for their family, refer the case to BEP. A policy specialist will assess their hardship claim on a case by case basis.

1 4. Travel/Transportation Allowances and Reimbursements.

a. Transportation fringe benefits- Certain employment fringe benefits are excluded as income when their value is under $270 per month. They include:

· Transportation in a commuter highway vehicle, such as a van. At least 80% of the vehicle’s mileage must be reasonably expected to be:

o For transporting employees between one’s home and work place,

o On trips during which employees occupy at least half of the vehicle’s adult seating capacity (not less than six individuals), not including the driver.

· A transit pass , token, fare card, voucher entitling a person to ride public or private mass transit for free or at a reduced rate, or

· Qualified parking . This is parking provided to an employee at or near the employer's place of business. It also includes parking provided on or near a location from which the employee commutes to work by mass transit, in a commuter highway vehicle, or by car pool. It doesn't include parking at or near the employee's home.

b. Necessary travel expenses that are incurred while traveling away from home on a temporary job or assignment are reimbursable. An expense doesn’t have to be required to be considered necessary.

· If using one’s own vehicle see Table I for standard mileage rate for business.

· The individual must keep records of all the expenses they incur and any advances received from the employer. Those records can be kept in a log, diary, notebook, or any other written record to keep track of those expenses.

c. Cash reimbursements by employers for the previously mentioned expenses under a bona fide reimbursement arrangement are also excludable.

(440-5-calculating-income-for-magi-based-programs)440-5 Calculating Income for MAGI-Based Programs#

(440-5-calculating-income-for-magi-based-programs)(block-1)Effective Date: August 1, 2024#

Previous Policy

A. Individual Statement of Income

Calculate the client's statement of monthly income for each individual in the MAGI household for CHIP whose income must be counted as per 440-5. Each person's household composition may not be the same which can result in different countable income for each family member.

Follow the budgeting policies in 435 to arrive at the best estimate possible of monthly income.

1. Calculate gross income . (See sec. 435 for budgeting policy)

a. Add all income reported by the individual as per 440-5. Do not count income excluded under 417 and 419-4.

i. Some income may be prorated over the certification period when the income is expected but is not received monthly. For example, include seasonal income that has a history of being received and is expected in the future.

ii. Income that will be received for only a set period of time, such as unemployment income, will be prorated over the certification period to determine a monthly amount.

iii. Count a lump sum payment only in the month it is received. (Sec. 421)

b. The result is the gross countable income.

2. Deductions from the gross income.

Applicants or recipients must report whether they anticipate having any of the following expenses and the amount of those expenses. An individual does not have to file a tax return to receive a deduction from income for these expenses. These expenses are what the individual expects for the tax year in which the agency is making a CHIP eligibility determination.

Subtract from the gross countable income the following expenses reported by the individual. (IRS form numbers are included only as a possible resource if the agency must request verification from the individual.)

a. Educator expenses up to the limit of $250 per educator per tax year

i. The individual must be an educator.

ii. If the spouse is also an educator, they can each claim up to $250 a year.

b. Contribution to a traditional IRA.

· The individual or spouse must have earned income to take this deduction.

c. Alimony paid by the individual. Allow a deduction for alimony paid by an individual only if the divorce or separation agreement was in place before January 1, 2019. Do not allow a deduction of alimony payments when the divorce or separation agreement was created or modified on or after January 1, 2019.

d. Certain business expenses of reservists, performing artists, and fee-basis government officials. (Form 2106 or 2106-EZ)

e. Health savings account deduction (Form 8889)

f. Moving expenses (Form 3903)

g. Deductible part of self-employment tax (Schedule SE)

h. Self-employed SEP, SIMPLE, and qualified plans

i. Self-employed health insurance deduction

j. Penalty on early withdrawal of savings

k. Student loan interest deduction

Subtract the total deductions for each individual (or couple if filing jointly) from the individual's (or couple's) total gross income. This is the MAGI-based income for that individual.

3. Total Household Income

a. To determine the total household income for each individual, add together the MAGI-based income for each person in that individual's MAGI household whose income must be counted to determine eligibility. (See 440-1 Whose Income Counts for the MAGI Household)

b. Use this amount as the client's statement of income for the compatibility test to decide if the individual is eligible for CHIP.

B. Income from Electronic Data Match

To determine the countable income based on information available through electronic data matches, add income found through available electronic data matches. Use the same budgeting methodology for electronic data match (as applicable) as used to arrive at the best estimate of income using client statement.

1. Earned income:

a. Use the most current available earned income data match as long as it is from the same employer reported by the individual.

b. If the employer does not match what the individual has reported, do not use that source.

c. For earned income, follow the budgeting process defined in 430 to derive a monthly income amount.

2. Unearned income:

a. Use Unemployment Insurance income found on the data match. Prorate the total remaining UI payments over the certification period to arrive at a monthly amount.

b. Use the gross Social Security monthly benefit income found on the data match.

c. If alimony income is available through the ORS data match, use that amount.

Follow the budgeting policies in 430 to arrive at the best estimate of income.

Subtract any allowable expenses from A.2. reported by the individual from the individual's gross countable income determined through electronic data match. This is the MAGI-based income from electronic data match. Add income from all individuals in the individual's MAGI household whose income must be counted to arrive at the total household income for that individual.

C. Reasonably compatible test

1. After calculating the income based on client statement and the income based on electronic data matches, determine if the amounts are reasonably compatible.

a. For a CHIP eligibility decision, income is reasonably compatible if both the client's statement of income and the income based on electronic data match are above the income limit for the MAGI-based Child Medicaid coverage group, and are equal to, below or above the income standard for CHIP.

b. If income is reasonably compatible for a CHIP eligibility decision, do not request verification from the individual. Proceed with the eligibility determination.

c. If eligible for CHIP, the income from the electronic data match will be used to determine the CHIP plan.

Example : The individual reports monthly income of $2900. They have a household size of 4. The electronic data match verifies income of $3200 per month. Client's statement indicates CHIP plan B. The electronic data match indicates CHIP plan C. The worker uses the electronically verified amount of $3200.

2. If income is not reasonably compatible, request the needed verification of income. (See Sec. 705 .) Income is not reasonably compatible for CHIP if the client's statement and the data match income fall one above and one below the Child Medicaid income limit, even if both income amounts are below the maximum CHIP income limit. In this case, request verification from the individual to decide if the child is really Medicaid eligible or CHIP eligible.

a. For example, the income is not reasonably compatible when looking at Child Medicaid, but both amounts are below the maximum CHIP income limit.

b. Request verification of income before denying eligibility for Medicaid.

c. If the verification is not received by the end of the application or review period or the due date (whichever is longer), deny eligibility due to incomplete verification.

d. If verification is received on time, use the verified income amount to determine if the child is eligible for either Medicaid or CHIP.

3. If both income amounts are above the Child Medicaid income limit, but one is above and one is below the maximum CHIP income limit, the amounts are also not reasonably compatible. Request verification of income from the individual. Use the verified income amount to determine the child's eligibility.

4. If the individual exceeds the income limit for CHIP Plan C after the reasonable compatibility test is completed, deduct an amount equal to 5% of the 100% of the FPL for the applicable household size from the income amounts determined. If the individual meets the income limit with the 5% disregard, the individual qualifies for CHIP Plan C.

(440-6-whose-income-counts-for-magi-household)440-6 Whose Income Counts for MAGI Household?#

(440-6-whose-income-counts-for-magi-household)(block-1)Effective Date: November 1, 2021#

No Previous Policy

To determine countable MAGI-based income for each individual, decide who is included in the individual's household. Then decide whose income must count for that individual's eligibility.

A. Whose Income to Count

1. Count the MAGI-based income of every individual included in the household with the following exception.

2. Do not count income of a child or other relative who does not expect to be required to file a tax return.

3. Accept the client's statement about whether a dependent expects to be required to file a tax return unless the eligibility agency has information that contradicts the client’s statement. Only request additional verification when it appears the dependent will have enough income to be required to file a tax return.

B. Income of a Tax Dependent

There are two different classes of dependents: Child and Other Relatives (which includes certain unrelated persons.) See section 402-2 for the definition of a qualifying tax dependent. Instructions for completing a 1040 tax return explain who meets the criteria for the two classes of dependents. (See IRS website)

Most of the time, the tax filer's dependent will not have a filing requirement. They will not usually "expect to be required" to file a tax return. In that case, the income of the dependent does not count.

In some cases, a tax dependent who is required to file a tax return may still meet the tax dependent criteria. (See IRS publication 1040 Instructions for the income limits for a dependent to be required to file a tax return.) IRS Filing requirements for dependents

The tax filing income threshold for a dependent is different if the income is unearned (like interest income) or earned. The threshold is less if the only income is unearned. Refer to C. for tax dependents' filing limits.

1. Child

Even if a child expects to be required to file a tax return, the child counts in the MAGI household of the tax filer. Count the MAGI-based income of a child for the MAGI household in which that child is included only if the child is expected to be required to file a tax return.

2. Other Relative

If relative dependents are required to file a tax return, they may not qualify as a tax dependent. The income threshold to meet the criteria of being an other relative is less than the earned income filing requirement threshold.

Include the other relative's income in the tax filer's household income if the individual still meets the dependent relative criteria, but expects to be required to file.

a. If the agency has information that suggests the tax filer cannot claim an individual as a relative, do not count that individual in the MAGI household and do not count his income.

b. If the agency questions whether an individual can be claimed as an other relative, the tax filer may provide evidence to establish their claim. If the tax filer can establish a basis for claiming the person as a dependent, include the dependent in the MAGI household. Then decide if the dependent's income must be counted.

c. The income threshold to claim someone as an other relative changes each year. Do not count the dependent's Social Security income to decide if the individual meets the threshold. (See Table VII in the Medicaid Manual)

C. When a Dependent Must File a Tax Return

IRS rules set an income threshold for when a tax dependent must file a tax return. Some other rules may apply, too. In general, a person claimed by another tax filer must file a tax return if he has taxable income in excess of the IRS threshold. (See Table VII in the Medicaid Manual)

o Social Security Benefits. If a tax dependent's only source of income is Social Security benefits, the individual is not required to file a tax return. This is true even if the person receives more than the unearned income threshold. The individual would need to have other taxable unearned income or earned income in excess of the threshold to be required to file.

o For CHIP, the Social Security income of a dependent is counted only when the dependent is expected to be required to file a tax return.

(600-program-benefits)600 Program Benefits#

(600-program-benefits)(block-1)Effective Date: June 1, 2025#

Previous Policy

This section provides some general information about the type of services or benefits an enrollee may receive, and in some cases may describe some limits on certain services and the processes for obtaining certain services. Specific benefits covered by CHIP may change periodically as a result of action taken by the Department of Health and Human Services, State or Federal governments.

There are three benefit plans under CHIP. The plan is determined using the member's countable income and citizenship status. The benefits are the same under all plans, but the member's out of pocket costs are determined by which plan they are eligible to receive. Plan B - For children whose countable income is up to 150% FPL. Plan C - For children whose countable income is up to 200% FPL. State CHIP - For children whose countable income is up to 200% FPL.

CHIP benefits are provided by Medical and Dental Plans (Accountable Care Organizations (ACO)) that contract with the Department of Health and Human Services. The CHIP benefits and co-pays are the same under each plan, but providers and facilities may be different.

Enrollees should contact the customer service number for the selected health or dental plan with specific CHIP coverage questions or refer to CHIP member guide for a list of facilities and which CHIP plans are accepted ( 601 ). Members can access the CHIP member guide and co-payment summary online at: www.health.utah.gov/chip/resourcematerials.htm .

CHIP covers the following benefits: Well-child exams; Immunizations; Doctor visits; Medical emergency services; Prescriptions; Health and visions exams; Mental health services; and Dental services.

Members can view their medical coverage and health plan information online using the MyBenefits lookup tool at www.mybenefits.utah.gov .

Incarcerated CHIP members who are in a participating facility are eligible for pre-release services. Services include but are not limited to intensive case management, Medication-Assisted Treatment (MAT) services for all types of Substance Use Disorders (SUD), a 30-day supply of prescription medication upon release, lab and radiology services, targeted outpatient services, diagnosis and treatment of physical and behavioral health conditions, and screening for housing related services.

(601-health-plan-selections-and-education)601 Health Plan Selection and Education#

(601-health-plan-selections-and-education)(block-1)Effective Date: July 1, 2024#

Previous Policy

(601-health-plan-selections-and-education)(block-2)A. CHIP Education#

The Office of Managed Health Care's Health Program Representatives (HPRs) will provide CHIP education, help the members understand their CHIP benefits, and assist them with choosing a health and dental plan.

HPRs provider information on CHIP-covered services, including primary care, specialists, dental services and mental health services.

Any questions about CHIP services or covered benefits should be referred to the HPR phone number 1-866-608-9422 or members can contact their health or dental plan.

Additional information about benefits, providers, forms, and cost sharing (co-pays, deductibles, etc.) can be found online at: www.health.utah.gov/chip/ .

(601-health-plan-selections-and-education)(block-3)B. Health/Dental Plan Selection Requirement#

CHIP is administered by the Utah Department of Health and Human Services and contracts with medical and dental plans to provide health and dental services.

Individuals who are determined eligible for CHIP must enroll in a medical and dental plan before they can access their benefits or services. All CHIP members will be auto enrolled in their dental plan.

Members must enroll in a medical plan within 2 weeks of approval or a plan will be assigned to them.

Medical plan options include:

Select Health Community Care - 1-800-538-5038

Molina Health Care - 1-888-483-0760

Healthy U CHIP - 1-801-213-0525 or 1-833-404-4300

CHIP dental benefits are provided through Premier Access and members will be auto enrolled in the CHIP dental plan.

Dental plan options include:

Premier Access - 1-877-854-4242

CHIP members can select a medical plan with one of the following options:

By phone: 1-866-608-9422

Email their selection to chiphpr@utah.gov

Note: When selecting a plan via email, they must include their plan selection, case number, name of the primary individual on the case, and their contact information.

Mail the health plan selection form to:

BMHC CHIP HPR

PO Box 143108

SLC, UT 84114

Fax the health plan selection form to 1-801-237-0743

The plan selection form is included in the CHIP member guide and can be accessed online at: www.health.utah.gov/chip/resourcematerials.htm .

Once the member is enrolled in a health and dental plan, they will receive a plan specific member handbook from their selected plans. The member handbook includes an explanation of covered benefits and a provider directory.

(601-health-plan-selections-and-education)(block-4)C. Making Changes in the Health Plan Selection#

Under certain circumstances a member may change their health plan outside of the annual open enrollment period. Enrollees must contact the HPR with any specific plan requests by phone at 1-866-608-9422.

(602-cost-sharing-requirements)602 Cost Sharing Requirements#

(602-cost-sharing-requirements)(block-1)602 Cost Sharing Requirements#

Effective Date: July 1, 2026

Previous Policy

Most CHIP clients have cost sharing requirements with some exceptions. Cost sharing includes deductibles, co-payments, and coinsurance. The amount the client is required to pay is determined by the CHIP benefit plan for which they qualify .

Households that have children who qualify for different CHIP benefit plans will be assigned the lower out of pocket max and copay of the eligible plans.

Exception: If the household has children on both CHIP and State CHIP, they will be assigned the lower out of pocket max but will still have plan C copays.

A. Quarterly Premiums

There is no quarterly premium.

B. Co-Payments, Coinsurance and Deductibles

Most CHIP clients are required to pay co-payments, coinsurance and deductibles for medical and dental services. Copayments, coinsurance and deductibles are types of cost sharing fees the client is required to pay for services covered by their health plan.

A copayment is a fixed amount the client is required to pay for covered health care services and can vary by the type of covered services. The amount of the co-payment depends on which plan the client qualifies for ( 600 ).

Coinsurance is a percentage of the allowed amount that the member is required to pay (usually after the deductible for covered health care services). The percentage will vary by the plan and type of covered service.

A deductible is the amount the client is required to pay for covered health services before the health plan begins to pay.

Clients can view co-payment information and the types of services that require a co-payment at: www.health.utah.gov/chip/resourcematerials.htm .

