Maine § 18. - Private Health Insurance Premium Program

§ 18.. Private Health Insurance Premium Program

1.  Program.  The Private Health Insurance Premium Program is operated by the Office of MaineCare Services within the department and implements the provisions of 42 United States Code, Section 1396a(a)(25)(G) and 1396e. The office shall seek to maximize enrollment in the program by establishing procedures to identify families or individuals with access to other public or private insurance coverage and educating members and employers about the purpose and benefits of the program.

2.  Condition for eligibility.  The department shall require, as a condition of being or remaining eligible for medical assistance, an individual otherwise entitled to medical assistance under this Title to apply for enrollment in a group health plan in which the individual is otherwise eligible to be enrolled, if the department determines that enrollment is cost-effective. For purposes of this section, the term "cost-effective" means that the reduction in medical assistance expenditures as a result of the individual's enrollment in a group health plan is likely to be greater than the additional expenditures by the department for premiums and cost-sharing with respect to that enrollment.

3.  Payments covered.  If the individual enrolls in a group health plan or is accepted for coverage under an individual health insurance policy pursuant to the department's approval under the Private Health Insurance Premium Program, except as provided in subsection 5, the department shall provide for payments of all premiums, deductibles, coinsurance and other cost-sharing obligations for items and services otherwise covered under the department's medical assistance program and shall treat coverage under the group health plan or the individual health insurance policy as a 3rd-party liability under section 14.

4.  Family enrollment in employer plan.  The department shall require, as a condition of being or remaining eligible for medical assistance, an individual who is a parent, is eligible for medical assistance under this Title and is eligible for family health coverage through an employer, to apply for enrollment for each eligible child. If the employed parent refuses to apply for such enrollment, the employer shall accept an application for enrollment of children, if otherwise eligible for family health coverage, submitted by the other parent or by the department. The employer shall enroll children in the employer plan without regard to any enrollment season restrictions.

5.  Cost-effective enrollment.  If some members of a family are not eligible for medical assistance under this Title and enrollment of the family members who are eligible for medical assistance is not possible without also enrolling the members who are not eligible for medical assistance, the department shall provide for payment of enrollment premiums for all family members if, taking into account payment of all such premiums, the enrollment is cost-effective.