Current through Register Vol. 41, No. 3, September 23, 2024
A. Definitions. The following words and terms
when used in this section shall have the following meanings unless the context
clearly indicates otherwise:
"Case" means all family members who are eligible for
coverage under the qualified employer-sponsored insurance plan and who are
eligible for Medicaid.
"Code" means the Code of Virginia.
"DMAS" means the Department of Medical Assistance Services
consistent with Chapter 10 (§ 32.1-323 et seq.) of Title 32.1 of the Code
of Virginia.
"DSS" means the Department of Social Services consistent
with Chapter 1 (§ 63.2-100 et seq.) of Title 63.2 of the Code of
Virginia.
"Family member" means an individual in the household, who
is not a parent and who is related by blood, marriage, adoption, or legal
custody.
"Group health plan" means a plan which meets §
5000(b)(1) of the Internal Revenue Code of 1986 and includes continuation
coverage pursuant to Title XXII of the Public Health Service Act (42 USC §
201 et seq.), § 4980B of the Internal
Revenue Code of 1986, or Title VI of the Employee Retirement Income Security
Act of 1974 (42 USC § 200I et seq.). Section 5000(b)(1) of the Internal
Revenue Code provides that a group health plan is a plan, including a
self-insured plan, of, or contributed to by, an employer (including a
self-insured person) or employee association to provide health care (directly
or otherwise) to the employees, former employees, or the families of such
employees or former employees, or the employer.
"High deductible health plan" means a plan as defined in
§ 223(c)(2) of the Internal Revenue Code of 1986, without regard to
whether the plan is purchased in conjunction with a health savings account (as
defined under § 223(d) of the Internal Revenue Code of 1986).
"HIPP" means the Health Insurance Premium Payment Program
administered by DMAS consistent with § 1906 of the Social Security Act
(42 USC §
301 et seq.) (the Act).
"HIPP for Kids" means the Health Insurance Premium Payment
Program administered by DMAS consistent with § 1906A of the Act.
"Member" means a person who is eligible for Medicaid as
determined by DMAS or a DMAS designated agent, including the Department of
Social Services.
"Network provider" means a provider who is enrolled with a
DMAS contracted managed care organization (MCO) as a provider and meets the
requirement for an expedited enrollment as a fee-for-service (FFS) Medicaid
provider for payment and billing purposes.
"Parent" means the biological or adoptive parent, or the
biological or adoptive parent and the stepparent, living in the home with the
Medicaid-eligible child. The health insurance policyholder shall be a parent as
defined in this section.
"Payee" means the insured employee who is the policy holder
of the qualified employer-sponsored insurance plan who is paid the HIPP or HIPP
for Kids premium and cost-sharing reimbursement.
"Premium" means the fixed cost of participation in the
qualified employer-sponsored insurance plan, which cost may be shared by the
employer and employee or paid in full by either party.
"Premium assistance subsidy" means the amount that DMAS
will pay of the employee's cost of participating in the qualified
employer-sponsored insurance plan to cover the Medicaid eligible member younger
than 19 years of age if DMAS determines it is cost effective to do so.
"Qualified employer-sponsored insurance" as defined in
§ 2105(c)(10)(B) of the Social Security Act means a group health plan or
health insurance coverage offered through an employer:
1. That qualifies as creditable coverage as a
group health plan under § 2701(c)(1) of the Public Health Service
Act;
2. For which the employer
contribution toward any premium for such coverage is at least 40%;
and
3. That is offered to all
individuals in a manner that would be considered a nondiscriminatory
eligibility classification for purposes of § 105(h)(3)(A)(ii) of the
Internal Revenue Code of 1986 without regard to § 105(h)(3)(B)(i).
"State Plan" means the State Plan for Medical Assistance
for the Commonwealth of Virginia.
B. Program purpose. The purpose of the HIPP
for Kids program shall be to:
1. Enroll
members who are eligible for coverage under a qualified employer-sponsored
insurance plan.
