Title 42
SECTION 457.805
457.805 State plan requirement: Procedures to address substitution under group health plans.
§ 457.805 State plan requirement: Procedures to address substitution under group health plans.(a) State plan requirements. The state plan must include a description of reasonable procedures to ensure that health benefits coverage provided under the State plan does not substitute for coverage provided under group health plans as defined at § 457.10.
(b) Limitations. (1) A state may not, under this section, impose a period of uninsurance which exceeds 90 days from the date a child otherwise eligible for CHIP is disenrolled from coverage under a group health plan.
(2) A waiting period may not be applied to a child following the loss of eligibility for and enrollment in Medicaid or another insurance affordability program.
(3) If a state elects to impose a period of uninsurance following the loss of coverage under a group health plan under this section, such period may not be imposed in the case of any child if:
(i) The premium paid by the family for coverage of the child under the group health plan exceeded 5 percent of household income;
(ii) The child's parent is determined eligible for advance payment of the premium tax credit for enrollment in a QHP through the Exchange because the ESI in which the family was enrolled is determined unaffordable in accordance with 26 CFR 1.36B-2(c)(3)(v).
(iii) The cost of family coverage that includes the child exceeds 9.5 percent of the household income.
(iv) The employer stopped offering coverage of dependents (or any coverage) under an employer-sponsored health insurance plan;
(v) 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);
(vi) The child has special health care needs; or
(vii) The child lost coverage due to the death or divorce of a parent.
[78 FR 42313, July 15, 2013, as amended at 81 FR 86466, Nov. 30, 2016]