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Effective: December 1, 2006 |
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15.10ar1 - MA and GAMC Types of Other Insurance Coverage (Archive) |
Archived: October 1, 2008 |
MA and GAMC do not have insurance barriers to eligibility. However, the programs do have certain requirements that must be met for a client to have access to or current health insurance concurrently with MA or GAMC.
What is Other Health Insurance Coverage?
Reporting Other Health Insurance Coverage.
MA for Breast and Cervical Cancer.
Other Coverage Evaluation Steps.
What is Other Health Insurance Coverage?
People may have health insurance coverage through privately held policies or through an employer.
Other health insurance coverage includes:
l Employers purchasing coverage from insurance companies or providing it through a self-insured plan.
Examples of health insurance coverage include:
n Basic hospital.
n Medical-surgical.
n Health Maintenance Organization (HMO).
n Vision.
n Dental.
n Prescription drug coverage.
l Potential COBRA coverage or enrollment in COBRA.
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 CHAMPVA.
n Free services at veterans’ clinics and hospitals.
Reporting Other Health Insurance Coverage
Applicants and enrollees must report current other health insurance coverage or access to it on the Health Care Application (HCAPP), when there is a change or at renewal. They must report both private and employer-based coverage.
Applicants with other health care coverage that is creditable coverage are not eligible for MA-BC.
Exceptions:
l Creditable coverage that does not cover the cancer treatment including any of the following:
n There is a pre-existing condition exclusion.
n There is an HMO affiliation period.
n There is a lifetime cap under the plan.
Note: Co-payments and deductibles are not considerations for this exception.
Do not require verification of insurance meeting this exception.
l Access to Indian Health Services.
Pregnant women whose eligibility for state-funded MA (NMED), due to their immigration status, is being determined and who have the following types of other health care coverage are not eligible for (NMED):
l Employer health plan coverage.
l Medical services policy.
l Hospital policy.
l Health Maintenance Organization (HMO).
l Veteran’s Affairs policy.
Determine eligibility for Emergency Medical Assistance for women ineligible for NMED at the time of the baby’s birth.
Other Coverage Evaluation Steps
1. Review the application for possible sources of health insurance or other third party liability.
See Third Party Liability for information on types of coverage other than health insurance.
2. Determine if other health care coverage is available.
l If the coverage is not available, the evaluation is complete.
l If the coverage is available and is:
n Through an employer or group, such as a union, go to Step 3.
n Not through an employer or group, go to Step 4.
3. Determine if the other health insurance coverage is cost-effective.
4. Record the other coverage in the TPL subsystem on MMIS.
This will notify the Benefit Recovery Section (BRS) at DHS that an MA or GAMC applicant or enrollee has other coverage.
Note: It is only necessary to notify BRS when the client is receiving MA with federal financial participation (FFP). Do not notify BRS or GAMC clients who have CHAMPUS/TRICARE coverage.