UIPL 28-84 Attachment
Voluntary Health Insurance Programs for
Individuals Receiving Unemployment Compensation
Introduction. - Past efforts to address the problems of unemployed individuals left a major gap in the area of health insurance coverage. For the unemployed individual who confronts possible illness or injury while not covered by health insurance, the anxieties are considerable. Besides possible loss of entitlement to an employer plan, the unemployed individual is usually ineligible for Medicaid and unable to afford the high cost of purchasing individual health insurance coverage. Such individuals are in jeopardy of incurring large medical debts without interim health insurance coverage.
To mitigate this problem, Section 523 of Public Law 98-21 permits a State, on a voluntary basis, to establish a health insurance program for individuals who are eligible for unemployment compensation for weeks of unemployment beginning on or after April 20, 1983, and who elect to have an amount deducted from their weekly unemployment benefits to pay the premium for coverage under such program.
Definitions.
"Act" means section 523 of Social Security Amendments of 1983, approved April 20, 1983.
"ETA" means the Employment and Training Administration, U.S. Department of Labor.
"Health insurance benefit plan" means a plan of health care benefits to be provided to recipients of unemployment compensation and their families, if such plan is approved by the Secretary of Labor.
"Health insurance program" means an individual State's program which includes a health insurance benefit plan and system for administering the program, if such program is approved by the Secretary of Labor.
"Insurance carrier" means the insurance company or other carrier which provides the benefits under the health insurance benefit plan.
"Member" means a recipient of unemployment compensation who is eligible for and elects coverage under a health insurance benefit plan.
"Premium" means the portion of unemployment benefits designated by the member to be deducted to pay for coverage under a health insurance benefit plan.
"Secretary" means the Secretary of Labor of the United States.
"Assistant Secretary" means the Assistant Secretary of Labor for Employment and Training.
"SESA" means the State Employment Security Agency of a State which administers the State law.
"State" means the States of the United States, the District of Columbia, the Commonwealth of Puerto Rico, and the U.S. Virgin Islands.
"State law" means the unemployment compensation law of a State approved by the Secretary under Section 3304(a) of the Internal Revenue Code of 1954 (26 U.S.C. 3304(a)).
"Unemployment compensation" means the unemployment compensation payable under the State law and any Federal unemployment compensation law administered by the SESA. It also means assistance or an allowance payable with respect to unemployment under any other Federal law administered by the SESA.
Criteria for Approving a Health Insurance Program. Each State may establish a health insurance program for recipients of unemployment compensation. However, in accordance with Secretary's Order 4-75, the Assistant Secretary for Employment and Training is delegated the responsibility for approving this program.
To be approved by the Assistant Secretary of Labor, the program must include a health insurance benefitplan and a system for administering the program as follows:
Health Insurance Benefit Plan. The State will determine the terms and conditions of the health care benefits under the health insurance benefit plan. The State may contract with a commercial or nonprofit insurance carrier to provide the benefits under the health insurance benefit plan or the State (other than the SESA) may be the insurance carrier.
Administration. The system for administering the health insurance program must include methods and procedures to ensure that the program is described and offered to all claimants who are eligible for coverage as determined by the SESA.
Approval of a Health Insurance Plan. Section 523 requires that a State's health insurance program be approved by the Secretary of Labor. In accordance with Secretary's Order 4-75, the authority to approve a State program is delegated to the Assistant Secretary for Employment and Training who has the authority to further delegate such responsibility. All States which choose to establish a health insurance program must submit a copy of their proposed health insurance benefit plan and administration to the Assistant Secretary. Such programs should be sent to the National Office, Attn: TEUMI, via the Regional Office. The States' plan requests will be processed for the Assistant Secretary's review and decision.
Guidelines for Administering a Health Insurance Program. The following guidelines are provided to assist a SESA to administer a health insurance program.
Notification to Claimants. The State's health insurance program should be made available to all claimants for unemployment compensation under any State or Federal law administered by the SESA (excluding those Federal laws or programs which provide health insurance coverage) who are eligible for coverage as determined by the State. Such eligible claimants may include:
Each claimant in continued claim status at the start of the State's health insurance program;
Each claimant filing a new, additional or reopened claim after the start of the State's health insurance program; and
Any active claimant who may later elect to participate if the State's health insurance program permits entry into the plan at any time during the claims series.
In notifying eligible claimants of the State's health insurance program, the SESA should provide informational material on the program, including an explanation of the benefits under the health insurance benefit plan and the amount to be deducted from weekly unemployment benefits to pay the premium for coverage under the program.
The informational material should contain sufficient facts to enable claimants to make a choice on participation and an Election to Participate form (Exhibit A). The material may be given to claimants in person, or may be mailed to those who file by mail, but in either event it should be furnished at the earliest opportunity.
Interstate Claimants. To the extent feasible, if the liable State has a health insurance program,the claimant filing in the agent State should be given the opportunity to elect participation in the liable State's program. The liable State may wish to send the claimant the informational material and Election to Participate form (Exhibit A) at the same time the monetary determination notice is mailed. The claimant would mail the form back to the liable State. The Handbook for Interstate Claimstaking, in Section A, Special Provisions, will show if a health insurance program is available in the liable State.