C. Out-of-Pocket Maximums

Individuals enrolled in CHIP are not required to pay more than 5% of the household’s countable income for out-of-pocket expenses during the certification period with the exception of State CHIP (see table I-B for State CHIP). The maximum amount is per family, not per child. DHHS’s payment system keeps track of the member’s incurred expenses including their out-of-pocket maximum for each certification period.

If a 5% disregard was applied in the calculation of countable income, the amount of income before applying 5% disregard is the income used in determining the out-of-pocket maximum.

The eligibility system will calculate the maximum out of pocket amount for co-payments and deductibles the client will be required to pay for the certification period. The CHIP approval and renewal notices will include the maximum out of pocket amount. To determine their out-of-pocket maximum, take the total annual income and multiply that by .05.

Example: If the client’s annual countable income is $25,800.

$25,800 times .05 = $1,290, this means that $1,290 is the family’s maximum out of pocket amount for the entire certification period.

Once the household has met their annual co-pay and deductible maximum, they no longer have to pay co-pays, coinsurance, or deductibles for that benefit period.

If the Out-of-Pocket Maximum has been met and a due process month is issued, the co-pay, coinsurance, and deductible exemptions are extended in the due process month(s).

D. Cost Sharing Exemptions

Verified American Indian/Alaska Native individuals are not required to pay co-payments, deductibles, or coinsurance. The tribe must be recognized by the Federal government. The definition of who is an American Indian/Alaska Native is defined by the tribe.

See Table VI for acceptable verification of American Indian/Alaska Native Status and how to verify if the tribe is recognized by the United States Bureau of Indian Affairs. Applicants : Allow CHIP coverage with the cost sharing exemption upon approval when an individual declares to be an American Indian/Alaska Native, a descendent or a tribal member or have federal Indian status, and there is no evidence that contradicts their claim.

Give the client reasonable time to provide documentation of their status. "Reasonable time" is at least 95 days. A client may request more time if needed.

If the client has been given reasonable time and does not provide the documentation or proof that they are working on obtaining it, remove the exemption with proper 10- day notice.

Recipients: Allow the exemption when a member makes a new declaration to be an American Indian/Alaskan Native, a descendant of a tribal member or have federal Indian status.

Example: At application the individual declares to be Native Hawaiian or Other Pacific Islander and was approved for CHIP. The member then contacts the Eligibility Agency and declares to be an American Indian/Alaska Native. The member is given reasonable time to provide required documentation.

Give the client reasonable time to provide documentation of their status. “Reasonable time” is at least 95 days. A client may request more time if needed. If the client fails to provide the verification or proof that they are working on obtaining it, remove the exemption with proper 10-day notice.

If verification of a person's American Indian/Alaska Native status is received at any time, allow the exemption starting the month verification is received.

(701-1-what-is-an-application)701-1 What is an Application?#

(701-1-what-is-an-application)(block-1)Effective Date: March 1, 2022#

Previous Policy

The Federally Facilitated Marketplace will only accept the Federal Single Streamlined application, online or on a paper application.

The Medicaid agency will accept applications in the following ways:

A. Paper Application for Medical Assistance

1. All paper applications must have an original signature. The agency will consider the following as an original signature:

a. Signed paper application received by mail or in person at a DWS employment center.

b. A signed paper application sent by FAX.

c. A telephonic signature

2. If the agency receives an unsigned paper application, the agency will send a signature page to the applicant to sign and return.

B. Online Applications for Medical Assistance

1. Applicants may apply online .

2. The online application process includes an online signature that meets state law as a legal signature. The applicant must complete the online signature for the application to be valid. Electronic, handwritten or telephonic signatures transmitted via any other electronic transmission must be accepted.

C. Federally Facilitated Marketplace (FFM) Account Transfers

1. A pplicants have the option to apply for medical assistance through the state Medicaid and CHIP agency or through the single streamlined application through the FFM.

2. For individuals assessed eligible for Medicaid/CHIP by the FFM, their account will be transferred to the state Medicaid/CHIP agency for a final determination. This may include an initial application, a FFM review or a change report through the FFM. (See section 220-9 to determine what actions to take to coordinate with FFM plans.)

D. Non-Medical Review Forms as Applications

Households with an open non-medical assistance case may use the review form as an application for medical programs. The review form must be signed.

1. The individual or worker must write on the review form what assistance the individual wants to apply for.

2. The individual or worker can write a new household member’s name on the review form and state the individual wants to apply for medical assistance for that person.

3. The review form with the request for assistance must be submitted to DWS.

E. Telephone Applications

1. Applicants may ask to apply by telephone.

2. I ndividuals must complete all eligibility sections, including the TPL information of an application.

3. The applicant must sign within the application processing period. The applicant may sign by

a. Telephonic signature

i. Documented and stored by the agency.

ii. A confirmation receipt will be sent to the applicant via the communication method they have selected.

b. Mailed application returned no later than the last day of the application processing period received

· In person

· By mail or

· Fax

F. Verbal Request to Add Medical Assistance to a Pending Application

1. An applicant who has a pending application for other types of assistance may make a verbal request to add CHIP to the application.

2. The applicant must make the verbal request while the application for other assistance is still pending, and within 30 days of the application date. If the 30th day is a non-business day, the applicant has until the first business day following the 30th day to make the verbal request. The date the applicant makes the verbal request to add CHIP is the date of application for medical assistance.

3. If the agency has approved or denied the application for other assistance, or if it is more than 30 days after the application date, the applicant cannot make a verbal request to add CHIP. The applicant must submit a new application to request medical assistance.

G. The Following Situations are Considered New Applications, but do not Require an Application Form

1. A household with an open medical case can add a new household member by contacting the eligibility agency. Request information about the new household member as needed to determine eligibility. A signature is not required. TPL information for the new household member must be requested and the voter registration option must be offered to a new adult household member.

2. When medical assistance ends because the individual did not return requested verification for a change report, the date the individual provides all of the requested verification is a new application date if it is submitted by the last day of the month immediately following closure. A signature is not required. TPL, voter registration and rights and responsibilities information can be waived.

3. If medical assistance ends for failure to complete the review, an individual can re-apply by responding to the review request within 3 months following the review closure. No signature is required.

· The response may be a phone call, submission of the review papers or verification documents.

· If the individual provided updated TPL information during the failed review period, do not request it again to complete the review.

· TPL, voter registration and rights and responsibilities information can be waived if the worker completed these in the review period.

4. When an application is denied because the applicant fails to provide all requested verification, the applicant may provide all of the requested verification within 30 days of the denial notice date. The date the verification is received is a new application date. No signature is required. TPL, voter registration and rights and responsibilities information can be waived. If a medical assistance case is closed for more than one calendar month, the individual must complete and sign a new application form.

H. Unsigned Applications

If the agency receives an unsigned application for medical assistance, require the applicant to complete the signature page. If the applicant completes and returns the signature page within the application-processing time, retain the date of application. (See Section 701-2 ) If the applicant does not return the signature page within the application-processing time, the agency will deny the application.

· If the individual returns the completed signature page within the 30 days following the date the denial notice was mailed, consider the date of receipt a new application date with a new retroactive period.

I. Incomplete Applications

When the application is not complete enough for the agency to determine eligibility, the agency will contact the applicant and offer ways for the applicant to complete the form. The applicant must complete the form by the end of the application-processing period or the agency will deny the application.

(701-2-date-of-application)701-2 Date of Application#

(701-2-date-of-application)(block-1)Effective Date: September 1, 2026#

Previous Policy

The eligibility agency must establish the date of application to determine when CHIP coverage can begin.

Establish the date of application as follows.

A. Paper Applications

1. The date of application is the date the eligibility agency receives a completed, signed application by the close of business on a business day.

2. When an applicant leaves a paper application at an eligibility agency office, other than an outreach location, after business hours, the date of application is the next business day.

B. Applications Received Through the FFM

1. The date of application for an application transmitted from the FFM is the date the application was received by the FFM. See section 220-9 for effective dates.

2. The 30-day processing period begins on the date DWS receives the electronic case from the FFM.

C. Applications Sent Via FAX

1. When the eligibility agency receives an application sent by FAX on a business day by the close of business, the date of application is that day.

2. When the eligibility agency receives an application sent by FAX after the close of business, or on a state holiday or weekend, the date of application is the next business day.

D. Applications received via email

When the eligibility agency receives an application sent by email on a business day by the close of business, the date of application is that day.

When the eligibili ty agency receives an application sent by email after the close of business, on a state holiday, or weekend, the date of application is the next business day.

E. Applications Received Online Through the "myCase" System

The application date for an application received online through " myCase " is the date the application is filed online.

F. Applications received at Outreach Locations

1. When the agency receives an application at an outreach office location during business hours, the application date is the date the application is received by the outreach worker.

2. When the agency receives an application at an outreach office location when the office is closed, the application date is the last business day that a DWS staff person was available at the outreach office to accept or collect applications.

G. Verbal Request

If an applicant for other types of assistance makes a verbal request to add medical assistance to a pending application within 30 days of the application date of that pending application, the date of application for medical assistance is the date of the verbal request.

H. Ineligible in Application Month

If an applicant is ineligible for medical assistance in the application month, the agency may use the same application form to determine eligibility for the following month. In this case, the new application date is the first day of such following month. (See section 701-3 )

I. Unsigned or Incomplete Applications

1. If the eligibility agency receives an unsigned application, the applicant must provide a signature within the application-processing period (See section 701-5 ) to retain the original application date. The agency will notify the applicant of this requirement.

2. An applicant who files an application online must complete the online signature. If the applicant fails to complete the online signature, the eligibility agency will send a signature page to the applicant. The applicant must sign and return the signature page within the application-processing period (See section 701-4 ) to retain the application date of the online application.

3. If the eligibility agency receives the signature page within 30 days after sending the denial notice for lack of a signature, the date the agency receives the signature page is the new application date. If the agency receives the signature page more than 30 days after denying the application, the applicant will have to reapply.

4. If an application is incomplete, the eligibility agency contacts the applicant and offers ways for the applicant to complete the application. The application must be completed by the end of the application-processing period, or the agency will deny the application. If the applicant completes the application in the 30 days after the agency denies the application for being incomplete, the new application date is the date the application is completed. A new application-processing period begins on the new application date.

J. Phone Application

When a worker completes an application over the phone with an applicant, the date of application is the date the worker takes the application over the phone. The applicant must physically, electronically or verbally sign within the application-processing period to retain the original application date. The eligibility agency follows the provisions of M. below, if it receives the signed signature page after the agency has denied the application.

K. Adding Someone to an Open Case

When the household already receives medical assistance for some household members, the application date is the date the household requests medical assistance for a new household member by the close of business on a business day. If the request is mailed to the office, the date of application is the date the eligibility agency receives the written request. Use the same rules if the member asks to change to Medicaid from CHIP or the UPP program.

L. Applications Received When An Application Is Already Pending

1. If a new application is received while an application is already pending, the application date does not change.

2. The agency reviews the second (or third, etc) application for any new information.

3. If new information is discovered or needs to be addressed, it becomes a part of the already existing application process.

M. Applications Received After Medical Benefits Are Issued

1. Review the new application for changes and new information.

2. If new information is discovered, and no new household members are requesting medical assistance, consider the new application to be a change report and take appropriate action. (See section 804 )

N. Application Dates for Cases Closed or Denied

1. For denied applications, the date the individual provides all requested verification is a new application date. Allow application time frames.

2. See section 704 for cases closed at review.

(701-3-effective-dates-of-certification)701-3 Effective Dates of Certification#

(701-3-effective-dates-of-certification)(block-1)Effective Date: June 1, 2025#

Previous Policy

A. New CHIP Applicants

CHIP enrollment begins the first day of the month in which the application is received. If any family member is enrolled in an FFM plan see section 220-9 to determine the effective date for CHIP. Exceptions to benefits starting on the first day of a month: The individual applies during the first four days of the month and the 4-Day Grace Period is allowed. The application date is within 60 days of birth, adoption, or foster care placement and another household member is covered by an FFM plan ( 220-9 ). The application date is within 60 days of birth, adoption, or foster care placement and another household member is covered by CHIP ( 804-3 ). The individual is enrolled in health insurance coverage that terminated involuntarily or COBRA coverage ends during the application month, in which case eligibility begins the day after the health insurance coverage ends. The individual moved to Utah to take up residency during the application month, in which case eligibility cannot begin before the date the person arrived in Utah. The individual is a qualified alien who was subject to the five-year bar for CHIP during the application month, in which case eligibility cannot begin before the date the five-year-bar ended. The individual became a qualified alien who was not subject to the five-year bar during the application month, in which case eligibility cannot begin before the date the individual became a qualified alien. The individual is discharged from the State Hospital or other IMD, in which case eligibility cannot be earlier than the date the person was released.

A pregnant woman who is in her third trimester of pregnancy may apply for CHIP for her unborn child even if she has no other children. The effective date is the date of birth. See section 230-1 for information on household composition.

If the applicant is not eligible for the application month, the same application can be used to determine eligibility for the following month. When denying the original application month and determining eligibility for the next month, the application date and the benefit effective date changes to the first day of that next month, subject to the following exceptions.

A Medicaid or UPP recipient reports a change that causes the member to no longer be eligible for Medicaid or UPP, but the member does qualify for CHIP. The effective date of coverage for CHIP is the first day of the month immediately following the Medicaid or UPP closure.

B. Four Day Grace Period

When an application is received during the first four days of a month and a child has a medical need, allow a grace enrollment period beginning no earlier than four days prior to the date an applicant submits a completed and signed application.

To receive the coverage, the applicant must have been unable to apply during the last four days of the previous month because of an emergency situation.

The applicant must request that eligibility be determined for the grace period before the application process is completed. If they fail to request it until after their application is approved, they are not eligible for the grace period coverage.

All factors of eligibility must be met in the grace period.

Consider eligibility for the Child Medically Needy program when the grace period does not match the dates of medical need.

Examples

#1: An application is received on April 1 for CHIP. The child had a medical need on March 28. The grace period and CHIP coverage can go back to March 28.

#2 The application is received on July 3. The child had a medical need on June 27. The earliest date for the grace period is June 29. Consider Child Medically Needy coverage for the month of June.

(701-4-what-to-do-with-an-application)701-4 What to do with an Application#

(701-4-what-to-do-with-an-application)(block-1)Effective Date: November 1, 2024#

Previous Policy

Each application must be processed to a decision for every applicant unless:

The individual and other household members are already on the most beneficial medical program. (See section 102-1 when a new medical application is received for an open CHIP case.) If no better coverage is available, document that no action was taken on the application.

The individual has already applied and that application is still pending. (See section 102-1 .)

The individual withdraws the application.

The individual cannot be located, in which case deny the application. If the individual contacts the agency before the end of the application-processing period, resume the application process.

Deny applications that do not meet the signature requirements within the application-processing time as an incomplete application. Do not make a determination of eligibility. See section 102-1 and 701 on who can apply and how to get the best signature.

All applicants have the right to register to vote at application ( 101 ).

Determine if any child applying for CHIP is eligible for coverage under Medicaid.

A child who is eligible for Medicaid is not eligible for CHIP.

A child enrolled in an FFM plan may be eligible for CHIP if determined ineligible for Medicaid ( 220-9 ).

A child who is only eligible for Medicaid with a spenddown and chooses not to pay it may be eligible for CHIP. (If an individual wants Medicaid with a spenddown, additional verification may be needed to determine eligibility. Determine CHIP eligibility for any applicant who has applied for Medicaid, but was found ineligible. A new application is not required.

Screen the application and address all factors of eligibility. 705 details the various methods of verification.

Request any needed verifications.

An interview may be helpful in gathering information, but is not required.

If the applicant has expenses and not enough income to cover them, the applicant must verify how they are meeting their expenses ( 705 ).

If the application has health insurance listed, the agency must determine if insurance is an FFM plan ( 220-9 ).

(701-5-eligibility-decisions)701-5 Eligibility Decisions#

(701-5-eligibility-decisions)(block-1)701-5 Eligibility Decisions#

Effective Date: July 1, 2024

Previous Policy

A. Deadline for determining eligibility

1. The eligibility worker must make an eligibility decision within 30 days of the date of the application. In the case of an application received through the FFM, make the decision within 30 days from the date the individual’s electronic account was received. Determine eligibility for MAGI programs first, including CHIP, before looking at non-MAGI or medically needy programs.

a. Applicants may request more time to provide verifications before the end of the application period.

b. If you cannot make an eligibility decision by the deadline, document the cause of the delay.

