Current through Register Vol. 50, No. 6, December 1, 2023
RELATES TO:
42 C.F.R.
400.203,
430.10,
26
U.S.C. 4980B,
5000(b)(1),
29
U.S.C. 1161-1169,
42 U.S.C.
1396e(a)-(e)
NECESSITY, FUNCTION, AND CONFORMITY: The Cabinet for Health and
Family Services, Department for Medicaid Services has responsibility to
administer the Medicaid Program.
KRS
205.520(3) authorizes the
cabinet, by administrative regulation, to comply with a requirement that may be
imposed or opportunity presented by federal law for the provision of medical
assistance to Kentucky's indigent citizenry.
42 U.S.C.
1396e(a) through (e)
authorizes states to establish a health insurance premium payment, or HIPP,
program to provide health insurance coverage outside of Medicaid to Medicaid
enrollees, and any family member of Med-icaid enrollees, if the department
determines that HIPP program participation would be cost effective for the
department. This administrative regulation establishes the Kentucky integrated
health insurance premium payment program requirements as authorized by
42 U.S.C.
1396e(a) through (e).
Section 1. Definitions.
(1) "Buying in" means purchasing benefits
from Medicare on behalf of an individual.
(2) "Department" means the Department for
Medicaid Services or its designee.
(3) "Federal financial participation" is
defined in
42 C.F.R.
400.203.
(4) "Group health insurance plan" means any
plan, including a self-insured plan, of, or contributed to by, an employer to
provide health care directly or otherwise to the employer's employees, former
employees, or the families of the employees or former employees, if the plan:
(a) Meets the criteria established in
26 U.S.C.
5000(b)(1); and
(b) Includes continuation coverage pursuant
to
26
U.S.C. 4980B or
29
U.S.C. 1161 to
1169.
(5) "Income" means:
(a) Wages, salary, or compensation for labor
or services;
(b) Money received
from a statutory benefit including Social Security, Veteran's Administration
pension, black lung benefit, or railroad retirement benefit; or
(c) Money received from any pension plan,
rental property, or an investment including interest or dividends.
(6) "Income deduction" means a
deduction from an individual's income for the purpose of obtaining or trying to
obtain Medicaid eligibility.
(7)
"Kentucky integrated health insurance premium payment program participant" or
"KI-HIPP program participant" means an individual receiving health insurance
benefits in accordance with this administrative regulation.
(8) "Medicaid" means the Kentucky Medicaid
program.
(9) "Medicaid enrollee"
means an individual eligible for and participating in Medicaid pursuant to
907 KAR
1:005,
907
KAR 20:010,
907
KAR 20:020, and
907
KAR 20:025.
(10) "Spend-down program" means a program by
which an individual becomes eligible for Medicaid benefits:
(a) By spending down income in excess of the
Medicaid income threshold; and
(b)
In accordance with
907
KAR 20:020.
(11) "State plan" is defined in
42 C.F.R.
430.10.
(12) "Wrap-around coverage" means coverage of
a benefit not covered by an individual's group health insurance plan.
Section 2. KI-HIPP Program
Eligibility and Enrollment.
(1) If a Medicaid
enrollee, or a person acting on the Medicaid enrollee's behalf, elects to
participate, or attempt to participate, in the KI-HIPP program, the enrollee or
person acting on the Medicaid enrollee's behalf shall cooperate in providing
information to the department necessary for the department to establish
availability and cost effectiveness of a group health insurance plan by:
(a) Completing the Kentucky Health Insurance
Premium Payment Program Application; and
(b) Submitting the Kentucky Health Insurance
Premium Payment Program Application to the individual's local Department for
Community Based Services office, the office administering the Kentucky
integrated health insurance premium payment program, or on-line via the
Kentucky Online Gateway self-service portal.
(2) A Medicaid enrollee or beneficiary may
participate in the KI-HIPP program if the department determines in accordance
with this administrative regulation that the Medicaid enrollee or beneficiary's
participation in the KI-HIPP program would be cost-effective.
(3) If a Medicaid enrollee, KI-HIPP program
applicant, participant, parent, guardian, or caretaker fails to provide
information to the department, within thirty (30) days of the department's
request, necessary to determine availability and cost effectiveness of a group
health insurance plan, the department shall not enroll the applicant in the
KI-HIPP program unless good cause for failure to cooperate is demonstrated to
the department within thirty (30) days of the department's denial.