Election to Participate. When the claimant returns the Election to Participate form (Exhibit A), the SESA should do the following:
If the claimant elects not to participate, file the Election to Participate form (Exhibit A) in the appropriate SESA record.
If the claimant elects to participate, determine the claimant's eligibility to participate in the health insurance program as follows:
(1) Eligible for unemployment compensation. If the claimant is eligible for unemployment compensation andno disqualification applies, process the Election to Participate form (Exhibit A) as an authorization to deduct health insurance premiums from weekly unemployment benefits.
(2) Not eligible for unemployment compensation. If the claimant is ineligible for unemployment compensation or is disqualified, notify the claimant, if possible, on the same nonmonetary determination which assesses such ineligibility or disqualification by adding a statement such as:
"By reason of this determination you are not eligible to participate in the health insuranceprogram; therefore, we will take no action on your request to participate in this program."
File the Election to Participate form (Exhibit A) in the appropriate SESA record.
Termination of Coverage.
a. Upon Nonmonetary Ineligibility. A claimant is no longer eligible to participate in the health insurance program when he/she becomes ineligible or disqualified for unemployment compensation. Inthe event of ineligibility or disqualification, the SESA should notify the claimant of termination of health insurance coverage by Termination of Coverage form (Exhibit B).
b. Upon Exhaustion of Unemployment Compensation. At the time of the claimant's last unemployment compensation check for a benefit year (including any extended and supplemental benefits available), the SESA should notify the claimant by Termination of Coverage form (Exhibit B) that his/her health insurance coverage is terminated because of exhaustion of unemployment compensation.
c. Upon Claimant Request. A State may allow a claimant to voluntarily terminate participation in the health insurance program at specified times or at any time. If a claimant elects to terminate participation in the health insurance program:
(1) The claimant should complete and sign a Request for Termination form (Exhibit C);
(2) The SESA should process the Request for Termination form (Exhibit C) to ensure that no deductions for health insurance premiums are made for any weeks beginning after the effective date of the termination; and
(3) The SESA should notify the claimant of termination of health insurance coverage by Termination of Coverage form (Exhibit B).
Deduction from Weekly Unemployment Benefits. The SESA should deduct the amount of premium authorized by the claimant from weekly unemployment benefits payable after the election to participate in the health insurance program. In addition, the SESA shall maintain such accounting records as will enable it to identify the amount and date of all premium deductions for each claimant.
Transmitting the Amounts Deducted as Health Insurance Premiums. At intervals prescribed in the State's health insurance program, the SESA should transmit the amounts deducted as premiums from weekly unemployment benefits to the insurance carrier. These amounts should be transmitted with such records as may be required by the health insurance program.
Overpayments. If an overpayment of unemployment benefits is made for a week with respect to which a health insurance premium was deducted, the SESA shall establish the overpayment for the entire weekly benefit amount payable before the deduction, and shall process the overpayment in accordance with regular State overpayment procedures. In addition, the SESA should notify the insurance carrier of the overpayment and should furnish the carrier a copy of the notice of overpayment issued to the claimant. If any action is required with regard to health insurance coverage or payment of medical claims for an illness or injury that occurred during the period overpaid, such action will be the responsibility of the insurance carrier.
Validation. The SESA should review annually a random sample of claim records in which deductions for health insurance premiums were made to ensure the validity of the methods and procedures used in administering the health insurance program.
HEALTH INSURANCE PROGRAM
ELECTION TO PARTICIPATE
_____________
______________
Claimant's Name
Social Security No.
I HEREBY ACKNOWLEDGE that I have been furnished information regarding the _____(name)_____ health insurance program, that I understand the options that are available to me, and that I freely make the following decision with regard to participation in the health insurance program.
___ I elect to participate in the health insurance program. I choose Option ___ I know that if I am found eligible to participate, __(amount)__ will be deducted from my weekly unemployment benefits to pay the premium for coverage under the health insurance program.
___ I do NOT elect to participate in the health insurance program.
______________
_______
Claimant Signature
Date
_________________
_______
Agency Representative
Date
HEALTH INSURANCE PROGRAM
TERMINATION OF COVERAGE
______________
______________
Claimant's Name
Social Security No.
Your coverage under the __(name)__ health insurance program is
terminated ___(effective date)___ because:
___ You have exhausted all entitlement to unemployment compensation.
___ You are ineligible or disqualified for unemployment compensation.
___ You requested that your participation be terminated.
__________________
_____
Agency Representative
Date
HEALTH INSURANCE PROGRAM
REQUEST FOR TERMINATION
_____________
_______________
Claimant's Name
Social Security No.
I HEREBY GIVE NOTICE OF TERMINATION of my participation in the (name)
health insurance program. This termination is to be effective (date)
.
_______________
______
Claimant's Signature
Date
_________________
______
Agency Representative
Date