New Hampshire Code of Administrative Rules
He - Department of Health and Human Services
Subtitle He-W - Former Division of Human Services
Chapter He-W 500 - MEDICAL ASSISTANCE
Part He-W 511 - HEALTH INSURANCE PREMIUM PAYMENT PROGRAM (HIPP)
Section He-W 511.04 - Recipient Participation

Universal Citation: NH Admin Rules He-W 511.04

Current through Register No. 40, October 3, 2024

(a) Participation in HIPP shall be mandatory when a newly eligible adult has access to a group health plan and the department determines, in accordance with He-W 511.05 below, that it is cost effective for the individual to enroll in the group health plan.

(b) Pending the determination of cost effectiveness, the newly eligible adult shall be eligible to receive medicaid covered services through the medicaid fee-for-service program.

(c) Premium assistance through the HIPP program shall not be available when:

(1) The insurance plan is an indemnity plan that pays only a predetermined amount for covered services, such as dental or vision only plans, or long-terms care plans;

(2) The insurance plan is a school-based plan offered based on attendance or school enrollment;

(3) The individual is only eligible for medicaid through in and out medical assistance in accordance with He-W 678.01;

(4) The insurance plan is only offered for a temporary time period;

(5) The eligible individual does not qualify for full medicaid benefits;

(6) The insurance plan is through New Hampshire's high-risk pool;

(7) The insurance plan is a medicare supplemental policy, if the HIPP application was filed after March 1, 1996;

(8) The insurance plan is COBRA; or

(9) The newly eligible adult is eligible for, but is not enrolled in Medicare Part B.

(d) The newly eligible adult shall inform the department if he or she has access to group health plan coverage, at the time of application, and within 10 days of any other such time as coverage becomes available.

(e) Within 30 days of receiving a written request from the department or the department's vendor, the newly eligible adult shall provide information necessary to establish the cost effectiveness of the group health plan, including the following:

(1) Health plan information, such as the plan name and policy number;

(2) Premium liability, which is the portion of the premium that is paid by the policy holder;

(3) Co-insurance, which is the policy holder's share of the cost of a covered health care services, and is generally calculated as a percentage of the total charge for the service;

(4) Deductibles, which is the amount the policy holder must pay for health care services before the group health plan begins to pay;

(5) Co-pay liability, which is a fixed amount the policy holder pays for a health care service, and generally paid for at the time the services are rendered;

(6) Covered benefits and services;

(7) Any service limits applied to the benefit and service use by the health plan; and

(8) Demographic information relative to other individuals on the policyholder's plan, including gender and age.

(f) In addition to the information listed in (e) (1) -(8) above, the newly eligible adult shall also provide employer and employment information to the department within the 30-day timeframe described in (e) above, to include:

(1) The employer's business name;

(2) The number of hours worked by the employee per week; and

(3) Contact information for the employer's human resource department.

(g) The newly eligible adult shall be granted an additional 15 days to provide the information required in (e) and (f) above when the individual informs the department or the department's vendor that the failure to comply with (e) above was due to one of the following reasons:

(1) There was a serious illness or death in the individual's family;

(2) There was a family emergency or household disaster, such as a fire, flood, or tornado;

(3) The individual offers a cause beyond the individual's control, such as the individual has made multiple unsuccessful attempts to obtain the information; or

(4) There was a failure to receive the department's request for information or notification for a reason not attributable to the individual's lack of a forwarding address.

(h) Except as allowed by (i) below, if the department or the department's vendor determines that the group health plan is cost effective, the newly eligible adult shall:

(1) Enroll in the health plan within 15 days of receiving notification from the department or the department's vendor that the plan is cost effective; and

(2) Upon enrollment, provide the department or the department's vendor with confirmation of the start date of coverage.

(i) In the event that the newly eligible adult is already enrolled in cost effective group health plan prior to applying for medicaid, then the HIPP premium payments will begin in the month following HIPP approval notification.

(j) If the department or the department's vendor determines that the group health plan is not cost effective, the newly eligible adult shall be enrolled in the medicaid care management program in accordance with He-W 506.

(k) Enrollment in a group health plan shall not change the individual's eligibility for medicaid benefits.

#10632, eff 7-1-14

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