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§ 40-8.4-12 - RIte Share Health Insurance Premium Assistance Program.

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SECTION 40-8.4-12 § 40-8.4-12RIte Share Health InsurancePremium Assistance Program. – (a) Basic RIte Share Health Insurance Premium Assistance Program. Thedepartment of human services is authorized and directed to amend the medicalassistance Title XIX state plan to implement the provisions of § 1906 ofTitle XIX of the Social Security Act, 42 U.S.C. § 1396e, and establish theRhode Island health insurance premium assistance program for RIte Care eligibleparents with incomes up to one hundred seventy-five percent (175%) of thefederal poverty level who have access to employer-based health insurance. Thestate plan amendment shall require eligible individuals with access toemployer-based health insurance to enroll themselves and/or their family in theemployer-based health insurance plan as a condition of participation in theRIte Share program under this chapter and as a condition of retainingeligibility for medical assistance under chapters 5.1 and 8.4 of this titleand/or chapter 12.3 of title 42 and/or premium assistance under this chapter,provided that doing so meets the criteria established in § 1906 of TitleXIX for obtaining federal matching funds and the department has determined thatthe individual's and/or the family's enrollment in the employer-based healthinsurance plan is cost-effective and the department has determined that theemployer-based health insurance plan meets the criteria set forth in subsection(d). The department shall provide premium assistance by paying all or a portionof the employee's cost for covering the eligible individual or his or herfamily under the employer-based health insurance plan, subject to the costsharing provisions in subsection (b), and provided that the premium assistanceis cost-effective in accordance with Title XIX, 42 U.S.C. § 1396 et seq. (b) Individuals who can afford it shall share in thecost. The department of human services is authorized and directed to applyfor and obtain any necessary waivers from the secretary of the United StatesDepartment of Health and Human Services, including, but not limited to, awaiver of the appropriate sections of Title XIX, 42 U.S.C. § 1396 et seq.,to require that individuals eligible for RIte Care under this chapter orchapter 12.3 of title 42 with incomes equal to or greater than one hundredfifty percent (150%) of the federal poverty level pay a share of the costs ofhealth insurance based on the individual's ability to pay, provided that thecost sharing shall not exceed five percent (5%) of the individual's annualincome. The department of human services shall implement the cost-sharing byregulation, and shall consider co-payments, premium shares or other reasonablemeans to do so. (c) Current RIte Care enrollees with access toemployer-based health insurance. The department of human services shallrequire any individual who receives RIte Care or whose family receives RIteCare on the effective date of the applicable regulations adopted in accordancewith subsection (f) to enroll in an employer-based health insurance plan at theindividual's eligibility redetermination date or at an earlier date determinedby the department, provided that doing so meets the criteria established in theapplicable sections of Title XIX, 42 U.S.C. § 1396 et seq., for obtainingfederal matching funds and the department has determined that the individual'sand/or the family's enrollment in the employer-based health insurance plan iscost-effective and has determined that the health insurance plan meets thecriteria in subsection (d). The insurer shall accept the enrollment of theindividual and/or the family in the employer-based health insurance planwithout regard to any enrollment season restrictions. (d) Approval of health insurance plans for premiumassistance. The department of human services shall adopt regulationsproviding for the approval of employer-based health insurance plans for premiumassistance and shall approve employer-based health insurance plans based onthese regulations. In order for an employer-based health insurance plan to gainapproval, the department must determine that the benefits offered by theemployer-based health insurance plan are substantially similar in amount,scope, and duration to the benefits provided to RIte Care eligible persons bythe RIte Care program, when the plan is evaluated in conjunction with availablesupplemental benefits provided by the department. The department shall obtainand make available to persons otherwise eligible for RIte Care as supplementalbenefits those benefits not reasonably available under employer-based healthinsurance plans which are required for RIte Care eligible persons by state lawor federal law or regulation. (e) Maximization of federal contribution. Thedepartment of human services is authorized and directed to apply for and obtainfederal approvals and waivers necessary to maximize the federal contributionfor provision of medical assistance coverage under this section, including theauthorization to amend the Title XXI state plan and to obtain any waiversnecessary to reduce barriers to provide premium assistance to recipients asprovided for in Title XXI of the Social Security Act, 42 U.S.C. § 1397 etseq. (f) Implementation by regulation. The department ofhuman services is authorized and directed to adopt regulations to ensure theestablishment and implementation of the premium assistance program inaccordance with the intent and purpose of this section, the requirements ofTitle XIX, Title XXI and any approved federal waivers.
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  • SECTION 40-8.4-12

