Revision 11-3; Effective September 1, 2011

 

As a condition of an applicant's/recipient's eligibility for Medicaid Buy-In for Children (MBIC), a parent living in the same household as the applicant/recipient must apply for, enroll in and pay any required premiums for employer-sponsored health insurance (ESI) if:

  • the parent is actively employed, and
  • the parent's employer offers ESI that meets the following criteria:
    • the ESI is a group health plan that covers the applicant/recipient, and
    • the employer contributes at least 50 percent of the total cost of annual premiums.

 

N-5100 ESI Chart

Revision 11-3; Effective September 1, 2011

 

The following chart outlines the eligibility treatment for various situations involving ESI:

 

If Then
A parent living in the same household as the applicant/recipient has a job that offers ESI that meets the criteria but (1) the parent is not enrolled in the ESI and (2) there is a future open enrollment period during which the parent can enroll. Certify an applicant for MBIC if all other eligibility criteria are met. On the ESI Details screen, use "Is there an open enrollment period?" and "open enrollment start date" fields to monitor.
A parent living in the same household as the applicant/recipient has a job that offers ESI that meets the criteria but (1) the parent is not enrolled in the ESI and (2) enrollment is available to the parent at the time of application. Do not certify the applicant for MBIC until the parent's enrollment in ESI is verified.
A parent living in the same household as the applicant/recipient has only unearned income (such as retirement or pension) or self-employment income. ESI is not an eligibility requirement.
A parent not living in the same household as the applicant/recipient has health insurance that covers the applicant or recipient. Example: A father living outside the household that is legally required to carry insurance on the applicant/recipient. Consider that parent's insurance as a third-party resource (TPR). Follow regular Medicaid for the Elderly and People with Disabilities (MEPD) policy for TPR.
A parent living in the same household as the applicant/recipient has ESI that meets the criteria and a parent not living in the same household as the applicant/recipient has health insurance that covers the applicant or recipient. The parent living in the same household as the applicant/recipient still must apply for, enroll in and pay any required premiums for the ESI. Follow regular MEPD policy for TPR for the other parent's insurance.
An applicant or recipient works and has employer-sponsored health insurance. Consider the applicant's/recipient's health insurance as TPR. Follow regular MEPD policy for TPR.
A parent living in the same household as the applicant/recipient has begun the enrollment process for ESI, but the employer needs more time to complete the enrollment. Verify the approximate date of the enrollment decision and certify the applicant for MBIC if all other eligibility criteria are met. On the ESI Details screen, use the "Decision enrollment pending" and "potential insurance follow up date" fields to monitor.
A parent living in the same household as the applicant/recipient voluntarily withdraws from ESI after enrollment. Deny or terminate the applicant/recipient following regular MEPD policy. Client statement is acceptable verification for voluntary withdrawal from ESI