2. Provide premium
assistance subsidy for payment of the employee share of the premiums and other
cost-sharing obligations for the Medicaid-eligible child younger than 19 years
of age. In addition, to provide cost sharing for the child's parent who is not
Medicaid eligible for items and services covered under the qualified
employer-sponsored insurance that are also covered services under the State
Plan. There is no cost sharing for parents for services not covered by the
qualified employer-sponsored insurance.
3. Treat coverage under such qualified
employer-sponsored insurance plan as a third-party liability consistent with
§ 1906 of the Social Security Act.
C. Cost effectiveness methodology.
1. DMAS shall evaluate the member to
determine the appropriate managed care organization (MCO) capitation rate to be
used. The capitation rate will be determined based on aid category, nursing
facility or waiver eligibility, age, gender, and region.
2. DMAS shall adjust the capitation rate to
exclude Medicaid services that are not available through commercial group
health insurance policies. This requires that the capitation rate be adjusted
to exclude services, including nursing facility and long-term services and
supports provided in the Commonwealth Coordinated Care (CCC) Plus program as
well as community mental health services and nonemergency transportation
services available in CCC Plus and Medallion.
3. DMAS shall adjust the reduced capitation
rate from subdivision 2 of this subsection to reflect the higher prices
employer plans pay. The Virginia price factor shall be based on the national
factor of 1.3 that is published by the Centers for Medicare and Medicaid
Services.
4. The qualified
employer-sponsored insurance plan cost for the member shall be increased to
reflect the amount of coinsurance and other member cost sharing typically
imposed on HIPP members and paid by DMAS. Such amount shall be determined by
averaging the aggregate amount of such expenditures by DMAS in the most
recently completed fiscal year by the number of HIPP members covered during the
fiscal year.
5. The qualified
employer-sponsored insurance plan cost determined in subdivision 4 of this
subsection shall be increased to reflect the DMAS administrative expenses
directly related to the HIPP program. This additional cost is determined based
on the average total monthly compensation paid to each HIPP analyst employed by
DMAS and divided by the anticipated caseload.
6. The cost effectiveness shall be affirmed
if the adjusted capitation rate from subdivision 3 of this subsection equals or
exceeds the adjusted qualified employer-sponsored insurance plan cost from
subdivision 5 of this subsection.
D. Member eligibility.
1. DMAS shall obtain specific information on
qualified employer-sponsored insurance available to the members in the case
including the effective date of coverage, the services covered by the plan, the
deductibles and copayments required by the plan, and the amount of the premium
paid by the employer and employee. Coverage that is not comprehensive shall be
denied premium assistance. A qualified employer-sponsored insurance plan must
provide the following services in order to be considered comprehensive:
a. Physician services;
b. Inpatient and outpatient
hospitalization;
c. Outpatient
labs, shots, and x-rays; and
d.
Prescription drugs.
2.
All Medicaid-eligible family members younger than 19 years of age who are
eligible for coverage under the qualified employer-sponsored insurance shall be
eligible for consideration for HIPP for Kids except the following:
a. The member who is Medicaid eligible due to
"spenddown"; or
b. The member who
is currently enrolled in the qualified employer-sponsored insurance and is only
retroactively eligible for Medicaid.
E. Application required. A completed HIPP for
Kids application must be submitted to DMAS to be evaluated for program
eligibility. The HIPP for Kids application consists of the forms prescribed by
DMAS and any necessary information as required by the program to evaluate
eligibility and determine if the plan meets the criteria for qualified
employer-sponsored insurance.
F.
Exceptions. The term "qualified employer-sponsored insurance" does not include
coverage consisting of:
1. Benefits provided
under a health flexible spending arrangement (as defined in § 106(c)(2) of
the Internal Revenue Code of 1986);
2. A high deductible health plan (as defined
in § 223(c)(2) of the Internal Revenue Code of 1986), without regard to
whether the plan is purchased in conjunction with a health savings account (as
defined under § 223(d) of the Internal Revenue Code of 1986); or
3. For self-employed individuals, qualified
employer-sponsored insurance obtained through self-employment activities shall
not meet the program requirements unless the self-employment activities are the
family's primary source of income and the insurance meets the requirements of
the definition of qualified employer-sponsored insurance in subsection A of
this section. Family for this purpose includes family by blood, marriage, or
adoption.
