003.01
VOLUNTARY PARTICIPATION IN
HEALTH INSURANCE PREMIUM PAYMENT (HIPP). Participation in the
Health Insurance Premium Payment (HIPP) Program is voluntary. For Medicaid
eligible clients, enrollment in the Health Insurance Premium Payment (HIPP)
Program does not change the client's eligibility for benefits through the state
plan or cost sharing obligations under the state plan.
003.02
PARTICIPATION
DETERMINATION FOR HEALTH INSURANCE PREMIUMPAYMENT (HIPP).
003.02(A)
REQUIRED
DOCUMENTATION. The Department may request any documentation from
the client that it deems to be necessary to determine whether the client's
enrollment in an available group health plan or individual market health plan
is cost effective. Documentation that must be submitted includes, but is not
limited to:
(i) Signed application for
enrollment in the Health Insurance Premium Payment (HIPP) Program;
(ii) Summary of covered benefits from the
group health plan or individual market health plan;
(iii) If applicable, verification of the
client's ongoing medical diagnosis. Verification must be provided by an
appropriate physician or entity;
(iv) Completed verification form for employer
sponsored insurance; and
(v)
Monthly proof of health insurance premium payments.
003.03
EFFECTIVE DATE
OF PARTICIPATION IN THE HEALTH INSURANCE PREMIUM PAYMENT (HIPP)
PROGRAM. The effective date for Health Insurance Premium Payment
(HIPP) participation is the first day of the month that the following criteria
are met:
(A) The client is enrolled in a
group health plan or individual market health plan;
(B) All documentation necessary for Medicaid
to determine cost effectiveness has been submitted; and
(C) The Department has determined that the
client's participation in Health Insurance Premium Payment (HIPP) would be cost
effective.
003.04
COST-EFFECTIVENESS DETERMINATION. The Department
determines the cost-effectiveness for payment of qualifying group health
insurance or individual market health insurance premiums.
003.04(A)
COST-EFFECTIVE MEDICAL
CONDITIONS. Any Medicaid-eligible client who has an existing,
ongoing, medically confirmed medical condition determined by the Department to
be considered a cost-effective condition, is deemed to meet the cost-effective
criteria.
003.04(B)
COST-EFFECTIVENESS CALCULATION. When the criteria of
471 Nebraska Administrative Code (NAC) 30-003.03(A) are not met,
cost-effectiveness will be calculated as follows:
(i) Determine the annual anticipated cost for
Medicaid services generally covered by the private health insurance based on
the client's age, sex, and eligibility category;
(ii) Total the results of each of the
following calculations:
(1) The portion of the
group health insurance or individual market health insurance premium payable by
the Health Insurance Premium Payment (HIPP) program;
(2) A predetermined annual administration
cost per participant; and
(3) The
expected cost to Medicaid for any deductibles, coinsurance, or
copayments.
(iii)
Subtract the result of (ii) from the result of (i);
(iv) If the result is greater than or equal
to $10, the policy would be determined cost effective; and
(v) If the result is less than $10, the
policy would not be considered cost effective.
003.04(C)
SUPPLEMENTAL
INFORMATION. When the criteria of 471 NAC 30-003.04(A) and 471 NAC
30-004.03(B) are not met, specific information relating to the individual
circumstances of the Medicaid-eligible client may be provided. On a
case-by-case basis and at the sole discretion of the Department, a
determination of cost effectiveness can be made if sufficient evidence is
provided to demonstrate savings to Medicaid.
003.04(D)
EXCLUDED
CASES. The Department will not make a determination of cost
effectiveness in the following circumstances:
(i) The client is eligible for or enrolled in
Medicare;
(ii) Payment of health
insurance premiums have been fully reimbursed or offset by a third party,
including, but not limited to:
(1) An
employer; or
(2) An individual
court-ordered to provide medical support.
(iii) The recipient is only eligible for a
medically needy, spend-down, program; or
(iv) The group health insurance or individual
market health insurance only provides catastrophic, limited benefit, limited
duration, or indemnity coverage.
003.04(E)
MULTIPLE
POLICIES. When more than one group or individual market health
insurance policy is available, the Department shall pay only for the most
cost-effective policy.
003.04(E)(i)
EXCEPTION FOR SUPPLEMENTAL POLICIES. At the sole
discretion of the Department, in the circumstance when an additional
supplemental policy is available and that policy is found to provide coverage
that does not duplicate coverage included in the primary health insurance plan,
the Department may include both the primary health plan and supplemental policy
in its cost-effectiveness calculation. If the Department finds that paying the
costs described in 471 NAC 30-003.04 for both the primary and supplemental
health policies is more cost effective than paying solely for the costs of the
primary health policy, the Department may pay for the costs of both the primary
and supplemental health policies.
003.04(F)
REDETERMINATIONS.
003.04(F)(i)
ANNUAL
REDETERMINATION. The Department conducts a redetermination of
participation annually for all clients enrolled in the Health Insurance Premium
Payment (HIPP) Program. This redetermination includes:
(1) Verification of eligibility for Medicaid;
and
(2) Completion of the
cost-effective calculation as outlined in 471 NAC 30-004.03(A) through
30-004.03(C).
003.04(F)(ii)
CHANGES IN
CIRCUMSTANCES. A redetermination of participation may be conducted
at any point if:
(1) The monthly premium of
the group health insurance or individual market health insurance increases by
more than $50;
(2) There is a
change in eligibility category or status for Medicaid;
(3) The services offered by the group health
insurance or individual market health insurance decrease;
(4) There is a change in the deductible,
co-insurance, or any other cost-sharing provisions of the group health policy
or individual market health policy; or
(5) There is reason to believe a change has
occurred which may affect participation for Health Insurance Premium Payment
(HIPP) enrollment.
The client has an affirmative obligation to report any change
in circumstances.
003.05
TERMINATION OF HEALTH
INSURANCE PREMUIM PAYMENT (HIPP) PARTICIPATION. Failure to provide
requested documentation in accordance with 471 NAC 30-003.02(A), or failure to
meet Health Insurance Premium Payment (HIPP) enrollment participation criteria
as outlined in 471 NAC 30-004.01 and 30-004.03, may result in termination of
participation in the Health Insurance Premium Payment (HIPP) Program.
