Texas Administrative Code, Division 7, Section 354.2361 - Medicaid Health Insurance Premium Payment Program | Texas Administrative Code

(a) Purpose. The Medicaid Health Insurance Premium Payment (HIPP) program is established under §1906 of the Social Security Act (RSA 1396e) to reimburse an eligible individual's portion of employer-sponsored health insurance premium payments, when cost-effective.

(b) Definitions. The following words and terms, when used in this section, have the following meanings unless the context clearly indicates otherwise:

(1) Cost-effective--In accordance with §1906 of the Social Security Act (RSA 1396e(e)(2)), the amount paid for premiums, coinsurance, deductibles, other cost sharing obligations under a group health plan, and additional administrative costs is less than the amount paid for an equivalent set of Medicaid services.

(2) Employer-sponsored insurance (ESI)--A group health plan offered to an employee through the employer.

(3) Explanation of Benefits (EOB)--A document provided by the insurance company that shows the type of medical service, the date of service, the amount paid by the insurance company, and the amount paid by the individual receiving medical services.

(4) Family member--Any member of a family for which the employer-sponsored insurance plan will allow coverage, such as a spouse or child.

(5) Group health plan--In accordance with Title 26, Internal Revenue Code, §5000(b)(1), a plan (including a self-insured plan) of, or contributed to by, an employer (including a self-employed person) or employee organization to provide health care (directly or otherwise) to the employees, former employees, the employer, others associated or formerly associated with the employer in a business relationship, or their families.

(6) Health and Human Services Commission (HHSC)--The single state agency charged with administration and oversight of the Texas Medicaid program, or its designee.

(7) Open enrollment--The time period established by an employer during which an employee is eligible to sign up for ESI or make changes to an existing ESI benefit plan.

(8) Qualifying event--An event which allows for an individual to enroll in or dis-enroll from a group health plan at any time, within or outside the plan's open enrollment period.

(9) Rate sheet--A document provided by an employer or an insurance company that shows the insurance premium amount the employee is responsible for paying each month.

(10) Summary of benefits--A document provided by an employer or an insurance company that shows the amount the insurance company pays for medical services provided under the benefit plan.

(c) Employee eligibility and requirements.

(1) To qualify for the HIPP program, an employee must be enrolled in:

(A) Medicaid or have a family member that is enrolled in Medicaid;

(B) ESI; and

(C) an ESI plan that allows enrollment of a family member that is enrolled in Medicaid.

(2) The following plans or programs are not eligible for the HIPP program:

(A) Children's Health Insurance Program (CHIP); and

(B) STAR Health Managed Care Program.

(3) Premium payment reimbursement may be available for eligible individuals and their family members who get ESI benefits when it is determined that the cost of insurance premiums, coinsurance, deductibles, and other cost sharing obligations is less than the cost of projected or actual Medicaid expenditures for the family member(s) eligible to receive Medicaid services.

(4) Individuals enrolled in Medicaid and eligible for the HIPP program can receive Medicaid-covered services that are not covered by ESI; Medicaid services not covered by ESI must be provided by a Medicaid-enrolled provider.

(5) Individuals enrolled in Medicaid and eligible for the HIPP program must obtain medical services through their ESI before seeking those services through Medicaid. Medicaid is a payor of last resort and, as such, can be used only for those services not available through their ESI.

(6) Each HIPP program case is subject to an annual re-evaluation of each new ESI benefit period to determine if the case is still cost-effective, regardless of any changes to the individual's Medicaid or ESI. On-going eligibility is approved if a case is determined cost-effective at the annual review.

(7) A determination of HIPP program eligibility is effective for the current ESI benefit period or one year from the date of acceptance into the program unless:

(A) the employer's insurance benefit plan open enrollment period occurs prior to the date of initial acceptance into the program;

(B) the employee's ESI changes and, as a result, a new case review determines the case to no longer be cost-effective;

(C) the employee's or the family member's Medicaid eligibility changes or is denied;

(D) the employee is no longer employed, or the employee's ESI is terminated prior to the employee's renewal date in the HIPP program; or

(E) the employee has not provided required documentation in accordance with HIPP program timelines.