G. Payments.
When DMAS determines that a qualified employer-sponsored insurance plan is
eligible and other eligibility requirements have been met, DMAS shall provide
for the payment of premium assistance subsidy and other cost-sharing
obligations for items and services otherwise covered under the State Plan,
except for the nominal cost-sharing amounts permitted under § 1916 of the
Social Security Act.
1. Effective date of
premium assistance subsidy. Payment of premium assistance subsidies and other
cost-sharing obligations shall become effective on the first day of the month
following an approved application for which qualified employer-sponsored
insurance becomes effective. Payments shall be made to the individual who is
carrying the qualified employer-sponsored insurance plan coverage.
2. Payments for deductibles, coinsurances,
and other cost-sharing obligations.
a.
Medicaid eligible children younger than 19 years of age pursuant to §
1906A of the Act. The Medicaid agency pays all premiums, deductibles,
coinsurance, and other cost-sharing obligations for items and services covered
under the State Plan, as specified in the qualified employer-sponsored
insurance, without regard to limitations specified in § 1916 or 1916A of
the Act, for eligible individuals younger than 19 years of age who have access
to and elect to enroll in such coverage. The eligible individual is entitled to
services covered by the State Plan that are not included in the qualified
employer-sponsored insurance.
b. In
order to receive reimbursement, the individual shall submit to DMAS an
explanation of benefits or similar documentation from the insurance company or
doctor's office showing the date of service (DOS), that the expense is the
responsibility of the member or parent, that the expense was paid prior to the
submission of the request, and sufficient identification codes for the DOS to
enable DMAS to determine if the service is reimbursable before applying the
remaining cost sharing criteria.
c.
Reimbursement for cost sharing shall be processed on a quarterly
basis.
d. Ineligible family
members. When coverage for Medicaid-eligible family members younger than 19
years of age is not possible unless a parent who is not Medicaid eligible
enrolls in qualified employer-sponsored health insurance, the Medicaid agency
pays premiums for enrollment of the parent who is not Medicaid eligible and
other family members who are eligible for coverage under the qualified
employer-sponsored insurance. In addition, the agency provides cost sharing for
the parent who is not Medicaid eligible for items and services covered under
the qualified employer-sponsored insurance that are also covered services under
the State Plan. There is no cost sharing for parents who are not Medicaid
eligible for items and services not covered by the qualified employer-sponsored
insurance.
3.
Documentation required for premium assistance subsidy reimbursement. A payee to
whom DMAS is paying a qualified employer-sponsored insurance premium assistance
subsidy shall, as a condition of receiving such payment, provide documentation
as prescribed by DMAS of the payment of the qualified employer-sponsored
insurance plan premium, as well as payment of coinsurances, copayments, and
deductibles for services received.
H. Cost-sharing wrap.
1. Premium assistance enrollment will be
voluntary. Individuals enrolled in the Commonwealth's Health Insurance Premium
Payment (HIPP) program are afforded the same member protections provided to all
other Medicaid enrollees. Cost sharing shall only be charged to Medicaid
members as permitted under §§ 1916 and 1916A of the Social Security
Act. Cost sharing shall not exceed 5.0% of household income.
2. The Commonwealth will provide a
cost-sharing wrap to any cost-sharing amounts of a Medicaid covered service
that exceeds the cost-sharing limits described in the State Plan, regardless of
whether individuals enrolled in a HIPP program receive care from a Medicaid
participating provider or a nonparticipating provider.
3. To effectuate the cost-sharing wrap, the
Commonwealth will encourage nonparticipating providers to enroll by conducting
targeted outreach to inform nonparticipating Medicaid providers on how to
enroll in Medicaid for the purposes of receiving payment from the Commonwealth
for cost-sharing amounts that exceed the Medicaid permissible limits.
4. The Commonwealth will inform members
regarding options available when the member obtains care from a
nonparticipating provider, including, as applicable, reimbursement for
out-of-pocket, cost-sharing costs from this provider.
