5. Individuals enrolled in more than one health insurance plan can only receive a premium reimbursement for one plan. (See example below)

B. Access to Employer Sponsored Insurance

1. When the individual has access to a qualified employer-sponsored health plan, request verification to determine if the plan meets the criteria of a qualified plan (348-3 ).

· An individual may have access even if there is a waiting period before coverage becomes effective.

2. If the employer does not offer a qualified employer-sponsored health plan, the individual is not required to enroll.

3. If an individual has access to enroll as a dependent in their spouse’s qualified employer-sponsored health plan, the individual can choose to enroll in that plan if both are eligible for Adult Expansion.

· If the policyholder loses eligibility for Adult Expansion, the spouse will no longer be eligible to receive the ESI reimbursement.

4. If both spouses have access to enroll in their own qualified ESI, and both are eligible for Adult Expansion Medicaid, they can choose to enroll in their own qualified employer-sponsored health plan, or their spouse’s.

Example: Bill and Gina are both employed and have access to an employer sponsored qualified health plan.

Option 1: Bill and Gina decide to each enroll with their employer’s plans. The ESI reimbursement is for the “employee only” cost of each plan.

Option 2: Bill and Gina decide to enroll in a qualified “employee + spouse” plan with Gina’s employer. An ESI reimbursement for the “employee + spouse” cost of Gina’s plan is issued.

Option 3: Bill and Gina each decide to enroll in their employer’s “employee + spouse” plan. They can choose to either have one “employee + spouse” plan reimbursed, or they can choose to have the “employee only” cost of each plan reimbursed.

· If they enroll in the same plan and the policyholder loses their qualified employer-sponsored health plan or loses their eligibility under Adult Expansion, premium reimbursement will end for both individuals.

C. Qualified Health Plan

An ESI “Qualified Health Plan" is the term applied to any health plan that meets the minimum essential coverage requirements which include the following:

1. The plan covers physician visits, inpatient and outpatient hospital care, prescription drug coverage, laboratory services, preventive and wellness services, pregnancy and childbirth.

2. The network deductible is $4000 or less per person.

· This does not include the annual deductible amount that must be met before the health plan begins to pay for covered medical benefits.

3. The plan pays at least 70% of an in network inpatient stay (after deductible).

4. The plan does not cover abortion services; OR the plan only covers abortion services in the case where life of the mother would be endangered if the fetus were carried to term or in the case of incest or rape.

5. For employer-sponsored health plans only - the employer pays at least 50% of the premium for the policy holder.

6. The lifetime maximum benefit is at least $1,000,000, or the plan has no maximum.

Other Definitions

Some employers may offer one or both of the following options as part of their benefits. These are not part of the employee's cost for health insurance premiums. (See 348-3 )

· HSA- Health Savings Account: An account that allows an individual to set aside pre-tax funds for qualified medical expenses in combination with an HDHP (High Deductible Health Plan). The individual and employer contribute funds that can accumulate from year to year.

· FSA- Flexible Spending Account: An account that allows an individual to set aside a limited amount of pre-tax funds through payroll deductions to pay qualified medical expenses. The funds must be used in the plan year.