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.
"Cost effective" and "cost effectiveness" mean the
reduction in Title XIX expenditures, which are likely to be greater than the
additional expenditures for premiums and cost-sharing items required under
§ 1906 of the Social Security Act (the Act), with respect to such
enrollment.
"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 that 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, § 4980B
of the Internal Revenue Code of 1986, or Title VI of the Employee Retirement
Income Security Act of 1974. 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 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 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 that 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
group health plan; such cost may be shared by the employer and employee or paid
in full by either party.
"Premium assistance subsidy" means the portion that DMAS
will pay of the employee's cost of participating in a qualified
employer-sponsored insurance plan to cover the Medicaid eligible members under
the employer-sponsored plan if DMAS determines it is cost effective to do
so.
"Qualified employer-sponsored insurance" as defined under
§ 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
Program shall be to:
1. Enroll members who
have qualified employer-sponsored insurance plans that are likely to be cost
effective;
2. Provide premium
assistance subsidy for payment of the employee share of the premiums and other
cost-sharing obligations for items and services otherwise covered under the
State Plan for Medical Assistance; and
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 individual 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 cost for the individual 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 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
all group health plans available to the recipients in the case including the
effective date of coverage, the services covered by the plan, the deductibles
and copayments required by the plan, the exclusions to the plan, and the amount
of the premium. 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 persons who are eligible for coverage under the qualified
employer-sponsored insurance plan and who are eligible for Medicaid shall be
eligible for consideration for HIPP, except those identified in subdivisions 2
a through 2 e of this subsection.
a. The
recipient is Medicaid eligible due to "spenddown."
b. The recipient is currently enrolled in the
qualified employee-sponsored insurance plan and is only retroactively eligible
for Medicaid.
c. The recipient is
in a nursing home or has a deduction from patient pay responsibility to cover
the insurance premium.
d.
Currently, Medicare beneficiaries who are enrolled in a MCO do not qualify for
participation in the HIPP Program. If a Medicaid beneficiary is enrolled in an
MCO, the beneficiary must wait until he is disenrolled from the MCO to become
eligible for HIPP. HIPP applications are not approved until the managed care
eligibility has ended at the end of the month.
e. The recipient is eligible for Medicare
Part B but is not enrolled in Part B.
E. Application required. A completed HIPP
application must be submitted to DMAS to be evaluated for HIPP program
eligibility; if HIPP program eligibility is established, DMAS shall then
evaluate the group health plan for cost effectiveness. The HIPP application
consists of the forms prescribed by DMAS and any necessary information as
required by the program to evaluate eligibility and perform a
cost-effectiveness evaluation.
1. Effective
date of premium assistance subsidy. Payment of premium assistance subsidy shall
become effective on the first day of the month following the month in which
DMAS approves the application and makes the cost effectiveness determination.
Payment shall be made to either the employer, the insurance company, or to the
individual who is carrying the group health plan coverage.
2. Termination date of premium assistance
subsidy. 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
recipient loses eligibility for coverage in the qualified employer-sponsored
insurance plan; or
c. 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 redetermined that the group health plan is no longer cost
effective.
3.
Non-Medicaid-eligible family members. Payment of premium assistance subsidy for
non-Medicaid-eligible family members may be made when their enrollment in the
qualified employer-sponsored insurance plan is required in order for the
recipient to obtain the qualified employer-sponsored insurance plan coverage.
Such payments shall be treated as payments for Medicaid benefits for the
recipient. No payments for deductibles, coinsurances, and other cost-sharing
obligations for non-Medicaid-eligible family members shall be made by
DMAS.
4. Evidence of enrollment
required. The payee to whom DMAS is paying the qualified employer-sponsored
insurance plan premium assistance subsidy shall, as a condition of receiving
such payment, provide to DSS or DMAS, upon request, written evidence of the
payment of the employee's share of the plan premium for the qualified
employer-sponsored insurance plan that DMAS determined to be cost
effective.
F.
Cost-sharing wrap.
1. Premium assistance
enrollment is voluntary. Individuals enrolled in the 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 state 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.
G. HIPP program participation requirements.
Participants must comply with the following program requirements as prescribed
by DMAS for continued enrollment in HIPP. Failure to comply shall result in
termination from the program.
1. Submission
of documentation of any change 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 change, including income and
individuals in 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 participation and program requirements
as required by DMAS.
H.
HIPP redetermination. DMAS shall redetermine the cost effectiveness of the
qualified employer-sponsored insurance plan periodically, and at least every 12
months. DMAS shall also redetermine cost effectiveness when changes occur with
the recipient's average Medicaid cost or with the qualified employer-sponsored
insurance plan information that was used in determining the cost effectiveness.
When only part of the household loses Medicaid eligibility, DMAS shall
redetermine the cost effectiveness to ascertain whether payment of the premium
assistance subsidy of the qualified employer-sponsored insurance plan continues
to be cost effective.
I. Multiple
group health plans. When a member is eligible for more than one group health
plan, DMAS shall perform the cost effectiveness determination on the group
health plan in which the member is enrolled. If the member is not enrolled in a
group health plan, DMAS shall perform the cost effectiveness determination on
each group health plan available to the member.
J. Third-party liability. When recipients are
enrolled in group health plans, these plans shall become the first sources of
health care benefits, up to the limits of such plans, prior to the availability
of Title XIX benefits.
K. 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)
.
L. Provider requirements.
Providers shall be required to accept the greater of the group health plan's
reimbursement rate or the Medicaid rate as payment in full and shall be
prohibited from charging the recipient or Medicaid amounts that would result in
aggregate payments greater than the Medicaid rate as required by
42 CFR
447.20.
M. Provider participation or enrollment. The
Commonwealth will enroll network providers as full Medicaid providers or 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 state enrolls providers
for the sole purpose of being reimbursed for cost sharing, the payee 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. 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.
