***This version of the Health Care Programs Manual has been replaced and is no longer in effect. Please see the current Health Care Programs Manual for policy in effect as of December 1, 2006.***

The terminology used to describe people with disabilities has changed over time. The Minnesota Department of Human Services ("Department") supports the use of "People First" language. Although outmoded and offensive terms might be found within documents on the Department's website, the Department does not endorse these terms.

MDHS Health Care Programs Manual (Eligibility Policy through 11/30/06)

Chapter 0910 - Other Health Coverage

All chapters are numbered beginning with 09. The first chapter is 0901 (Table of Contents).

Chapter 0910

0910

OTHER HEALTH COVERAGE

PDF(s) Apr 04 | Jul 03 | Jan 03 | Apr 02

0910.03

TYPES OF OTHER COVERAGE

PDF(s) Jul 03

0910.03.03

OTHER COVERAGE -- PRESCRIPTION DRUG

PDF(s) Jan 05 | Dec 02 | Jul 02

0910.05

CURRENT HEALTH INSURANCE

PDF(s) Apr 04 | Apr 02 | Jun 02

0910.05.01

CURRENT HEALTH INSURANCE -- MA/GAMC

PDF(s) Apr 04

0910.05.03

HEALTH INSURANCE PREMIUM PAYMENT

PDF(s) Apr 04

0910.05.03.03

MAIL ORDER PRESCRIPTION DRUG REIMBURSEMENT

PDF(s) Apr 04 | Jan 04 | Oct 02

0910.05.05

MEDICARE PREMIUM PAYMENT

PDF(s) Jan 04 | Oct 02

0910.07

4-MONTH RULE

PDF(s) Apr 04 | Oct 03

0910.09

DETERMINING IF A CHILD IS UNDERINSURED

PDF(s) Apr 04

0910.11

ACCESS TO EMPLOYER SUBSIDIZED INSURANCE

PDF(s) Jan 04 | Jan 03

0910.11.01

VERIFICATION OF ESI

PDF(s) Apr 06 | Jan 04

0910.11.03

ACCESS TO ESI IN PAST 18 MONTHS

PDF(s) Jan 04 | Jul 03 | Jan 03 | Oct 02

0910.11.04

EMPLOYER TERMINATES ESI

PDF(s) Jan 04 | Jul 03 | Jan 03 | Oct 02

0910.11.05

DETERMINING THE EMPLOYER CONTRIBUTION

PDF(s) Oct 02

0910.11.06

OPEN ENROLLMENT AND ESI

PDF(s) Jan 04 | Oct 02

0910.13

THIRD PARTY LIABILITY

PDF(s) Apr 04

OTHER HEALTH COVERAGE 0910

Availability of other health coverage may affect people's eligibility for MinnesotaCare. Availability of other coverage does not affect eligibility for MA or GAMC. However, when people who have other coverage also have coverage under any of the three health care programs, the other health coverage is usually the payor of first resort. Notify the Benefit Recovery Section when people have other health coverage. See §0910.05 (Current Health Insurance) and §0910.13 (Third Party Liability) and §0914.03 (Service Delivery - People W/Other Coverage).

MinnesotaCare:

MinnesotaCare has several insurance barriers that exist to prevent individuals and employers from dropping health coverage in favor of MinnesotaCare.

Generally, applicants and enrollees are ineligible for MinnesotaCare if they:

• Had health coverage in the past 4 months. See §0910.07 (4-Month Rule).

• Have current health coverage. See §0910.05 (Current Health Insurance).

• Have access to employer subsidized insurance (ESI). See §0910.11 (Access to Employer-Subsidized Insurance).

• Had access to ESI through a current employer in the past 18 months. See §0910.11.03 (Access to ESI in Past 18 Months).

• Lost ESI because their employer terminated ESI as an employee benefit in the past 18 months. See §0910.11.04 (Employer Terminates ESI).
There are exceptions to each of these insurance barriers. See the specific manual sections for detailed information.

Parents who have children with other health coverage must assign their children’s rights to coverage to DHS as a condition of eligibility. People assign their rights by signing the application. Adults who refuse to assign the rights of other household members for whom they are legally able to assign rights are not eligible for MinnesotaCare. Do not sanction children whose parents refuse to assign their rights to insurance or other third party liability.

People must cooperate with the MinnesotaCare agency and the state Benefit Recovery Section (BRS) in identifying potential sources of other health coverage. Applicants and enrollees must provide information on other health insurance which is or may be available to them or their dependents, regardless of whether the applicant or enrollee is the policy holder.

Children with Group 2 status cannot have had coverage in the past 4 months, or have current coverage or current access to ESI. Generally, they cannot have had access to ESI through a current employer in the past 18 months. See §0907.05 (MinnesotaCare Eligibility Group 2) and §0910.11.03 (18-Month Rule).

Group 2, Group 3 and Group 4 adults are subject to all of the insurance barriers. They cannot have current coverage or current access to ESI, cannot have had coverage in the preceding 4 months, and cannot have had access to ESI in the preceding 18 months if the employer dropped coverage. See §0907.05 (MinnesotaCare Eligibility Group 2), §0907.07 (MinnesotaCare Eligibility Group 3), and §0907.08 (MinnesotaCare Eligibility Group 4).

M.S. 256L.07 subd. 2, 3

MA/GAMC:

Availability of other health coverage does not affect people’s eligibility for MA or GAMC. People who have other health coverage must assign their rights to coverage to DHS as a condition of eligibility. People assign their rights by signing the CAF or HCAPP. Adults who refuse to assign their rights or the rights of other household members for whom they are legally able to assign rights are not eligible for MA or GAMC. Do not sanction children whose parents refuse to assign their rights to insurance or other third party liability.

People must cooperate with the county agency and the state Benefit Recovery Section (BRS) in identifying potential sources of other health coverage. Applicants and enrollees must provide information on other health insurance which is or may be available to them or their dependents, regardless of whether the applicant or enrollee is the policy holder.

EXAMPLE:

Heather, age 17, applies for MA for herself. She does not live with either parent. She thinks she may be covered on her father's group insurance plan. Heather must provide as much information as she can about the insurance.

People may be required to enroll in or maintain group or private health insurance if it is cost effective. See §0910.05 (Current Health Insurance) and §0910.05.03 (Health Insurance Premium Payment).

Return to Top

TYPES OF OTHER COVERAGE 0910.03

MinnesotaCare:

Consider the following types of coverage as other health insurance for MinnesotaCare:

• Basic hospital insurance. • Medical-surgical coverage or major medical coverage. • HMO coverage. • Medicare Part A and B.

Do not require clients who must pay premiums for Part A to apply for or accept Part A or Part B. Clients who must pay premiums for Part A may drop Medicare coverage to be eligible for MinnesotaCare. This also includes clients who cannot get Part A at no cost and have elected to enroll in Part B only.

EXAMPLE:

Rosa is a 65-year-old Lawful Permanent Resident (LPR). She does not have sufficient work quarters to qualify for Medicare Part A at no cost. She would have to pay over $300 per month to enroll. She could enroll in Part B without Part A by paying only the Part B premium. If Rosa chooses to enroll in either Part A or Part B, she is ineligible for MinnesotaCare because of having other coverage. However, she is not required to apply for or accept either Part A or Part B. If she is already enrolled in Part A, Part B or both, she may drop the coverage and become eligible for MinnesotaCare after a 4-month wait.