2. If unverified eligibility factors do not affect the eligibility of the entire household, approve the application for those household members determined eligible. For example, the individual has not given proof of alien status for one child. Do not approve the application if unverified eligibility factors affect the whole household. (For example, the wages of a working parent are unverified.)

a. Take steps to obtain the unverified eligibility factors.

b. If the applicant does not respond to the requests by the deadline, or by the end of the processing time, whichever is longer, deny the application.

3. If the applicant asks for more time to provide verifications before the end of the application processing time, OR the agency asks for more information, give the individual at least 10 more days to provide the verifications, extending the application time as needed to give the individual time to return verifications.

4. When verifications are received that show the applicant is ineligible, deny the case.

a. You do not have to wait until the end of the 30- day period to send the denial notice when you have proof the individual is not eligible.

b. Do not deny the application before the end of the 30-day processing period if verifications have not been received. Instead, wait until the end of the application processing time before denying for lack of verifications.

5. If the applicant returns verifications within 30 days after an application has been denied, use the date the verifications are received as a new application date.

a. The individual does not have to complete a new application form; however, document the new application date.

b. Determine the CHIP grace period based on the new application date if the child has a medical need. (See Sec. 701-2 )

B. Withdrawal of an Application

1. An applicant may withdraw an application for any reason at any time prior to a decision being made on the application.

2. Encourage the applicant to write a statement to withdraw the application.

3. If the applicant does not write a statement, document the request in the case notes.

4. Properly deny the application and send a denial letter to the applicant stating that the reason for the denial is that they withdrew the application.

C. Documentation of Decision

Document the eligibility decision.

1. If the application is denied, note the date and the reason for the denial.

2. If the application is approved, indicate the date and the medical assistance programs approved for the various household members. If some members are approved and others denied, clearly narrate this.

D. Notification of Approval or Denial

When the application is approved or denied, notify the applicant in writing of the approval or denial. If different decisions are made for different household members, address each decision in the notice or notices.

1. If the application is denied, state the reason for the action and give the policy citation for the denial reason.

2. Tell the individual where to call if the individual has questions or concerns.

E. Transferring an Electronic Account to the FFM

Individual information will be transferred to the FFM if the application is denied.

(702-re-opening-chip)702 Re-Opening CHIP#

(702-re-opening-chip)(block-1)Effective Date: January 1, 2024#

Previous Policy

You may re-open CHIP when:

The case was closed because of an administrative error within the last 12 months. Re-open the case back to the date of closure. Do not require the enrollee to complete a new application.

The case was closed for failure to complete the review. The enrollee must complete the review process and provide all requested verifications by the last day of the review month. If the case closes at the end of the review month, re-determine eligibility if the individual submits the review within 3 months of case closure. This date is a new application date and allows for application time frames to provide verification. The effective date is the first day of the month the review/application is received.

The case was closed in a non-review month for failure to provide requested information or verification and the information is received by the end of the month of closure, continue with the eligibility determination. Do not require the enrollee to complete a new application. See section 704 . If the agency can complete the eligibility determination and send 10-day advance notice of an adverse change, the effective date is the following month. If the agency cannot complete the eligibility determination and provide 10-day advance notice of an adverse change before the end of the month, continue benefits to the following month. (See Section 803 .)

The case was closed because a parent was activated to military duty, so the children became eligible for military insurance coverage. If there are still months left on the original certification period, do not require a new application. If the certification period has expired, the individual must complete an application and provide verification of their current circumstances.

An enrollee became eligible for Medicaid because they were removed from the home and placed in foster care. When the child is returned to the home, if there are still months left on the original certification period, do not require a new application. If the certification period has expired, the individual must complete an application and provide verification of their current circumstances.

(703-1-length-of-the-certification-period)703-1 Length of the Certification Period#

(703-1-length-of-the-certification-period)(block-1)Effective Date: June 1, 2025#

Previous Policy

The certification period for CHIP is 12 months. Once a child is determined eligible for CHIP, the child remains eligible for the entire certification period, with few exceptions.

Exceptions to the 12-Month Certification Period

In the following situations, eligibility may change or end before the end of the 12-month certification period if a member:

turns age 19 before the end of the certification period (see section 210 );

moves out of state;

dies;

Change in immigration status;

The member requests voluntary termination;

The member is eligible for Medicaid and requests to move programs.

The covered child is pregnant or in the 12 month postpartum period;

Requests a redetermination of eligibility and becomes eligible for another medical program, such as Medicaid without a spenddown or MWI premium. (See Section 703 );

Reports a change that was required to be reported at review which causes a change to eligibility for the new certification period; (See Section 102-3 )

The agency determines that eligibility was determined incorrectly at the most recent determination or redetermination of eligibility because of agency error or fraud, abuse or perjury attributed to the individual;

When to Allow a Due Process Month

Reviews - If you cannot give 10-day notice before determining eligibility, extend benefits to the following month. This month is not part of any certification period. (See Sections 704 & 803 )

Change Report - When you cannot give 10-day notice for an adverse action, continue benefits to the following month. This month remains part of the current certification period.

When to Establish a New 12-Month Certification Period

The enrollment period for CHIP must be re-determined at 12 months. A new 12-month certification period may be established when:

A review is completed and ongoing eligibility for CHIP is established.

The agency receives a report of a change that occurred before 10-day notice in the review month. The change affects the eligibility decision made at the review.

A member requests an income redetermination and they become eligible for a lesser cost CHIP plan (i.e. Plan C to Plan B).

A member requests an income redetermination when completing a review on another program and all information needed to determine CHIP eligibility has been provided and CHIP eligibility does not change to a higher cost plan (Plan B to Plan C).

When a new application is submitted and CHIP eligibility has been re-determined. (See section 804 to determine what actions to take on changes)

(703-certification-period)703 Certification Period#

(703-certification-period)(block-1)Effective Date: January 1, 2024#

Previous Policy

A child who is eligible and covered by CHIP receives 12-months of continuous eligibility. With some exceptions, the certification period begins with the first day of the month a completed and signed application is received if the applicant is determined eligible for CHIP.

See Section 701-2 and 220-9 for exceptions.

The certification period for CHIP is 12 months see section 703-1 for exceptions.

If the four day grace period coverage is approved, the certification period does not count those days as a month in the 12 month period.

Covered services the child received on or after the effective date of eligibility are payable by CHIP as long as the child remains covered.

The last month of the certification period is the review month.

If changes are discovered or reported during the 12 month certification period, only act on the information when the enrollee requests a Medicaid determination, asks for a new income redetermination, or the reported change is an exception to the 12 month certification period. Otherwise, only take action on changes at review or when a medical application is received. See sections 703-1 and 804 for more information on changes.

Request for an Income Redetermination or Medicaid : If an enrollee submits a new application, asks for Medicaid (in person, via phone, fax, email, in writing), or asks for a new CHIP income determination, redetermine the child’s eligibility for a better benefit. Determine the effect of the change on each child and take appropriate action. If the child is Medicaid eligible, end CHIP coverage and move the child to Medicaid.

If the change is a decrease in income and it makes the enrollee eligible for a lesser cost CHIP plan (i.e. Plan C to B), make the change effective the month of report when verified timely. Begin a new 12 month certification period. If not verified timely, make the change effective the month it is verified.

If the change is a decrease in income and it makes the enrollee eligible for Medicaid (without a spenddown or MWI premium), close CHIP and open Medicaid effective the month of report when verified timely. If not verified timely, make the change effective the month it is verified.

If the change is an increase in income and would make the enrollee ineligible for CHIP, continue CHIP through the end of the certification period.

No Request for Income Redetermination or Medicaid : Only make a change at review. If the enrollee reports an income change only, do not determine eligibility for a lower CHIP Plan or Medicaid. Continue CHIP through the end of their certification period. See Section 804-5 for more information about reported changes and Section 201-1 for Medicaid eligibility screening. Example: Enrollee reports via MyCase a decrease in hours worked. The enrollee has not asked for a better CHIP plan or Medicaid. The CHIP program continues through the end of the current certification period. If the change becomes known through interface matches or tasks, continue the certification period and take action at review.

(704-1-ex-parte-reviews-reviews-not-requiring-member-participation)704-1 Ex Parte Reviews (Reviews Not requiring Member Participation)#

(704-1-ex-parte-reviews-reviews-not-requiring-member-participation)(block-1)704-1 Ex Parte Reviews (Reviews Not requiring Member Participation)#

Effective Date: March 1, 2023

No Previous Policy

The eligibility agency must attempt an ex parte review on all CHIP programs. This is a redetermination of eligibility based on current, reliable information without the member participation.

A. Completing the Ex Parte Review

1. Use current electronic data sources and reliable case information to complete the review without contacting the member.

a. Determine if the electronic information can be used to update the case file (706).

b. Electronic income not previously reported may be verified if there is enough information to complete a best estimate.

· At least one full quarter of wages is needed to complete a new best estimate.

2. Any form of verification (705) may be used as long as it does not involve requesting information from the member, such as, electronic verification or collateral contact.

3. Do not change income that cannot be verified by an electronic data source if they are not questionable or have already been verified through another source within the last 6 months.

· This includes income such as alimony, cash contributions, or child support payments.

4. Signatures are not required for ex parte reviews.

5. Members can be moved between programs during an ex parte review.

· If moving to Medicaid, members cannot be moved to a Medically Needy, MWI, on UPP program, nor can they be moved to the NH or LTC Waiver programs if they have a contribution to the cost of care. Member participation is required (704-2).

6. Collateral contact should be made by phone when access to affordable health insurance has not been verified in the last 6 months or the agency is questioning access to affordable health insurance. If unable to obtain the necessary information after an attempt is made:

· Complete the ex parte determination, update eligibility, and set a new certification period.

· Send a notice requesting verification of the access to affordable health insurance.

· Give the member at least 10 days from the date of the notice to return verification. If verification is received, make any necessary updates and redetermine eligibility. If verification is not returned by the due date, close with proper notice. Closure should not occur prior to the end of the previously renewed certification period.

7. Set the certification period as the month after the review month (703).

8. If the member responds to the ex parte review notice of decision, treat the response as a change report (804 and 102-3).

B. When Member Participation May be Required

Below are examples when member participation may be required if you cannot gather the information without member participation (i.e. by electronic verification, collateral contact, etc.):

1. If a member would lose eligibility for all medical programs, do not close the current program. Member participation must be required (704-2).

2. If a data match finds income that has not been reported and there is not information to complete a best estimate of income, such as not having a full quarter of wages.

3. If income cannot be verified electronically or has not been verified by a reliable source within the last 6 months and is subject to change on a regular basis (i.e. Yearly COLA for retirement income, self-employment or rental income).

(704-2-reviews-requiring-member-participation)704-2 Reviews Requiring Member Participation#

(704-2-reviews-requiring-member-participation)(block-1)704-2 Reviews Requiring Member Participation#

Effective Date: January 1, 2024

Previous Policy

1. Members must participate in the CHIP review process when it’s been determined an ex parte review cannot be completed. Participation can begin as soon as it is determined an ex parte review is unsuccessful.

2. The agency will send a pre-populated review form to the member in the month before the review month. The review form will explain the review date and what the member is required to do to complete the review process. Signatures are required on reviews that require member participation and follow the same rules as application signatures found in section 102-1.

a. If the member completes the review form by the due date or during the review month, a written request for needed verification must be sent to the member. The agency must allow the member at least 10 days to provide the requested verification.

b. If the member does not return all requested verification by the due date, eligibility ends at the end of the month for which the eligibility agency gave 10-day notice.

c. The member has three months after the effective closure date to complete the review without having to re-apply.

3. If the agency cannot give 10-day notice before deciding eligibility for a new enrollment period, extend benefits to the following month; this is called the “due process month”. (See Section 803 for exceptions to 10-day advanced notice.)

· For a CHIP eligible child who turns age 19 before or during the review month, benefits cannot be extended during the eligibility review, unless the child became pregnant while covered by CHIP and has not completed their 12 months of postpartum coverage.

4. If the member provides all the requested verifications either by the verification due date or after the due date but before the end of the review month, the eligibility agency will proceed with the eligibility decision.

a. The agency continues eligibility into the following month (the “due process month”) while it makes a decision if needed.

b. Do not end or adversely change eligibility until the end of the month for which the eligibility agency can give 10-day notice. This includes changing CHIP plans from B to C.

5. If eligibility continues into the due process month, the member must provide verification by the verification due date.

a. If the member provides verification by the due date, complete the review and send the notice of the eligibility decision. Do not end or adversely change eligibility until the end of the month for which the eligibility agency can give 10-day notice.

b. If the member provides verification by the due date but the agency cannot complete review and notify the member of an adverse action before 10-day notice, approve a second due process month. Complete the review and send a notice of decision.

c. If the member fails to provide verification by the due date, close the case effective the end of the due process month and send notice of decision.

d. If the member provides verification after the due date but before the end of the due process month, the date verifications are received is a new application date. If eligible, benefits are effective the first day of the month after the due process month.

6. If additional verification is requested, give the member at least ten days to provide the verification. Approve a second due process month if needed.

7. If the member fails to complete the review process the case will close because the member failed to complete the review.

Eligibility ends at the end of the month in which proper notice can be sent.

The member has three months following the closure date to complete the review without submitting a new application.

If eligibility is extended into a due process month, the three-month period begins the month after the due process month.

The benefit effective date is the first day of the month in which the member contacts the eligibility agency or submits all previously requested verification.

There is no retroactive benefit for CHIP.

The member may request coverage for the 4-day grace period (See Section 701-2 ).

An interview or application form is not required.

Eligibility does not continue while the agency makes a decision.

Application processing timeframes apply.

If the member provided updated TPL information during the failed review period, do not request it again to complete the review.

If the member fails to respond within the three months after the case closes for failure to complete the review, require a new application.

If an overpayment investigation determines individuals were not eligible in the review month and a due process month was issued, the referral must include the due process month (See Section 806-2 ).

To determine what action to take for changes reported after the review requiring member participation is completed, see section 804 and 102-3 .

(704-eligibility-review)704 Eligibility Review#

(704-eligibility-review)(block-1)704 Eligibility Review#

Effective Date: November 1, 2024

Previous Policy

An eligibility review is the process of gathering and verifying all factors of eligibility to determine if a member remains eligible.

Reviews are required for all CHIP programs once every 12 months, and no more frequently than once every 12 months.

Exception: the member became pregnant while covered by the CHIP program. See section 222.

The eligibility agency must begin the review process early enough that a redetermination can be made before the end of the current certification period.

The agency must use all reliable information available, such as electronic data sources. Reliable information may also include:

Information received within the last 6 months from other benefit programs or reliable sources for the determination as long as no discrepancies are identified (e.g., information provided in the Supplemental Nutrition Assistance Program (SNAP) recertification (705).

Available information in the members’ account that is recent and reliable.

Information from the initial determination at application or the member’s last renewal if it relates to circumstances that generally are not subject to change (e.g., citizenship or satisfactory immigration status).

The eligibility agency must attempt a redetermination of benefits based on current, reliable information without requiring any information from the member (ex parte review see 704-1).

Any form of verification may be used as long as it does not involve asking the member. (705)

Members may move between medical programs during the ex parte review.

If available information is insufficient to determine continued eligibility, member participation in the eligibility review is required (704-2).

If an ex parte review has not been attempted and an eligibility review (online, telephonic or pre-populated) has been completed, the ex parte must be attempted before using the completed eligibility review. If the ex parte can be completed, use the completed eligibility review as a change report form (804). If the ex parte cannot be completed, use the eligibility review form to complete a member participation eligibility review 704-2).

If unable to complete the ex parte review, member participation is required (704-2).

See 703 for length of a certification period.

See 435 for budgeting of income.

See 804 and 102-3 for changes during the certification period.

(705-2-what-is-acceptable-verification)705-2 What is Acceptable Verification#

(705-2-what-is-acceptable-verification)(block-1)Effective Date: June 1, 2026#

Previous Policy

Acceptable Verification

Verify items of eligibility by electronic match before asking an individual to provide verification. If data is not available through any electronic data system or the electronic data received is different than what the individual has told you, ask the individual for an explanation. If needed, ask for hard copy documentation.

