Medicaid Policy
Medicaid Policy
The following definitions apply to terms used for UPP.
"Access" Means an employee is eligible to complete or file forms to enroll in the employer sponsored health insurance.
An individual may have access even if there is a 90-day waiting period before coverage becomes effective.
“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. To be UPP reimbursable, the COBRA insurance must be an UPP Qualified Health Plan. (See N below.) There are other types of COBRA plans that may qualify for reimbursement:
FIA COBRA – Continuation coverage provided through FDIC.
Mini COBRA – Continuation coverage for small businesses (under 25 employees). Coverage is only available for a maximum of 6 months.
See "Qualifying Events for COBRA" definition below.
"Enrolled" means an individual is signed up in a health insurance plan and is receiving benefits under that plan.
“Employer-Sponsored Health Coverage or Plan” is health insurance offered to employees that provides medical care to the employee or their dependents.
“Health Insurance Coverage or Plan” is a benefit plan offered by a health insurance issuer or government agency that provides coverage for the cost 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. It may also be Medicare, Medicaid or the Veteran's Health Insurance System.
“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:
A plan that provides a limited scope of services such as dental or vision benefits only.
Benefits only for long-term care, nursing home care, home health care, community-based care, or any combination thereof.
Coverage limited to a specific disease or illness, such as cancer.
Workers' compensation or similar insurance.
Coverage limited to an accident, disability income insurance or any combination thereof.
Hospital indemnity or other fixed indemnity insurance, (for example, plans that pay a fixed daily rate to the individual for inpatient stays.)
Coverage for on-site medical clinics.
Liability insurance, including general liability insurance, and homeowners or automobile liability/medical insurance.
Other similar insurance coverage under which benefits for medical care are secondary or incidental to other insurance benefits.
Credit-only insurance, that pays a loan payment during a period of incapacity of disability.
Coverage issued as a supplement to liability insurance.
“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.
”Open Enrollment Period” is a period of time when an individual can sign up for health insurance or make changes to their medical coverage.
“Qualifying Events” are certain events that allow an employees and/or dependents to enroll in the employer sponsored insurance plan outside of the annual open enrollment period. This applies to employees that have not yet enrolled in employer sponsored health insurance coverage. Examples of a qualifying events are:
Eligible for UPP.
New spouse.
Birth of a child.
Adoption of a child.
“Qualifying Events for COBRA” are certain events that would cause an individual to lose health insurance coverage. The type of qualifying event will determine who the qualified beneficiaries are and the amount of time that a plan must offer the health insurance to them under COBRA. A plan, at its discretion, may provide longer periods of continuation coverage.
1. Qualifying Events for Employees:
Voluntary or involuntary termination of employment for reasons other than gross misconduct.
Reduction in the number of hours of employment.
2. Qualifying Events for Spouses:
Voluntary or involuntary termination of the covered employee’s employment for any reason other than gross misconduct.
Reduction in hours worked by the covered employee.
Covered employee’s becoming entitled to Medicare.
Divorce or legal separation of the covered employee.
Death of the covered employee.
3. Qualifying Events for Dependent Children:
Loss of dependent child status under the plan rules.
Voluntary or involuntary termination of the covered employee’s employment for any reason other than gross misconduct.
Reduction in the hours worked by the covered employee.
Covered employee’s becoming entitled to Medicare.
Divorce or legal separation of the covered employee.
Death.
"Student Health Insurance Plan" is a health insurance plan that is offered to students directly through a college, university or other educational facility or through private health insurance companies that offer coverage plans specifically for students. Student health insurance plans are not eligible for UPP reimbursement.
"UPP Qualified Health Plan" is the term applied to any health plan that meets all of the following requirements:
1. The plan covers physician visits, inpatient and outpatient hospital care, prescription drugs, laboratory services, preventive and wellness services, pregnancy and childbirth.
2. The network deductible is $4,000 or less per person.
3. The plan pays at least 70% of an in network inpatient stay (after deductible).
4. The plan does not cover abortion services; OR the plan only covers abortion services in the case where life of the mother would be endangered if the fetus were carried to term or in the case of incest or rape.
5. For employer-sponsored health plans only - the employer pays at least 50% of the premium for the primary insured individual (See E above).
A qualified health plan does not include benefits provided under a health flexible spending arrangement or a high deductible health plan.
6. The lifetime maximum benefit is at least $1,000,000, or the plan has no maximum.
”Waiting Period” means the time between the date the employee has access to enroll in the employer sponsored health insurance and the date the plan becomes effective. An employer may impose a waiting period up to 90 days for new or newly qualified employees.