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Effective: December 1, 2006 |
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15.05.20ar1 - Employer-Subsidized Insurance (ESI) (Archive) |
Archived: March 1, 2008 |
Employer-Subsidized Insurance (ESI) is one of several insurance barriers to receiving MinnesotaCare coverage.
Note: Health care coverage available through self-employment, or as an independent contractor, is not reviewed as ESI.
See MinnesotaCare Insurance Barriers for more information on how having current or past access to ESI affects MinnesotaCare eligibility.
Special Enrollment Period and ESI.
Employer-Subsidized Insurance (ESI) is coverage offered to employees for which an employer or union pays at least 50% of the cost of coverage.
Example:
Janet is employed by the Acme Company which offers its employees health insurance. Acme pays $150 per month for Janet’s insurance and she pays a $50 per month premium for the insurance.
Action:
Janet’s health insurance is considered ESI. The total cost of the insurance is $200 ($150 employer paid + $50 employee paid). Acme is paying over half of the cost of the insurance.
In many cases the employer contributes a specific amount for the employee and a set amount for dependent coverage regardless of the number of dependents.
l Some employers contribute only toward the cost of employee coverage.
l They may not offer dependent coverage or may offer it at full cost to the employee.
Employers who offer health insurance usually allow workers to sign up for the health insurance when they are first hired. Employers may allow employees to sign up for health insurance during open enrollment or may offer a special enrollment.
For more information on how to determine if coverage through an employer is ESI see:
l Determining ESI – Cash Benefits.
Verify access to ESI for each employer reported for all MinnesotaCare applicants and enrollees reporting employment, spousal employment or a child’s employment regardless of whether the worker or agency has knowledge of a particular employer’s policy on offering health insurance.
Exceptions:
n Do not delay or deny coverage for children with a verified Group 1 status regardless of their parents’ failure to verify access to ESI.
n Deny or close eligibility for applicants and enrollees who report access to ESI. Do not require verification prior to denial or closure if enough information is provided to make the ESI determination.
l Acceptable verification includes:
Note: Do not contact the employer or union without written consent from the applicant or enrollee to verify access to ESI. Submit a question to the DHS Health Care Policy Center if the employer refuses to provide ESI verification.
By signing the HCAPP (DHS-3417) or the Minnesota Health Care Programs Renewal Form (DHS-3418) the client agrees to allow contact with their employers for the purposes of verifying access to ESI.
n A Request for Verification of Employer Insurance (DHS-3348) can be used to verify ESI. The client must sign the form and request the employer to complete or send it to the worker to contact the employer.
Note: This form is incorporated into the HCAPP (DHS-3417) and the Minnesota Health Care Programs Renewal Form (DHS-3418).
n Documents from an employer which provide insurance information including:
m Open enrollment materials.
m Employee handbooks.
m New employee orientation papers.
m Union contracts.
n A written statement from the employer or union.
l Require verification at application and at each renewal, for all currently employed enrollees, for all employers listed, regardless of whether verification was collected previously.
l Require verification of access to ESI between renewals if the enrollee reports new employment or a change in employers for themselves, their spouse or their children.
Exceptions: Do not verify access to ESI for applicants and enrollees who are any of the following:
m Children with a verified Group 1 status.
m Farmers with no other type of employment in the household.
m Self employed with no other type of employment in the household.
Pend eligibility (P30 or C48) if the client does not provide the insurance information for each employer.
l Request ESI verification.
l Document all actions and requests for verification in case notes.
l Clients have 30 days to provide verification of access to ESI.
l Eligibility will automatically be denied or closed by MMIS in 60 days for applicants or at the end of the renewal period for enrollees renewing coverage.
Example:
Jack applies for MinnesotaCare for himself and his family on April 3. Jack answers ”r;no” to the employer-offered health insurance question on the application. Jack is employed. His wife is self-employed. Income verification has not been submitted with the application.
Action:
Pend eligibility for Jack and his family because the application is incomplete as they have not provided income and insurance verifications.
Jack faxes copies of his pay stubs and tax forms as income verification. He has not provided his insurance documentation.
Action:
Continue the pending status for ESI. MMIS will automatically deny the application in 60 days.
Some employers offer a time each year when employees and dependents can join the employer's health benefit plan. This time is referred to as open enrollment.
Note: Not all employers offer an open enrollment period.
l Applicants and enrollees who have access to ESI during an employer’s open enrollment period are considered to have current access to ESI.
l Applicants and enrollees who had access to ESI during an employer’s open enrollment period and refused to accept the ESI at that time have had access to ESI in the past. If they refused the ESI during the past 18 months they are ineligible for MinnesotaCare.
Example:
Tim’s employer offers ESI to Tim, his wife Nancy, and their two children. The children have Group 1 status. They can sign up for the insurance annually in April but have chosen not to sign up. They apply for MinnesotaCare in July, two months after Tim’s open enrollment period ended.
Action:
Tim and Nancy are ineligible for MinnesotaCare because a current employer offered ESI within the past 18 months. The children are eligible for MinnesotaCare because, although they had access to ESI, they have Group 1 status.
Example:
Janice’s employer offers her health insurance when she is first hired. Janice declines the coverage. Janice’s employer does not offer open enrollment. Janice applies for MinnesotaCare.
Action:
Janice is ineligible for MinnesotaCare for 18-months from the day her employer offered her health insurance which is considered ESI.
Special Enrollment Period and ESI
Clients meeting the criteria for special enrollment are required to request access to the ESI from their employer.
Example:
Gary and his family are enrolled in MinnesotaCare. They have Group 2 status.
At the time of the annual renewal in July, the MinnesotaCare worker discovers that Gary had an opportunity to enroll the entire family in ESI at the time of his employer’s annual open enrollment six months earlier. Gary chose not to accept the coverage because he had MinnesotaCare.
Action:
Close MinnesotaCare for the first month for which you can give 10-day notice. Advise Gary to ask his employer if he can enroll in ESI without waiting for the next open enrollment period since he has lost his MinnesotaCare coverage.
The family remains ineligible for MinnesotaCare for 18 months from the date Gary could have enrolled in the ESI. The 18-month period starts over if Gary again has an opportunity to enroll in the ESI and refuses.