Electronic Data Sources

Use the electronic data sources ( 706-1 ) to verify:

Citizenship/identification

Immigration/non-citizen status

Social Security Number

Other financial and non-financial items of eligibility.

Client's Statement

You may accept client statement to verify most eligibility items. Only require other verification from the individual if you have reasonable data to suggest that the client’s statement is not accurate, and for items where client statement is not allowed.

You must accept client statement for proof of pregnancy and the number of children expected.

Accept client statement of residency in Utah unless the agency has information that conflicts with such statement.

Follow policy 803-2 if any electronic data source including the National Change of Address (NCOA) or any imaged documents such as pay checks and/or bank statements show an out of state address.

Exceptions for Special Circumstances

We may accept client statement, on a case by case basis, for almost all eligibility criteria when documentation does not exist at the time of application or review or is not reasonably available. This may apply in the case of individuals who are homeless or have experienced domestic violence or natural disaster.

This special circumstance never applies to citizenship and immigration status.

For a case by case exception:

The eligibility worker will forward the special circumstance request and all supporting documentation to the Office of Eligibility Policy (OEP). OEP will review the request and the supporting documentation to determine if a special circumstance exists.

Eligibility workers must

Verify all eligibility items that are reasonably available.

Document in the case notes:

Why the special circumstance was requested.

If the special circumstance was approved or denied.

OEP will inform the worker when to review the exception for special circumstances.

In the event of a larger scale event that affects more than just one case, BEP may issue a statement to DWS approving this exception for these cases. The statement will also notify DWS of the duration of the exemption.

When Client Statement is not Allowed

Citizenship/immigration status : Citizenship and immigration status must be verified by electronic verification first. Request hard copy verification when a match is not received through the electronic interface. See Table IV for acceptable sources.

Income : Verify household income with electronic data sources first. If income cannot be verified through a computer match, or the electronic data is not reasonable compatible with what the individual has told you, ask the individual for an explanation and request hard copy verification, or make a collateral contact with the employer or the entity providing the income to the individual. For self-employment income see 410-2.

Hard Copy Verification

Request hard copy verification when you cannot obtain the information in another way such as through reliable computer matches. When an eligibility factor has been verified do not re-verify that eligibility factor unless it is subject to change or if you have current information that contradicts the accuracy of the verification. Examples of eligibility factors that are not subject to change are citizenship, date of birth, and relationship (except for when marital status changes).

Collateral Contacts

A collateral contact is when a worker contacts a third party to verify an eligibility factor. A third party may include medical providers and employers, or a family member or friend whom the individual has given the eligibility agency permission to contact to validate information. Contact may be made over the phone and properly documented. A signed disclosure form may be requested by the third party before information can be released to you ( 705-4 ) .

(705-4-verification-from-collateral-contacts)705-4 Verification from Collateral Contacts#

(705-4-verification-from-collateral-contacts)(block-1)705-4 Verification from Collateral Contacts#

Effective Date: January 1, 2018

Previous Policy

(705-4-verification-from-collateral-contacts)(block-2)What is a Collateral Contact#

A collateral contact is when you contact a third party to verify an eligibility factor. A third party may include medical providers, employers, family members or friends whom the individual has given us permission to contact to validate information. Contact may be made over the phone and properly documented, or by sending a release of information asking for the needed information.

(705-4-verification-from-collateral-contacts)(block-3)Requesting Collateral Contact#

If the individual cannot obtain the verification , suggest other possible sources. Try to help the individual. You may contact an agency, organization, or other people by telephone, letter, or in person to get verification. These other sources of verification are called collateral contacts.

Some collateral contacts may be made without permission from the enrollee, but they should be told that the contact will be made.

A collateral contact with an employer must include the employer or business name, the phone number and the name of the individual who was contacted and the date of contact.

An employer may verify wage information, frequency of pay.

A collateral contact with some other entity or person who is providing income to the individual must document similar information about the source, amount and frequency.

Get written permission from the enrollee before contacting State or Federally chartered financial institutions about financial transactions or other information about the individual's financial condition. Use the form 114 Authorization to Release Information and Release from Liability .

If the enrollee refuses to get the needed verification from collateral sources or refuses to consent to collateral contact, deny or close the case.

(705-verification)705 Verification#

(705-verification)(block-1)Effective Date: January 1, 2018#

Previous Policy

Previous Policy (705-1 was incorporated into 705 as of January 1, 2018)

A. Verification

The eligibility agency must use all available resources to determine eligibility for medical programs. The applicant or recipient is responsible for obtaining acceptable verification when the eligibility agency cannot access the information. Help the individual to get the verification if the individual needs help.

If the individual cannot obtain appropriate verification, the eligibility worker will make necessary contact on behalf of the individual to verify information. Document these contacts in the case record. If a third party is unwilling or unable to cooperate with an agency request, the worker will investigate other methods of verification with the individual.

The eligibility agency is required to verify items of eligibility through electronic interfaces before requesting that an individual provide documentation. The agency must use an individual’s SSN, or other identifying information if an SSN is not available, for the electronic match. The agency cannot require an individual to provide verification when the information is available through electronic interfaces.

The eligibility agency may accept client statement for many items of eligibility. Some eligibility factors require a form of verification other than client statement, including citizenship and immigration status.

The agency can only ask an individual to provide documentation if:

verification is not available electronically;

the client statement is not reasonably compatible with electronic matches; or

the client statement is not reasonably compatible with the case history.

Income information from electronic matches is reasonably compatible with client statement if both are either above or at or below the income limit or threshold. If income information is not compatible the agency must request information from the individual, including:

A statement that explains the discrepancy; or

Other information from the individual that is not available electronically.

If the individual has expenses and not enough income to cover them, the individual must verify how they are meeting their expenses.

If information is not compatible, the eligibility agency cannot deny or close a program or reduce benefits until it has given the individual an opportunity to provide verification.

Applicants and recipients are required to cooperate with and provide requested verifications to the Department of Health and Human Services and the Department of Workforce Services to assist in quality control and payment accuracy reviews ( 102-2 ) .

B. How to Verify Information

There are several ways to verify items of eligibility, and in some cases, the information available in the record of a individual participating in one program can be used to verify their eligibility for another program.

This includes being able to use income verification sources that were obtained or verified within the last six months as part of an eligibility determination for the Supplemental Nutrition Assistance Program (SNAP) or Temporary Assistance for Needy Families (TANF) programs.

This income data should be used when more current data sources are not available(Table VI), and the member indicates it is reflective.

Example: July paycheck stubs were submitted as part of a SNAP application two months ago. Wage data is currently only available for the 2nd quarter and work number is not available. If the member indicates that those paychecks are reflective, they may be used to create a best estimate of income for Medicaid determination as they are more current than other available data sources.

Explore all possible avenues of eligibility and rely on information that is reasonably available.

Use computer matches and collateral contacts whenever possible to verify items of eligibility.

Client statement can serve as verification for most eligibility factors.

Provide a written request for verifications that are needed to make an eligibility decision. Do not request verification of items available to the eligibility agency through electronic interfaces that do not require independent verification. Do not request verification of items that are not subject to change and which have been verified before.

Give individuals at least 10 days from the date you mail the written request to provide verifications. If the 10th day is a non-business day, give the individual until the business day following the 10th day to provide verifications ( 102-3 ) .

Help individuals get verifications when requested by making collateral contacts or sending signed release of information forms to entities that have the needed verifications.

Individuals may request more time to provide verifications. The eligibility agency can also extend the due date when circumstances have made it difficult for the individual to respond timely or if the worker knows more time will be needed.

The individual must request more time by the date that the verifications were due.

Applicants must request more time by the end of the application period.

If the post office returns the request for verification notice with no forwarding address ( 803-2 ) .

(706-1-sources-of-ievs-data)706-1 Sources of IEVS Data#

(706-1-sources-of-ievs-data)(block-1)Effective Date: September 1, 2016#

Previous Policy

All CHIP enrollees and members of their household who have been counted in the household size and recipients of Medicaid, FEP, or Food Stamps are included in the Income and Eligibility Verification System (IEVS) computer matches. The frequency of the match depends on the type of income and the source of the match. Any individual, who was not on a match list when he applied, will be in the next match after his case is approved. The individual's SSN will be checked with all IEVS sources. Each match is described below.

Department of Workforce Services (DWS) Matches

Wages - Employers in Utah must report employee wages to DWS at the end of each quarter. Eligibility workers have online access to work registration records and wage match records. Use these online matches to check information on all members of the CHIP household. Update this information for members of recipient households at each certification.

Unemployment Compensation Benefits (UCBs) - This online access matches SSNs of CHIP enrollees to SSNs of DWS UCB claimants. Then it compares UCB payment amounts to the amount we have on the CHIP record. This match is run each week for all members of open cases.

Other information – Eligibility workers have online access to new hire information, wage match and UCB payment records. Use this on-line access to verify information on both applicants and recipients. Update the information at each certification.

Social Security Administration (SSA) Matches

There are several types of matches with SSA. These compare both income and SSNs. Use any of the four matches described below to verify SSNs.

SSNs Only - (Numident) This verifies SSNs. This third-party, on-line query system matches Medicaid records with Social Security records of all SSNs ever issued. Once an individuals SSN is correctly verified by the on-line SSA match, there is no need to verify the SSN a second time.

Citizenship and Identity - State Children’s Health Insurance Program – Internet (SCHIP-I or SCHIP) is a Web-based application enabling State agencies to submit data requests to the Social Security Administration (SSA) and receive citizenship verification real-time via the Internet. This verifies information regarding a person’s claim of U.S. citizenship or nationality. A positive match also meets the identification requirement. The person’s SSN and other identifying information interfaces with the Social Security Administration database and returns a response in real time about the person's citizenship or National status. See Section 202 and Table IV .

Social Security Payments and Other Pensions - The electronic verification search matches with Social Security Administration to find benefit information for people receiving Social Security retirement, disability and survivor’s benefits.

Wages, Self-Employment and Farm Income Amounts - (BEERS) This is a match of earned income. The records contain all earnings on which FICA was paid in the past year. Some of the sources are wages, self-employment and earnings from farms. This is a quarterly match for enrollees who receive CHIP or Medicaid.

SSI Records - (SDX) - The electronic verification match will show if someone is receiving SSI benefits.

Public Assistance Reporting Information Match (PARIS)

This computer match system runs every three months. It uses individual name and Social Security number to match with other states’ public assistance records to find individuals who are enrolled in assistance programs in other states. This helps identify individuals who have moved to another state without reporting it, and those who have recently moved to Utah, but have not reported that to the state they left. It also provides benefit information from the Veteran’s Administration and federal payment for military or civilian retirement.

PARIS match information can be found when doing an electronic verification search.

If unknown income information from Veteran’s benefits, military or federal civilian retirement that is different than reported information, or that was previously unknown, request verification from the individual. Make any changes that are needed upon receiving verification. Refer an overpayment, if appropriate, for prior month.

If information shows an individual enrolled in Utah is also enrolled in another state’s assistance program during concurrent months, request verification of where the individual is living. If the individual has left the other state and lives in Utah now, contact the other state to verify assistance has ended. If the individual has moved from Utah to the other state, request verification and close the case if the individual has moved to the other state. If the individual does not respond to the request, close the case for failure to provide verification.

Internal Revenue Service (IRS) Match

The match compares lists of enrollees with lists of all people whose IRS tax records include unearned income. Here are some examples of IRS unearned income:

Interest, dividends, and royalties

Winnings from Gambling, Contests, Other Prizes and Awards

All payments from and deductions for Pensions and IRAs

Unemployment Compensation

Taxable Grants and agricultural subsidies

Capital Gains

Rents

Stocks and Bonds

Bartering

Tax Refunds from Prior Years

Profit and Loss from a Business

The IRS match takes place once a year. It includes cases which are now open as well as those which were open for CHIP at any time during the prior year. There is also a monthly match for those who have applied for enrollment.

(706-3-what-to-do-with-match-reports)706-3 What to Do With Match Reports#

(706-3-what-to-do-with-match-reports)(block-1)Date Effective: January 1, 2014#

Restrict Access To Match Reports

Income match report information is private. Protect it as explained in Section 110-1 and 110-2 . Do not allow unauthorized individuals to access or view computer match information or printed match reports. There are even more rules for protecting IRS match reports. IRS data must NOT be identifiable in case records. INSTEAD, note a report of possible unreported income, or income-producing assets or investments.

Take Action On Match Reports

Promptly evaluate all information received from the individual, on behalf of the household, or from electronic data matches to see if the information impacts eligibility for medical assistance.

If the information is reasonably compatible (what the individual tells you is the same as the electronic data) you can take action on the change. Income information is compatible if what the individual tells you and the electronic data tells you are both below the income limit (individual is eligible), the same as the income limit (individual is eligible), or if both are above the income limit (individual is not eligible).

Example 1 :Household reports that unemployment benefits have ended and that their household income is now $0. An electronic data match shows that the household is still receiving unemployment benefits of $1000 a month. The income limit for the medical program the children in the household qualify for is $1628. What the individual tells you and the electronic data are both below the income limit. The income information is compatible.

Example 2 : Household requests to add a family member to the medical assistance. They report earnings of $1200/month. An electronic data match shows this person earning $1800/month. The income limit for the program is $1628. The information is not compatible because what the individual reports is below the limit and the electronic data is above the limit. There are no other electronic data sources to check. Request an explanation from the household and if needed request documentation.

Example 3 : Household reports they are now receiving unemployment benefits of $1700/month. An electronic data match confirms that the household is receiving UC benefits of $1750/month. The income limit for the medical assistance is $1628. The income information is compatible because both amounts are above the income limit. Re-determine eligibility and look for another program the household may be eligible for.

If the information is not compatible check other sources of data to resolve the discrepancy. Do not require the individual to provide documentation unless you cannot verify the information with electronic data or the information is still not compatible.

If you cannot resolve the discrepancy ask the individual/household to explain why the information is different. If needed, request documentation from the individual/household. The household may need to contact another agency to correct a date of birth or make a name change before the data will match. When the household says they have done that try to match the data electronically again.

All requests must describe the issue that must be resolved and explain that a match indicates the person has unreported income. The notice must explain what must be verified and the time period or specific monthly amounts needed. It may include information such as the employer's name, the type of pension, etc. To comply with Safeguard rules, the notice MUST NOT name the source.

Follow the rules for proper and timely notice. Tell the recipient when the verification is due, and what will happen if the individual fails to comply with the request.

Notify the Household

Do not deny, reduce, or terminate benefits for any household member until you have asked the household to explain/verify information that is incompatible.

Provide proper notice and hearing rights to households that have their benefits denied, reduced or terminated.

Special Federal Income Match Rules

Federal rules require complete actions on all match data for open cases. Once an Income Match report is received (on-line or printed), an application or case review CANNOT be approved before appropriate actions are taken that resolve questions about current eligibility. Send all requests for verification to resolve conflicting information within 30 days of receipt of the match report. The agency must complete action on at least 80% of the cases on the report. (The agency may exceed the 30-day limit for taking action on the match reports on up to 20% of the cases ONLY WHEN you are waiting for responses to requests for verification.)

The Federal Income Match rules define complete action as:

Comparing the match data to the case record: It may prompt a need to verify both current and past eligibility. Decide if further action or verification is needed. Record the SSA or DWS match and the action needed in the case file. To prevent violation of safeguard rules, NEVER identify IRS match data in the case record.

Requesting verification when the income match data differs from the case record: Request verification from the individual, or the source of income. (You do not need the individual's permission to contact the source.) Make the request in writing. electronic notices are available to send to the individual.

Completing the action on the income match data: A complete action includes documenting the actions taken and providing written ten-day notice of any change in eligibility or benefits.

(803-2-returned-mail)803-2 Returned Mail#

(803-2-returned-mail)(block-1)Effective Date: June 1, 2026#

Previous Policy

A. Introduction

Receiving returned mail does not always indicate the member is ineligible. There are circumstances where returned mail does not affect the member’s eligibility. Below are the common returned mail circumstances and how to handle them.

Returned mail that has a forwarding address.

a. Follow the section below titled “Locate the Member” and attempt to locate the member.

Returned mail that does not have a returned address. Follow section titled “Locate the Member” and attempt to locate the member to gather the new address information.

