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500.10 Non-Financial Eligibility for MinnesotaCare |
Effective: January 1, 2014 |
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500.10.20 Minimum Essential Coverage for MinnesotaCare |
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Individuals who attest to being enrolled in minimum essential coverage (MEC) are not eligible for MinnesotaCare.
People enrolled or eligible to enroll in any of these MEC programs are ineligible for MinnesotaCare:
Government-sponsored coverage
Medicare Part A, Part B or Medicare Supplement
Medical Assistance
Medical Assistance in another state
Children’s Health Insurance Program (CHIP)
CHIP in another State
TRICARE
CHAMPUS
Veteran’s health care and related programs if enrolled
Coverage obtained through another state's health care marketplace
Peace Corps
Minnesota Comprehensive Health Association (MCHA)
Pre-Existing Condition Insurance Plan (PCIP)
Refugee Medical Assistance (RMA)
Medicare Advantage Plans
Non-appropriated Fund Health Benefits Program (NAF) of the Department of Defense
Employer-sponsored plans
Other coverage
Health care through the Consolidated Omnibus Budget Reconciliation Act (COBRA), or other continuation coverage if enrolled
Grandfathered health plans
Student health plans offered through institutions of higher learning if enrolled
Other coverage as determined by the Secretary of the Department of Health and Human Services
Insurance policies that provide limited benefits do not qualify as MEC. The following policies are excepted benefit policies and are not considered MEC.
Coverage only for accident or disability
Supplemental liability insurance coverage
Liability insurance
Worker’s Compensation
Automobile medical payment insurance
Credit-only insurance
Coverage for on-site medical clinics
Limited scope dental or vision benefits
Benefits for long-term care, nursing home care, home health or community care
Coverage just for specific diseases or illnesses
Hospital indemnity or fixed indemnity insurance
Supplemental coverage with no comprehensive coverage
Other similar coverage that is secondary or incidental to other insurance benefits
Emergency Medical Assistance (EMA)
Family planning-only coverage
Tuberculosis-only coverage
Pregnancy-only coverage
MinnesotaCare may be temporarily approved or extended for a person who is complying with requirements to obtain government-sponsored coverage. For example, a person waiting for an eligibility determination for Medical Assistance (MA) with a spenddown may be approved for MinnesotaCare until the MA determination is complete.
A person may not be considered to have access to minimum essential coverage until the first day of the first full month in which he or she may begin receiving benefits under the program.
If a person is eligible for government-sponsored MEC and fails to complete the process to apply for or activate the coverage, he or she is treated as eligible for MEC and therefore ineligible for MinnesotaCare on the first day of the fourth calendar month after the date or event that established eligibility for the government-sponsored MEC. Additionally, a person is ineligible for MinnesotaCare if coverage under government-sponsored MEC was terminated due to failure to comply with program requirements.
To be considered qualifying coverage, the employer-sponsored plan must meet both minimum value and affordability standards of the Affordable Care Act (ACA). Affordability is determined by comparing the premium cost to the person’s household income. Minimum value is defined as a plan that covers at least 60 percent of the total allowed costs under the plan.
An employee will be considered to have access to MEC if enrolled or eligible to enroll in a qualified employer-sponsored health plan. An employee will be considered as having MEC if he or she failed to enroll in an eligible employer-sponsored coverage at the time of the employer’s special or open enrollment period, if it is determined that the employer-sponsored plan meets the minimum value and affordability requirements.
For employed people, a health plan offered through an employer is affordable if the cost of premiums for employee-only coverage does not exceed 9.5% of the household income. For the purpose of this affordability determination, the employed person's net income must be increased by any amount being deducted from the gross amount for health care coverage.
In general, if a person is enrolled in an employer-sponsored plan, he or she cannot receive MinnesotaCare, even if that insurance is not affordable or does not provide minimum value. An employee whose employer-sponsored coverage does not meet minimum value or affordability requirements is allowed to terminate his or her employer-sponsored coverage and is considered eligible for MinnesotaCare the day after his or her employer-sponsored coverage is terminated. Additionally, if the new eligibility system determines that an employer-sponsored plan will not provide qualifying coverage at some point in the future, the employee may terminate his or her employer-sponsored coverage and request enrollment through MNsure in coordination with the termination of the employer-sponsored coverage.