5. In order to receive reimbursement, the
individual shall submit to DMAS an explanation of benefits or similar
documentation from the insurance company or doctor's office showing DOS, that
the expense is the responsibility of the member or parent, that the expense was
paid prior to the submission of the request, and sufficient identification
codes for the DOS to enable DMAS to determine if the service is reimbursable
before applying the remaining cost-sharing criteria.
6. Reimbursement for cost-sharing shall be
processed on a quarterly basis.
I. Program participation requirements.
Participants must comply with program requirements as prescribed by DMAS for
continued enrollment in HIPP for Kids. Failure to comply with the following may
result in termination from the program:
1.
Submission of documentation of any changes to the qualified employer-sponsored
insurance plan, to include any changes to the employee share of the premium
expense, within 10 days of receipt of notice of the change.
2. Any household changes, including income
and individuals in the household, must be reported within 10 days of the
change.
3. Completion of annual
redetermination.
4. Completion of
consent forms. Participants may be required to complete a consent form to
release information necessary for HIPP for Kids participation and program
requirements as required by DMAS.
J. HIPP for Kids redetermination. DMAS shall
redetermine the eligibility of the qualified employer-sponsored insurance
periodically, at least every 12 months. DMAS shall also redetermine eligibility
when changes occur with the qualified employer-sponsored insurance plan
information that was used in determining HIPP for Kids eligibility.
K. Program termination. Participation in the
HIPP for Kids program may be terminated for failure to comply or meet program
requirements. Termination will be effective the last day of the month in which
advance notice has been given (consistent with federal requirements at
42 CFR 431.211) .
1. Participation may be terminated for
failure to meet program requirements including the following:
a. Failure to submit documentation of payment
of premiums;
b. Failure to provide
information required for reevaluation of the qualified employer-sponsored
insurance;
c. Loss of Medicaid
eligibility for all household members;
d. Medicaid household member no longer
covered by the qualified employer-sponsored insurance;
e. Medicaid-eligible child turns 19 years of
age; or
f. Employer-sponsored
health plan no longer meets qualified employer-sponsored insurance
requirements.
2.
Termination date of premiums. Payment of premium assistance subsidy shall end
on whichever of the following occurs the earliest:
a. On the last day of the month in which
eligibility for Medicaid ends;
b.
The last day of the month in which the member loses eligibility for coverage in
the qualified employer-sponsored insurance plan;
c. The last day of the month in which the
child turns 19 years of age;
d. The
last day of the month in which adequate notice has been given (consistent with
federal requirements at
42 CFR 431.211)
that DMAS has determined that the qualified employer-sponsored insurance plan
no longer meets program eligibility criteria; or
e. The last day of the month in which
adequate notice has been given (consistent with federal requirements at
42 CFR 431.211)
that HIPP for Kids participation requirements have not been
met.
L.
Third-party liability. When members are enrolled in qualified
employer-sponsored insurance plans, these plans shall become the first sources
of health care benefits, up to the limits of such plans, prior to the
availability of payment under Title XIX.
M. Appeal rights. Applicants and members
shall be given the opportunity to appeal adverse agency decisions consistent
with agency regulations for client appeals (12VAC30-110-10
through
12VAC30-110-370)
.
N. Provider requirements.
Providers shall be required to accept the greater of the qualified
employer-sponsored insurance plan's reimbursement rate or the Medicaid rate as
payment in full and shall be prohibited from charging the member or the
Medicaid program amounts that would result in aggregate payments greater than
the Medicaid rate as required by
42 CFR
447.20.
O. Provider participation or enrollment. The
Commonwealth will enroll network providers as full Medicaid providers or enroll
as fee-for-service Medicaid providers solely for the purpose of receiving cost
sharing, similar to processes related to enrolling Medicare-participating
providers that serve dually eligible members. If the Commonwealth enrolls
providers for the sole purpose of being reimbursed for cost sharing, the
provider would make the decision to enroll knowing that the provider network
would be the same as for other enrollees of the qualified employer-sponsored
insurance plan. In either scenario, the member would never pay more than the
permissible Medicaid copayment.
Statutory Authority: §32.1-325 of the Code of Virginia; 42 USC §
1396 et
seq.
