All Medicaid Programs |
Obsolete Policy |
Effective Date: February 1, 2021 - November 30, 2021
Enrolled in Health Insurance
When an individual reports they are enrolled in an employer-sponsored health plan, the agency must verify if the plan is a qualified health plan (QHP) (348-3).
If the agency determines that is not a qualified health plan or is not sponsored by an employer, the individual is not eligible for a premium reimbursement and is not required to enroll.
The individual will remain eligible for Adult Expansion Medicaid.
If the individual enrolls in a health plan that is not a qualified employer-sponsored health plan they are not eligible for an ESI premium reimbursement, but are eligible to receive Adult Expansion Medicaid.
An individual enrolled in their spouse’s a qualified employer-sponsored health plan, may receive a premium reimbursement when both spouses are eligible for Adult Expansion Medicaid.
If the policyholder loses eligibility for Adult Expansion, the spouse will no longer be eligible to receive the ESI reimbursement.
Individuals enrolled in more than one health insurance plan can only receive a premium reimbursement for one plan.
Access to Employer Sponsored Insurance
When the individual has access to a qualified employer-sponsored health plan, request verification to determine if the plan meets the criteria of a qualified plan (348-3).
An individual may have access even if there is a waiting period before coverage becomes effective.
If the employer does not offer a qualified employer-sponsored health plan, the individual is not required to enroll.
If an individual has access to enroll as a dependent in their spouse’s qualified employer-sponsored health plan, the individual can choose to enroll in that plan if both are eligible for Adult Expansion.
If the policyholder loses eligibility for Adult Expansion, the spouse will no longer be eligible to receive the ESI reimbursement.
If both spouses have access to enroll in their own qualified ESI, and both are eligible for Adult Expansion Medicaid, they can choose to enroll in their own qualified employer-sponsored health plan, or their spouse’s.
If they enroll in the same plan and the policyholder loses their qualified employer-sponsored health plan or loses their eligibility under Adult Expansion, premium reimbursement will end for both individuals.
Qualified Health Plan
An ESI “Qualified Health Plan" is the term applied to any health plan that meets the minimum essential coverage requirements which include the following:
The plan covers physician visits, inpatient and outpatient hospital care, prescription drug coverage, laboratory services, preventive and wellness services, pregnancy and childbirth.
The network deductible is $4000 or less per person.
This does not include the annual deductible amount that must be met before the health plan begins to pay for covered medical benefits.
The plan pays at least 70% of an in network inpatient stay (after deductible).
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.
For employer-sponsored health plans only - the employer pays at least 50% of the premium for the policy holder.
The lifetime maximum benefit is at least $1,000,000, or the plan has no maximum.
Other Definitions
Some employers may offer one or both of the following options as part of their benefits. These are not part of the employee's cost for health insurance premiums. (See 348-3)
o HSA- Health Savings Account: An account that allows an individual to set aside pre-tax funds for qualified medical expenses in combination with an HDHP (High Deductible Health Plan). The individual and employer contribute funds that can accumulate from year to year.
o FSA- Flexible Spending Account: An account that allows an individual to set aside a limited amount of pre-tax funds through payroll deductions to pay qualified medical expenses. The funds must be used in the plan year.