Returned mail from General Delivery address.

a. If there is an in state forwarding address.

i. Follow section titled “Locate the Member” and attempt to locate the member.

b. If there is an out of state forwarding address or no returned address.

i. Follow section titled “Locate the Member” and attempt to locate the member.

B. Locate the Member

Attempt to confirm the member’s address using the methods below until the member’s address is confirmed, or all options have been exhausted.

Attempt to contact the member by phone to confirm address. If contact was successful, update the address and resend notice. See 804-1 for information on change of address. If contact with the member was unsuccessful, attempt to contact other contacts listed on the case. If unable to reach the member or contacts that were listed on the case, then continue to the next step.

Compare the address from the envelope with the address in the eligibility system. If the address in the system is more current than address on the returned mail, resend notice to new address. If the system address is not more current, or if the resent notice has now returned, continue to the next step.

If the returned mail contained an instate forwarding address, update the address and resend the notice. See 804-1 for information on change of address. If no forwarding address was provided, or the resent notice has now been returned, continue to the next step.

If the returned mail contained an out of state forwarding address, update the mailing address and resend the notice. See 804-1 for information on change of address. If no forwarding address was provided, or the resent notice has now been returned, continue to the next step.

Check electronic data sources for the updated address and update if steps 1-3 were unsuccessful . If search does not provide an updated address continue to number 6. If search returns an updated in state address update the address and resend notice to new address. See 804-1 for information on change of address.

If search returns an updated out of state address, update the address, resend notice to new address, then close with proper notice. See 804-1 for information on change of address.If other methods of contact are listed on the case (email or text) then attempt to contact the member by the listed method if possible.

(803-notification)803 Notification#

(803-notification)(block-1)Effective Date: January 1, 2014#

Previous Policy

Notice Requirements

The agency must provide all applicants and recipients with a written notice of:

the decision on an application or review;

any action to terminate, discontinue, or suspend an individual's medical assistance;

any action that changes the form or amount of benefits;

any request for information or verification needed to determine eligibility.

Notice to Approve or Increase Benefits

The eligibility agency must notify an individual whenever it approves the individual's application or renews the individual's eligibility at review for medical assistance benefits. The agency must notify the individual of any positive action affecting the form or amount of the individual's benefits, such as a change from Plan C to Plan B.

A notice to approve or renew eligibility or increase benefits must include the following information:

What action the agency is taking, i.e., approval of an application or review or a change to a different medical program that allows an member to receive more medical services.

Who the action affects, and any differences in how each person is affected. If an action affects everyone in the household in the same way, the notice does not have to name each person separately or explain the effect more than once.

The date such action is effective.

A notice to approve or renew eligibility or improve benefits does not require 10-day advance notice. The notice of a positive change can be sent after the effective date, but should be sent as soon as possible upon making a change.

Adverse Action Notices

The eligibility agency must notify the individual of an adverse action taken on an application or eligibility review, including a change from Plan B to Plan C.

Most adverse actions require 10-day advance notice before the date of the adverse action.

The agency must send the notice to a mailing address agreed upon by the individual or the individual’s representative.

An individual can request to get copies of notices at the local office or electronically (MyCase).

An adverse action notice must include the following information: What action the agency is taking, i.e., denial of an application; change to a different CHIP plan; termination of eligibility. Who the action affects and any differences in how each person is affected. If an action affects everyone in the household in the same way, the notice does not have to name each person separately or explain the effect more than once. The date such action is effective. The reason for the action. The basis of the verification for MAGI programs. The policy citation or the federal or state regulation that supports the action. An explanation of the individual's right to a fair hearing.

Exceptions to 10-day Advance Notice

Negative action can be taken without giving the recipient 10-day advance notice in the following situations:

The recipient requests in writing that his case be closed.

The recipient has been admitted to an institution under governmental administrative supervision.

The recipient’s whereabouts are unknown and the post office returns mail indicating no forwarding address.

The local office has determined the recipient is receiving assistance in another state.

The local office has factual information confirming the death of a recipient. In this instance, the notice must be mailed on the date the case closure is recorded in the case record. The effective date of the closure is the date the person died.

The recipient has moved out of Utah and is not expected to return.

The recipient is eligible for Medicaid.

Five Day Advance Notice for Suspected Intentional Program Violation

If the facts indicate that there has been an intentional program violation by the recipient, send the notice of adverse action at least 5 days before the effective date of action.

Requesting Information or Verification

When the eligibility agency needs forms, information or verification from the individual to determine eligibility, the agency must send a written request to the individual.

The request must say what is required and the due date for providing the requested information, form or verification.

The agency must allow the individual at least 10 days from the date on the notice to respond.

The notice must tell the individual he may ask for more time to respond and may ask the agency to help obtain information or verification if the individual cannot get it.

For policy about verifications, see sections 701 (applications), 704 (reviews), 705 (verifications), and 804 (changes).

Proper Notice for Renewals

When members do not complete renewals, the agency gives 10-day notice for closure.

If the member contacts the agency before the end of the review month, benefits must be restored for the following month if there is a request for additional verification or workload prevents workers from re-determining eligibility timely.

If the eligibility agency makes an adverse decision before the end of the review month, take the negative action in the first month for which proper notice can be given. Use of Electronic Notices

The eligibility agency must give applicants and recipients the option to receive notices and information through an electronic format. Confirm by regular mail the individual’s choice to receive electronic notices. The individual may choose to receive notices through regular mail at any time.

Electronic notices must be posted to the recipient’s account within 1 business day. Send an email or other electronic communication to alert the member that a notice has been posted.

If the electronic notice is not transmitted successfully, send the notice by regular mail 3 days from the failed electronic notice date.

At the member’s request, the eligibility agency must provide any notice by regular mail that had previously been posted electronically.

Informing Individuals of Hearing Rights

The eligibility agency must inform individuals of the right to ask for a fair hearing if the individual disagrees with an agency action, or does not make a timely decision on an application.

Individuals must be informed at application and any time the eligibility agency takes an action affecting the individual's eligibility.

The notices sent to individuals must explain: how the individual can ask for a hearing, how long the individual has to ask for a hearing, how a recipient may receive continued benefits while the hearing takes place (See 120-5 ), and how the individual may represent himself, or have a family member, friend, representative or attorney represent him.

(804-3-adding-eligible-children-to-open-chip-cases)804-3 Adding Eligible Children to Open CHIP Cases#

(804-3-adding-eligible-children-to-open-chip-cases)(block-1)Effective Date: July 1, 2024#

Previous Policy

Adding a child during the certification period

A child may be added to an open CHIP case without requiring a new application. All other eligibility requirements must be met. Starting a new certification period may change the member’s cost sharing requirement. (See Section 701 )

Determine if the child applying for CHIP is eligible for coverage under Medicaid. If the child is eligible for Medicaid, the child is not eligible to be added to the CHIP household. A child, who only qualifies for Medicaid by paying a monthly spenddown and chooses not to meet the spenddown each month, may be added to CHIP. If it is clear that the applicant does not meet the requirements for Medicaid, do not request any verification that does not apply to CHIP enrollment.

If the child is eligible for CHIP, add the child for the remainder of the current certification period.

If the new child’s countable income is over the income limit for CHIP, the agency will transfer the electronic record to the Federally Facilitated Marketplace (FFM) for that child.

Children who have been receiving CHIP and move to a new CHIP household cannot receive CHIP benefits in both households during the same month. Add the child or children to the new household the first day of the month after they have been removed from the previous CHIP household. CHIP cannot be approved in the same month Medicaid has already issued.

Medicaid Screening

If Medicaid screening shows the additional child may be Medicaid eligible, request needed verifications including current income and then take the following action: If current income is provided and the child meets all factors of Medicaid eligibility - add the child to Medicaid. Any other children in the household who are eligible for Medicaid, must be removed from CHIP and opened for Medicaid. If current income is provided and the child does NOT meet Medicaid income eligibility, add the child to CHIP if the child meets the income limit and all other eligibility criteria. Do NOT use the new income or change the certification period if the income adversely affects eligibility and changes the CHIP plan from Plan B to Plan C. Use the newly verified income and begin a new certification period if income makes the member eligible for a lesser cost CHIP plan. If the member fails to provide current income, deny Medicaid for the additional child and do not add the child to CHIP.

Note: The out of pocket maximum, co-payment and deductibles could also change. The worker must educate the member about how this change may affect their cost-sharing requirement.

Effective Date of Enrollment in CHIP

A newborn child, newly adopted child, child placed for adoption or a child placed for foster care that are not already insured may be added to the CHIP program if the request or application is within 60 days of the event. The child’s coverage effective date will be the date of the event, if eligible.

If the request or application is filed more than 60 days after the event, the effective date of CHIP enrollment is the first day of the month in which the request or application was filed.

Other Children: Children who are not enrolled in a health plan at the time of application, the effective date to enroll in CHIP is the first day of the application month. (See Section 701-2 ) Children who are enrolled in an FFM plan at the time of application, the effective date to enroll in CHIP is the day following the termination date of the FFM plan. The effective date for children being re-opened in conjunction with a new application is the same date as the additional child. See section 701-1 and 702 for more information. The effective date for a child that loses Medicaid coverage is the day following the termination date of the Medicaid.

Adding a Child Increases the Household Size

After adding a child to CHIP, the household size change may result in a change in the plan level. Before the plan level can be changed, current household income must be requested for a new income determination.

Leave the CHIP case open and take no further action if: Current income is not provided; OR Current income is provided and the new income adversely affects the current eligibility (changes from plan B to C). Post the new income best estimate.

If the new income best estimate causes the member to remain on the same plan or the individual(s) are now eligible for Plan B, (IE: plan C to plan C; plan B to plan B; plan C to plan B ) begin a new certification period starting the next possible issuance month.

Note : T he out of pocket maximum, co-payment and deductibles could also change. The worker must educate the member about how this change may affect their cost-sharing requirement.

Check eligibility factors for all household members.

(804-5-income-changes)804-5 Income Changes#

(804-5-income-changes)(block-1)Effective Date: July 1, 2024#

Previous Policy

Income Changes during the Certification Period

CHIP members are not required to report changes of income during the 12 month enrollment period.

When an income change is reported, only redetermine eligibility when the member requests a Medicaid determination, asks for a CHIP income redetermination or the reported change is an exception to the 12 month enrollment period. (See Section 703-1 )

Report of Increased Income

Increased income changes do not require action until the end of the current enrollment period.

Require income verification at the next review.

If the member reports the change and requests a new income redetermination, do the following: If the new income does not adversely affect CHIP eligibility, treat the income change as a review and establish a new 12 month certification period.

Note : T he out of pocket maximum, co-payment and deductibles could also change. The worker must educate the member about how this change may affect their cost-sharing requirement.

If the new income adversely affects eligibility (IE, changes Plan B to Plan C or ineligibility for CHIP), do not act on the change until the next certification period.

Report of Decreased Income

When the individual’s countable household income decreases and they request a new income redetermination, they may verify the decreased income and have their new benefit plan start the month of request, when verified timely. If not verified timely, the change is effective the month it is verified.

Request for an Income Redetermination or Medicaid : If a member submits a new application, asks for Medicaid (in person, via phone, fax, email, in writing), or asks for a new CHIP income determination, redetermine the child’s eligibility for a better benefit. If Medicaid eligible, close CHIP and open Medicaid for all Medicaid eligible household members. If the change is a decrease in income and it makes the member eligible for a lesser cost CHIP plan (i.e. Plan C to B), make the change effective the month of report, when verified timely. Begin a new 12 month certification period. If it is not verified timely, make the change effective the month it is verified.

NOTE : T he out of pocket maximum, co-payment and deductibles could also change. The worker must educate the member about how this change may affect their cost-sharing requirement.

If the change is a decrease in income and it makes the member eligible for Medicaid (without a spenddown or MWI premium), close CHIP and open Medicaid effective the month of report, when verified timely. If not verified timely, make the change effective the month it is verified.

No Request for Income Redetermination or Medicaid : Only make a change at application or review. If the member reports an income change only, do not determine eligibility for a lower CHIP Plan or Medicaid. Continue CHIP through the end of their enrollment period. See Section 804 for more information about reported changes and Section 201-1 for Medicaid eligibility screening.

Example : Member reports via MyCase a decrease in hours worked. The member has not asked for a better CHIP plan or Medicaid. The CHIP program continues through the end of the current certification period.

If the change becomes known through interface matches or tasks; continue the enrollment period and take action at application or review.

If a family requests a new CHIP income determination or Medicaid coverage for any household member and then fails to verify the decreased income, no action is taken.

If the reduction of income is a result of employment loss for a State CHIP child’s parent coverage may not end before the 12 month certification period even if no parent in the home has unsubsidized employment, see section 703-1.

(804-changes)804 Changes#

(804-changes)(block-1)Effective Date: November 1, 2015#

Previous Policy

Reporting Requirements

Members must report certain changes at any time during the certification period and certain changes at review.

The agency will determine what actions to take depending on the change. (See Section 102-3 for reportable changes)

The agency must take action on reported changes within 10 days.

Taking Action on Reported Changes Required During a Certification Period

Evaluate a reported change to determine if it could affect eligibility during the 12-month certification period. Take the following actions on changes that are reportable during the certification period. (See Sections 102-3 & 703-1 ) .

The agency must take action on reported changes within 10 calendar days of report.

When an income change is reported see section 804-5 to determine which actions to take.

Use available electronic data sources to verify the change before requesting information from the member.

If the agency cannot determine continued eligibility by electronic data match, then the agency must request the necessary verification from the member.

Workers must only request verification needed to determine eligibility.

Give the member at least 10 days from the date of the notice to provide verification.

If the 10th day is a non-business day, give the member until the first business day following the 10th day to provide the verification.

The agency must provide a 10 day advance notice of any adverse actions taken on the case. (See section 803 for notification requirements)

If the member does not provide all requested verification for reportable changes by the verification due date, the eligibility agency ends benefits for the first month it can give 10-day advance notice.

If the reported change was not required and the member fails to follow up with verification, CHIP remains open.

If the member provides all requested verification by the verification due date, or by the end of the report month, whichever is later, the agency continues with the eligibility determination. If the action results in a better CHIP plan, make the change effective the month of change report. If the action results in a better benefit, such as eligibility for Medicaid, make the change effective the month of the change report.

For an adverse action, make the change for the first month the eligibility agency can give 10-day notice.

See section 703-1 to ensure the adverse action meets an exception to the 12-month certification period.

Example : The member reports on September 27th that a child has left the household. The child remains eligible for CHIP coverage through Oct. 31st. Do not re-determine eligibility for any remaining eligible children.

If the eligibility agency receives all requested verification by the last day of the month following the effective closure date, consider this a new application with application time frames.

Individual information will be transferred to the FFM if the individual is no longer eligible for CHIP.

Mail returned by the post office with no forwarding address indicates a change. (See Section 803-2 to decide what steps to take.)

When a household reports a change of address, provide the household with voter registration information. (See Section 101 )

Failure to make a timely report of a reportable change may result in an overpayment of benefits. (See Section 806 )

Taking Action on Reported Changes Required at Reviews

The agency may complete an ex parte review or a review requiring member participation. In either case, the agency notifies the member of the review decision. If the member is eligible for a new certification period, the notice tells the member to report any changes that occurred during the current certification period and prior to the start of the new certification period.

Take client statement on the effective date of the change unless the agency has information that conflicts with the client statement.

Only act on changes that occurred prior to 10-day notice in the review month. (See section 102-3 to determine reportable changes)

A member may report a change that could affect eligibility for the current certification period. Only change the current certification period if the change is an exception to the 12-month certification period, or when the member asks for a re-determination. (See section B. above to determine what actions to take.) If the change affects the current certification period, re-evaluate the decision for the new certification period.

Re-determine eligibility for the new certification period

If the change is a reportable change, re-determine eligibility for the new certification period. (See section 102-3 for reportable changes. ) If verification is needed to determine eligibility, give the member at least 10 days from the date of the notice to provide verifications.

If the change results in an adverse action on the member, make the change effective the first of the month for which the eligibility agency can give proper 10-day notice

When the member remains eligible for CHIP, but the change will become effective in a month after the first month of the new certification period, establish a new 12-month certification period.

