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Effective: November 1, 2009 |
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15.10.05ar5 - Cost Effective Health Care Coverage - MA and GAMC (Archive) |
Archived: September 1, 2010 |
Medical Assistance (MA) and General Assistance Medical Care (GAMC) clients are required to maintain or enroll in other health care coverage if it is determined to be cost effective. Evaluate health care policies for MA and GAMC clients for potential cost effectiveness at application, renewal, and any time a client reports access to other health care coverage. It is important to identify and maintain coverage primary to MA and GAMC to save public funds.
More information on cost effective coverage can be found in the following sections:
l Determining Cost Effectiveness.
l Medicare Cost Effective Requirements.
l Cost Effective Premium Reimbursement.
What is Cost Effective Coverage?
Cooperation Requirements for Cost Effective Health Care Coverage.
Special Enrollment Period - CHIPRA.
When More than One Group Plan is Available.
What is Cost Effective Coverage?
Cost effective coverage is other health care coverage for which the amount paid for premiums, coinsurance, deductibles, and other costs is likely to be less than the amount paid by MA or GAMC for an equivalent set of services. Cost effective coverage could include, but is not limited to, coverage through:
l COBRA.
l Individual health care coverage.
l Long-term care insurance.
l Medicare.
Cooperation Requirements for Cost Effective Health Care Coverage
Clients must cooperate in determining the cost effectiveness of any other individual or group health care coverage they have or any group health care coverage for which they may be eligible.
Clients must provide information about the plan and complete the applicable forms to determine the cost effectiveness of premium payment.
l Cost Effective Insurance Information - Employer or Insurance Company (DHS-2841).
l Cost Effective Insurance Referral - Applicant/Enrollee (DHS-2841B).
In general, clients who are enrolled in cost effective individual or group health care coverage must maintain that coverage to be eligible for MA or GAMC if the premiums are paid by the local agency or if there is no cost to the client.
l Clients who become eligible for cost effective group health care coverage must enroll in that coverage at the earliest possible date to be eligible for MA or GAMC. This includes enrolling in group health care coverage during an open enrollment or special enrollment period.
l Adult MA or GAMC enrollees who disenroll after notification of cost effective group health care coverage are ineligible for MA or GAMC until the next open enrollment period for that group plan, unless:
n they are allowed to enroll due to a special enrollment period. They must re-enroll to reestablish MA or GAMC eligibility.
n after disenrolling from cost effective coverage, the employer or insurer rules do not permit them to re-enroll. The person must provide written documentation of the date of the request for disenrollment (to determine if it occurred before or after notice of cooperation requirement) and inability to re-enroll to be eligible for MA or GAMC.
l Do not deny or close eligibility for people who do not enroll or maintain enrollment in cost effective health plans if they cannot do so on their own behalf.
l Deny or close eligibility of enrolled adults and their spouses if, following notification of cost effective coverage, they fail to enroll or maintain enrollment in cost effective health plans on their own behalf and on behalf of enrolled dependents.
l Require applicants or enrollees who are eligible to continue group health care coverage through COBRA to cooperate with cost effective insurance requirements.
l Contact the DHS Benefit Recovery Section (BRS) if the client indicates he or she is unable to use the cost effective coverage because there are no providers for that plan in the area.
Example:
Auggie’s dad provides his insurance. His dad lives in New Mexico and the employer or insurer only provides coverage in that state.
Action:
Contact BRS regarding Auggie’s policy. Continue his eligibility.
Employers with group health care coverage must offer a special enrollment period for certain life events. During a special enrollment period, an employee has an opportunity to enroll in group health care coverage without waiting for an open enrollment period. Group health care coverage provides individuals with an opportunity for special enrollment if they:
l Initially declined group health care coverage because they had alternative coverage but since have lost that alternative coverage.
l Have new dependents through marriage, birth or adoption.
l Are covered by a Qualified Medical Support Order.
Note: Other life events such as marriage, divorce or a new job may result in the individual having the opportunity for special enrollment.
Clients with a change in health care coverage or a change in dependents must request a special enrollment period from the employer following program provisions. An employer may request a Certificate of Creditable Coverage (COCC) to verify eligibility for special enrollment.
Adult applicants who disenroll from or decline an offer of cost effective group health care coverage prior to their MA or GAMC application may be eligible for MA or GAMC.
l Require the client to contact the employer to inquire about a special enrollment period.
l Require the client to enroll in the cost effective plan if a special enrollment period is available.
l Continue eligibility and track for the next open enrollment period if a special enrollment period is not available. Require the client to enroll in the cost effective plan at that time.
Special Enrollment Period - CHIPRA
The Children’s Health Insurance Program Reauthorization Act (CHIPRA) added two conditions for which fully insured and self-insured group health plans must offer a special enrollment period. Effective April 1, 2009, a plan sponsor of a group health plan must permit employees and dependents who are eligible, but not enrolled for coverage to enroll in that coverage within 60 days of:
l termination of the employee or dependents’ MA coverage due to loss of eligibility.
l eligibility of the employee or dependent for a premium assistance under MA. (CHIPRA considers the cost effective health insurance program a premium assistance program.)
When More than One Group Plan is Available
An employee must select the plan that best fits their needs if an employer offers more than one health plan to its employees. Complete the cost effective review process for other health care coverage plan options available to the client if the first plan is not determined cost effective. Refer enrollees to their insurance products’ benefit administrators or human resources staff if they have questions about which plan would be best for them.
Notify clients whose eligibility is ending that MA or GAMC will no longer pay premiums on the cost effective policy. Use the appropriate MAXIS SPEC/LETR.
See TEMP manual TE02.13.48 (Cost Effective SPEC/LETR) for more information on using MAXIS SPEC LETR to notify clients of decisions on cost effective health insurance premium payments.
People whose MA or GAMC ends will automatically receive a Certificate of Creditable Coverage (COCC) two months after closure. Request the COCC in MMIS if the former enrollee needs it sooner.