People who are eligible for Part A at no cost may not refuse or drop coverage to become eligible for MinnesotaCare. See §0911.03.03 (Applying for Other Benefits).

EXAMPLE:

Zeke is eligible for Medicare Part A at no cost and may also choose to enroll in Part B with a premium. He prefers MinnesotaCare because he could get better coverage at a lower premium. Because he is eligible for Part A at no cost, he is not eligible for MinnesotaCare and may not refuse or drop coverage to become eligible.

• Medicare supplement policies. • Minnesota Comprehensive Health Association (MCHA). • Vision, dental, or prescription drug coverage offered as part of a comprehensive package. • CHAMPVA.

See §0902 (Glossary) for definitions of specific coverage types.

People may have basic hospital, medical-surgical, HMO, vision, dental, or prescription coverage through privately held policies or through an employer. Employers may purchase coverage from insurance companies or provide it through a self-insured plan. Employees who terminate employment may elect to continue coverage under their employer's health plan for up to 18 months. This is known as the COBRA option. Usually the employee is responsible for the full cost of the premium. See COBRA COVERAGE in §0902.07 (Glossary: Client...).

Do not consider the following types of coverage as other health insurance when determining whether someone meets the insurance barrier requirements. However, some of these types of coverage may be a potential source of 3rd party liability. Submit a HIIF to Benefit Recovery for these coverage types. See §0910.13 (Third Party Liability).

• Dental, vision, or prescription-only coverage that is not part of a comprehensive package including basic hospital and medical-surgical coverage. See §0910.09 (Determining if Someone Is Underinsured).

Although these coverage types are not considered other health insurance for eligibility purposes, the enrollee's health plan may be able to recover payments for these services from the private insurer. Complete a HIIF for each policy.

• Workers' Compensation. Tell Benefit Recovery which household member is covered. • Indemnity policies which pay a fixed amount for each day of hospitalization or nursing home confinement. Complete a HIIF. • Long term care/nursing home-only policies. Complete a HIIF. • Disability insurance. • Cancer insurance. Complete a HIIF. • Access to facilities which provide free health care to people who qualify, such as Indian Health Centers and community clinics. • Access to care through the Department of Veterans Affairs (VA), if the person wants to enroll in MinnesotaCare. Complete a HIIF for enrollees who have VA benefits. • Do not require people who have access to care through the VA to enroll in MinnesotaCare under the All or Nothing Rule if they do not want MinnesotaCare. Consider VA benefits to be other health coverage for people who have access to services through the VA and do not wish to enroll in MinnesotaCare. • Medical expense accounts which an employee funds with pre-tax dollars. • Auto, homeowners', or other liability insurance that pays medical expenses resulting from an accident. Notify Benefit Recovery if you know that one or more household members has this kind of coverage. Also send the MinnesotaCare Medical Service Questionnaire (DHS 2237B) and instruct the household to return it to Benefit Recovery. • MA and GAMC: Generally a person cannot have MinnesotaCare and MA or GAMC in the same month. See §0904 (Applications). However, do not consider MA or GAMC when determining if someone has had other coverage in the preceding 4 months. See §0910.07 (4-Month Rule). • TRICARE, formerly known as CHAMPUS, provides coverage to active-duty members of the armed forces and their dependents. People eligible for TRICARE may choose among 3 options: TRICARE standard, which provides the same benefits as CHAMPUS; TRICARE Prime, which is similar to a managed care plan; and TRICARE Extra, which allows enrollees to seek care at discounted prices from providers in the TRICARE network. See §0910.05 (Current Health Insurance) for information on when to submit a HIIF to Benefit Recovery when people have current TRICARE coverage.

See §0902 (Glossary) for definitions of specific types of TPL.

M. S. 256L.07 Subd. 3

Minnesota Rules 9506.0010 Subp. 16

MA/GAMC:

People may have health insurance coverage such as basic hospital, medical-surgical, HMO, vision, dental, or prescription coverage through privately held policies or through an employer. Employers may purchase coverage from insurance companies or provide it through a self-insured plan.

Many employees who terminate employment may elect to continue coverage under their employer's health plan for up to 18 months. This is known as the COBRA option. Usually the employee is responsible for the full cost of the premium. See COBRA COVERAGE in §0902.07 (Glossary: Client...).

The HCAPP asks if people have coverage currently or if they could get it through an employer. It also asks if people had or could have had insurance through an employer in the past 18 months. Review the responses to determine possible sources of health insurance or other 3rd party liability, including:

• Cost-effective coverage available through an employer. See §0910.05 (Current Health Insurance). • Possible COBRA coverage. In addition to possible continuation coverage available to former employees for up to 18 months, COBRA coverage may be available to:
• A widow(er) of a deceased employee. • A divorced spouse of an employee. • A spouse of a Medicare-eligible employee. • A dependent child of any person listed above. • An employee's dependent child who loses coverage due to age.
• Coverage available through a non-custodial parent, separated or divorced spouse, or parent of minor child living apart from parents. • Coverage available through military service, including CHAMPUS/TRICARE, CHAMPVA, and/or free services at veterans’ clinics and hospitals. See CHAMPVA in §0902.05 (Glossary: Capital...) and TRICARE in §0902.39 (Glossary: Tennessen...) for more information.

Notify BRS of any other health coverage in effect for MA or GAMC applicants or enrollees by recording the applicable information in the TPL subsystem on MMIS.

NOTE:

It is not necessary to notify BRS when GAMC clients have CHAMPUS/TRICARE coverage.

Notify BRS of CHAMPUS/TRICARE coverage for federally funded MA clients (program M). See §0910.13 (Third Party Liability) for information on TPL sources other than health insurance.

Return to Top

OTHER COVERAGE -- PRESCRIPTION DRUG 0910.03.03

MinnesotaCare:

No provisions.

MA:

No provisions for MA, QMB, SLMB, QWD and QI. For the Prescription Drug Program (PDP), consider the following types of coverage to be prescription drug coverage in determining whether an applicant has current coverage or has had coverage in any of the 4 months preceding the first month of PDP enrollment:

• Prescription drug coverage available through a health plan or HMO. • CHAMPUS/TRICARE • Medicare supplemental policies (Medsup or Medigap) where the enrollee has opted for prescription drug coverage through a rider or selected drug coverage as an option.

Basic Medicare supplement plans and health insurance plans without drug riders do not provide prescription drug coverage. Minnesota law requires that these policies include the following warning on the first page of the contract:

Notice to Buyer: This contract does not cover prescription drugs. Prescription drugs can be a very high percentage of your medical expenses. Coverage for prescription drugs may be available to you. Please ask for further details.

Advise applicants who are unsure whether their policies include prescription drug coverage to check the policy to see if it contains this warning.

People currently enrolled in MA without a spenddown or MinnesotaCare are ineligible for PDP. See §0907.21.09.11 (Medicare Supplement Programs: PDP). Enrollment in MA or MinnesotaCare in the 4 months preceding the month of application is NOT a barrier to PDP enrollment.

