All Medicaid Programs |
Obsolete Policy |
Effective Date: December 1, 2021 - January 31, 2022
A. Required Participation
1. Enrollment requirements apply to all individuals on Adult Expansion who have access to a qualified employer-sponsored health plan (QHP) with the exception of:
· Verified American Indian or Alaska Native individuals
· Individuals who are already enrolled in any other type of health insurance plan that is not their employer-sponsored health plan (348-3.2).
2. All individuals receiving coverage on Adult Expansion Medicaid, whose employer offers qualified health insurance, are required to enroll and maintain enrollment in that plan.
· An individual may have access even if there is a waiting period before coverage becomes effective.
B. Optional Participation
The following individuals are exempt from the ESI requirement, but can choose to participate if they are receiving Adult Expansion Medicaid. In addition, if an exempt individual chooses to participate but voluntarily terminates coverage in that plan, a disenrollment period will not apply (348-3.3).
1. Verified American Indian or Alaska Native individuals.
2. A spouse who is eligible for Adult Expansion but only has access to enroll as a dependent in their spouse’s qualified employer-sponsored health plan.
· Both spouses must be eligible for Adult Expansion for a spouse to receive an ESI premium reimbursement.
· The premium reimbursement will be the cost of the employee + spouse portion of the monthly insurance premium of the QHP.
3. Individuals already enrolled in any other type of health insurance plan that is not their employer-sponsored health plan and choose to also enroll in their employer’s sponsored health insurance.
C. Enrollment Time Frames
The agency must notify the client of the requirement to enroll in a qualified employer-sponsored health plan (QHP). Premium reimbursement begins once the client has completed the following steps.
1. The individual must enroll in the qualified employer-sponsored health plan within 30 days of being notified of the requirement. Qualifying for ESI premium assistance creates a special enrollment period. The special enrollment period allows an employee to enroll outside the regular open enrollment period.
2. Individuals who previously enrolled in a QHP, and those who comply with the requirement and enroll in a qualified employer-sponsored health plan, must complete steps a-c.
a. Provide proof of enrollment with the effective date.
b. Provide proof that the plan is a qualified plan.
c. Provide proof of premium payment including the date the payment began.
3. Reimbursements will not be issued before the client provides proof of enrollment and proof of the premium paid has been verified.
· If the employer deducts the health insurance premium in a month prior to the insurance effective date, the individual is eligible to receive a reimbursement in the month the premium was paid but not before the application date.
D. Verification Time Frames
1. The agency must give the individual at least 45 days to provide all required verification.
2. The individual may request more time to provide verifications, if needed (731).
· The individual must request additional time by the due date.
3. If the individual fails to provide all requested verification by the due date, Adult Expansion Medicaid may close.
· If an individual provides all the required verification after the due date, the ESI reimbursement will begin the month the verification is received.
4. If the individual does not enroll in a qualified employer-sponsored health plan, Adult Expansion Medicaid will close (348-3.3).
5. If the individual enrolls in a plan that is not a qualified employer-sponsored health plan, they will remain eligible for Adult Expansion Medicaid but will not receive a premium reimbursement for that plan.
E. Reportable Changes
1. Reported changes must be evaluated to determine if they could affect eligibility. The agency must give at least 10-days from the date of the notice to provide verifications.
2. In addition to the reporting requirements in section 107-4 & 815, individuals receiving a premium reimbursement must report the following changes within ten (10) days of the change.
a. The client enrolls or gains access to Medicare.
b. The client becomes covered by or gains access to the Veteran's Health Care System.
c. The client enrolls or gains access to new employer-sponsored health insurance coverage.
d. The coverage in the employer sponsored insurance is terminated.
e. The client changes insurance plans.
· Change in health insurance plans need to be reported within 10-days from either the day the client signs up or the date coverage begins, whichever is later.
f. Any changes to the premium amounts or the plan no longer meets the definition of a “Qualified ESI Plan” (348-3.2).
g. The client enrolls in any other kind of health insurance coverage other than the employer-sponsored health plan.
· Individuals receiving ESI who enroll in any other type of health insurance are not eligible for the ESI reimbursement.
3. If the client provides all requested verification by the verification due date, or by the end of the report month, the agency will continue with the eligibility determination.
· If the change increases the ESI payment amount, the change will become effective the month immediately following the change report month.
· If a change causes a recipient to lose eligibility, the agency will determine eligibility for other medical programs (827).
F. Quarterly Insurance Confirmation
The Office of Recovery Services (ORS) will confirm the health insurance coverage is still active and there are no changes in covered individuals.
1. If ORS verifies there are no changes to the health plan or covered individuals, the ESI payment will continue.
2. If any of the following changes occur, ORS will notify the eligibility agency to take action on the case.
a. The health insurance coverage has ended;
b. There are changes to the health plan benefits, including who is covered; or
c. The status of the health insurance cannot be verified.
· If ORS cannot verify the health insurance status, the eligibility agency must request the necessary verification from the client.
· If the client does not provide all requested verification by the verification due date, the eligibility agency ends benefits for the first month it can give proper 10-day notice.
3. If there are changes that were not reported but effect eligibility for ESI, the worker must determine if the client will be sanctioned for coverage for the Adult Expansion Medicaid (348-3.4).