(1) "Group health plan" means any plan of an employer or any plan to which an employer contributes including a self-insured plan to provide health care, directly or otherwise, to the employer's employees, former employees, or the families of such employees, or former employees.

(2) "Individual health plan" means any plan to provide health care to an individual and/or his family which is not a plan of the individuals's employer or to which the individual's employer contributes.

(3) "Cost effective" means the amount paid for premiums, coinsurance, deductibles, and other cost sharing obligations under an individual or group health plan plus the additional departmental administrative costs is likely to be less than the department would pay out for Medicaid services for a Medicaid recipient, determined on an actuarial basis.

(a) Cost effective criteria may include assessment of medical diagnoses and health risk assessment.

(4) Payment of individual or group health premiums is a Medicaid benefit.

(5) The Department of Public Health and Human Services may pay premiums of an individual or group health plan which provides benefits not covered by Medicaid as long as it has determined that payment of the premiums will be cost effective.

(6) Coinsurance and deductibles will be paid for services covered by a health plan when these same services are provided by Medicaid. Payment amounts cannot exceed the reimbursement schedule set by Medicaid.

(a) Coinsurance and deductibles will not be paid for non-Medicaid eligible persons who are covered by the health plan.

(b) Coinsurance and deductibles will not be paid for persons who are eligible for Medicaid as COBRA continuation beneficiaries, as defined in ARM 46.12.3215.

(7) Payment of premiums may be made for a retroactive period up to three months if necessary to insure enrollment or continuation of enrollment.

(8) Payment of premiums may be in the form of direct payments to insurance companies or employers offering the health plan or direct reimbursement to the recipient or insured.

(9) Premiums for non-Medicaid recipients may be paid only if it is a condition of the enrollee's eligibility in the health plan to enroll family members, and if premium payments are cost effective.

(a) Ineligible family members may reside in a separate household.

(10) Medicaid payment of health plan premiums may begin as of the Medicaid eligibility effective date for:

(a) applicants who are already enrolled in a health plan; and

(b) applicants who have a waiting period before health plan coverage begins.

(i) Full Medicaid coverage is available to applicants during the waiting period.

(11) Health plans are treated as a third party resource in accordance with ARM 37.85.407.

History: 53-2-201, 53-6-111, 53-6-113, MCA; IMP, 53-6-101, 53-6-103, 53-6-131, MCA; NEW, 1991 MAR p. 1021, Eff. 6/28/91; TRANS, from SRS, 2000 MAR p. 476.