(8) The following documentation is required to be submitted by an individual at initial enrollment and annual re-enrollment in the HIPP program, unless there are no changes to the information provided at initial enrollment or an employer has submitted the information on behalf of the individual:

(A) ESI summary of benefits;

(B) ESI rate sheet; and

(C) ESI card.

(9) HHSC may request additional documentation if needed to establish eligibility in the HIPP program, such as:

(A) ESI explanation of benefits;

(B) proof of ESI payment (paycheck stub); or

(C) a signed HIPP program authorization form for HHSC to obtain ESI information on behalf of the individual.

(10) During enrollment or re-enrollment in the HIPP program, if HHSC determines that an ESI benefit plan costs more than Medicaid, HHSC may cover fewer family members in the HIPP program, if HHSC determines that covering fewer family members is cost-effective.

(d) Employer requirements.

(1) To be eligible for participation in the HIPP program, an insurance benefit plan offered to employees by the employer must:

(A) be able to cover family members eligible for Medicaid; and

(B) pay at least 60 percent of the costs for the following:

(i) doctor's visits;

(ii) prescriptions;

(iii) out-patient care;

(iv) lab tests or x-rays; and

(v) inpatient care.

(2) Upon receiving a signed HIPP program authorization form, or in response to a request directly from an employee, an employer must provide the requested ESI insurance benefits and coverage information to HHSC, or the employee, in a timely manner to prevent delays in the employee's enrollment in the HIPP program.

(3) As established under Texas Insurance Code §§ RSA 1207.001 to 1207.004, upon written notification from HHSC that the employee is eligible for Medicaid, an employer must treat an employee's enrollment in the HIPP program as a qualifying event by allowing the employee to enroll in or dis-enroll from the employer's group health insurance plan at any time during the plan year.

(4) To prevent premium payment reimbursement delays during the HIPP program renewal period, an employer must provide to HHSC information reflecting any changes from the current year's ESI benefit plan to the new year's ESI benefit plan as soon as it is available during the open enrollment period or before an open enrollment period starts. The information must include:

(A) insurance company change;

(B) insurance rate sheet;

(C) summary of benefits; and

(D) any additional changes to the ESI benefit plan affecting employees.

(e) Premium Reimbursements.

(1) Payments made to reimburse an employee for the employee's portion of the ESI premium cannot begin until HHSC has received and validated all required and complete documentation for enrollment or re-enrollment in the HIPP program.

(2)Proof of insurance premium payment must be sent to HHSC each month before HHSC reimburses an employee for the employee's portion of the ESI premium.

(3) HHSC does not reimburse an employee for the employee's portion of the ESI premium for premium payments paid prior to the HIPP program eligibility start date.

(4) HHSC may reimburse an employee for the employee's portion of the ESI premium up to three months after the month the premium was paid for currently enrolled individuals; HHSC does not reimburse employees for proof of payments received after three months from the date the premium was paid.

(f) HHSC notifies Medicaid individuals in writing in the following circumstances:

(1) After review of a complete application, HHSC provides:

(A) eligibility approval for the HIPP program, including the premium reimbursement amount to be paid; or

(B) denial of eligibility for the HIPP program, including the reason for the denial.

(2) At yearly renewal or when the HIPP program has identified potential changes to an individual's ESI, family, or Medicaid status, HHSC provides a request for information.

(3)When HHSC has identified an overpayment, HHSC provides notice of the overpayment and repayment options.

(4) When HHSC receives notification that a HIPP program premium reimbursement was not received, HHSC provides a stop payment request which must be completed and returned to HHSC before HHSC issues a replacement check.

(g) Overpayments.

(1) HHSC recovers identified overpayments as a result of erroneous HIPP program reimbursements.

(2) HHSC notifies individuals in writing that a HIPP program overpayment has occurred.

(3) If the HIPP program overpayment is not refunded to HHSC prior to the next scheduled HIPP program reimbursement, HHSC automatically deducts the overpayment from the next scheduled HIPP program reimbursement and each month following until the overpayment has been fully refunded to HHSC.

(4) An individual enrolled in the HIPP program, or an employer with an employee enrolled in the HIPP program, must notify HHSC of any known HIPP program overpayments.