(4) Good cause for failure to cooperate shall
exist if:
(a) There was a serious illness or
death of the applicant, participant, parent, guardian, or caretaker or of a
member of the applicant's, participant's, parent's, guardian's, or caretaker's
immediate family;
(b) There was a
fire, tornado, flood, or similar family emergency or household disaster
affecting the applicant, participant, parent, guardian, or caretaker or member
of his or her immediate family;
(c)
The applicant, participant, parent, guardian, or caretaker demonstrates that a
good cause beyond that individual's control has occurred; or
(d) There was a failure to receive the
department's request for information or notification for a reason not
attributable to the applicant, participant, parent, guardian, or caretaker. The
lack of a forwarding address shall be attributable to the applicant,
participant, parent, guardian, or caretaker.
(5) For a Medicaid enrollee who is a KI-HIPP
program participant:
(a) The department shall
pay all group health insurance plan premiums and deductibles, coinsurance and
other cost-sharing obligations for items and services otherwise covered under
Medicaid, up to the Medicaid allowed amount, minus any Medicaid cost-sharing
that would normally be paid, including the cost-sharing required under
907 KAR
1:604, as applicable; and
(b)
1. The
individual's group health insurance plan shall be the primary payer;
and
2. The department shall be the
payer of last resort.
(6) For a KI-HIPP program participating
family member who is not a Medicaid enrollee:
(a) The department shall pay a KI-HIPP
program premium; and
(b) The
department shall not pay a deductible, coinsurance or other cost-sharing
obligation.
(7) If an
individual who was a Medicaid enrollee at the time the department initiated a
KI-HIPP program cost effectiveness review for the individual loses Medicaid
eligibility by the time the cost effectiveness review has been conducted, the
department shall not enroll the individual or any family member into the
KI-HIPP program.
Section
3. Wrap-around Coverage.
(1) If a
service to which a health insurance premium payment program participant would
be entitled via Medicaid is not provided by the individual's group health
insurance plan, the department shall reimburse for the service.
(2) For a service referenced in subsection
(1) of this section, the department shall reimburse:
(a) The provider of the service;
and
(b) In accordance with the
department's administrative regulation governing reimbursement for the given
service. For example, a wrap-around dental service shall be reimbursed in
accordance with
907 KAR
1:626.
Section 4. Cost Effectiveness.
(1) Enrollment in a group health insurance
plan shall be considered cost effective if the cost of paying the premiums,
coinsurance, deductibles and other cost-sharing obligations, and additional
administrative costs is estimated to be less than the amount paid for an
equivalent set of Medicaid services.
(2) When determining cost effectiveness of a
group health insurance plan, the department shall consider the following
information:
(a) The cost of:
1. The insurance premium,
2. The coinsurance,
3. Medicaid's anticipated expenses for the:
a. KI-HIPP program participant;
b. KI-HIPP program participant's household;
or
c. KI-HIPP program participant's
subdivision of a household, and
4. The deductible;
(b) The scope of services covered under the
insurance plan, including exclusions for preexisting conditions, exclusions to
enrollment, and lifetime maximum benefits imposed;
(c) The average anticipated Medicaid
utilization:
1. By age, sex, and coverage
group for persons covered under the insurance plan; and
2. Using a statewide average for the
geographic component; and
(d) Annual administrative expenditures of an
amount determined by the department per Medicaid participant covered under the
group health insurance plan.
(3)
(a) An
eligible recipient shall be provided the opportunity to:
1. Ask the employer to complete a Loss of
Medicaid or KI-HIPP Eligibility as a Qualifying Event to End Coverage
form;
2. Submit the completed form
to the department; and
3. Retain a
copy of the completed form.
(b) If the recipient loses Medicaid or
KI-HIPP eligibility, and no longer wishes to participate in the employer
sponsored insurance plan, the recipient may use the completed form to end
coverage in the employer sponsored insurance plan by providing written notice
to the employer.
(c) The department
shall inform KI-HIPP applicants of the potential financial risks of
participation if loss of Medicaid or KI-HIPP eligibility is not treated as a
qualifying event to end coverage by the employer of the recipient.
(4) An employer may complete and
submit an Employer Certification that Loss of Medicaid or KI-HIPP Eligibility
is a Qualifying Event to End Coverage form to the Department for Medi-caid
Services for all employees or future employees.