If the member is no longer eligible for CHIP, end the CHIP benefits effective the month for which the agency can give proper 10-day notice.

Refer the case for a possible overpayment if the member reported the change late and CHIP eligibility was issued in error. (See Section 806 )

If the change makes the member eligible for a better benefit, make the change effective the month of report when verified timely, but not earlier than the first month of the new certification period.

A better benefit would be a lower cost plan, lower out of pocket cost or Medicaid eligibility.

Verification is timely if received by the verification due date, or by the end of the report month, if later.

If verification is not received timely, make the change effective the month it is verified.

If the member does not return all requested verification for reportable changes by the verification due date, end benefits effective the first of the month for which the agency can give proper 10-day notice.

(806-1-causes-of-improper-chip-coverage)806-1 Causes of Improper CHIP Coverage#

(806-1-causes-of-improper-chip-coverage)(block-1)Effective Date: July 1, 2011#

Previous Policy

Agency Error

Agency errors are the result of mistakes made when determining eligibility. Agency errors include:

Untimely action on a change the household reported.

Incorrect decisions about the household’s CHIP assistance eligibility.

Policy incorrectly applied.

Information entered incorrectly.

Inadvertent Error

Inadvertent errors are unintended mistakes the enrollee or their representative makes when providing information, or a failure to report changes that affect eligibility.

Suspected Intentional Program Violation (SIPV)

Use this cause when you suspect that the enrollee or their representative committed any of the acts described under “Intentional Program Violation”. Use the SIPV until the DWS adjudication process proves the action was intentional or the enrollee or their representative acknowledges the IPV in writing. SIPV includes any of the reason listed in #4 (IPV) below.

Intentional Program Violation (IPV)

As determined by the adjudication process, any person who personally or through a representative, commits any of the acts described below to obtain, maintain, increase or prevent the decrease or termination of CHIP assistance benefits is guilty of an Intentional Program Violation (IPV). Acts which constitute an IPV include, but are not limited to:

Knowingly making false or misleading statements

Misrepresenting, concealing, or withholding facts

Violating program regulations on the use, presentation, acquisition, receipt or possession of CHIP assistance or the CHIP card; or

Not reporting the receipt of a CHIP card or CHIP service that the individual knows the enrollee was not eligible to receive;

Posing as someone else;

Not reporting a change within 10 days after the change occurs; and the individual knew the reporting requirements;

Intentionally submitting a signed application or eligibility review containing false or misleading statements in an attempt to obtain public assistance payments, even if no assistance was received;

Intentionally receiving CHIP coverage for which the enrollee or representative knows he is not eligible.

Intentionally failing to report when a child obtains health insurance coverage.

(806-2-what-to-do-when-improper-chip-coverage-occurs)806-2 What to do When Improper CHIP Coverage Occurs#

(806-2-what-to-do-when-improper-chip-coverage-occurs)(block-1)Effective Date: July 1, 2022#

Previous Policy

Submit or send an overpayment referral to the DWS overpayment unit for overpayments caused by Suspected Intentional Program Violation and untimely reporting of other health insurance for CHIP issued months.

1. Agency and Inadvertent Errors

When improper CHIP coverage occurs due to an agency or an inadvertent error, correct the error and send the proper notice.

2. Suspected Intentional Program Violation (SIPV) Errors

When improper CHIP coverage occurs because of a SIPV error or untimely reporting on the part of the enrollee, submit an overpayment. See Section 806-1 .

3. Overpayment is calculated and collected for monthly health plan premium paid in error.

o Error amount is calculated for each ineligible child(ren) and for all ineligible CHIP month(s).

o Coordination of claims is the responsibility of the CHIP health plan and customer.

(See Section 220-1 for definition of Health Insurance Coverage or Plan))

4. There is a 3-year statute of limitations on the collection of any overpayment.

a. Overpayments will not be adjudicated and collected on from periods older than 3 years prior to the date the Notice of Agency Action (NAA) is mailed to the individual.

b. The overpayment worker will determine which part of the overpayment does not exceed that time frame.

Example –

Member’s overpayment dates from March 2010 to March 2016

The overpayment worker sends the NAA on January 26, 2022 to cover this overpayment period.

Based on the mail date, the 3-year statute of limitations for the overpayment consists of January 2019 through the current date.

Because the overpayment period falls outside the statute of limitations period, we cannot collect anything on this.

Example –

Member’s overpayment dates from March 2014 to March 2020

The overpayment worker sends the NAA on January 26, 2022 to cover this overpayment period.

Based on the mail date, the 3-year statute of limitations period for overpayment consists of January 2019 through today.

The overpayment period consists of any overpayment amount accrued from January 2019 to March 2020. March 2014 through December 2018 are outside the Statute of Limitations and are not allowed.

Example –

Member’s overpayment dates from March 2019 to January 2022

The overpayment worker sends the NAA on January 26, 2022 to cover this overpayment period.

Based on the mail date, the 3-year statute of limitations period for overpayment consists of January 2019 through today.

The overpayment for March 2019 to January of 2022 can be collected because it is within the statute of limitations period.

(1203-1-verification-of-utah-residence)1203-1 Verification of Utah Residence#

(1203-1-verification-of-utah-residence)(block-1)1203-1 Verification of Utah Residence#

Effective Date: January 1, 2024

No Previous Policy

Verification

How to Verify Information

There are several ways to verify items of eligibility, and in some cases, the information available in the record of an individual participating in one program can be used to verify their eligibility for another program. Explore all possible avenues of eligibility and rely on information that is reasonably available.

The individual must request more time by the date the verifications were due.

Applicants must request more time by the end of the application period.

If the post office returns the request for verification notice with no forwarding address see policy 803-2.

What is Acceptable Verification

Electronic Data Sources

Use the electronic data sources (706-1) for verification.

Client Statement

Hard Copy Verification:

School records

Medical records

Statement of Residency for Non-Citizen Children

Other reasonably compatible physical documentation

Collateral Contact

(1203-utah-residence)1203 Utah Residence#

(1203-utah-residence)(block-1)1203 Utah Residence#

Effective Date: January 1, 2024

No Previous Policy

To be eligible for State CHIP a child must be a Utah resident for at least 180 days. Eligibility begins the first of the month in which a child is a Utah resident for 180 consecutive days.

Use the following guidelines to determine if an individual is a Utah resident.

1. Living in the State . The person must be physically present in the state or temporarily absent to be a resident of Utah.

a. A resident need not have a permanent residence or a fixed address.

d. To decide if the absence is temporary, you may need to find out if:

the absence is for a specific period-of-time,

the person is maintaining their home in Utah, or

other factors exist that indicate the person intends to return to Utah when the reason for the absence ends.

2. Duration . Residency requires a person to be in Utah for 180 days. If the member changes residency to another state the 180 day count restarts when they return.

3. Reason for living in Utah . Do not consider the reason why the individual is in Utah, except to the extent that the reason may indicate that the individual is not in Utah voluntarily or is in Utah only temporarily. For example:

An individual from Arizona is visiting or traveling through the state, and is arrested for a crime and jailed. This individual is not in the state voluntarily and is not a state resident. An individual from Nevada is in Utah to give their baby up for adoption and intends to move back to Nevada after the baby is born. This individual is in the state temporarily and is not a state resident.

4. Citizenship . Citizenship is not relevant to the determination of state residency.

5. Residents of Public Institutions such as Jails or Prisons .

b. If another state places the person in a public institution in Utah, the individual is not a Utah resident. Residency does not change from the previous state. (See Sec. 203-5 and 203-6 )

c. State residency does not change when an individual in a public institution goes directly to a hospital for an inpatient stay.

6. Residents of other institutions .

a. Any individual placed in an institution by another state is a resident of that state. This includes individuals from another state placed in a Utah nursing home or hospital. (Sec. 203-5 )

b. A competent individual who leaves an institution after having been placed by another state will be considered a Utah resident after 180 days of being physically located in Utah.

c. For residents of an institution who are not placed by another state, see sec. 203-4 .

7. Cases of disputed residency between two states . If an individual has come to Utah from another state, and the two states cannot resolve which state is the person's state of residency, the individual is a resident of the state in which the individual is physically located.

(1250-open-enrollment-periods)1250 Open Enrollment Periods#

(1250-open-enrollment-periods)(block-1)1250 Open Enrollment Periods#

Effective Date: January 1, 2024

No Previous Policy

Open Enrollment

The Department of Health and Human Services limits the number of eligible individuals covered under State CHIP. The eligibility agency accepts applications only during certain State CHIP open enrollment periods.

State CHIP Applications

A complete application must be submitted during the open enrollment period to be considered for enrollment. This includes applications for individuals residing in households with open Medicaid cases, who are not included in the Medicaid coverage because they do not qualify for a Medicaid program.

Applications may be submitted by various methods. 102-1 State CHIP coverage can begin no earlier than the first day of the month the application is received. A State CHIP application that has health insurance coverage that will end during the open enrollment period or by the end of the month immediately following the open enrollment period may be considered for State CHIP. The effective date for the State CHIP coverage would be the first day after the coverage ends. A State CHIP applicant who applies during open enrollment but is not eligible for the application month can be reviewed to determine eligibility for the following month even if the following month is not during open enrollment. When denying the original application month and determining eligibility for the next month, the application date and the benefit effective date changes to the first day of the next month as an exception to open enrollment.

Exceptions to Open Enrollment for State CHIP Reviews If a State CHIP recipient fails to complete the review process during the review month and the case closes at the end of the review month, the member has three additional months from the date of case closure to complete the review process without submitting a new application. If a due process month was issued to give proper notice the three-month period begins after the month the case closed for not completing the review process.

Waive the State CHIP open enrollment requirement if the review process is completed or a new application is received in the three-month period immediately following the month the review closed for incomplete review.

The application processing time period applies. The new application date is the date the review, review verification or application is received. The client must provide requested verification within the application processing time period.

If eligible, the first day of the month in which the recipient contacts the agency is the new effective date. There is no retroactive benefit, and no interview or application form is required.

An application received more than three months after the case closes for incomplete review will be denied if it is not an open enrollment period.

Exceptions to Open Enrollment for State CHIP Reported Changes

If a State CHIP recipient submits requested verification for a reported change after the case was closed but by the effective date of the closure, and there is not time to send 10 day notice of an adverse action, reopen State CHIP and extend benefits to the next month while eligibility is being determined.

If a State CHIP recipient submits all requested verification for a reported change after the effective closure date, and by the last day of the month after closure, treat the verification as a new application.

Waive the State CHIP open enrollment requirement in the month immediately following the closure.

The new application date is the date all requested verification is received.

The member must provide any additional verification within the application processing time period.

If the requested verification is received more than one month after the closure, the member must wait to reapply at the next open enrollment period.

If a child loses eligibility to Medicaid or CHIP due to a loss of citizenship/immigration status this is an exception to open enrollment for State CHIP.

A member who loses eligibility to Medicaid or CHIP due to a loss of citizenship/immigration status and is pregnant can move to State CHIP even if they are 19 years old. This change creates an exception to open enrollment.

Emergency Medicaid back to State CHIP

There is no State CHIP open enrollment requirement when an individual is moving from the Emergency Medicaid program to the State CHIP program and there is no break in coverage as long as the individual was found eligible for State CHIP during the last open enrollment period and the member opted for Emergency Medicaid at that time. The State CHIP application date is the first of the month after Emergency Medicaid ends.

Pending Medical Applications

Consider State CHIP for any child who is included in the household for a medical application that is pending when open enrollment begins. The State CHIP effective date is the first day of the month open enrollment began. A new application is not required.

Medicaid Closures and Denials

Consider State CHIP eligibility in the following situations: (A new application is not required.)

A Medicaid case is closed during open enrollment and eligibility will end on the last day of the open enrollment month or the month immediately following the open enrollment period. The effective date of coverage for State CHIP is the first day of the month immediately following the closure.

A Medicaid recipient reports a change during an open enrollment period, returns requested verification by the due date, and the client is determined to be ineligible as of the last day of the open enrollment month or the month immediately following the open enrollment period. The effective date of coverage for State CHIP is the first day of the month immediately following the closure.

An individual applies for Medicaid before the open enrollment period and returns all requested verification by the due date during the open enrollment period and the applicant is determined to be ineligible. The State CHIP effective date is the first day of the month open enrollment began.

Medicaid Reviews

Consider State CHIP eligibility in the following situation:

A Medicaid household turns in a review form or requested verifications during an open enrollment period, and you determine that children in the household may be eligible for the State CHIP program. Consider State CHIP for those children. The effective date of coverage for State CHIP begins the first day of the month immediately following the Medicaid closure and a new application is not required.

(1701-1-what-is-an-application)1701-1 What is an Application?#

(1701-1-what-is-an-application)(block-1)1701-1 What is an Application?#

Effective Date: January 1, 2024

No Previous Policy

The Medicaid agency will accept applications in the following ways:

Paper Application for Medical Assistance

All paper applications must have an original signature. The agency will consider the following as an original signature: Signed paper application received by mail or in person at a DWS employment center. A signed paper application sent by FAX. A telephonic signature

If the agency receives an unsigned paper application, the agency will send a signature page to the applicant to sign and return.

Online Applications for Medical Assistance

Applicants may apply online .

The online application process includes an online signature that meets state law as a legal signature. The applicant must complete the online signature for the application to be valid. Electronic, handwritten or telephonic signatures transmitted via any other electronic transmission must be accepted.

Non-Medical Review Forms as Applications

Households with an open non-medical assistance case may use the review form as an application for medical programs. The review form must be signed.

The individual or worker must write on the review form what assistance the individual wants to apply for.

The individual or worker can write a new household member’s name on the review form and state the individual wants to apply for medical assistance for that person.

The review form with the request for assistance must be submitted to DWS.

Telephone Applications

Applicants may ask to apply by telephone.

Individuals must complete all eligibility sections, including the TPL information of an application.

The applicant must sign within the application processing period. The applicant may sign by Telephonic signature

Documented and stored by the agency.

A confirmation receipt will be sent to the applicant via the communication method they have selected. Mailed application returned no later than the last day of the application processing period received

· In person

· By mail or

· Fax

Verbal Request to Add Medical Assistance to a Pending Application

An applicant who has a pending application for other types of assistance may make a verbal request to add CHIP to the application.

The applicant must make the verbal request while the application for other assistance is still pending, and within 30 days of the application date. If the 30th day is a non-business day, the applicant has until the first business day following the 30th day to make the verbal request. The date the applicant makes the verbal request to add CHIP is the date of application for medical assistance.

If the agency has approved or denied the application for other assistance, or if it is more than 30 days after the application date, the applicant cannot make a verbal request to add CHIP. The applicant must submit a new application to request medical assistance.

The Following Situations are Considered New Applications, but do not Require an Application Form

A household with an open medical case can add a new household member by contacting the eligibility agency. Request information about the new household member as needed to determine eligibility. A signature is not required. TPL information for the new household member must be requested and the voter registration option must be offered to a new adult household member.

When medical assistance ends because the individual did not return requested verification for a change report, the date the individual provides all of the requested verification is a new application date if it is submitted by the last day of the month immediately following closure. A signature is not required. TPL, voter registration and rights and responsibilities information can be waived.

If medical assistance ends for failure to complete the review, an individual can re-apply by responding to the review request within 3 months following the review closure. No signature is required.

· The response may be a phone call, submission of the review papers or verification documents.

· If the individual provided updated TPL information during the failed review period, do not request it again to complete the review.

· TPL, voter registration and rights and responsibilities information can be waived if the worker completed these in the review period.

When an application is denied because the applicant fails to provide all requested verification, the applicant may provide all of the requested verification within 30 days of the denial notice date. The date the verification is received is a new application date. No signature is required. TPL, voter registration and rights and responsibilities information can be waived. If a medical assistance case is closed for more than one calendar month, the individual must complete and sign a new application form.

Unsigned Applications

If the agency receives an unsigned application for medical assistance, require the applicant to complete the signature page. If the applicant completes and returns the signature page within the application-processing time, retain the date of application. (See Section 1701-2 ) If the applicant does not return the signature page within the application-processing time, the agency will deny the application.

If the individual returns the completed signature page within the 30 days following the date the denial notice was mailed, consider the date of receipt a new application date with a new retroactive period.

