{"identifier":"/us/usc/t42/s1396e\u20131","title":42,"num":"\u00a7\u202f1396e\u20131.","heading":"Premium assistance","text":"\u00a7\u202f1396e\u20131.\nPremium assistance\n(a)\nIn general\nA State may elect to offer a premium assistance subsidy (as defined in subsection (c)) for qualified employer-sponsored coverage (as defined in subsection (b)) to all individuals who are entitled to medical assistance under this subchapter (and, in the case of an individual under age 19, to the parent of such an individual) who have access to such coverage if the State meets the requirements of this section and the offering of such a subsidy is cost-effective, as defined for purposes of\nsection 1397ee(c)(3)(A) of this title\n(b)\nQualified employer-sponsored coverage\n(1)\nIn general\nSubject to paragraph (2)),\n(A) that qualifies as creditable coverage as a group health plan under section 2701(c)(1) of the Public Health Service Act;\n2\n2 See References in Text note below.\n(B) for which the employer contribution toward any premium for such coverage is at least 40 percent; and\n(C) that is offered to all individuals in a manner that would be considered a nondiscriminatory eligibility classification for purposes of paragraph (3)(A)(ii) of section 105(h) of the Internal Revenue Code of 1986 (but determined without regard to clause (i) of subparagraph (B) of such paragraph).\n(2)\nException\nSuch term does not include coverage consisting of\u2014\n(A) benefits provided under a health flexible spending arrangement (as defined in section 106(c)(2) of the Internal Revenue Code of 1986); or\n(B) a high deductible health plan (as defined in section 223(c)(2) of such Code), without regard to whether the plan is purchased in conjunction with a health savings account (as defined under section 223(d) of such Code).\n(3)\nTreatment as third party liability\nThe State shall treat the coverage provided under qualified employer-sponsored coverage as a third party liability under\nsection 1396a(a)(25) of this title\n(c)\nPremium assistance subsidy\nIn this section, the term \u201cpremium assistance subsidy\u201d means the amount of the employee contribution for enrollment in the qualified employer-sponsored coverage by the individual or by the individual\u2019s family. Premium assistance subsidies under this section shall be considered, for purposes of\nsection 1396b(a) of this title\n(d)\nVoluntary participation\n(1)\nEmployers\nParticipation by an employer in a premium assistance subsidy offered by a State under this section shall be voluntary. An employer may notify a State that it elects to opt-out of being directly paid a premium assistance subsidy on behalf of an employee.\n(2)\nBeneficiaries\nNo subsidy shall be provided to an individual under this section unless the individual (or the individual\u2019s parent) voluntarily elects to receive such a subsidy. A State may not require such an election as a condition of receipt of medical assistance. A State may not require, as a condition of an individual (or the individual\u2019s parent) being or remaining eligible for medical assistance under this subchapter, that the individual (or the individual\u2019s parent) apply for enrollment in qualified employer-sponsored coverage under this section.\n(3)\nOpt-out permitted for any month\nA State shall establish a process for permitting an individual (or the parent of an individual) receiving a premium assistance subsidy to disenroll the individual from the qualified employer-sponsored coverage.\n(e)\nRequirement to pay premiums and cost-sharing and provide supplemental coverage\nIn the case of the participation of an individual (or the individual\u2019s parent) in a premium assistance subsidy under this section for qualified employer-sponsored coverage, the State shall provide for payment of all enrollee premiums for enrollment in such coverage and all deductibles, coinsurance, and other cost-sharing obligations for items and services otherwise covered under the State plan under this subchapter (exceeding the amount otherwise permitted under section 1396\no\no\nsection 1396a(a)(25) of this title","url":"https://projectusc.org/usc/t42/s1396e\u20131.html","content":[{"t":"sec","id":"/us/usc/t42/s1396e\u20131","children":[{"t":"num","text":"\u00a7\u202f1396e\u20131."