Sec. 32.0422. HEALTH INSURANCE PREMIUM PAYMENT REIMBURSEMENT PROGRAM FOR MEDICAL ASSISTANCE RECIPIENTS. (a) In this section, "group health benefit plan" means a plan described by Section 1207.001, Insurance Code.
(b) The commission shall identify individuals, otherwise entitled to medical assistance, who are eligible to enroll in a group health benefit plan. The commission must include individuals eligible for or receiving health care services under a Medicaid managed care delivery system.
(b-1) To assist the commission in identifying individuals described by Subsection (b):
(1) the commission shall include on an application for medical assistance and on a form for recertification of a recipient's eligibility for medical assistance:
(A) an inquiry regarding whether the applicant or recipient, as applicable, is eligible to enroll in a group health benefit plan; and
(B) a statement informing the applicant or recipient, as applicable, that reimbursements for required premiums and cost-sharing obligations under the group health benefit plan may be available to the applicant or recipient; and
(2) not later than the 15th day of each month, the office of the attorney general shall provide to the commission the name, address, and social security number of each newly hired employee reported to the state directory of new hires operated under Chapter 234, Family Code, during the previous calendar month.
(c) The commission shall require an individual requesting medical assistance or a recipient, during the recipient's eligibility recertification review, to provide information as necessary relating to any group health benefit plan that is available to the individual or recipient through an employer of the individual or recipient or an employer of the individual's or recipient's spouse or parent to assist the commission in making the determination required by Subsection (d).
(d) For an individual identified under Subsection (b), the commission shall determine whether it is cost-effective to enroll the individual in the group health benefit plan under this section.
(e) If the commission determines that it is cost-effective to enroll the individual in the group health benefit plan, the commission shall:
(1) require the individual to apply to enroll in the group health benefit plan as a condition for eligibility under the medical assistance program; and
(2) provide written notice to the issuer of the group health benefit plan in accordance with Chapter 1207, Insurance Code.
(e-1) This subsection applies only to an individual who is identified under Subsection (b) as being eligible to enroll in a group health benefit plan offered by an employer. If the commission determines under Subsection (d) that enrolling the individual in the group health benefit plan is not cost-effective, but the individual prefers to enroll in that plan instead of receiving benefits and services under the medical assistance program, the commission, if authorized by a waiver obtained under federal law, shall:
(1) allow the individual to voluntarily opt out of receiving services through the medical assistance program and enroll in the group health benefit plan;
(2) consider that individual to be a recipient of medical assistance; and
(3) provide written notice to the issuer of the group health benefit plan in accordance with Chapter 1207, Insurance Code.
(f) Except as provided by Subsection (f-1), the commission shall provide for payment of:
(1) the employee's share of required premiums for coverage of an individual enrolled in the group health benefit plan; and
(2) any deductible, copayment, coinsurance, or other cost-sharing obligation imposed on the enrolled individual for an item or service otherwise covered under the medical assistance program.
(f-1) For an individual described by Subsection (e-1) who enrolls in a group health benefit plan, the commission shall provide for payment of the employee's share of the required premiums, except that if the employee's share of the required premiums exceeds the total estimated Medicaid costs for the individual, as determined by the executive commissioner, the individual shall pay the difference between the required premiums and those estimated costs. The individual shall also pay all deductibles, copayments, coinsurance, and other cost-sharing obligations imposed on the individual under the group health benefit plan.
(g) A payment made by the commission under Subsection (f) or (f-1) is considered to be a payment for medical assistance.
(h) A payment of a premium for an individual who is a member of the family of an individual enrolled in a group health benefit plan under Subsection (e) and who is not eligible for medical assistance is considered to be a payment for medical assistance for an eligible individual if:
(1) enrollment of the family members who are eligible for medical assistance is not possible under the plan without also enrolling members who are not eligible; and
(2) the commission determines it to be cost-effective.
(i) A payment of any deductible, copayment, coinsurance, or other cost-sharing obligation of a family member who is enrolled in a group health benefit plan in accordance with Subsection (h) and who is not eligible for medical assistance:
(1) may not be paid under this chapter; and
(2) is not considered to be a payment for medical assistance for an eligible individual.
(i-1) The commission shall make every effort to expedite payments made under this section, including by ensuring that those payments are made through electronic transfers of money to the recipient's account at a financial institution, if possible. In lieu of reimbursing the individual enrolled in the group health benefit plan for required premium or cost-sharing payments made by the individual, the commission may, if feasible:
(1) make payments under this section for required premiums directly to the employer providing the group health benefit plan in which an individual is enrolled; or
(2) make payments under this section for required premiums and cost-sharing obligations directly to the group health benefit plan issuer.
