42 U.S.C. § 1396e — Enrollment of individuals under group health plans

(a) Requirements of each State^* plan; guidelines. (1) A State plan may use guidelines established by the Secretary^*, consistent with subsection (b), to identify when enrolling a person^* who is otherwise entitled to Medicaid in an eligible group health plan^* would be “cost-effective.” This section does not define the quoted term; subsection (e)(2) points to its definition elsewhere. (2) For a person identified under paragraph (1), and as a condition of eligibility or continued eligibility for Medicaid, the State may require the person—or the child’s parent^*, if the person is a child—to apply for enrollment in the group plan, subject to subsection (b)(2) and despite other provisions of this subchapter. (3) If the person enrolls, the State plan must pay all premiums and all deductibles, coinsurance, and other cost-sharing^* for items and services otherwise covered by Medicaid, except as subsection (c)(1)(B) provides. The State must treat the group plan as third-party liability under section 1396a(a)(25).

(b) Timing of enrollment; failure to enroll. (1) When creating its guidelines, the Secretary must account for the fact that group plans may allow enrollment only at limited times and only when other people who are not entitled to Medicaid enroll at the same time. (2) If a child’s parent does not enroll the child as required, that failure does not affect the child’s Medicaid eligibility.

(c) Premiums considered payments for medical assistance^*; eligibility. (1)(A) For section 1396b(a), premiums, deductibles, coinsurance, and other cost-sharing paid under this section count as payments for medical assistance. (B) If not every family member qualifies for Medicaid and the eligible members cannot enroll in the group plan without enrolling the ineligible members too, premiums for the ineligible members count as medical-assistance payments for the eligible members if paying all the premiums would be cost-effective. Their deductibles, coinsurance, and other cost sharing do not count that way. (2) Enrollment in a group plan under this section does not change the person’s Medicaid eligibility. It only means that, under section 1396a(a)(25), the group plan pays covered benefits first.

(d) Repealed. This subsection was repealed by the cited 1997 law.

(e) Definitions. (1) “Group health plan” has the meaning given in section 5000(b)(1) of the Internal Revenue Code of 1986. It also includes continuation coverage under title XXII of the Public Health Service Act, section 4980B of that Code, or title VI of ERISA. (2) “Cost-effective” has the meaning given in section 1397ee(c)(3)(A) of this title. This section does not define that quoted term itself.