Current through Reg. 50, No. 187; September 24, 2024
(1) Under the Health Insurance Premium
Payment (HIPP) program, the Agency for Health Care Administration (AHCA) shall
provide financial assistance to recipients in order to obtain or maintain
Employer Sponsored Insurance (ESI) coverage pursuant to Sections
409.9122(14)
and 409.977(4),
F.S. This includes the recipient's share of the ESI premiums, copayments,
deductibles, coinsurance and other cost sharing obligations for Medicaid
services and items covered under the State Plan. The amount of financial
assistance provided for each recipient may not exceed the amount of the
Medicaid managed care premium that would have been paid for that recipient.
(a) The recipient's health care services will
be covered through their ESI primary coverage. Medicaid will cover the lesser
of the ESI required copayments, deductibles, or coinsurance, up to the Medicaid
fee when the recipient's ESI provider is also a Medicaid enrolled provider.
Medicaid will deduct any applicable Medicaid copay for covered state plan
services. If a recipient chooses to utilize non-Medicaid providers, only the
ESI coverage will apply and the recipient may be subject to ESI required
copayments, deductibles, or coinsurance.
(b) Medicaid will cover any state plan
services that are not provided by the recipient's ESI when those services are
provided by an enrolled Medicaid provider.
(2) Participation in the HIPP program.
(a) Recipients must enroll in or be enrolled
in and maintain their ESI coverage during the period of participation.
Recipients will be identified by AHCA, or its designee, and will be sent an
enrollment package.
(b)
Participation in the program shall be subject to a cost effectiveness
determination as defined in subsection (3) of this rule by AHCA and subsequent
redeterminations, at least once every six months.
1. For non-pregnant adult Medicaid recipients
with access to ESI for whom AHCA has made a determination of cost
effectiveness, participation shall be mandatory.
2. For Medicaid recipients with proof of ESI
through a spouse or other family member for whom AHCA has made a determination
of cost effectiveness, participation shall be voluntary.
(c) Health Insurance Premium Payment program
participation may terminate upon any of the following events:
1. Loss of Medicaid eligibility.
2. Loss of access to ESI coverage.
3. A determination of non-cost
effectiveness.
(3) Health Insurance Premium Payment
assistance cost effectiveness determination.
(a) When determining cost effectiveness, the
following data elements shall be considered:
1. The amount of the Medicaid managed care
premium that would have been paid for that recipient.
2. The amount of the recipient's share of the
ESI premium.
3. The amount of
copayments, coinsurance, deductibles and other cost sharing obligations as
determined by the average fee-for-service expenditures for recipients with
other comparable insurance coverage.
4. The amount of AHCA's administrative
cost.
(b) The calculation
used to determine whether a recipient qualifies for HIPP assistance shall be a
[GREATER THAN EQUAL TO] (b+c+d). The Medicaid managed care premium (a), must be
greater than or equal to amount of the recipient's share of the ESI premium
(b), plus the amount for copayments, coinsurance, deductibles and other cost
sharing obligations (c), plus the amount of any administrative cost
(d).
(4) HIPP premium
payments.
Any financial assistance provided towards the payment of a
recipient's share of the ESI premium shall be in the form of a reimbursement
issued after receipt of the proper documentation. Recipients must pay their ESI
premium and submit a request with supporting documentation for reimbursement to
AHCA, or its designee.
Rulemaking Authority 409.919 FS. Law Implemented 409.977(4)
FS.
New 3-30-15.