Do not consider the following types of coverage to be prescription drug coverage when determining eligibility for PDP:

• Access to prescription drug discount cards. Examples include:
• Discount cards provided by insurance companies only to people who opt for health insurance without a prescription drug rider. • Discounts offered by pharmacies to encourage people to use their prescription services. • Discount cards offered through prescription "clubs". • Discount cards offered through senior organizations or other associations.
• Access to prescription drugs through pharmaceutical manufacturers’ prescription drug patient assistance programs. • Access to facilities which provide prescription drug coverage to people who qualify, such as veterans’ medical centers, Indian Health Centers, and community clinics. • Auto, homeowner’s or other liability insurance that pays prescription drug costs resulting from an accident. • Workers’ Compensation coverage for prescription drug costs resulting from a work-related injury. • Basic Medicare supplement plans required by law to provide 80 percent coverage for physician-prescribed diabetic equipment and supplies and injectable insulin. • UCare for Seniors Classic Plan for people who were enrolled in both PDP and the UCare Classic Plan on March 1, 2001. This exception expires on June 30, 2003.

See §0907.21.09.11 (Medicare Supplement Programs: PDP).

GAMC:

No provisions.

Return to Top

CURRENT HEALTH INSURANCE 0910.05

MinnesotaCare:

People who have other current health care coverage are not eligible for MinnesotaCare.

EXCEPTION:

Children under age 21 who have coverage that is considered underinsured may keep that coverage and enroll in MinnesotaCare. For a definition of Group 1, see §0907.03 (MinnesotaCare Eligibility Group 1). For information on how to determine if someone is underinsured, see §0910.09 (Determining if Someone Is Underinsured).

Children with Group 1 status with current coverage that does not meet the definition of underinsured in §0910.09 (Determining if Someone Is Underinsured) are not eligible for MinnesotaCare. Children with Group 2 status and all adults who have current coverage are not eligible regardless of whether the coverage is considered underinsured. See §0907.05 (MinnesotaCare Eligibility Group 2), §0907.07 (MinnesotaCare Eligibility Group 3), and §0907.09 (MinnesotaCare Eligibility Group 4).

EXAMPLE:

Jessica applies for MinnesotaCare for herself and her 3 children. Jessica has insurance through her employer, but it is not considered ESI because the employer pays less than 50% of the cost. The insurance meets the definition of underinsured. Jessica has Group 4 status. Her children have Group 1 status. Jessica is ineligible for MinnesotaCare because she has current insurance. If she drops the insurance, she is ineligible for MinnesotaCare for 4 months. Jessica’s children are eligible for MinnesotaCare because they are underinsured. They are not required to drop the insurance.

EXAMPLE: Arnold applies for MinnesotaCare. He has ESI through his employer. He is ineligible for MinnesotaCare because he has current health insurance. If Arnold drops the insurance and remains with the same employer, he continues to be ineligible for MinnesotaCare for 18 months because he had access to ESI through a current employer in the past 18 months. See §0910.11.03 (Access to ESI in the Past 18 Months). If families with verified income equal to or less than 150% FPG choose not to request coverage for children with other insurance or access to ESI, deny the child for not wanting coverage. Send the child’s caretaker the Request for Child Insurance Information (DHS 3448) or follow up by phone to explain that the child may qualify for MinnesotaCare if the other insurance is considered underinsured. If the family would like MinnesotaCare for the child, request the insurance information on the DHS 3448 or a copy of the child’s insurance card. If the family returns the information, contact the insurance company to determine if the coverage is underinsured according to §0910.09 (Determining if Someone is Underinsured). Add the child to MinnesotaCare if the other insurance meets the underinsured criteria.

When people qualify for MinnesotaCare with current health insurance or policies that are not considered other health care, complete a Health Insurance Information Form (HIIF, DHS 1922b) for each policy OR note the coverage types on the completed insurance page of the HCAPP. Forward the HIIF or copy of the HCAPP page to the Benefit Recovery Section, or for county enrollment sites, enter the information on the MMIS TPL screens. Benefit Recovery and the enrollee’s managed care plan are responsible for coordinating benefits with the other health insurance.

EXCEPTION:

When people qualify for MinnesotaCare with CHAMPUS/TRICARE, submit a HIIF, appropriate HCAPP page or enter the

information on MMIS for any household members with CHAMPUS/TRICARE for whom DHS receives FFP. Do not report

CHAMPUS/TRICARE coverage to BRS for household members whose MinnesotaCare coverage is entirely state funded.

If a state-funded enrollee with CHAMPUS/TRICARE becomes eligible for FFP, notify BRS by sending a HIIF or

appropriate HCAPP page or by entering the information on MMIS.

M. S. 256L.04 Subd. 2

M. S. 256L.07 Subd. 3

Minnesota Rule 9506.0020 Subp. 1(d)

Minnesota Rule 9506.0020 Subp. 3

MA/GAMC:

See §0910.05.01 (Current Health Insurance--MA/GAMC).

Return to Top

CURRENT HEALTH INSURANCE -- MA/GAMC 0910.05.01

MinnesotaCare:

See §0910.05 (Current Health Insurance).

MA/GAMC:

Require applicants or enrollees who are eligible to enroll on their own behalf in a cost effective group health plan to enroll as a condition of eligibility for MA or GAMC. Cost effective coverage is coverage which provides services at a lower premium than the costs DHS would incur if the client was not enrolled in the coverage.

Clients already enrolled in a cost effective group health plan must remain enrolled to be eligible. Adults who disenroll from a cost effective group health insurance plan are ineligible for MA or GAMC until the next open enrollment period for the cost effective group plan. They must re-enroll at that time to reestablish eligibility. Do not deny or terminate eligibility for children whose parents or other caretakers refuse or fail to maintain enrollment in cost effective plans.

Require applicants or enrollees who are eligible to continue group health plan coverage through COBRA to cooperate with cost effective insurance requirements. COBRA-eligible people include:

• Employees who are terminated, laid off, or whose hours are reduced below 20 hours per week can continue coverage up to 18 months. • Widows, divorced spouses, spouses of Medicare-eligible employees, dependent children of any of these people, and dependent children who lose eligibility due to age can continue coverage up to 3 years.

Require applicants or enrollees who are eligible for Medicare Part B to enroll or remain enrolled in Medicare Part B unless an increased premium is assessed due to late enrollment, or the client would be terminated from a group health insurance plan if enrolled in Medicare Part B. If either circumstance applies, request a cost effective decision from the Benefit Recovery Section.

Clients must cooperate in determining the cost effectiveness of any health insurance they have or any group health plan they may be eligible for by providing information about the plan and completing the Health Insurance Premium Cost Effectiveness Review Form (DHS 2841). The following policies are considered cost-effective by BRS and do not require further review:

• Policies where annual covered medical expenses exceed annual premium costs by a 2:1 ratio if the client's medical condition remains the same as in the period reviewed. Review insurance payment reports or the EOMB to determine benefit versus cost. • Policies covering people who have AIDS or who are HIV positive when the premiums are not substantially increased due to the person's condition or policy conversion. • Family coverage when the applicant's or enrollee's out-of-pocket premiums are $100 or less per month, if all family members are on MA or GAMC.

EXAMPLE:

Paul applies for MA for himself, his wife, and their two children. He has group health coverage through his employer. The employer pays $200 per month. Paul pays $95. Consider the coverage to be cost effective.

Paul is laid off while receiving MA and has the option of continuing coverage through COBRA. He must pay the full $295 premium. Redetermine cost effectiveness by determining if there is a 2:1 cost-benefit ratio. Submit a request to BRS if the policy is not cost effective based on the available information or there is not enough payment history to make the determination.