},{"t":"heading","text":"Premium assistance"},{"t":"subsec","id":"/us/usc/t42/s1396e\u20131/a","children":[{"t":"num","text":"(a)"},{"t":"heading","text":"In general"},{"t":"content","children":[{"t":"p","text":"A State may elect to offer a premium assistance subsidy (as defined in subsection (c)) for qualified employer-sponsored coverage (as defined in subsection (b)) to all individuals who are entitled to medical assistance under this subchapter (and, in the case of an individual under age 19, to the parent of such an individual) who have access to such coverage if the State meets the requirements of this section and the offering of such a subsidy is cost-effective, as defined for purposes of ","children":[{"t":"ref","text":"section 1397ee(c)(3)(A) of this title","href":"/us/usc/t42/s1397ee/c/3/A","tail":"."}],"tail":"\n"}],"tail":"\n"}],"tail":"\n"},{"t":"subsec","id":"/us/usc/t42/s1396e\u20131/b","children":[{"t":"num","text":"(b)"},{"t":"heading","text":"Qualified employer-sponsored coverage"},{"t":"para","id":"/us/usc/t42/s1396e\u20131/b/1","children":[{"t":"num","text":"(1)"},{"t":"heading","text":"In general"},{"t":"chapeau","text":"Subject to paragraph (2)),","children":[{"t":"ref","text":"1"},{"t":"num","text":"1","tail":"\u202fSo in original. The second closing parenthesis probably should not appear."},{"t":"text","text":"\u202fSo in original. The second closing parenthesis probably should not appear.","tail":" in this paragraph, the term \u201cqualified employer-sponsored coverage\u201d means a group health plan or health insurance coverage offered through an employer\u2014"}]},{"t":"subpara","id":"/us/usc/t42/s1396e\u20131/b/1/A","children":[{"t":"num","text":"(A)"},{"t":"content","text":" that qualifies as creditable coverage as a group health plan under section 2701(c)(1) of the Public Health Service Act;\u202f","children":[{"t":"ref","text":"2"},{"t":"num","text":"2","tail":"\u202fSee References in Text note below."},{"t":"text","text":"\u202fSee References in Text note below."}],"tail":"\n"}],"tail":"\n"},{"t":"subpara","id":"/us/usc/t42/s1396e\u20131/b/1/B","children":[{"t":"num","text":"(B)"},{"t":"content","text":" for which the employer contribution toward any premium for such coverage is at least 40 percent; and","tail":"\n"}],"tail":"\n"},{"t":"subpara","id":"/us/usc/t42/s1396e\u20131/b/1/C","children":[{"t":"num","text":"(C)"},{"t":"content","text":" that is offered to all individuals in a manner that would be considered a nondiscriminatory eligibility classification for purposes of paragraph (3)(A)(ii) of section 105(h) of the Internal Revenue Code of 1986 (but determined without regard to clause (i) of subparagraph (B) of such paragraph).","tail":"\n"}],"tail":"\n"}],"tail":"\n"},{"t":"para","id":"/us/usc/t42/s1396e\u20131/b/2","children":[{"t":"num","text":"(2)"},{"t":"heading","text":"Exception"},{"t":"chapeau","text":"Such term does not include coverage consisting of\u2014"},{"t":"subpara","id":"/us/usc/t42/s1396e\u20131/b/2/A","children":[{"t":"num","text":"(A)"},{"t":"content","text":" benefits provided under a health flexible spending arrangement (as defined in section 106(c)(2) of the Internal Revenue Code of 1986); or","tail":"\n"}],"tail":"\n"},{"t":"subpara","id":"/us/usc/t42/s1396e\u20131/b/2/B","children":[{"t":"num","text":"(B)"},{"t":"content","text":" a high deductible health plan (as defined in section 223(c)(2) of such Code), without regard to whether the plan is purchased in conjunction with a health savings account (as defined under section 223(d) of such Code).","tail":"\n"}],"tail":"\n"}],"tail":"\n"},{"t":"para","id":"/us/usc/t42/s1396e\u20131/b/3","children":[{"t":"num","text":"(3)"},{"t":"heading","text":"Treatment as third party liability"},{"t":"content","children":[{"t":"p","text":"The State shall treat the coverage provided under qualified employer-sponsored coverage as a third party liability under ","children":[{"t":"ref","text":"section 1396a(a)(25) of this title","href":"/us/usc/t42/s1396a/a/25","tail":"."