Incomplete Applications

(1701-2-date-of-application)1701-2 Date of Application#

(1701-2-date-of-application)(block-1)1701-2 Date of Application#

Effective Date: September 1, 2026

Previous Policy

The eligibility agency must establish the date of application to determine when State CHIP coverage can begin.

Establish the date of application as follows.

A. Paper Applications

1. The date of application is the date the eligibility agency receives a completed, signed application by the close of business on a business day.

2. When an applicant leaves a paper application at an eligibility agency office, other than an outreach location, after business hours, the date of application is the next business day.

B. Applications Sent Via FAX

1. When the eligibility agency receives an application sent by FAX on a business day by the close of business, the date of application is that day.

2. When the eligibility agency receives an application sent by FAX after the close of business, or on a state holiday or weekend, the date of application is the next business day.

C. Applications Received Online Through the "myCase" System

The application date for an application received online through " myCase " is the date the application is filed online.

D. Applications received via email

1. When the eligibility agency receives an application sent by email on a business day by the close of business, the date of application is that day.

2. When the eligibility agency receives an application sent by email after the close of business, on a state holiday, or weekend, the date of application is the next business day.

E. Applications received at Outreach Locations

1. When the agency receives an application at an outreach office location during business hours, the application date is the date the application is received by the outreach worker.

F. Verbal Request

G. Ineligible in Application Month

H. Unsigned or Incomplete Applications

1. If the eligibility agency receives an unsigned application, the applicant must provide a signature within the application-processing period (See section 1 701-5 ) to retain the original application date. The agency will notify the applicant of this requirement.

2. An applicant who files an application online must complete the online signature. If the applicant fails to complete the online signature, the eligibility agency will send a signature page to the applicant. The applicant must sign and return the signature page within the application-processing period (See section 1 701-4 ) to retain the application date of the online application.

I. Phone Application

When a worker completes an application over the phone with an applicant, the date of application is the date the worker takes the application over the phone. The applicant must physically, electronically or verbally sign within the application-processing period to retain the original application date. The eligibility agency follows the provisions of L. below, if it receives the signed signature page after the agency has denied the application.

J. Adding Someone to an Open Case

K. Applications Received When An Application Is Already Pending

1. If a new application is received while an application is already pending, the application date does not change.

2. The agency reviews the second (or third, etc) application for any new information.

3. If new information is discovered or needs to be addressed, it becomes a part of the already existing application process.

L. Applications Received After Medical Benefits Are Issued

1. Review the new application for changes and new information.

2. If new information is discovered, and no new household members are requesting medical assistance, consider the new application to be a change report and take appropriate action. (See section 804 )

M. Application Dates for Cases Closed or Denied

1. For denied applications, the date the individual provides all requested verification is a new application date. Allow application time frames.

2. See section 1704 for cases closed at review.

(1701-3-effective-dates-of-certification)1701-3 Effective Dates of Certification#

(1701-3-effective-dates-of-certification)(block-1)1701-3 Effective Dates of Certification#

Effective Date: January 1, 2024

No Previous Policy

A. New CHIP Applicants

1. State CHIP enrollment begins the first day of the month during open enrollment and the member is a Utah resident for 180 days when the program enrollment maximum has not been met.

If any family member is enrolled in an FFM plan see section 220-9 to determine the effective date for CHIP.

Exceptions to benefits starting on the first day of a month:

· The individual applies during the first four days of the month and the 4-Day Grace Period is allowed.

· The individual is enrolled in health insurance coverage that terminated involuntarily or COBRA coverage ends during the application month, in which case eligibility begins the day after the health insurance coverage ends.

· The individual is sanctioned for voluntary termination of health insurance coverage and the ineligibility period ends during the application month, in which case eligibility begins the day after the ineligibility period ends.

A Medicaid or UPP recipient reports a change that causes the member to no longer be eligible for Medicaid or UPP, but the member does qualify for State CHIP and it is during open enrollment or an exception to open enrollment. The effective date of coverage for CHIP is the first day of the month immediately following the Medicaid or UPP closure.

B. Four Day Grace Period

A State CHIP applicant is eligible for the four day grace period when open enrollment spans both months.

To receive the coverage, the applicant must have been unable to apply during the last four days of the previous month because of an emergency situation.

All factors of eligibility must be met in the grace period.

Consider eligibility for the Child Medically Needy program when the grace period does not match the dates of medical need.

Examples

An application is received on April 1 for State CHIP. The child had a medical need on March 28. Open enrollment runs from March 25 through April 10. The grace period and State CHIP coverage can go back to March 28.

An application is received October 2 for State CHIP. The child has a medical need on September 30. Open enrollment runs from October 1 through October 6. Can not review for the grace period. Can still consider Emergency Medicaid for September.

An application is received on July 3 for State CHIP. The child had a medical need on June 27. Open enrollment runs from June 1 through July 15. The earliest date for the grace period is June 29. Can still consider Emergency Medicaid coverage for the month of June.

An application is received May 2 for State CHIP. The Child had a medical need on April 28. Open enrollment runs from April 30 through May 15. The earliest date for the grace period is April 30 when open enrollment began. Can still consider Emergency Medicaid for April.

(1701-4-what-to-do-with-an-application)1701-4 What to do with an Application#

(1701-4-what-to-do-with-an-application)(block-1)1701-4 What to do with an Application#

Effective Date: June 1, 2024

Previous Policy

1. Each application must be processed to a decision for every applicant unless:

a. The individual and other household members are already on the most beneficial medical program. (See section 102-1 when a new medical application is received for an open CHIP case.) If no better coverage is available, document that no action was taken on the application.

b. The individual has already applied, and that application is still pending. (See section 102-1 .)

c. The individual withdraws the application.

d. The individual cannot be located, in which case deny the application. If the individual contacts the agency before the end of the application-processing period, resume the application process.

2. Deny applications that do not meet the signature requirements within the application-processing time as an incomplete application. Do not make a determination of eligibility. See section 102-1 and 701 on who can apply and how to get the best signature.

3. All applicants have the right to register to vote at application ( 101 ).

4. Determine if any child applying for CHIP is eligible for coverage under Medicaid.

a. A child who is eligible for Medicaid is not eligible for CHIP.

b. A child enrolled in an FFM plan may be eligible for CHIP if determined ineligible for Medicaid ( 220-9 ).

5. A child who is only eligible for Emergency Medicaid may be eligible for State CHIP. (If an individual wants Emergency Medicaid additional verification may be needed to determine eligibility.) Determine State CHIP eligibility first for any applicant who has applied for Medicaid but was found ineligible. A new application is not required. If a child is eligible for both State CHIP and Emergency Medicaid approve State CHIP unless the member requests otherwise.

6. Request any needed verifications.

a. An interview may be helpful in gathering information but is not required.

b. Screen the application and request the needed verifications.

c. If the applicant has expenses and not enough income to cover them, the applicant must verify how they are meeting their expenses ( 705 ).

d. If the application has health insurance listed, the agency must determine if insurance is an FFM plan ( 220-9 ).

e. Send a written request for verifications to the applicant ( 705 ).

f. Give applicants at least 10 days from the mailing date of the request to return verifications. Applicants may request more time by the due date. In which case, give applicants at least 10 more days.

g. Applicants have until the end of the application-processing period to provide verifications. Do not deny an application for lack of verifications until the end of the processing period. The processing period is 30 days for CHIP.

h. Request only those verifications that the agency cannot obtain through other means like electronic matches.

7. Determine eligibility after receiving verifications (1 700 ) .

8. Mail a notice of the eligibility decision to the applicant, and the representative if applicable ( 803 ) .

9. Document decisions made on each application in the case record.

(1702-re-opening-state-chip)1702 Re-Opening State CHIP#

(1702-re-opening-state-chip)(block-1)1702 Re-Opening State CHIP#

Effective Date: January 1, 2024

No Previous Policy

You may re-open State CHIP when:

The case was closed because of an administrative error within the last 12 months. Re-open the case back to the date of closure. Do not require the enrollee to complete a new application.

The case was closed in a non-review month for failure to provide requested information or verification and the information is received by the end of the month of closure, continue with the eligibility determination. Do not require the enrollee to complete a new application. See section 704 . If the agency can complete the eligibility determination and send 10-day advance notice of an adverse change, the effective date is the following month. If the agency cannot complete the eligibility determination and provide 10 day advance notice of an adverse change before the end of the month, continue benefits to the following month. (See Section 803 .)

The case was closed because a parent was activated to military duty so the children became eligible for military insurance coverage. If there are still months left on the original certification period, do not require a new application. If the certification period has expired, the individual must complete an application and provide verification of their current circumstances.

(table-iv-proof-of-u-s-citizenship-and-identification)TABLE IV - Proof of U.S. Citizenship and Identification#

(table-iv-proof-of-u-s-citizenship-and-identification)(block-1)TABLE IV - Proof of U.S. Citizenship and Identification#

Effective Date: July 1, 2026

Previous Table

Clients who do not meet an exempt status as defined in Section 202 , and whose citizenship and identity are not verified through an electronic match must provide:

One document from Chart 1 as acceptable evidence of U.S. Citizenship and Identification; or

One document from Chart 2 as verification of Citizenship; and

One document verifying identity from Chart 3

Assist individuals who need to get proof of citizenship. Accept a photocopy, facsimile, scanned or other copy of a document unless information is inconsistent with other information in the case record or you question the validity of information on the document.

CHART 1

Accept any document in Chart 1 as stand-alone proof of citizenship and identity.

(Note: References to documents issued by the United States Citizenship and Immigration Services (USCIS) include documents issued by its predecessor, the Immigration and Naturalization Services (INS). On March 1, 2003, the former INS became part of DHS, and its naturalization function was assumed by U.S. Citizenship and Immigration Services (USCIS) within DHS. However, even documents issued after this date may bear INS legends.)

Stand-alone Documents Explanation U.S. Passport U.S. Passport Card The Department of State issues this. A U.S. passport/card does not have to be currently valid to be accepted as evidence of U.S. citizenship, as long as it was originally issued without limitation. Exception: Do not accept any passport as evidence of U.S. citizenship when it was issued with a limitation. However, such a passport may be used as proof of identity. Exception: As of November 1, 2010, do not accept an expired passport issued to a person born in Puerto Rico. Certificate of Naturalization (N-550 or N-570) Department of Homeland Security issues for naturalization. Certificate of Citizenship (N-560 or N-561) Department of Homeland Security issues certificates of citizenship to individuals who derive citizenship through a parent. A valid State-issued driver’s license that meets certain requirements The valid State-issued driver’s license may be used when: · The state issuing the license requires proof of U.S. citizenship, or · Obtains and verifies a social security number from the applicant who is a citizen before issuing the license. Verification of citizenship by a Federal Agency or another State. The verification must have been done on or after July 1, 2006. Example: child born to a Medicaid or CHIP eligible mother and the child received the one year of deemed newborn eligibility. Documentation from Federally Recognized American Indian Tribes, as published in the Federal Register by the Bureau of Indian Affairs . Examples include: Documents issued by a Federally recognized Indian tribe that identify the Federally recognized Tribe, the individual by name and confirms membership, enrollment or affiliation with the Tribe. Tribal Enrollment Card Certificate of Degree of Indian or Alaska Native Blood (CDIB) Tribal census document Documents on Tribal letterhead, issued under the signature of the appropriate Tribal official.

CHART 2

If an applicant does not provide documentary evidence from Chart 1, the following must be accepted as satisfactory evidence to establish citizenship if also accompanied by an identity document from Chart 3.

Evidence Explanation A U.S. public birth record showing birth in one of the 50 U.S. States; District of Columbia; American Samoa Swain’s island *Puerto Rico (if born on or after Jan. 13, 1941); Virgin Islands of the U.S. (on or after Jan. 17, 1917); Northern Mariana Islands (after Nov. 4, 1986 (NMI local time) Guam The birth record document may be issued by the State, Commonwealth, territory or local jurisdiction. Note : If the document shows the individual was born in Puerto Rico, the Virgin Islands of the U.S,,or the Northern Mariana Islands before these areas became part of the U.S., the individual may be a collectively naturalized citizen. Collective naturalization occurred on certain dates listed for each of the territories. Contact a Policy Specialist to verify these situations. Cross match with a State vital statistics agency documenting a record of birth Certification of Report of Birth (DS-1350) The Department of State issues a DS-l350 to U.S. citizens in the U.S. who were born outside the U.S. and acquired U.S. citizenship at birth, based on the information shown on the FS-240. When the birth was recorded as a. Consular Report of Birth (FS-240), certified copies of the Certification of Report of Birth Abroad (DS-1350) can be issued by the Department of State in Washington, D.C. The DS-1350 contains the same information as that on the current version of Consular Report of Birth FS-240. The DS-1350 is not issued outside the U.S. Consular Report of Birth Abroad of a Citizen of the United States of America (FS-240) The Department of State consular office prepares and issues this. A Consular Report of Birth can be prepared only at an American consular office overseas while the child is under the age of 18. Children born outside the United States to U.S. military personnel usually have one of these. Certification of Birth Abroad (FS-545) Before November 1, 1990, Department of State consulates also issued Form FS-545 along with the prior version of the FS-240. In 1990, U.S. consulates ceased to issue Form FS-545, Treat an FS-545 the same as the DS-135O. United States Citizen Identification Card (I-197)or the prior version I-179 (Section 6036 referred to these documents in error as an I-97) INS issued the I-179 from 1960 until 1973. It revised the form and renumbered it as Form I-197. INS issued the I-197 from 1973 until April 7, 1983. INS issued Form I-179 and I-197 to naturalized U.S. citizens living near the Canadian or Mexican border who needed it for frequent border crossings. Although neither form is currently issued, either form that was previously issued is still valid. Northern Mariana Card (I- 873) The former Immigration and Naturalization Service (INS) issued the 1-873 to a collectively naturalized citizen of the U S who was born in the NMI before November 4, 1986 The card is no longer issued, but those previously issued are still valid. Final adoption decree The adoption decree must show the child’s name and U.S. place of birth. In situations where an adoption is not finalized and the State in which the child was born will not release a birth certificate prior to final adoption, a statement from a State approved adoption agency which shows the child’s name and U. S. place of birth is acceptable. The adoption agency must state in the certification that the source of the place of birth information is an original birth certificate. Evidence of civil service employment by the U.S. government The document must show employment by the U.S. government before June 1, 1976 through electronic verification. Official Military record of service The document must show a U.S. place of birth (for example a DD-214 or similar official document showing a U.S. place of birth) Data match with SAVE SAVE (Systematic Alien Verification for Entitlements) interface Evidence of meeting the automatic criteria for U.S. citizenship outlined in the Child Citizenship Act of 2000. See Section 202-1 Medical Records Includes, but not limited to: hospital, clinic, or doctor records or admission papers from a nursing facility, skilled care facility, or other institution that indicate a U.S. place of birth. Life, Health or other Insurance record showing a U.S place of birth Life or health insurance records may show biographical information for the person including place of birth; the record can be used to establish U S citizenship when it shows a U.S. place of birth. Religious records of birth Record must show the birth occurred in the U.S. The record must be an official record recorded with the religious organization. (Entries in a family bible are not considered religious records.) School record showing U.S. place of birth. The school record must show the name of the child and a U.S. place of birth . Federal or State census record showing U.S. citizenship or a U.S. place of birth Note: Census records from 1900 through 1950 contain certain citizenship information. To secure this information the applicant, recipient or State should complete a Form BC-600, Application for Search of Census Records for Proof of Age. Add in the remarks portion “U.S. citizenship data requested.” Also add that the purpose is for Medicaid eligibility. This form requires a fee. If the applicant does not have one of the documents from Chart 1 or any of the above documents from Chart 2, he may submit an affidavit signed by another individual The affidavit must be signed under penalty of perjury by the individual who can reasonably attest to the applicant’s citizenship, and that contains the applicant’s name, date of birth, and place of U.S. birth. The affidavit does not need to be notarized.