• Policies covering a pregnant woman's maternity care are cost-effective for the pregnant woman and any other MA-eligible household members covered by the same premium. Request that the Benefit Recovery Section review the policy at the end of 60-day postpartum period or if coverage of maternity care is unclear. If there are other family members covered by the policy, determine whether their portion of the premium is cost-effective under any of the other provisions in this section. If you cannot approve the other family members’ portion as cost-effective, refer the policy to Benefit Recovery.
EXAMPLE: Paula applies for MA-PW. She has health insurance for herself, her husband and her daughter. The health insurance covers maternity care. Paula is the only family member who is eligible for MA. Refer the case to Benefit Recovery to determine whether it is cost effective to pay the premium for the entire family. EXAMPLE: Maia applies for MA for herself and her two children. Maia is pregnant and has health insurance for herself and the children that covers maternity care. Maia’s cost for family coverage is under $100 per month. The entire premium is cost effective: Maia’s portion because it covers maternity care, and the children’s portion because the cost is under $100 per month and they both receive MA. If the children’s portion did not meet any of the cost effective provisions in this section, refer to Benefit Recovery.
• Children covered by policies when the child is:
• Receiving MA under the TEFRA Option if the child's portion of the premium is $50 or less per month. • Receiving MA as part of IV-E or state adoption assistance if the child's portion of the premium is $50 or less per month. • Receiving MA while living in an ICF-MR or NF when medical coverage through the policy is accessible to the child. Consider coverage to be accessible if providers covered by the policy are available within 30 minutes or 30 miles of the facility where the child resides. • Receiving MA while hospitalized (request the Benefit Recovery Section to review the policy 6 months after discharge).
• Medicare Part A premiums when the client is QMB or QWD eligible. • Medicare Part B when the client enrolls timely (paying the base rate for coverage) and is not enrolled in a group policy which terminates with enrollment in Medicare. • Medicare Supplement/Plus policies with drug coverage if the client's monthly drug expense exceeds the premium cost. • Policies covering LTCF residents when, at a minimum, coverage includes the Medicare co-insurance for the current nursing facility stay. Request the Benefit Recovery Section to review the policy at the end of 3 months.

The following policies are not cost effective and do not require BRS review:

• Medicare supplement policies for clients with routine medical needs. The only exception is a policy with drug coverage if the client's prescription needs exceed the premium.

If an applicant or enrollee’s Medicare supplement policy is not cost effective, the applicant or enrollee may request suspension of the policy for up to 24 months during a period of MA enrollment. The suspension allows the person to re-enroll in the policy without reapplying if MA ends during the suspension. The policyholder must request the suspension from the insurer within 90 days of the effective date of MA enrollment.

• Hospital indemnity policies which provide cash payments for each day in a hospital or nursing facility if the client is not currently collecting benefits.

Do not submit Minnesota Comprehensive Health Association (MCHA) policies for cost effectiveness review. Minnesota statutes prohibit MA and GAMC from paying MCHA premiums. MA/GAMC enrollees may carry MCHA coverage at their own expense but are not required to do so as a condition of eligibility.

Send all other policies to the BRS for review of cost effectiveness. Include the following information:

• Three copies of a completed DHS 2841 (with particular attention to Section 4). • A copy of the health care policy. • The applicant or enrollee's prorated cost of the health care premium. Include the prorated amount for all family members who are applying for or receiving MA. • Available payment reports or Explanation of Medical Benefits (EOMB).

If a policy will lapse before the DHS 2841 can be reviewed, call the Benefit Recovery Section for an oral decision.

Notify the client if cost effective payments are approved. Use the appropriate MAXIS SPEC LETR.

If payment of health insurance premiums is denied, notify the client of the decision and the right to appeal the action. BRS will reconsider denials if the client provides additional information to support a finding of cost effectiveness within 30 days. Use the appropriate MAXIS SPEC LETR.

Clients are not required to maintain private or group coverage that is not determined to be cost effective. If they do maintain non-cost effective coverage, they must continue to assign their rights and to cooperate with the county agency and BRS in providing information about the coverage.

If MA or GAMC ends, notify the client that MA/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 payments.

County agencies must reimburse clients or directly pay premiums for cost effective health insurance. When the policy holder and dependents are covered by the cost effective health care plan but are not all MA recipients, prorate the premium to determine what portion of the premium is reimbursable. See §0910.05.03 (Health Insurance Premium Payment).

Return to Top

HEALTH INSURANCE PREMIUM PAYMENT 0910.05.03

MinnesotaCare:

No provisions.

MA and GAMC:

The county agency must pay health insurance premiums if DHS determines the premiums are cost effective according to the provisions in §0910.05 (Current Health Insurance) AND the premium was not used to meet a spenddown. See §0913.21 (Allowable Medical Bills to Meet Spenddown). Pay premiums directly to the insurance provider, or as a reimbursement to the client.

A client is eligible for reimbursement of cost effective health insurance premiums for the month of application and retroactive months if:

• The client was eligible for MA or GAMC during the retroactive month(s).

AND

• The client or a financially responsible relative other than a non-custodial parent who is court ordered to provide medical support paid the premium.

AND

• The premiums were not used to meet a spenddown or asset reduction.

If only part of a premium was used to meet a spenddown or asset reduction, the client is eligible for reimbursement of the difference between the total amount paid for premiums in the application and retroactive months and the amount used to meet the spenddown or asset reduction.

EXAMPLE:

Pete applies for MA in April requesting retroactive coverage for March. He has health insurance which is determined to be cost effective. He paid his health insurance premium of $80 per month for March and April. $60 of the March premium was used to meet his 6-month spenddown. Reimburse Pete for $20 of the March premium and all of the April premium for total reimbursement of $100. Pete must maintain the cost effective coverage as a condition of continued eligibility. After the month of application, the county may either reimburse Pete for the premium each month or pay it directly to the insurance company.

For retroactive reimbursement, issue a check within 30 days of the decision to approve MA or GAMC. Verify the amount to be reimbursed. If the county elects to reimburse clients rather than pay premiums directly to the insurance company after the month of application, issue reimbursements in the same month clients pay the premiums.

When all people covered by the insurance policy are NOT receiving MA or GAMC, pay only the portion of the premium that covers family members enrolled in MA or GAMC. Consider paying premiums for other family members only if their enrollment is a condition of the MA or GAMC family members' eligibility for the health plan and it is cost effective.

EXAMPLE:

Sara is eligible for MA using the TEFRA waiver. She lives with her parents and her brother, none of whom receive MA or GAMC. Her father has health insurance through his employer at no charge for the employee. The cost of dependent coverage for Sara, her mother, and her brother is $96 per month. Reimburse (or pay directly) $32 of the premium (one-third of the cost of dependent coverage).

Note that this policy is considered cost effective without BRS review because Sara receives MA through TEFRA and her share of the premium is less than $50 per month.

EXAMPLE:

Mary is eligible for MA for herself and her two daughters. Her husband John, the children's stepfather, does not receive MA or GAMC. Mary has health insurance through her employer at a cost of $300 per month for Mary and all dependents. Mary would pay $30 for employee-only coverage. Based on this information, consider $30 of the $300 premium to be Mary's share and $270 to be the cost of dependent coverage for John and the children. Reimburse (or pay directly) $210 of the premium ($30 for Mary plus $90 each prorated for the two children).

