Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 20 - ADMINISTRATION OF MEDICAL ASSISTANCE SERVICES › Part IV - Third Party Liability › Section 12VAC30-20-210 - State method on cost effectiveness of qualified employer-sponsored insurance plans

Current through Register Vol. 40, No. 24, July 15, 2024
A. Definitions.
				  The following words and terms when used in this section shall have the
				  following meanings unless the context clearly indicates otherwise:
"Case" means all family members who are eligible for
					 coverage under the qualified employer-sponsored insurance plan and who are
					 eligible for Medicaid.
"Code" means the Code of Virginia.
"Cost effective" and "cost effectiveness" mean the
					 reduction in Title XIX expenditures, which are likely to be greater than the
					 additional expenditures for premiums and cost-sharing items required under
					 § 1906 of the Social Security Act (the Act), with respect to such
					 enrollment.
"DMAS" means the Department of Medical Assistance Services
					 consistent with Chapter 10 (§ 32.1-323 et seq.) of Title 32.1 of the Code
					 of Virginia.
"DSS" means the Department of Social Services consistent
					 with Chapter 1 (§ 63.2-100 et seq.) of Title 63.2 of the Code of
					 Virginia.
"Family member" means an individual in the household, who
					 is not a parent and who is related by blood, marriage, adoption, or legal
					 custody.
"Group health plan" means a plan that meets §
					 5000(b)(1) of the Internal Revenue Code of 1986, and includes continuation
					 coverage pursuant to Title XXII of the Public Health Service Act, § 4980B
					 of the Internal Revenue Code of 1986, or Title VI of the Employee Retirement
					 Income Security Act of 1974. Section 5000(b)(1) of the Internal Revenue Code
					 provides that a group health plan is a plan, including a self-insured plan, of,
					 or contributed to by, an employer (including a self-insured person) or employee
					 association to provide health care (directly or otherwise) to the employees,
					 former employees, or the families of such employees or former employees, or the
					 employer.
"High deductible health plan" means a plan as defined in
					 § 223(c)(2) of Internal Revenue Code of 1986, without regard to whether
					 the plan is purchased in conjunction with a health savings account (as defined
					 under § 223(d) of the Internal Revenue Code of 1986).
"HIPP" means the Health Insurance Premium Payment Program
					 administered by DMAS consistent with § 1906 of the Act.
"Member" means a person who is eligible for Medicaid as
					 determined by DMAS or a DMAS-designated agent, including the Department of
					 Social Services.
"Network provider" means a provider that is enrolled with a
					 DMAS contracted managed care organization (MCO) as a provider and meets the
					 requirement for an expedited enrollment as a fee-for-service (FFS) Medicaid
					 provider for payment and billing purposes.
"Parent" means the biological or adoptive parent, or the
					 biological or adoptive parent and the stepparent, living in the home with the
					 Medicaid-eligible child. The health insurance policyholder shall be a parent as
					 defined in this section.
"Payee" means the insured employee who is the policy holder
					 of the qualified employer-sponsored insurance plan who is paid the HIPP or HIPP
					 for Kids premium and cost-sharing reimbursement.
"Premium" means the fixed cost of participation in the
					 group health plan; such cost may be shared by the employer and employee or paid
					 in full by either party.
"Premium assistance subsidy" means the portion that DMAS
					 will pay of the employee's cost of participating in a qualified
					 employer-sponsored insurance plan to cover the Medicaid eligible members under
					 the employer-sponsored plan if DMAS determines it is cost effective to do
					 so.
"Qualified employer-sponsored insurance" as defined under
					 § 2105(c)(10)(B) of the Social Security Act means a group health plan or
					 health insurance coverage offered through an employer:
1. That qualifies as creditable coverage as a
				  group health plan under § 2701(c)(1) of the Public Health Service
				  Act;
2. For which the employer
				  contribution toward any premium for such coverage is at least 40%;
				  and
3. That is offered to all
				  individuals in a manner that would be considered a nondiscriminatory
				  eligibility classification for purposes of § 105(h)(3)(A)(ii) of the
				  Internal Revenue Code of 1986 without regard to § 105(h)(3)(B)(i).
"State Plan" means the State Plan for Medical Assistance
					 for the Commonwealth of Virginia.