§ 25.5-4-210 — Purchase of health insurance for members

(1) (a) The state
department shall purchase group health insurance for a medical assistance
member who is eligible to enroll for coverage if enrollment of the member in the
group plan would be cost-effective. In addition, the state department may purchase
individual health insurance for a medical assistance member who is eligible to
enroll in a health insurance plan if enrollment of the member would be cost-effective to this state. A determination of cost-effectiveness must be in accordance
with federal guidelines established by the secretary of the federal department of
health and human services.

(b) Notwithstanding any provision of subsection (1)(a) of this section to the
contrary, the state department, in purchasing health insurance for medical
assistance members who are eligible to enroll for private coverage, shall not
purchase health insurance for more than two thousand individuals.

(2) Enrollment in a group health insurance plan is required of members for
whom enrollment has been determined to be cost-effective as a condition of
obtaining or retaining medical assistance. A parent is required to enroll a
dependent child member, but medical assistance for the child is not discontinued if
a parent fails to enroll the child.

(3) The state department shall pay any premium, deductible, coinsurance, or
other cost-sharing obligation required under the group plan for services covered
under the state medical assistance plan. In addition, the state department shall pay
any premium, deductible, coinsurance, or other cost-sharing obligation required
under an individual plan purchased by the state department for a medical
assistance member pursuant to subsection (1) of this section. Payment of the
services is treated as payment for medical assistance. Coverage provided by the
purchased health insurance plan is considered third-party liability for the purposes
of section 25.5-4-209.

(4) Services not available to a member under the purchased plan are
provided to the member if the services would otherwise be provided as medical
assistance services pursuant to this article 4 or article 5 or 6 of this title 25.5.
Nothing in this section requires services provided under a group health insurance
plan for medical assistance to be made available to members not enrolled in the
plan. Enrollment in a group health insurance plan pursuant to this section does not
affect the eligibility of a member who otherwise qualifies for medical assistance
pursuant to this article 4 or article 5 or 6 of this title 25.5.

Legislative History

Source: L. 2006: Entire article added with relocations, p. 1828, � 7, effective July 1. L. 2010: (1) amended, (SB 10-167), ch. 296, p. 1378, � 6, effective May 26. L. 2024: Entire section amended, (SB 24-176), ch. 152, p. 627, � 26, effective August 7.