       § 40-8.4-12  RIte Share Health InsurancePremium Assistance Program. – (a) Basic RIte Share Health Insurance Premium Assistance Program. Thedepartment of human services is authorized and directed to amend the medicalassistance Title XIX state plan to implement the provisions of § 1906 ofTitle XIX of the Social Security Act, 42 U.S.C. § 1396e, and establish theRhode Island health insurance premium assistance program for RIte Care eligibleparents with incomes up to one hundred seventy-five percent (175%) of thefederal poverty level who have access to employer-based health insurance. Thestate plan amendment shall require eligible individuals with access toemployer-based health insurance to enroll themselves and/or their family in theemployer-based health insurance plan as a condition of participation in theRIte Share program under this chapter and as a condition of retainingeligibility for medical assistance under chapters 5.1 and 8.4 of this titleand/or chapter 12.3 of title 42 and/or premium assistance under this chapter,provided that doing so meets the criteria established in § 1906 of TitleXIX for obtaining federal matching funds and the department has determined thatthe individual's and/or the family's enrollment in the employer-based healthinsurance plan is cost-effective and the department has determined that theemployer-based health insurance plan meets the criteria set forth in subsection(d). The department shall provide premium assistance by paying all or a portionof the employee's cost for covering the eligible individual or his or herfamily under the employer-based health insurance plan, subject to the costsharing provisions in subsection (b), and provided that the premium assistanceis cost-effective in accordance with Title XIX, 42 U.S.C. § 1396 et seq.

       (b) Individuals who can afford it shall share in thecost. The department of human services is authorized and directed to applyfor and obtain any necessary waivers from the secretary of the United StatesDepartment of Health and Human Services, including, but not limited to, awaiver of the appropriate sections of Title XIX, 42 U.S.C. § 1396 et seq.,to require that individuals eligible for RIte Care under this chapter orchapter 12.3 of title 42 with incomes equal to or greater than one hundredfifty percent (150%) of the federal poverty level pay a share of the costs ofhealth insurance based on the individual's ability to pay, provided that thecost sharing shall not exceed five percent (5%) of the individual's annualincome. The department of human services shall implement the cost-sharing byregulation, and shall consider co-payments, premium shares or other reasonablemeans to do so.

       (c) Current RIte Care enrollees with access toemployer-based health insurance. The department of human services shallrequire any individual who receives RIte Care or whose family receives RIteCare on the effective date of the applicable regulations adopted in accordancewith subsection (f) to enroll in an employer-based health insurance plan at theindividual's eligibility redetermination date or at an earlier date determinedby the department, provided that doing so meets the criteria established in theapplicable sections of Title XIX, 42 U.S.C. § 1396 et seq., for obtainingfederal matching funds and the department has determined that the individual'sand/or the family's enrollment in the employer-based health insurance plan iscost-effective and has determined that the health insurance plan meets thecriteria in subsection (d). The insurer shall accept the enrollment of theindividual and/or the family in the employer-based health insurance planwithout regard to any enrollment season restrictions.

       (d) Approval of health insurance plans for premiumassistance. The department of human services shall adopt regulationsproviding for the approval of employer-based health insurance plans for premiumassistance and shall approve employer-based health insurance plans based onthese regulations. In order for an employer-based health insurance plan to gainapproval, the department must determine that the benefits offered by theemployer-based health insurance plan are substantially similar in amount,scope, and duration to the benefits provided to RIte Care eligible persons bythe RIte Care program, when the plan is evaluated in conjunction with availablesupplemental benefits provided by the department. The department shall obtainand make available to persons otherwise eligible for RIte Care as supplementalbenefits those benefits not reasonably available under employer-based healthinsurance plans which are required for RIte Care eligible persons by state lawor federal law or regulation.

       (e) Maximization of federal contribution. Thedepartment of human services is authorized and directed to apply for and obtainfederal approvals and waivers necessary to maximize the federal contributionfor provision of medical assistance coverage under this section, including theauthorization to amend the Title XXI state plan and to obtain any waiversnecessary to reduce barriers to provide premium assistance to recipients asprovided for in Title XXI of the Social Security Act, 42 U.S.C. § 1397 etseq.

       (f) Implementation by regulation. The department ofhuman services is authorized and directed to adopt regulations to ensure theestablishment and implementation of the premium assistance program inaccordance with the intent and purpose of this section, the requirements ofTitle XIX, Title XXI and any approved federal waivers.

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