}],"tail":"\n"}],"tail":"\n"}],"tail":"\n"}],"tail":"\n"},{"t":"subsec","id":"/us/usc/t42/s1396e\u20131/c","children":[{"t":"num","text":"(c)"},{"t":"heading","text":"Premium assistance subsidy"},{"t":"content","children":[{"t":"p","text":"In this section, the term \u201cpremium assistance subsidy\u201d means the amount of the employee contribution for enrollment in the qualified employer-sponsored coverage by the individual or by the individual\u2019s family. Premium assistance subsidies under this section shall be considered, for purposes of ","children":[{"t":"ref","text":"section 1396b(a) of this title","href":"/us/usc/t42/s1396b/a","tail":", to be a payment for medical assistance."}],"tail":"\n"}],"tail":"\n"}],"tail":"\n"},{"t":"subsec","id":"/us/usc/t42/s1396e\u20131/d","children":[{"t":"num","text":"(d)"},{"t":"heading","text":"Voluntary participation"},{"t":"para","id":"/us/usc/t42/s1396e\u20131/d/1","children":[{"t":"num","text":"(1)"},{"t":"heading","text":"Employers"},{"t":"content","children":[{"t":"p","text":"Participation by an employer in a premium assistance subsidy offered by a State under this section shall be voluntary. An employer may notify a State that it elects to opt-out of being directly paid a premium assistance subsidy on behalf of an employee.","tail":"\n"}],"tail":"\n"}],"tail":"\n"},{"t":"para","id":"/us/usc/t42/s1396e\u20131/d/2","children":[{"t":"num","text":"(2)"},{"t":"heading","text":"Beneficiaries"},{"t":"content","children":[{"t":"p","text":"No subsidy shall be provided to an individual under this section unless the individual (or the individual\u2019s parent) voluntarily elects to receive such a subsidy. A State may not require such an election as a condition of receipt of medical assistance. A State may not require, as a condition of an individual (or the individual\u2019s parent) being or remaining eligible for medical assistance under this subchapter, that the individual (or the individual\u2019s parent) apply for enrollment in qualified employer-sponsored coverage under this section.","tail":"\n"}],"tail":"\n"}],"tail":"\n"},{"t":"para","id":"/us/usc/t42/s1396e\u20131/d/3","children":[{"t":"num","text":"(3)"},{"t":"heading","text":"Opt-out permitted for any month"},{"t":"content","children":[{"t":"p","text":"A State shall establish a process for permitting an individual (or the parent of an individual) receiving a premium assistance subsidy to disenroll the individual from the qualified employer-sponsored coverage.","tail":"\n"}],"tail":"\n"}],"tail":"\n"}],"tail":"\n"},{"t":"subsec","id":"/us/usc/t42/s1396e\u20131/e","children":[{"t":"num","text":"(e)"},{"t":"heading","text":"Requirement to pay premiums and cost-sharing and provide supplemental coverage"},{"t":"content","children":[{"t":"p","text":"In the case of the participation of an individual (or the individual\u2019s parent) in a premium assistance subsidy under this section for qualified employer-sponsored coverage, the State shall provide for payment of all enrollee premiums for enrollment in such coverage and all deductibles, coinsurance, and other cost-sharing obligations for items and services otherwise covered under the State plan under this subchapter (exceeding the amount otherwise permitted under section 1396","children":[{"t":"text","text":"o","tail":" of this title or, if applicable, section 1396"},{"t":"text","text":"o","tail":"\u20131 of this title). The fact that an individual (or a parent) elects to enroll in qualified employer-sponsored coverage under this section shall not change the individual\u2019s (or parent\u2019s) eligibility for medical assistance under the State plan, except insofar as "},{"t":"ref","text":"section 1396a(a)(25) of this title","href":"/us/usc/t42/s1396a/a/25","tail":" provides that payments for such assistance shall first be made under such coverage."}],"tail":"\n"}],"tail":"\n"}],"tail":"\n"},{"t":"text","text":"\n"},{"t":"text","text":"\n"}]}]}