EXAMPLE:

Bill applies for MA for his two sons. He is not eligible for MA for himself. He has health coverage through his employer at a cost of $50 for the employee and $100 for dependent coverage. He cannot enroll his sons in the health plan unless he is enrolled.

Determine whether the premium is cost effective by comparing the full cost of the premium ($150) to insurance payments made for the children. See §0910.05 (Current Health Insurance). If the policy is cost effective based on only the sons' medical expenses, reimburse (or pay directly) the full $150 premium since the children cannot be enrolled in the health plan unless Bill is enrolled.

If the policy is not cost effective using only the sons' medical expenses, do not reimburse or pay any part of the premium. Do not require Bill to maintain dependent coverage as a condition of eligibility.

Do not reimburse or pay premiums for non-custodial parents who are court-ordered to provide medical support unless all the following conditions are met:

• The non-custodial parent leaves a job and has continued dependent coverage available through COBRA.

AND

• The Child Support Officer determines that the non-custodial parent is no longer financially able to keep the coverage in effect.

AND

• The coverage is cost effective. The Child Support Officer will refer the insurance policy to the MA worker for a cost effectiveness determination. Determine cost effectiveness following the provisions in §0910.05 (Current Health Insurance).

Do not reimburse the non-custodial parent directly for the cost of premiums. Make the payment directly to the employer or to the custodial parent if the custodial parent makes payments to the employer.

The Child Support Officer may pursue repayment of the premiums from the non-custodial parent at a later date.

EXAMPLE:

Brent receives MA for his son Jerod. Jerod's mother, Susan, is court-ordered to provide health insurance for Jerod. She has dependent coverage available through her employer at a cost of $75 per month. Susan contacts the county and requests reimbursement of the $75 premium because Jerod receives MA. Do not reimburse or pay the premium regardless of whether the policy is cost effective.

Several months later, Susan is laid off. She can continue coverage for Jerod for up to 18 months under COBRA at a cost of $150 per month. The child support officer determines that Susan is unable to pay the premium and requests a cost effectiveness determination. The policy is determined to be cost effective. Pay the $150 premium directly to the employer or insurance company.

Return to Top

MAIL ORDER PRESCRIPTION DRUG REIMBURSEMENT 0910.05.03.03

MinnesotaCare: No provisions. MA and GAMC: Some employer-sponsored and private health plans offer prescription drug benefits only through mail order companies such as CareMark, ExpressScripts, and Merck-MedCo. These mail order companies refuse to enroll as MA/GAMC providers and will not bill enrollee co-payments to Minnesota Health Care Programs. MA and GAMC can reimburse the enrollee directly for out-of-pocket payments to these mail order companies if:
• They were not used to meet an MA spenddown
AND
• The enrollee receives MA or GAMC through fee-for-service
AND
• Benefit Recovery determines that it is cost-effective. In this instance, "cost-effective" means it is less costly to reimburse the client for the mail order co-payments using 100% state funding than to pay the full cost of the drug through MA at a retail pharmacy.
Contact Benefit Recovery if an enrollee who receives MA or GAMC on a fee-for-service basis has a mail-order only drug benefit with co-payments. Do not contact Benefit Recovery for enrollees who receive MA or GAMC from managed care plans. Refer the enrollee to the managed care plan for help with benefit coordination.

Return to Top

MEDICARE PREMIUM PAYMENT 0910.05.05

MinnesotaCare:

Except for Group 1 children, Medicare eligibility may be a bar to MinnesotaCare. See §0910.03 (Types of Other Coverage). If MinnesotaCare enrollees appear to be eligible for Medicare Part A at no cost, use the Medicare Application Referral Letter (DHS 3444) to refer them to the Minnesota regional Social Security Office. See §0911.03.03 (Applying for Other Benefits).

MinnesotaCare enrollees are not eligible for the Buy-In.

MA/GAMC:

The Medicare program has two components. Part A covers hospital, hospice, and some home health care. Part B covers doctor services, x-rays, laboratory, and medical supplies.

The following people are eligible for Medicare Part A at no cost:

• People age 65 and over who are eligible for or receiving RSDI or Railroad Retirement benefits. • Other people age 65 and over who had Medicare-covered government employment. • People who have been receiving RSDI or Railroad Retirement benefits based on a disability for more than 24 months. • People receiving continuous dialysis due to permanent kidney failure or who have had kidney transplants.

Because there is no cost to the enrollee, it is not necessary to review Part A for cost effectiveness for these groups.

People who are age 65 and over who receive only SSI may be eligible for Part A with a monthly premium. People who do not receive SSI but are eligible as QWD's are also eligible with a premium. DHS pays the premium directly to the SSA through the automated Buy-In process. People must be active on QMB or QWD to have Part A premiums paid through the Buy-In. See §0907.21.09.03 (Medicare Supplement Programs: QMB) and §0907.21.09.07 (Medicare Supplement Programs: QWD). For systems instructions, see TEMP Manual TE02.07.327 (Medicare Part A/B and the Buy-In (Part 1). Also see MMIS User Manual II-38 (Buy-In).

If a person who is not eligible for QMB or QWD receives Part A with a premium, determine if the premium is cost effective. If cost effective, send the Medicare Part A payment directly to:

HCFA Medicare Insurance

Medicare Premium Collection Center

PO Box 371384

Pittsburgh, PA 15250-7384

People who are enrolled in Part A can enroll in Part B for a monthly premium. Part B premiums are cost effective unless the client has increased premiums due to late enrollment, or the client participates in a group coverage which would terminate with Medicare enrollment. In these instances, refer the case to Benefit Recovery for review of cost effectiveness. See §0910.05 (Current Health Insurance). In all other cases, refer people who are eligible for Part B but who are not enrolled to the Social Security Administration. They must enroll in Part B as a condition of eligibility for MA.

DHS pays Part B premiums through the Buy-In for people who:

• Are enrolled in QMB, SLMB, or QI-1. See §0907.21.09 (MA Basis: Medicare Supplement Programs).

OR

• Receive MA with SSI or MSA or GRH.

OR

• Receive MA with Title IV-E adoption assistance, Title IV-E foster care, have 1619(a) or (b) status, or receive MA and MFIP.

People must be enrolled in Medicare before payments can begin through the Buy-In. Use the Medicare Buy-In Referral Letter (DHS 3439) to refer people who are eligible for the Buy-In to SSA if necessary outside the open enrollment period.

There is no advantage to QMB enrollment for people who have MA without a spenddown, are eligible for Part A with no premium and are eligible for the Part B buy-in, such as 1619(a) and (b) enrollees. Enroll SSI-only recipients in QMB to allow payment of the Part A premium.

For instructions on adding (accreting) or removing (deleting) people from Buy-In eligibility, see MMIS User Manual II-38 (Buy-In) and TEMP Manual TE02.07.326 (Enrollment in Medicare Part A and Part B) and TE02.07.327 (Medicare Part A/B and the Buy-In (Part 1).

People who become eligible for the Part B Buy-In may receive reimbursement for Part B premiums they have paid. See §0911.09.15.05 (Lump Sum RSDI and SSI Payments) for information on how to treat these payments.

