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Effective: December 1, 2006 |
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15.05ar1 - MinnesotaCare Insurance Barriers (Archive) |
Archived: December 1, 2007 |
MinnesotaCare has several insurance barriers that exist to prevent individuals and employers from dropping health coverage in favor of MinnesotaCare. Health insurance availability may affect people’s eligibility for MinnesotaCare.
The following are insurance barriers for MinnesotaCare eligibility:
l Current health care coverage.
l Enrollment in health care coverage in the past four months.
l Current and past access to employer subsidized insurance (ESI).
l Employer termination of ESI as an employee benefit.
This section provides in-depth policy on each of the MinnesotaCare insurance barriers.
People who are currently enrolled in other health care coverage are not eligible for MinnesotaCare.
l See Documenting Insurance Coverage for more information on what must be documented.
l See MinnesotaCare Types of Other Health Coverage to determine what types of insurance are considered other coverage.
Exception: Children under age 21 with Group 1 status who have coverage that is determined underinsured may keep that coverage and enroll in MinnesotaCare, regardless if the insurance is determined ESI or not.
If current coverage does not meet the definition of underinsured the children are not eligible for MinnesotaCare.
Note: Complete the following for families who choose not to request coverage for children with current insurance who have verified income which would result in the children having a Group 1 status:
l Notify, in writing or by phone, the caretaker to explain that the child may qualify for MinnesotaCare if the other insurance is considered underinsured.
l If the family would like MinnesotaCare for the child send the child’s caretaker the Request for Child Insurance Information (DHS-3448) or request a copy of the child’s insurance card.
l If the family returns the information, contact the insurance company to determine if the coverage is underinsured.
Example:
Jessica applies for MinnesotaCare for herself and her three children. Jessica has insurance through her employer. The insurance is not considered ESI but is determined to be underinsured. Jessica has Group 4 status. Her children have Group 1 status.
Action:
Jessica is ineligible for MinnesotaCare because she has current insurance. Jessica’s children are eligible for MinnesotaCare because they are underinsured. They are not required to drop the insurance.
People who were enrolled in other health coverage in the past four months are not eligible for MinnesotaCare.
l See Documenting Insurance Coverage for more information on what must be documented.
l See MinnesotaCare Types of Other Health Coverage to determine what types of insurance are considered other coverage.
Exceptions:
l Do not apply the four-month rule to any insurance held by children under age 21 with Group 1 status.
l Do not consider the following types of insurance as other health coverage.
l Health insurance determined cost-effective for Medical Assistance (MA), regardless if it was paid for by MA or applied to the enrollee’s spenddown is not considered when applying the four month rule.
If the enrollee keeps insurance after MA determines it is not cost-effective or after MA closes do apply the four-month rule.
l Do consider other coverage in effect while the applicant received GAMC, regardless of whether it was cost-effective.
Example:
Marcia’s MA is closed effective May 1 because she cannot meet a spenddown. She had other cost effective health insurance in effect for which MA paid the premium. She dropped the other coverage effective April 30, because she felt the premium was not affordable. She applies for MinnesotaCare on May 10.
Action:
Marcia is exempt from the four-month rule because the cost-effective insurance was paid for by MA. It does not count as other insurance for purposes of the four-month rule. If she had received GAMC instead of MA, or the other coverage was not considered cost-effective under MA, she would be ineligible for MinnesotaCare until September 1.
People who have current access to employer-subsidized insurance (ESI) coverage are ineligible for MinnesotaCare.
l See Documenting Insurance Coverage for more information on what must be documented.
l See ESI for more information on how coverage is determined to be ESI and for information on ESI and open enrollment.
Exception: Children under age 21with Group 1 status may have access to ESI and are not required to accept it, regardless of whether it is considered underinsured.
