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Effective: February 1, 2011 |
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15.10ar6 - Other Health Care Coverage - MA and GAMC (Archive) |
Archived: June 1, 2011 |
MA and GAMC do not have insurance barriers to eligibility. However, clients must meet certain requirements to be eligible for MA or GAMC while concurrently having access to other health care coverage .
Reporting Other Health Care Coverage.
Accessing Other Health Care Coverage.
MA for Breast and Cervical Cancer (MA-BC).
Other Health Care Coverage Evaluation Steps.
Long-Term Care (LTC) Insurance.
MA and GAMC applicants and enrollees may have other health care coverage such as basic hospital, medical-surgical, HMO, vision, dental, long-term care or prescription drug coverage.
Other health care coverage may be available from the following sources:
l Group health care coverage .
l Individual health care coverage .
l COBRA coverage.
l Coverage available through any of the following:
n A non-custodial parent.
n Separated or divorced spouse.
n Parent of minor child living apart from parents.
l Coverage available through military service, including:
n TRICARE.
n CHAMPVA.
n Free services at veterans’ clinics and hospitals.
l Medicare.
Reporting Other Health Care Coverage
MA and GAMC applicants and enrollees must report access to or enrollment in other health care coverage when they are applying for Minnesota Health Care Programs, when there is a change or at renewal.
Exception: CHIP-funded MA does not have cost effective insurance requirements and cannot pay cost effective insurance premiums. Pregnant women who are potentially eligible for CHIP-funded MA are not required to provide information about or pursue other health care coverage that may be available to them through an employer or other means. For more information, see Medical Assistance (MA) for Pregnant Women.
Accessing Other Health Care Coverage
MA applicants and enrollees who are eligible to enroll on their own behalf in group health care coverage are required to enroll as a condition of eligibility if the coverage meets either of the following:
l The other health care coverage is cost effective and premiums are paid by the county agency.
l There is no cost to the client.
This includes maintaining or enrolling in group health care coverage during an open enrollment period, if one is offered. Not all employers offer an open enrollment period.
MA applicants and enrollees currently enrolled in individual health care coverage on their own behalf are required to remain enrolled as a condition of eligibility if the coverage meets either of the following:
l The coverage is cost effective and premiums are paid by the county agency.
l There is no cost to the client.
Effective June 1, 2010, GAMC enrollees do not have other coverage evaluated for cost-effectiveness.
Not all people who are eligible for other health coverage are able to enroll or otherwise cooperate on their own behalf. Do not deny or close eligibility for people who do not enroll in, cooperate with or assign rights to other health coverage if they cannot do so on their own behalf.
Example:
Barbara and Sam are married. Barbara is on Medical Assistance. Sam's new employer offers individual and group health coverage. The group health coverage would be cost effective for Barbara, but Sam decides to accept only the individual coverage for himself.
Action:
Continue MA eligibility for Barbara. Sam's refusal to put her on his cost effective coverage does not affect her eligibility for MA since she is unable to enroll on her own behalf.
Example:
Kathy, who is 23 years old, applies for MA for herself and her daughter Amy. Kathy recently had insurance through her mother that ended because her mother stopped paying the premiums for Kathy.
Action:
Do not require Kathy to provide information about other health coverage available through her mother. Even though Kathy could remain enrolled under her mother’s coverage until age 26, Kathy cannot enroll on her own behalf.
Three months later, Kathy reports that her mother is now willing to put Kathy back on her insurance and will cooperate with a cost effective determination.
Action:
Determine whether the insurance available to Kathy is cost effective. Even though Kathy cannot enroll in the insurance on her own behalf, she has chosen to cooperate with a cost effective determination. If the coverage is determined to be cost effective, reimburse Kathy’s mother for Kathy’s portion of the total premium.
MA applicants and enrollees are not required to maintain or enroll in other health care coverage that is not determined to be cost effective if there would be a cost to them for the coverage. GAMC applicants and enrollees are not required to maintain any other health coverage.
MA and GAMC applicants and enrollees must cooperate with identifying sources of existing health coverage and assign rights to other health care coverage.
For information about requirements for enrolling in Medicare, see Medicare Cost Effective Requirements.
For more information about cost effective coverage, see Cost Effective Health Care Coverage - MA.
MA for Breast and Cervical Cancer (MA-BC)
Applicants and enrollees with other health care coverage that is creditable coverage may not be eligible for MA-BC. See MA for Breast and Cervical Cancer (MA-BC) for more information.
Undocumented or non-immigrant pregnant women are not eligible for CHIP-funded MA (NMED) if they are currently enrolled in other health care coverage.
See Medical Assistance for Pregnant Women for more information.
Upon the birth of a child, the parent or caretaker must provide information regarding potential health care coverage for the child.
l Request the information as soon as you receive the report of the birth.
l Document the contact information in case notes.
If you are not able to reach the parent or caretaker by phone, send both:
l Request for Information from parents (DHS-4599), which asks parents if their infant has or has access to other health care coverage; and
l MHCP Health Insurance Information Form (HIIF) (DHS-1922B), which requests detailed health care coverage information.
Do not deny or close the child's eligibility if the parent or caretaker fails to respond.
Other Coverage Evaluation Steps
1. Review the application for possible sources of other health care coverage or non-health care coverage third party liability.
See Non-Health Care Coverage Third Party Liability for information on liable third parties other than health care coverage.
2. Determine if other health care coverage is available and in effect.
l If other health care coverage is not in effect and group health care coverage is not available, the evaluation is complete.
l If other health care coverage is in effect or group health care coverage is available, go to Step 3.
3. Determine if the other health care coverage is cost effective.
4. Record the other health care coverage in the TPL subsystem on MMIS.
Long-Term Care (LTC) Insurance
Enter all LTC insurance information into the MMIS TPL subsystem. It is not necessary to send LTC insurance policies to BRS to determine if they are TPL. Do not count LTC insurance payments as income. Consider long-term care insurance as TPL, even if paid directly to the client.