CHART 3

Evidence of Identity

Documents to Establish Identify Explanation Any identity document described in 8 CFR 274a.2(b)(1)(v)(B)( 1 ) Accept the following as proof of identity, provided such document has a photograph or other identifying information including, but not limited to, name, age, sex, race, height, weight, eye color or address. Driver’s license issued by State or Territory. Do not accept a driver’s license issued by a Canadian government authority. School identification card U.S. military card or draft record Identification card issued by the Federal, State, or local government Military dependent’s identification card U S Coast Guard Merchant Mariner card For children under age 19 Clinic, doctor, hospital, or school record including preschool or day care records. Corroborating documents At state option, 2 or more documents containing consistent information corroborating an applicant’s identity such as marriage licenses, divorce decrees, high school or college diplomas, property deeds or titles, and employer ID. Finding of Identity from a Federal or State governmental agency Includes, but not limited to: public assistance, law enforcement, internal revenue or tax bureau, or corrections agency, if the agency has verified and certified the identity of the individual. Finding of identity from an express lane agency as defined in section 1902(e)(13)(F) Link to 1902(e)(13)(F) If the applicant does not have one of the documents listed above, the applicant may submit an affidavit. The affidavit must be signed under penalty of perjury by the individual who can reasonably attest to the applicant’s identity, and that contains the applicant’s name, date of birth, and place of U.S. birth. The affidavit does not need to be notarized.

(table-v-telephone-numbers)Table V - Telephone Numbers#

(table-v-telephone-numbers)(block-1)Updated: April 23, 2026#

CHIP Program Contact Information Office Director Michelle Smith 385-538-6347 Assistant Office Director Gina Boren 801-538-9082 Program Manager Marcel Larsen-Jones 801-538-6494 Policy Specialist Jeff Dart 801-538-6509 Co-payment & Out of Pocket Maximum HPR 801-526-9422 or 1-866-608-9422 CHIP Information Hotline 1-877-Kids-Now or 1-888-222-2542 CHIP Website www.health.utah.gov/chip Fax # 801-538-6099 Administration Office 801-538-6358 Health Program Representatives (Health Plan Selection) 801-526-9422 or 1-866-608-9422 CHIP Premium Line 801-526-0950 or 1-866-435-7414 option #5 CHIP Online Education Link http://www.health.utah.gov/umb/ Medicaid Policy Specialist UPP, Adult Expansion Employer Sponsored Insurance Premium Reimbursement and Targeted Adult Medicaid Jeff Dart 801-538-6509 Family, MAGI and Adult Expansion Brigham Andrew 801-538-9249 Presumptive Eligibility (BYB & HPE) Jeff McClellan 801-538-6082 Aged, Blind, Disabled and Medical transportation Tammy Berrie 801-538-6534 Nursing Home and HCBS Waivers Jane Ranquist 801-538-6495 Fair Hearing Oversight, Application, Review, Verification, Change Report and General Policy Jessica Ware 801-538-6192 Policy Coordinator Lane London 801-538-6505 Policy Coordinator Wendy Jones 801-538-6472 UPP Premium Specialist Jeff Dart 801-538-6509 For Policy Manual Issues Wendy Jones 801-538-6472 Constituent Services Representative Tracy Barkley 801-538- 6417 or 1-877-291-5583 Fax #801-536-0946 Medicaid Information Hotline, Billing and Prior Authorizations 801-538-6155 or 1-800-662-9651 Medicaid Eligibility Policy Manual https://bepmanuals.health.utah.gov/Medicaidpolicy/DOHMedicaid.htm UPP Website www.health.utah.gov/upp Vital Records Office of Vital Records and Statistics Utah Department of Health P.O. Box 141012 SLC, UT 84114-1012 801-538-6105 or 1-866-632-2602 Fax 801-538-7012 ORS Medicaid Information Unit For questions about insurance coverage, TPL & medical collections. 801-536-8798 To report possible receipt of insurance/personal injury settlements. TPLchanges@utah.gov ORS Part A and Part B Medicare BUY-IN 801-536-8798 extension 14722 Fax: 801-536-0377 ORS Child Support Services 801-536-8500 Other Agency Contact Information Department of Workforce Services Medicaid Eligibility 801-526-0950 or 1-866-435-7414 https://jobs.utah.gov/mycase/ Constituent Services Representative Department of Workforce Services 801-526-4390 or 1-800-331-4341 Department of Workforce Services Payment Error Prevention Unit (Investigations and Overpayments) (801) 526-9810 Toll free: 1-866-647-3862 Fax: (801) 532-2605 eREP HELPDESK 801-526-4357 or 1-866-826-6012

(table-vi-verification-and-interface-match)Table VI - Verification and Interface Match#

(table-vi-verification-and-interface-match)(block-1)Table VI - Verification and Interface Match#

Effective Date: July 1, 2026

Previous Table

The eligibility agency must attempt to verify all factors of eligibility electronically before asking client to provide hard copy verifications. 705 outlines the various methods of verification.

This table shows the interface matches that are available and gives EXAMPLES of hard copy verifications that may verify the information

you need, although not every example listed will verify all of the information shown under the Eligibility Factors column. Any other

reasonable method of verification can be used as long as it provides the information needed to determine eligibility.

Eligibility Factor Interface or Match Other U.S. Citizenship; Age; Identification Electronic Interface SCHIP See Table IV Non-Citizen (INS) Status Electronic Interface - Social Security screens, Alien Registration Alien Registration Card Correspondence from the Department of Homeland Security Social Security Number; Social Security Claim # Electronic Interface Birth Record SAVE SCHIP SOLQ Social Security Card SSA form 5028 or 2880 Birth Certificate showing SSN applied for Official Social Security document Utah Residence; Resident of an Institution Electronic Interface New Hire Registry Prisoner System Information NCOA (National Change of Address USPS interface) Current Utah Driver’s license Employment payroll check stubs Current UTES registration House payment receipt Current rent receipt Utah telephone book listing (referenced) Tribal Record correspondence Children's residence usually follows that of parents Nursing home resident (unless placed by another state) Form 131- Affidavit of Intent to Become a Utah Resident; or other statement of intent to remain in Utah. Duty of Support Relationship (Including Specified Relative); Paternity Electronic Interface, Birth Record Self-declaration of relationship (unless the agency has conflicting information) Birth Certificate Court Order Marriage Certificate DWS Form 941 - Acknowledgment of Paternity “Voluntary Declaration of Paternity” form filed with Vital Statistics County Records Adoption placement or finalization forms (placement forms may be used to determine that child is not with birth parents) Death records Divorce records Documents from other state agencies stating verified relationship Duty of Support Completed Application for Child Support Enforcement on each non-custodial parent Pregnancy Self-declaration (unless the agency has conflicting information) Current physician's or nurse mid-wife’s statement Current statement from Planned Parenthood Statement from a health clinic School Attendance DWS form 126 Telephone contact with school Application for Other Benefits Electronic Interface - Paris (VA income), Workers Comp, Social Security, Unemployment Statement from other agency American Indian/Alaska Native or descendents in the 1st or 2nd degree of a Federally recognized tribe member. * Copayment exemption requires verification of status after the client has had reasonable time to provide verification. American Indian/Alaska Native (AI/AN) Tribal Identification/Enrollment Card with number/tribal census document issued by a federally recognized tribe indicating the individual's affiliation with the tribe. Certificate of Degree of Indian or Alaska Native Blood (CDIB) signed by the Bureau of Indian Affairs (BIA), or another document from BIA recognizing the person as American Indian/Alaskan Native. Tribal court documents containing identifying information such as name and the date of birth. Indian Health Services (IHS) document indicating the individual is eligible for IHS services as an American Indian/Alaskan Native. (Such documents must have identifying information about the individual. IE, name and date of birth.) AI/AN Descendent Documents of ascendent (parent or grandparent) that verifies status as member of federally recognized AI/AN tribe. Provider document: Birth certificate, tribal court document or IHS face sheet showing lineal descent from ascendant to descendant. Earned Income Note: When a more current data source is not available, verified income data that was received within the past six months at a SNAP or TANF determination may be used. Wages; Self-Employment Electronic Interface, Wages Work Number, Wages TRUV, the Hub New Hire Registry Employment payroll check stubs Employer's wage record Statement from employer Self-employment records Copy of most recent tax return SNAP and TANF income data received within the last six months Training, Work Study Award letter Contracts Earned income in-kind (food, clothing, free housing, etc.) Employer's records Statement from employer Written agreement Unearned Income Note: When a more current data source is not available, verified income data that was received within the past six months at a SNAP or TANF determination may be used. Social Security Benefits (SSA); Supplemental Security Income (SSI); VA Benefits; Retirement; Labor Union Benefits; Pensions; Annuity; Disability Compensation; Scholarships/loans; Tribal Income; Cash gifts and prizes Electronic Interface, Social Security Screens SOLQ (does not show correct amount if deductions are being taken out of benefits. Compare both the BDX and the SOLQ to verify the correct amount is counted.) Client statement of benefits until information appears on the SDX/BDX Award letter Legally acceptable copy of check Bank statement showing direct deposit specifying source of income Tribal Records SNAP and TANF income data received within the last six months Unemployment Compensation Electronic Interface, Unemployment Statement from DWS Bank statement showing direct deposit Alimony and Child Support Electronic Interface, Recovery Services screens County Clerk records Divorce decree or other court order about payments including judgment for past due amounts. Copies of checks received Statement from ORS Dividend and Interest Bank Statements, dividend letters or statements Currently posted saving passbook Current credit union statement Internet on-line banking Real Property Sales Sales Contract Mortgage Payment of household expenses by others Client's statement Form 702 - Statement of Contribution Form 17 - Statement of Head of Household Expenses Health Insurance Electronic Interface Receipt for health insurance premiums paid Insurance records/billing statement Check stubs/statements showing amount paid by individual Medicare Part A & B Premium Amounts Electronic Interface - Social Security screens Medicare Card Official document from SSA Alimony and Child Support Paid Out Electronic Interface, Recovery Services screens (Unemployment Claim Adjustment Field) Court order showing alimony or child support owed and copies of checks showing payments made Income tax records Medical bills owed Copies of medical services received and current statement of amount owed Statement from provider of amount owed Other TPL: Auto No Fault, Health (hospital), Accident, Homeowners Policies Insurance Card Written or verbal notice from ORS Client's statement Health Insurance Coverage Policies Insurance Card Written or verbal notice from ORS Client's statement

(100-general-provisions)100 General Provisions#

(100-general-provisions)(block-1)100 General Provisions#

(100-general-provisions)100 General Provisions#

(100-general-provisions)(block-1)100 General Provisions#

(101-2-special-safeguards-for-irs-income-match-data)110-2 Special Safeguards for IRS Income Match Data#

(101-2-special-safeguards-for-irs-income-match-data)(block-1)Effective Date: January 1, 2014#

(101-3-who-may-have-access-to-income-match-records)110-3 Who May Have Access to Income Match Records#

(101-3-who-may-have-access-to-income-match-records)(block-1)Effective Date: January 1, 2014#

(101-enrollee-rights)101 Enrollee Rights#

(101-enrollee-rights)(block-1)Previous Policy#

(102-1-completion-of-an-application)102-1 Completion of an Application#

(102-1-completion-of-an-application)(block-1)Effective Date: March 1, 2022#

(102-2-verification)102-2 Verification#

(102-2-verification)(block-1)Effective Date: January 1, 2014#

(102-2-verification)(block-2)Verification#

(102-3-report-changes)102-3 Report Changes#

(102-3-report-changes)(block-1)Effective Date: January 1, 2024#

(102-5-cooperate-with-quality-reviews)102-5 Cooperate with Quality Reviews#

(102-5-cooperate-with-quality-reviews)(block-1)Effective Date: January 1, 2024#

(102-enrollee-responsibilities)102 Enrollee Responsibilities#

(102-enrollee-responsibilities)(block-1)No Previous Policy#

(103-1-prohibited-action)103-1 Prohibited Action#

(103-1-prohibited-action)(block-1)Effective Date: July 1, 2008#

(103-worker-responsibilities)103 Worker Responsibilities#

(103-worker-responsibilities)(block-1)Effective Date: August 1, 2018#

(104-authority-of-the-office-director)104 Authority of the Office Director#

(104-authority-of-the-office-director)(block-1)104 Authority of the Office Director#

(110-1-safeguards-of-income-match-data)110-1 Safeguards of Income Match Data#

(110-1-safeguards-of-income-match-data)(block-1)Effective Date: January 1, 2014#

(110-safeguarding-information)110 Safeguarding Information#

(110-safeguarding-information)(block-1)Effective Date: January 1, 2014#

(111-1-releasing-information-to-the-enrollee)111-1 Releasing Information to the Enrollee#

(111-1-releasing-information-to-the-enrollee)(block-1)Effective Date: December 1, 2010#

(111-2-use-of-confidential-information)111-2 Use of Confidential Information#

(111-2-use-of-confidential-information)(block-1)111-2 Use of Confidential Information#

(111-3-releasing-information-to-others)111-3 Releasing Information to Others#

(111-3-releasing-information-to-others)(block-1)Effective Date: January 1, 2014#

(111-confidential-information)111 Confidential Information#

(111-confidential-information)(block-1)111 Confidential Information#

(120-1-agency-conferences)120-1 Agency Conferences#

(120-1-agency-conferences)(block-1)Effective Date: July 1, 2010#

(120-2-fair-hearings)120-2 Fair Hearings#

(120-2-fair-hearings)(block-1)Effective Date: January 1, 2014#

(120-3-fair-hearing-requests)120-3 Fair Hearing Requests#

(120-3-fair-hearing-requests)(block-1)Effective Date: April 1, 2014#

(120-4-the-hearing)120-4 The Hearing#

(120-4-the-hearing)(block-1)Effective Date: January 1, 2023#

(120-5-benefits-pending-a-hearing-decision)120-5 Benefits Pending A Hearing Decision#

(120-5-benefits-pending-a-hearing-decision)(block-1)Effective Date: July 1, 2024#

(120-6-what-happens-during-a-fair-hearing)120-6 What Happens During a Fair Hearing#

(120-6-what-happens-during-a-fair-hearing)(block-1)Effective Date: January 1, 2023#

(120-8-fair-hearing-decisions)120-8 Fair Hearing Decisions#

(120-8-fair-hearing-decisions)(block-1)Effective Date: July 1, 2022#

(120-9-how-to-appeal-a-decision)120-9 What Records Are Kept of Hearing Decisions and Who Can See Them#

(120-9-how-to-appeal-a-decision)(block-1)Effective Date: January 1, 2014#

(120-complaints)120 Complaints#

(120-complaints)(block-1)Effective Date: July 1, 2010#

(130-hipaa-health-insurance-portability-and-accountability-act-of-1996)130 HIPAA (Health Insurance Portability and Accountability Act of 1996)#

(130-hipaa-health-insurance-portability-and-accountability-act-of-1996)(block-1)Effective Date: April 1, 2019#

(200-program-standards)200 Program Standards#

(200-program-standards)(block-1)200 Program Standards#

(201-1-screening-for-medicaid-eligibility)201-1 Screening for Medicaid Eligibility#

(201-1-screening-for-medicaid-eligibility)(block-1)Effective Date: January 1, 2014#

(201-1-screening-for-medicaid-eligibility)(block-2)Application#

(201-1-screening-for-medicaid-eligibility)(block-3)Review#

(201-1-screening-for-medicaid-eligibility)(block-4)Reported Changes#

(201-medicaid-eligibility)201 Medicaid Eligibility#

(201-medicaid-eligibility)(block-1)Effective Date: June 1, 2024#

(202-1-u-s-citizens)202-1 U.S. Citizens#

(202-1-u-s-citizens)(block-1)Effective Date: March 1, 2026#

(202-2-1-lawfully-present-children)202-2.1 Lawfully Present Children#

(202-2-1-lawfully-present-children)(block-1)Effective Date: December 5, 2017#

(202-2-qulaified-non-citizen)202-2 Qualified Non-Citizen#

(202-2-qulaified-non-citizen)(block-1)Effective Date: February 1, 2023#

(202-3-verification-of-non-citizen-status)202-3 Verification of Non-Citizen Status#

(202-3-verification-of-non-citizen-status)(block-1)Effective Date: May 1, 2018#

(202-3-verification-of-non-citizen-status)(block-2)Electronic Verification#

(202-3-verification-of-non-citizen-status)(block-3)Verifying Immigration Status#

(202-4-sponsored-non-citizens)202-4 Sponsored Non-Citizens#

(202-4-sponsored-non-citizens)(block-1)Effective date: January 1, 2014#