OKDHS - OAC 317:45-9-1. Employee eligibility requirements

317:45-9-1. Employee eligibility requirements

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Revised 6-25-11

(a) Employees must complete and submit the OHCA required forms and application to be considered for participation in the program.

(b) The eligibility determination will be processed within 30 days from the date the application is received. The employee will be notified in writing of the eligibility decision.

(c) All eligible employees described in this section must be enrolled in their employer's qualified health plan. Eligible employees must:

(1) have an annual gross household income at or below 250 percent of the Federal Poverty Level (FPL). The increase from 200 to 250 percent of the FPL will be phased in over a period of time as determined by the Oklahoma Health Care Authority. The standard deduction for work related expenses such as income tax payments, Social Security taxes, and transportation to and from work, is $240 per each full-time or part-time employed member;
(2) be a US citizen or alien as described in 317:35-5-25;
(3) be Oklahoma residents;
(4) provide social security number for all household members;
(5) not be receiving benefits from SoonerCare or Medicare;
(6) be employed with a qualified employer at a business location in Oklahoma;
(7) be age 19 through age 64 or an emancipated minor;
(8) be eligible for enrollment in the employer's qualified health plan;
(9) not have full-time employment with any employer who does not meet the eligible employer guidelines listed in 317:45-7-1(a)(1)-(2);
(10) select one of the qualified health plans the employer is offering; and
(11) provide in a timely manner any and all documentation that is requested by the Insure Oklahoma program by the specified due date.

(d) An employee's dependents are eligible when:

(1) the employer's health plan includes coverage for dependents;
(2) the employee is eligible;
(3) if employed, the spouse may not have full-time employment with any employer who does not meet the eligible employer guidelines listed in 317:45-7-1(a)(1)-(2); and
(4) the dependents are enrolled in the same health plan as the employee.

(e) If an employee or their dependents are eligible for multiple qualified health plans, each may receive a subsidy under only one health plan.

(f) Dependent college students must enroll under their parents and all annual gross household income (including parent income) must be included in determining eligibility. Independent college students may apply on their own without parent income included in the household. College student status as dependent or independent is determined by the student's current Free Application for Federal Student Aid (FAFSA). College students must also provide a copy of their current student schedule to prove full-time student status.

(g) Dependent children in families whose annual gross household income is from 185 up to and including 300 percent of the Federal Poverty Level may be eligible. The inclusion of children into the Insure Oklahoma program will be phased in over a period of time as determined by the OHCA. No other deductions or disregards apply.

(1) Children found to be eligible for SoonerCare may not receive coverage through Insure Oklahoma.
(2) Children are not eligible for Insure Oklahoma if they are a member of a family eligible for employer-sponsored dependent health insurance coverage under any Oklahoma State Employee Health Insurance Plan.
(3) Children who already have coverage through another source must undergo, or be excepted from, a six month uninsured waiting period prior to becoming eligible for Insure Oklahoma. Exceptions to the waiting period may include:

(A) the cost of covering the family under the ESI plan meets or exceeds ten percent of the annual gross household income. The cost of coverage includes premiums, deductibles, co-insurance, and co-payments;
(B) loss of employment by a parent which made coverage available;
(C) affordable ESI is not available; "affordable" coverage is defined by the OHCA annually using actuarially sound rates established by the Oklahoma State and Education Employee Group Insurance Board (OSEEGIB); or
(D) loss of medical benefits under SoonerCare.
(h) ESI approved individuals must notify the OHCA of any changes, including household status and income, that might impact individual and/or dependent eligibility in the program within 30 calendar days of the change.

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