Section 5. Cost Effectiveness Review.
(1) The department shall complete a cost
effectiveness review at least annually for an employer-related group health
insurance plan or a non-employer-related group health insurance plan.
(2) The department shall perform a cost
effectiveness re-determination if:
(a) A
predetermined premium rate, deductible, or coinsurance increases;
(b) Any of the individuals covered under the
group health insurance plan lose full Medicaid eligibility; or
(c) There is a:
1. Change in Medicaid eligibility;
2. Loss of employment if the insurance is
through an employer; or
3. Decrease
in the services covered under the policy.
(3)
(a) A
health insurance premium payment program participant who is a Medicaid
enrollee, or a person on that individual's behalf, shall report all changes
concerning health insurance coverage to the Third Party Liability Branch office
within the Department for Medicaid Services that administers the Kentucky
Integrated Health Insurance Premium Payment program, or to the participant's
local Department for Community Based Services (DCBS), Division of Family
Support, within thirty (30) days of the change.
(b) Except as allowed in subsection (4) of
this section, if a Medicaid enrollee who is a health insurance premium payment
program participant fails to comply with paragraph (a) of this subsection, the
department shall disenroll the KI-HIPP program participating Medicaid enrollee,
and any family member enrolled in the KI-HIPP program directly through the
individual, if applicable, from the KI-HIPP program.
(4) The department shall not disenroll an
individual, or any family member enrolled in the KI-HIPP program directly
through the individual, from KI-HIPP program participation if the individual
demonstrates to the department, within thirty (30) days of notice of KI-HIPP
program disen-rollment, good cause for failing to comply with subsection (3) of
this section.
(5) Good cause for
failing to comply with subsection (3) of this section shall exist if:
(a) There was a serious illness or death of
the individual, parent, guardian, or caretaker or a member of the individual's,
parent's guardian's, or caretaker's immediate family;
(b) There was a fire, tornado, flood, or
similar family emergency or household disaster affecting the applicant,
participant, parent, guardian, or caretaker or member of his or her immediate
family;
(c) The individual, parent,
guardian, or caretaker demonstrates that a good cause beyond that individual's
control has occurred; or
(d) There
was a failure to receive the department's request for information or
notification for a reason not attributable to the individual, parent, guardian,
or caretaker. The lack of a forwarding address shall be attributable to the
individual, parent, guardian, or caretaker.
Section 6. Provider Participation. Unless a
KI-HIPP patient's care needs are outside of the regular scope of practice,
level of care, or the provider's ability to safely meet the care needs of the
individual, a Medicaid enrolled provider shall not refuse to accept a new
patient who is a KI-HIPP participating Medicaid member if the provider is:
(1) Accepting any new:
(a) Medicaid patients; or
(b) Patients who have coverage under the
group health insurance plan that meets criteria for KI-HIPP
participation;
(2)
Enrolled with the department;
(3)
Listed on the most recent version of the Medicaid Provider Directory;
and
(4) A participating provider
within the group health insurance plan determined to meet criteria for KI-HIPP
participation.
Section
7. Coverage of Non-Medicaid Family Members.
(1) If determined to be cost effective, the
department shall enroll a family member who is not a Medicaid enrollee into the
KI-HIPP program if the family member has group health insurance plan coverage
through which the department can obtain health insurance coverage for a
Medi-caid-enrollee in the family.
(2) The needs of a family member who is not a
Medicaid enrollee shall not be taken into consideration when determining cost
effectiveness of a group health insurance plan.
(3) The department shall:
(a) Pay a KI-HIPP program premium on behalf
of a KI-HIPP program participating family member who is not a Medicaid
enrollee; and
(b) Not pay a
deductible, coinsurance, or other cost-sharing obligation on behalf of a
KI-HIPP program participating family member who is not a Medicaid
enrollee.
Section
8. Exceptions. The department shall not pay a premium:
(1) For a group health insurance plan if the
plan is designed to provide coverage for a period of time less than the
standard one-year coverage period;
(2) For a group health insurance plan if the
plan is a school plan offered on the basis of attendance or enrollment at the
school;
(3) If the premium is used
to meet a spend-down obligation and all persons in the household are eligible
or potentially eligible only under the spend-down program pursuant to
907
KAR 20:020. If any household member is eligible for
full Medicaid benefits, the premium shall:
(a)
Be paid if it is determined to be cost effective when considering only the
household members receiving full Medicaid coverage; and
(b) Not be allowed as a deduction to meet the
spend-down obligation for those household members participating in the
spend-down program.