MA-EPD enrollees must apply for and accept Part B if they are eligible for it. See §0907.21.07.05 (MA for Employed Persons with Disabilities MA-EPD). Reimburse Part B premiums retroactive to the date of MA-EPD eligibility for MA-EPD enrollees who

• have incomes no greater than 200% FPG. Do not count spousal income in this determination.

AND

• are not eligible for QMB or SLMB under the rules of those programs, including deeming of spousal income and assets.

EXAMPLE:

Steve receives MA-EPD and Medicare Part B at the standard premium rate. His income is approximately 115% of FPG for a household of 2. His wife, who does not receive MA-EPD, also has income of approximately 115% of FPG for a household of 2. Steve is not eligible for QMB or SLMB because household income exceeds the limits for those programs. Since Steve’s income alone is less than 200% FPG, reimburse his Part B premium.

Refer cases in which the enrollee has an increased Part B premium due to late enrollment to BRS for a determination of cost-effectiveness ONLY if the EPD enrollee’s income is no greater than 200% FPG. Reimburse the premium if BRS determines it is cost-effective. Do not refer to BRS or reimburse premiums if income is over 200% FPG.

Also reimburse Part B premiums for people on program IM who would be eligible for QMB or SLMB but for their IMD residence. See §0907.27 (MA/GAMC Basis: IMD Residents).

See MMIS User Manual II-37 (Medicare) for instructions on billing DHS for county-reimbursed Medicare payments.

Return to Top

4-MONTH RULE 0910.07

MinnesotaCare:

People who had other health coverage in the past 4 months are not eligible for MinnesotaCare.

EXCEPTION: Do not count the following types of insurance as other health coverage. Do not apply the 4-month insurance barrier to:
• Any insurance held by children under age 21 with Group 1 status. See §0907.03 (MinnesotaCare Eligibility Group 1). • CHAMPUS/TRICARE • MA • GAMC • Cost-effective health insurance that was paid for by MA OR applied to the enrollee’s spenddown. Do not consider the cost-effective health insurance to be exempt from the 4-month barrier if the enrollee kept the insurance after MA determined it was no longer cost-effective or after MA closed.

Do not consider MA or GAMC to be other coverage when determining whether applicants meet the 4-month rule. Do consider other coverage in effect while the applicant received GAMC, regardless of whether it was cost-effective.

EXAMPLE:

Marcia’s MA is terminated 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. She is exempt from the 4-month barrier because the cost-effective insurance that was paid for by MA does not count as other insurance for purposes of the 4-month insurance barrier. 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.

Do not submit a HIIF to Benefit Recovery for people who had health insurance in the past 4 months but no longer have it.

M. S. 256.9357 subd. 3

MA/GAMC:

No provisions.

Return to Top

DETERMINING IF A CHILD IS UNDERINSURED 0910.09

MinnesotaCare:

Consider a child as underinsured if the other health care coverage:

• Lacks coverage in 2 or more of the following areas:
• Basic hospital insurance. • Medical-surgical insurance. • Prescription drug coverage. • Preventive and comprehensive dental coverage (with or without co-pays). • Preventive and comprehensive vision coverage (with or without co-pays).

See §0902.07 (Glossary: Client...) and §0902.29 (Glossary: Pension...) for definitions of comprehensive and preventive coverage.

OR

• Has a deductible of $100 or more per person per year. If the policy has a per family rather than a per person deductible, divide the deductible by the number of family members covered by the policy to arrive at a per person amount.

OR

• Excludes services for a pre-existing condition.

OR

• Excludes coverage for a particular diagnosis.

OR

• The applicant/enrollee is a child who is enrolled in Medicare Part A, Part B, or both.

See §0910.05 (Current Health Insurance) and §0910.07 (4-Month Rule) to determine when someone who is underinsured can be eligible for MinnesotaCare.

M. S. 256L.07 subd. 3

Minnesota Rules 9506.0020 subp. 3 item B

MA/GAMC:

No provisions.

Return to Top

ACCESS TO EMPLOYER SUBSIDIZED INSURANCE 0910.11

MinnesotaCare:

People who have current access to employer subsidized insurance (ESI) coverage are ineligible for MinnesotaCare. ESI is coverage for which an employer pays at least 50% of the cost of coverage. See §0910.11.05 (Determining the Employer Contribution).

EXCEPTION:

Children under 21 with Group 1 status may have access to ESI and are not required to accept it, regardless of whether it is considered underinsured. If they have current ESI coverage, it must be considered underinsured to be eligible for MinnesotaCare.

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. See §0910.11.06 (Open Enrollment).

Applicants and enrollees whose employers offer a choice of either

• a higher salary with no ESI (pay in lieu of ESI)

OR

• a lower salary with ESI

will be considered to have access to ESI even if they choose the higher salary with no ESI. This applies only when the employee is offered a choice of compensation for the exact same job. Do not consider an employee to have access to ESI if their choice of compensation also dictates their work schedule or number of hours worked, flex time, job title, etc.

EXAMPLE:

Angie’s employer offers her the choice of two compensation plans. Under the first plan, employees are paid $8.00 per hour. They can choose to be covered by the employer’s insurance plan at a cost of $195 per month. The employer will not contribute to the cost of the insurance. Under the second plan, employees are paid $7.05 per hour. They must contribute $25.00 per month for the employer’s insurance plan, and the employer will pay $170 per month towards the insurance. Angie chooses the first plan, but does not purchase the insurance. Angie is ineligible for MinnesotaCare because she has access to ESI.

EXAMPLE

Katie’s new employer offers her a choice of working the day shift with ESI coverage and a lower hourly wage, or working the night shift with fewer hours per week, no health insurance, and a higher hourly wage. At initial application, Katie works the night shift position and cannot get insurance through her employer. She does not have access to ESI.

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.

MA/GAMC:

No provisions.

Return to Top

VERIFICATION OF ESI 0910.11.01

MinnesotaCare:

Access to ESI.

Verify access to ESI for all employed MinnesotaCare applicants and enrollees reporting employment. Deny or terminate eligibility for applicants and enrollees who report access to ESI. Do not require verification prior to denial or termination.

If an applicant or enrollee indicates that he or she is employed, their spouse is employed or their child(ren) are employed, verify whether there is access to ESI for each employer listed.

Do not delay or deny coverage for children in households with verified family incomes

at or below 150% FPG regardless of their parents’ failure to verify access to ESI.

Require verification of access to ESI for each employer listed by an applicant or enrollee, regardless of whether the worker or agency has knowledge of a particular employer’s policy on offering health insurance.

Do not verify access to ESI for applicants and enrollees who are:

• Children with verified family incomes at or below 150% FPG: • Farmers with no other type of employment in the household; or • Self employed with no other type of employment in the household

All applications and renewals must be pended (P30 or C47), awaiting verification of access to ESI from all employers listed on the application or renewal form unless verification has already been provided with the application or renewal. Request ESI verification and document all actions and requests for verification in case notes. Applicants and enrollees have 30 days to provide verification of access to ESI. Applicants and enrollees who fail to provide this verification will be denied or terminated automatically by MMIS in 60 days or for enrollees renewing coverage, at the end of the renewal period.

Require verification of access to ESI at each renewal, for all currently employed enrollees, for all employers listed, regardless of whether verification was collected previously.

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.

