016.20.18 Ark. Code R. 004

Current through Register Vol. 49, No. 10, October, 2024

Rule 016.20.18-004 - Exceptions to the 90 day waiting period for ARKids-B applicants with additional health insurance coverage.

F-180 Other Health Insurance Coverage

MS Manual 09/01/18

For most eligibility groups, an individual may be covered by other health insurance without affecting his or her eligibility for Medicaid. There are two exceptions to this which are described below.

Adult Expansion Group

An individual who is eligible for or enrolled in Medicare is not eligible for the Adult Expansion Group.

ARKids B

Children who have health insurance or who have been covered by health insurance other than Medicaid in the 90 days preceding the date of application will not be eligible for ARKids B unless one of the following conditions is met:

a. The premium paid by the family for coverage of the child under the group health plan exceeded 5 percent of household income.

*t NOTE: A group health plan means an employee welfare benefit plan that provides medical care to employees or their dependents directly or through insurance, reimbursement, or otherwise.

b. The child's parent is determined eligible for advance payment of the premium tax credit for enrollment in a Qualified Health Plan (QHP) through the Exchange because the Employer-Sponsored Insurance (ESI) in which the family was enrolled is determined unaffordable in accordance with 26 CFR 1.36B-2(c)(3)(v).

c. The cost of family coverage that includes the child exceeds 9.5 percent of the household income.

d. The employer stopped offering coverage of dependents (or any coverage) under an employer-sponsored health insurance plan.

e. A change in employment, including involuntary separation, resulted in the child's loss of employer-sponsored insurance (other than through full payment of the premium by the parent under COBRA).

f. The child has special health care needs. Special health care needs are defined as the health care and related needs of children who have chronic physical, developmental, behavioral or emotional conditions. Such needs are of a type or amount beyond that required by children generally

g. The child lost coverage due to the death or divorce of a parent.

h. Health insurance coverage is available to a child through a person other than the child's custodial adult and is determined to be inaccessible (e.g., the absent parent lives out of state and covers the child on his or her HMO, which the child cannot access due to distance). This determination will be made on a case-by-case basis by the caseworker based on information provided by the applicant.

If a parent or guardian voluntarily terminates insurance within the 90 days preceding application for a reason other than those listed above, the children will not be eligible for ARKids B.

The applicant's declaration regarding the child's health insurance coverage will be accepted.

This is a special requirement for ARKids B only and does not apply to ARKids A or other Medicaid categories.

016.20.18 Ark. Code R. 004

8/22/2018