(4)
For a group health insurance plan if the plan is an indemnity policy which
supplements the policy holder's income or pays only a predetermined amount for
services covered under the policy.
Section 9. Duplicate Policies.
(1) If more than one (1) group health
insurance plan or policy is available, the department shall pay only for the
most cost-effective plan except as allowed in subsection (2) of this
section.
(2) If the department is
buying in to the cost of Medicare Part A or Part B for an eligible Medicare
beneficiary, the cost of premiums for a Medicare supplemental insurance policy
shall also be paid if the department determines that it is likely to be cost
effective to do so.
Section
10. Discontinuance of Premium Payments.
(1) If all Medicaid-enrollee household
members covered under a group health insurance plan lose Medicaid eligibility,
the department shall discontinue KI-HIPP program payments as of the month of
Medicaid ineligibility.
(2) If one
(1) or more, but not all, of a household's Medicaid-enrollee members covered
under a group health insurance plan lose Medicaid eligibility, the department
shall re-determine cost effectiveness of the group health insurance plan in
accordance with Section 5(2) of this administrative regulation.
Section 11. Kentucky Integrated
Health Insurance Premium Payment Program Payment Effective Date.
(1)
(a)
KI-HIPP program payments for cost-effective group health insurance plans shall
begin with the month the health insurance premium payment program application
is received by the department, or the effective date of Medicaid eligibility,
whichever is later.
(b) If an
individual is not currently enrolled in a cost effective group health insurance
plan, premium payments shall begin in the month in which the first premium
payment is due after enrollment occurs.
(2) The department shall not make a payment
for a premium which is used as an income deduction when determining individual
eligibility for Medicaid.
Section
12. Premium Refunds. The department shall be entitled to any
premium refund due to:
(1) Overpayment of a
premium; or
(2) Payment for an
inactive policy for any time period for which the department paid the
premium.
Section 13.
Notice. The department shall inform a Kentucky integrated health insurance
premium payment program:
(1) Applicant, in
writing, of the department's initial decision regarding cost effectiveness of a
group health insurance plan and KI-HIPP program payment; or
(2) Participating household, in writing:
(a) If KI-HIPP program payments are being
discontinued due to Medicaid eligibility being lost by all individuals covered
under the group health insurance plan;
(b) If the group health insurance plan is no
longer available to the family; or
(c) Of a decision to discontinue KI-HIPP
program payment due to the department's determination that the policy is no
longer cost effective.
Section 14. Federal Financial Participation.
(1) The Kentucky integrated health insurance
premium program shall be contingent upon the receipt of federal financial
participation for the program.
(2)
If federal financial participation is not provided to the department for the
Kentucky integrated health insurance premium program, the program shall cease
to exist.
(3) If the Centers for
Medicare and Medicaid Services (CMS) disapproves a provision stated in an
amendment to the state plan, which is also stated in this administrative
regulation, the provision shall be null and void.
Section 15. Incorporation by Reference.
(1) The following material is incorporated by
reference:
(a) "Kentucky Health Insurance
Premium Payment Program Application", KIHIPP-100, April 2019;
(b) "Loss of Medicaid or KI-HIPP Eligibility
as a Qualifying Event to End Coverage", KIHIPP-024, January 2020; and
(c) "Employer Certification that Loss of
Medicaid or KI-HIPP Eligibility is a Qualifying Event to End Coverage",
KIHIPP-025, January 2020.
(2) This material may be inspected, copied,
or obtained, subject to applicable copyright law, at the Department for
Medicaid Services, 275 East Main Street, Frankfort, Kentucky 40621, Monday
through Friday, 8 a.m. to 4:30 p.m., or from the department's Web site at
https://chfs.ky.gov/agencies/dms/Pages/regsmaterials.aspx.
37 Ky.R. 986; eff.
11-05-2010; Crt eff. 7-23-2018; 45 Ky.R. 2496, 3412; eff. 7-5-2019; Crt eff.
12-6-2019; 46 Ky. R. 1713, 2482; eff.
6-30-2020.
STATUTORY AUTHORITY:
KRS
194A.010(1),
194A.030(2),
194A.050(1),
205.520(3),
205.560(2),
42 U.S.C.
1396e(a)-(e)