(j) The commission shall treat coverage under the group health benefit plan as a third party liability to the program. Subject to Subsection (j-1), enrollment of an individual in a group health benefit plan under this section does not affect the individual's eligibility for medical assistance benefits, except that the state is entitled to payment under Sections 32.033 and 32.038.
(j-1) An individual described by Subsection (e-1) who enrolls in a group health benefit plan is not ineligible for home and community-based services provided under a Section 1915(c) waiver program or another federal home and community-based services waiver program solely based on the individual's enrollment in the group health benefit plan, and the individual may receive those services if the individual is otherwise eligible for the program. The individual is otherwise limited to the health benefits coverage provided under the health benefit plan in which the individual is enrolled, and the individual may not receive any benefits or services under the medical assistance program other than the premium payment as provided by Subsection (f-1) and, if applicable, waiver program services described by this subsection.
(k) Repealed by Acts 2015, 84th Leg., R.S., Ch. 945 , Sec. 13(2), eff. September 1, 2015.
(l) The commission, in consultation with the Texas Department of Insurance, shall provide training to agents who hold a general life, accident, and health license under Chapter 4054, Insurance Code, regarding the health insurance premium payment reimbursement program and the eligibility requirements for participation in the program. Participation in a training program established under this subsection is voluntary, and a general life, accident, and health agent who successfully completes the training is entitled to receive continuing education credit under Subchapter B, Chapter 4004, Insurance Code, in accordance with rules adopted by the commissioner of insurance.
(m) The commission may pay a referral fee, in an amount determined by the commission, to each general life, accident, and health agent who, after completion of the training program established under Subsection (l), successfully refers an eligible individual to the commission for enrollment in a group health benefit plan under this section.
(n) The commission shall develop procedures by which an individual described by Subsection (e-1) who enrolls in a group health benefit plan may, at the individual's option, resume receiving benefits and services under the medical assistance program instead of the group health benefit plan.
(o) The commission shall develop procedures which ensure that, prior to allowing an individual described by Subsection (e-1) to enroll in a group health benefit plan or allowing the parent or caretaker of an individual described by Subsection (e-1) under the age of 21 to enroll that child in a group health benefit plan:
(1) the individual must receive counseling informing them that for the period in which the individual is enrolled in the group health benefit plan:
(A) the individual shall be limited to the health benefits coverage provided under the health benefit plan in which the individual is enrolled;
(B) the individual may not receive any benefits or services under the medical assistance program other than the premium payment as provided by Subsection (f-1);
(C) the individual shall pay the difference between the required premiums and the premium payment as provided by Subsection (f-1) and shall also pay all deductibles, copayments, coinsurance, and other cost-sharing obligations imposed on the individual under the group health benefit plan; and
(D) the individual may, at the individual's option through procedures developed by the commission, resume receiving benefits and services under the medical assistance program instead of the group health benefit plan; and
(2) the individual must sign and the commission shall retain a copy of a waiver indicating the individual has provided informed consent.
(p) The executive commissioner shall adopt rules as necessary to implement this section.
Added by Acts 2001, 77th Leg., ch. 1165, Sec. 2, eff. Aug. 31, 2001. Amended by Acts 2003, 78th Leg., ch. 198, Sec. 2.07(b), eff. Sept. 1, 2003.
Amended by:
Acts 2005, 79th Leg., Ch. 728 (H.B. 2018), Sec. 11.129, eff. September 1, 2005.
Acts 2005, 79th Leg., Ch. 728 (H.B. 2018), Sec. 11.130, eff. September 1, 2005.
Acts 2007, 80th Leg., R.S., Ch. 268 (S.B. 10), Sec. 18, eff. September 1, 2007.
Acts 2015, 84th Leg., R.S., Ch. 1 (S.B. 219), Sec. 4.117, eff. April 2, 2015.
Acts 2015, 84th Leg., R.S., Ch. 945 (S.B. 207), Sec. 13(2), eff. September 1, 2015.
Section: Previous 32.038 32.0381 32.039 32.0391 32.040 32.042 32.0421 32.0422 32.0423 32.0424 32.04242 32.0425 32.043 32.044 32.045 NextLast modified: September 28, 2016