When an employer has a wellness incentive program, the MEC calculation is based on the coverage for people who do not meet the wellness incentive. The exception is for tobacco use: MEC for wellness incentives based on tobacco use are based on the plan for people who do not use tobacco or participate in tobacco cessation.
This allows employers to use health reimbursement funds to be counted towards the employee’s required contribution provided that:
the amounts are newly available for the current plan year.
the health reimbursement arrangement is integrated with the employer-sponsored plan.
the employee may use the funds to pay premiums.
The new eligibility system will use the Federal Data Hub and other available electronic data to determine if the person is eligible for government-sponsored MEC. Applications require applicants who have access to employer-sponsored coverage to provide information about their health coverage in order to determine whether the employer-sponsored health plan is affordable and provides minimum value.
MinnesotaCare coverage is effective on the first day following the loss of minimum essential coverage, providing premiums have been paid on time. See MinnesotaCare Begin and End Dates for information about effective dates following the loss of MEC.
Circumstances which may lead to the lost of coverage include, but are not limited to:
the loss of coverage to due legal separation, divorce, loss of dependent status (such as attaining the maximum age to be eligible as a dependent), death of the employee, termination of employment or reduction in hours.
the loss of coverage when a person moves outside of the coverage area of the health insurance plan.
a person incurring a claim that meets or exceeds a lifetime limit on benefits.
a person’s plan no longer offering benefits to him or her.
the employer stopping contributions towards the cost of health care coverage.
the exhaustion of COBRA coverage.
A person is not considered to have lost MEC if his or her coverage is terminated due to failure to pay premiums on a timely basis, or for situations that call for rescinding coverage, such as fraud.
A person who is eligible for coverage under an employer-sponsored plan as a result of his or her relationship to an employee, and who is claimed by the employee as a tax dependent, is considered to have access to MEC if enrolled or eligible to enroll in the plan.
An eligible employer-sponsored plan is affordable for related people, who are claimed by the employer as tax dependents, if the portion of the annual premium the employee must pay for employee-only coverage does not exceed 9.5% of the taxpayer’s household income. If the cost of employee-only coverage does not exceed this limit, all household members claimed as tax dependents, who are eligible to enroll in the employer-sponsored plan, are considered to have access to MEC, regardless of the cost of employer-sponsored family coverage.
A person eligible for employer-sponsored coverage due to their relationship to an employee, but who is not claimed as a tax dependent by the employee, is only considered to have MEC if enrolled in the plan.
An employed person who is eligible for coverage in his or her own employer-sponsored plan, who is also eligible as a dependent in the employer-sponsored plan of another household member, is treated as an eligible employee and not as an eligible dependent. If two members of a family are employed and their respective employers offer employee-only coverage, affordability for each person is determined based on the premium cost for employee-only coverage offered by his or her own employer.
If a person's employer-sponsored coverage is unaffordable at application, and becomes affordable at some point later in the year, he or she may remain eligible for MinnesotaCare for the remainder of the employer-sponsored plan year. The employee is not treated as having access to employer-sponsored MEC for the remainder of the employer-sponsored plan year.
Once the person is able to enroll in affordable employer-sponsored coverage, he or she is no longer eligible for MinnesotaCare.
Code of Federal Regulations, title 26, section 1.36B-2
Code of Federal Regulations, title 26, section 1.5000A
Code of Federal Regulations, title 45, section 155.300
Code of Federal Regulations, title 45, section 155.305
Code of Federal Regulations, title 45, section 155.320
Code of Federal Regulations, title 45, section 155.420
Code of Federal Regulations, title 45, section 155.430
Code of Federal Regulations, title 45, section 155.602
Code of Federal Regulations, title 45, section 155.604
Patient Protection and Affordable Care Act, Public Law 111-148, section 1401
Patient Protection and Affordable Care Act, Public Law 111-148, section 5000A