Complete the following for families who choose not to request coverage for children with access to ESI who have verified income which would result in the children having a Group 1 status:
n Notify, in writing or by phone, the caretaker to explain that the child may qualify for MinnesotaCare if the other insurance is considered underinsured.
n If the family would like MinnesotaCare for the child send the child’s caretaker the Request for Child Insurance Information (DHS-3448) or request a copy of the child’s insurance card.
n If the family returns the information, contact the insurance company to determine if the coverage is underinsured.
l When determining whether people have access to ESI, do not consider the distance an individual must travel to see a provider enrolled in the ESI plan.
l If ESI becomes available to current MinnesotaCare children with Group 2 status or adults, they may not refuse the coverage to remain eligible for MinnesotaCare. They are ineligible regardless of whether they actually accept the ESI.
People who have had access to employer-subsidized insurance (ESI) through a current employer in the preceding 18 months are ineligible for MinnesotaCare.
Note: See ESI for more information on how coverage is determined to be ESI and for information on ESI and open and special enrollment.
Exception: Children under age 21 with Group 1 status may have had access to ESI through a current employer in the preceding 18 months and remain eligible for MinnesotaCare.
If people are terminated from MinnesotaCare because a current employer offered ESI within the past 18 months, advise them to:
l Ask if the employer offers special enrollment.
l Request enrollment under the employer’s plan within 30 days of MinnesotaCare termination to avoid a break in coverage.
Note: If there is a break in coverage, the person will not get credit for MinnesotaCare coverage to reduce a pre-existing condition exclusion.
A Certificate of Creditable Coverage (COCC) will be issued automatically two months after MinnesotaCare ends. If the former enrollee needs the COCC sooner, request one following your agency’s procedures.
Some employers only offer ESI to employees who work a certain number of hours.
l Full-time employees with access to ESI who lose access to ESI when they voluntarily reduce their hours or their employer reduces their hours, are ineligible for MinnesotaCare because they had access to ESI through a current employer in the past 18 months.
l People who are initially hired at part-time hours and are not eligible for their employer’s ESI would not be ineligible for MinnesotaCare due to this insurance barrier.
Example:
Lonnie works 40 hours a week at Acme Grocery. Acme Grocery offers ESI to all employees who work 38 hours or more. Lonnie decides to go to school part-time, so he reduces his hours at Acme Grocery to 20 hours a week. He is no longer eligible for ESI.
Action:
Lonnie is ineligible for MinnesotaCare because he had access to ESI through a current employer in the past 18 months.
Example:
Jaime works full-time for an employer who provides ESI to all its full-time employees. Due to a down-turn in the economy, Jaime’s employer reduces Jaime’s hours, making him ineligible for ESI.
Action:
Jaime is ineligible for MinnesotaCare because he had access to ESI through a current employer in the past 18 months.
Example:
Sonya is a full-time college student who accepts a part-time position with an employer that provides ESI to full-time employees, but not to part-time employees. Sonya was never a full-time employee and thus never had access to ESI in the past 18 months.
Action:
She is eligible for MinnesotaCare.
Example:
Arnold applies for MinnesotaCare. He has ESI through his employer.
Action:
Arnold is ineligible for MinnesotaCare because he has current health insurance.
Arnold applies for MinnesotaCare again after dropping the ESI insurance. He remains employed by the same employer.
Action:
Arnold continues to be ineligible for MinnesotaCare for 18 months because he had access to ESI through a current employer in the past 18 months.
People who lost coverage or access to employer subsidized insurance (ESI) because an employer chose to terminate health coverage as an employee benefit in any of the 18 months prior to the month of application are ineligible for MinnesotaCare.
Exceptions: The following are exceptions to the 18 Month Rule:
l People who lost ESI due to the employer dropping the coverage are exempt from this barrier if they were previously enrolled in MinnesotaCare and reapply within six months of MinnesotaCare termination.
l Children with Group 1 status may have had an employer terminate health coverage as an employee benefit in the past 18 months and become or remain eligible for MinnesotaCare.
Example:
Pascal’s employer provides ESI to its employees and their dependents. In October 2003, Pascal’s employer stops offering ESI as an employee benefit. Pascal and his son apply for MinnesotaCare. Pascal has a Group 4 status and his son a Group 1 status.
Action:
Pascal is ineligible for MinnesotaCare until March 2005, 18 months after the employer dropped ESI as an employee benefit. His son is not subject to the insurance barrier.