42 U.S.C. § 1396e : US Code - Section 1396E: Enrollment of individuals under group health plans

Search 42 U.S.C. § 1396e : US Code - Section 1396E: Enrollment of individuals under group health plans

(a) Requirements of each State plan; guidelines
Each State plan -
(1) may implement guidelines established by the Secretary,
consistent with subsection (b) of this section, to identify those
cases in which enrollment of an individual otherwise entitled to
medical assistance under this subchapter in a group health plan
(in which the individual is otherwise eligible to be enrolled) is
cost-effective (as defined in subsection (e)(2) of this section);
(2) may require, in case of an individual so identified and as
a condition of the individual being or remaining eligible for
medical assistance under this subchapter and subject to
subsection (b)(2) of this section, notwithstanding any other
provision of this subchapter, that the individual (or in the case
of a child, the child's parent) apply for enrollment in the group
health plan; and
(3) in the case of such enrollment (except as provided in
subsection (c)(1)(B) of this section), shall provide for payment
of all enrollee premiums for such enrollment and all deductibles,
coinsurance, and other cost-sharing obligations for items and
services otherwise covered under the State plan under this
subchapter (exceeding the amount otherwise permitted under
section 1396o of this title), and shall treat coverage under the
group health plan as a third party liability (under section
1396a(a)(25) of this title).
(b) Timing of enrollment; failure to enroll
(1) In establishing guidelines under subsection (a)(1) of this
section, the Secretary shall take into account that an individual
may only be eligible to enroll in group health plans at limited
times and only if other individuals (not entitled to medical
assistance under the plan) are also enrolled in the plan
simultaneously.
(2) If a parent of a child fails to enroll the child in a group
health plan in accordance with subsection (a)(2) of this section,
such failure shall not affect the child's eligibility for benefits
under this subchapter.
(c) Premiums considered payments for medical assistance;
eligibility
(1)(A) In the case of payments of premiums, deductibles,
coinsurance, and other cost-sharing obligations under this section
shall be considered, for purposes of section 1396b(a) of this
title, to be payments for medical assistance.
(B) If all members of a family are not eligible for medical
assistance under this subchapter and enrollment of the members so
eligible in a group health plan is not possible without also
enrolling members not so eligible -
(i) payment of premiums for enrollment of such other members
shall be treated as payments for medical assistance for eligible
individuals, if it would be cost-effective (taking into account
payment of all such premiums), but
(ii) payment of deductibles, coinsurance, and other cost-
sharing obligations for such other members shall not be treated
as payments for medical assistance for eligible individuals.
(2) The fact that an individual is enrolled in a group health
plan under this section shall not change the individual's
eligibility for benefits under the State plan, except insofar as
section 1396a(a)(25) of this title provides that payment for such
benefits shall first be made by such plan.
(d) Repealed. Pub. L. 105-33, title IV, Sec. 4741(b)(2), Aug. 5,
1997, 111 Stat. 523
(e) Definitions
In this section:
(1) The term "group health plan" has the meaning given such
term in section 5000(b)(1) of the Internal Revenue Code of 1986,
and includes the provision of continuation coverage by such a
plan pursuant to title XXII of the Public Health Service Act [42
U.S.C. 300bb-1 et seq.], section 4980B of the Internal Revenue
Code of 1986, or title VI (!1) of the Employee Retirement Income
Security Act of 1974.
(2) The term "cost-effective" means, as established by the
Secretary, that the reduction in expenditures under this
subchapter with respect to an individual who is enrolled in a
group health plan is likely to be greater than the additional
expenditures for premiums and cost-sharing required under this
section with respect to such enrollment.