Acceptable forms of verification include:

• A Request for Verification of Employer Insurance (DHS-3348) completed and signed by the employer or union. • Documents from an employer that show what health insurance is offered and how much the employer and employee pay for it. Open enrollment materials will often have this information. Employee handbooks or new employee orientation papers may also have this information: or • A written statement from the employer or union that provides information necessary to determine whether the employee and dependents have access to ESI.

EXAMPLE:

Jack applies for MinnesotaCare for himself and his family on April 3. Jack answers “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. The worker pends Jack and his family for Incomplete Application, noting that income and insurance verification are needed. See MMIS User Manual, MinnesotaCare Section, Reference Codes, Pending Codes, for information on correct MMIS codes.

The worker requests income verification and includes a Request for Verification of Employer Insurance (DHS 3348) and a note to Jack that he may submit open enrollment or other health insurance documents from his employer or give the verification form to his employer to complete. Jack faxes copies of his pay stubs and tax forms as income verification and provides the employer completed Request for Verification of Employer Insurance (DHS 3348). The ESI verification indicates that Jack and his dependents do not have access to ESI through his employer:

The family meets all income and eligibility requirements for MinnesotaCare. Approve the case as pending awaiting payment. If Jack submits income verification but does not submit the verification form or copies of his open enrollment materials or other employer documentation, continue the pending status for ESI. MMIS will automatically deny the application in 60 days.

Do not contact the employer or union without written consent from the applicant or enrollee to verify access to ESI.

Submit a HealthQuest if the employer refuses to provide ESI verification.

MA/GAMC:

No provisions.

Return to Top

ACCESS TO ESI IN PAST 18 MONTHS 0910.11.03

MinnesotaCare:

People who have had access to employer subsidized insurance (ESI) through a current employer in the preceding 18 months are ineligible for MinnesotaCare. ESI is coverage for which an employer pays at least 50% of the cost of coverage. See §0910.11.05 (Determining the Employer Contribution).

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.

At application, renewal, or on receipt of new information, deny or cancel coverage for adults and Group 2 children who have had access to ESI through a current employer within the past 18 months. Do not apply this restriction to Group 1 children. See §0910.11 (Employer Subsidized Insurance).

For more information on this insurance barrier and open enrollment, see §0910.11.06 (Open Enrollment).

Some employers only offer ESI to employees who work a certain number of hours. 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. However, people who are initially hired at part-time hours that do not make them eligible for 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. 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. 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. She is eligible for MinnesotaCare.

M. S. 256L.07 subd. 2

MA/GAMC:

The availability of ESI does not affect people’s eligibility for MA and GAMC. However, people must enroll in cost-effective coverage as a condition of eligibility for adults. See §0910.05.01 (Current Health Insurance--MA/GAMC). HIPAA allows current and former MA/GAMC enrollees to enroll in an employer’s plan outside of the open enrollment period under the same conditions as MinnesotaCare. People whose MA or GAMC ends will receive a COCC automatically two months after termination. See §0916.23 (Certificates of Creditable Coverage). If the former enrollee needs the COCC sooner, request one following your agency’s procedures.

Return to Top

EMPLOYER TERMINATES ESI 0910.11.04

MinnesotaCare:

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. ESI is coverage for which an employer pays at least 50% of the cost of coverage. See §0910.11.05 (Determining the Employer Contribution).

EXCEPTION:

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 6 months of MinnesotaCare termination.

EXCEPTION:

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 is ineligible for MinnesotaCare until March 2005, 18 months after the employer dropped ESI as an employee benefit. His son is a Group 1 child and thus is not subject to the insurance barrier.

Return to Top

DETERMINING THE EMPLOYER CONTRIBUTION 0910.11.05

MinnesotaCare:

Insurance is considered employer subsidized if the employer contributes at least 50% of the cost of coverage. 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. Some employers contribute only toward the cost of employee coverage. They may not offer dependent coverage or may offer it at full cost to the employee.

Determine access to ESI separately for the employee and dependents. To determine if the employee has or had access to ESI, first determine the total monthly premium for the employee's coverage. Then determine how much the employer contributes. If the employer share is at least half of the total, the employee has ESI.

To determine if other household members have or had access to ESI, determine whether the employer offers dependent coverage. If so, determine the full monthly premium for the dependents. Then determine how much the employer contributes. If the employer’s share is at least half of the total, the dependents for whom coverage is available have ESI. If the cost varies by the number of dependents, compare the total employer contribution to the total cost to determine if the coverage meets the ESI definition for all the dependents.

EXAMPLE:

Joe and Lisa apply for MinnesotaCare with their child. Joe’s employer offers employee-only health coverage at no cost to Joe. Joe has access to ESI. The cost to add 1 dependent is $250, of which the employer pays $150. The cost to add 2 dependents is $550, of which the employer pays $250. Since Joe has 2 dependents and the employer pays less than 50% of the cost to add both, neither Lisa nor the child have access to ESI.

If the applicant or enrollee does not know if the employer offers ESI or the amount of the employer contribution, use the Employer Verification of Health Insurance form. Have the applicant or enrollee give the form to the employer to complete, or obtain the applicant or enrollee's signature to allow you to mail the form directly to the employer.

EXAMPLE:

John applies for MinnesotaCare for himself, his wife, their 15-year-old daughter, and their 20-year-old son who is not a student. John's employer offers health benefits for employees and their dependents up to age 19 or age 25 for full-time students. The monthly cost for employee coverage is $80 for which the employer pays the full cost. The monthly cost for dependent coverage is $150 for which the employer contributes $80 and the employee must contribute $70. Because the employer pays 100% of John's insurance premium and 53% of the cost of dependent coverage, John, his wife, and his daughter all have access to ESI. His son does not have access to ESI, because he is over 19 and not a full-time student.

EXAMPLE:

Mary applies for MinnesotaCare for herself and her 12-year-old daughter. Her employer provides health insurance for the employee only. The cost of coverage is $100 per month for which the employer contributes $50. Employees may also purchase dependent coverage for an additional $200 per month. Because the employer pays 50% of the cost of Mary's coverage, she has access to ESI. Her daughter does not have access to ESI, because the employer does not contribute to the cost of dependent coverage.

Some employers offer cash benefits to employees for the purchase of health insurance rather than offering a choice of specific health plans that the employer purchases under contract. Employees may use the benefit toward the purchase of a health insurance plan of their choice. Because the cost of plans varies widely, the employer-provided cash benefit may be more or less than 50% of the cost of the coverage selected. Therefore, to determine if the employee and dependents have access to ESI, use the full cost of MinnesotaCare coverage for the family size to determine the proportion of the employer contribution.

Use the current MinnesotaCare premium tables to determine the full cost of coverage. Do not use the actual premium the family would be charged based on their income. The full cost of coverage is shown at the top of each page of the tables.

EXAMPLE:

Bob applies for MinnesotaCare for himself, his wife, and two minor children. His employer contributes $100 per month toward the cost of health insurance for the family. The table shows that the full cost of MinnesotaCare coverage for a family of four is $312. Because the employer's cash benefit is less than 50% of the cost of coverage, neither Bob nor his dependents have ESI.

The employer contribution under self-insured or self-funded plans may vary depending on what services the enrollee uses. To determine whether these plans are considered ESI, obtain the full cost of coverage the employer would charge under COBRA. If the employee contribution is equal to or less than 50%, consider the plan to be ESI. If the employer is unable to provide the COBRA amount, compare the employee contribution to the full cost of MinnesotaCare coverage for the household following the procedures for cash benefits.

EXAMPLE:

David’s employer offers health coverage through a self-insured plan. David pays $30 per month for his coverage and $150 per month for his wife and son. The employer’s contribution varies depending on claims submitted. The employer reports that the full cost of coverage for employees eligible for COBRA benefits is $100 per month for the employee and $300 per month for dependents. Since the employer pays at least 50% of the cost, David and his family have access to ESI.

If the employer is unable to provide a COBRA amount, compare the full cost of MinnesotaCare coverage for a family of 3 to the total amount David pays for himself and his family ($180 per month) to determine if his coverage is considered ESI.

M. S. 256L.07 subd. 2

MA/GAMC:

No provisions.

Return to Top

OPEN ENROLLMENT AND ESI 0910.11.06

MinnesotaCare:

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. Open enrollment means a time each year when employees and dependents can join the employer's health benefit plan. Not all employers offer an open enrollment period.

Applicants and enrollees who have access to ESI during an employer’s open enrollment period have current access to ESI. 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. They can sign up for the insurance annually in April. They apply for MinnesotaCare in July, two months after Tim’s open enrollment period ended. Tim and Nancy are ineligible for MinnesotaCare because a current employer offered ESI within the past 18 months. The children are eligible if 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. She is ineligible for MinnesotaCare for 18-months from the day her employer offered her health insurance.

Some employers offer a special enrollment period. During a special enrollment period an employee has an opportunity to enroll in a group health plan without having to wait for an open enrollment period. A group health plan must provide individuals with an opportunity for special enrollment if they:

• declined coverage under the plan because they had alternative coverage but since have lost that alternative coverage

OR

• have new dependents through marriage, birth or adoption.

Special enrollment may be available to people who declined ESI when it was first offered because they had MinnesotaCare and whose MinnesotaCare coverage later ends. If people are terminated from MinnesotaCare because a current employer offered ESI within the past 18 months, advise them to ask if the employer offers special enrollment. Also advise them to request enrollment under the employer’s plan within 30 days of MinnesotaCare termination to avoid a break in coverage. If there is a break in coverage, the person will not get credit for MinnesotaCare coverage to reduce a pre-existing condition exclusion.

EXAMPLE:

Gary and his family are enrolled in MinnesotaCare. They have Group 2 status. At the time of the annual renewal in July, the enrollment representative discovers that Gary had an opportunity to enroll the entire family in ESI at the time of his employer’s annual open enrollment 6 months earlier. Gary chose not to accept the coverage because he had MinnesotaCare. Terminate 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.

A Certificate of Creditable Coverage (COCC) will be issued automatically 2 months after MinnesotaCare ends. See §0916.23 (Certificates of Creditable Coverage). If the former enrollee needs the COCC sooner, request one following your agency’s procedures.

MA/GAMC:

No provisions.

Return to Top

THIRD PARTY LIABILITY 0910.13

In some situations people may have coverage for all or part of their medical expenses through a 3rd party payor that is not considered to be health insurance. Examples include:

• Workers' Compensation may be liable for the cost of medical care related to on-the-job injuries. • Auto insurance policies may cover medical costs related to auto accidents within certain limits. • Homeowners or business liability policies may cover medical costs related to accidents on the home or business owner's property. • Tort claims may result in court-ordered awards for recovery of medical expenses caused by another party's negligence or malpractice.

If an applicant or enrollee currently has access to 3rd party liability payments, notify the Benefit Recovery Section (BRS). BRS will coordinate payments for which the 3rd party is liable with payments made by the health care programs. Also notify BRS if an applicant or enrollee has a claim, settlement, or lawsuit pending that could result in payment of medical expenses. BRS may be able to file a lien to allow the Department to be reimbursed for medical care paid by the health care programs while the claim, settlement or lawsuit was pending.

Do not require a HIIF for current or potential 3rd party liability payments reported on an application. See the program specific provisions.

MinnesotaCare:

Do not consider actual or potential 3rd party liability payments to be health insurance in determining whether people meet the insurance requirements for eligibility. See §0910.03 (Types of Other Coverage). If someone indicates at application or renewal that a household member has been injured on the job or in an accident, follow up to determine if there are current or potential 3rd party liability payments. Send the Accident/Injury Follow-Up Request for Information (MS 1261) if the application does not contain enough information. Do not pend the application or renewal for receipt of this information. Also follow up if you become aware of possible 3rd party liability payments between renewals.

Notify BRS by MAXIS email to BRSS. Include the following:

• Enrollee’s name and PMI number • Date of injury • Type of potential TPL (auto insurance, workers’ compensation, homeowner’s insurance, etc.) • Whether a claim or settlement is pending and the name and address of the attorney if applicable.

M. S. 256.9354 Subd. 1a

MA/GAMC:

When applicants or enrollees report accidents or injuries with possible 3rd party liability, enter the information on the STAT/ACCI screen on MAXIS. MAXIS will interface the information to MMIS. MMIS will generate a Medical Services Questionnaire (MSQ) (DHS 2337) to be returned to Benefit Recovery. Benefit Recovery will monitor the return of the MSQs and will generate 2nd notices for the worker to send to the enrollee if necessary. If you receive a 2nd MSQ from BRS, send it to the applicant/enrollee and allow 10 days for its return. Deny or close with 10-day notice if the applicant or enrollee fails to respond to the 2nd request. Notify Benefit Recovery of the denial or termination. Do not deny or terminate benefits for children.

Complete the STAT/ACCI screen if:

• The applicant or enrollee is pursuing legal action on an old or recent injury.

OR

• Insurance is currently paying for medical costs related to the injury.

OR

• Potential insurance payments are available for costs associated with the injury.

Also complete the STAT/ACCI screen if the client has an active or pending Workers' Compensation claim. BRS will generate a Work Injury Report if they receive notice of possible Workers' Compensation eligibility through an interface with the Department of Labor and Industry.

EXAMPLE:

Mark applies for GAMC. He reports he was injured in a fall at a grocery store two years ago. He has not received any payments as a result of this injury but has retained an attorney and plans to file suit. Complete the STAT/ACCI screen. MMIS will generate an MSQ. Mark must supply the requested information to BRS. If the suit is successful, BRS may be able to recover amounts paid by GAMC for costs related to the injury.

EXAMPLE:

Jean applies for MA. She reports she was injured in an auto accident 2 months ago. Her auto insurance carrier is covering the costs of ongoing medical treatment related to the accident. Complete the STAT/ACCI screen. Jean must provide information on the auto insurance claim to BRS.

EXAMPLE:

Jolene applies for MA for herself and her children. She reports that her son was treated at the emergency room for cuts and bruises sustained in a sledding accident 2 months ago. There are no insurance claims active or pending. Jolene does not plan to file a suit. Do not complete the STAT/ACCI screen.

EXAMPLE:

Bob applies for MA for himself and his family. He was injured on the job 6 months ago and has been unable to return to work. He receives weekly payments from Workers’ Compensation as well as coverage for medical costs related to the injury. Complete the STAT/ACCI screen. Count the weekly payments as income.

Return to Top

Rate/Report this page Report/Rate this page