13 CSR 70-97.010 - Health Insurance Premium Payment (HIPP) Program
PUBLISHER'S NOTE: The secretary of state has determined that the publication of the entire text of the material which is incorporated by reference as a portion of this rule would be unduly cumbersome or expensive. This material as incorporated by reference in this rule shall be maintained by the agency at its headquarters and shall be made available to the public for inspection and copying at no more than the actual cost of reproduction. This note applies only to the reference material. The entire text of the rule is printed here.
(1) Definitions.
(A) "Group health insurance" shall mean any
plan of, or contributed to by, an employer (including a self-insured plan) to
provide health care (directly or otherwise) to the employer's employees, former
employees, or the families of the employees or former employees. A group health
plan must meet section 5000(b)(1) of the Internal
Revenue Code of 1986, as amended, and include continuation coverage pursuant to
Title XXII of the Public Health Service Act, section 4980B of the
Internal Revenue Code of 1986, or Title VI of the Employee
Retirement Income Security Act of 1974, as amended. Participation in a health
insurance plan that is not group health insurance as defined in this section is
not a condition of MO HealthNet eligibility.
(B) "Participant" shall mean MO HealthNet
enrollee eligible for comprehensive or full coverage under
Medicaid.
(2) Condition
of Eligibility. An individual eligible for MO HealthNet, or a person acting on
the participant's behalf, shall cooperate in providing information necessary
for the MO HealthNet Division to establish availability and cost-effectiveness
of group health insurance by completing the Application for Health Insurance
Premium Payment (HIPP) Program, Form MO886-3179(2-98). As a condition of MO
HealthNet eligibility, persons who are not enrolled in an available group
insurance plan which the division has determined is cost-effective, and who are
otherwise eligible for MO HealthNet, shall apply for enrollment in the plan.
(A) The Department of Social Services, MO
HealthNet Division shall pay all enrollee premiums and deductibles, coinsurance
and other cost-sharing obligations for items and services otherwise covered
under the MO HealthNet program. Payment of these items is considered as payment
for medical assistance; the group health insurance is the primary payer to MO
HealthNet. Only coverage of services not provided under the group health plan,
but to which the individual is entitled under the MO HealthNet program, shall
be provided under MO HealthNet as wrap-around coverage.
(B) When an applicant, participant, parent,
guardian, or caretaker fails to provide information necessary to determine
availability and cost-effectiveness of group health insurance, MO HealthNet
benefits of the applicant, participant, parent, guardian, or caretaker shall be
denied unless good cause for failure to cooperate is established. If an
applicant, participant, parent, guardian, or caretaker fails to enroll in a
group health insurance plan that has been determined cost-effective, or
disenrolls from a group health insurance plan the department has determined
cost-effective MO HealthNet benefits of the applicant, participant, parent,
guardian, or caretaker shall be terminated unless good cause for failure to
cooperate is established. Good cause for failure to cooperate shall be
established when the applicant, participant, parent, guardian, or caretaker
demonstrates one (1) or more of the following conditions exist:
1. There was a serious illness or death of
the applicant, participant, parent, guardian, or caretaker or a member of the
applicant's, participant's, parent's, guardian's, or caretaker's
family.
2. There was a family
emergency or household disaster such as a fire, flood, or tornado;
3. The applicant, participant, parent,
guardian, or caretaker offers a good cause beyond the applicant's,
participant's, parent's, guardian's, or caretaker's control; and
4. There was a failure to receive the
department's request for information or notification for a reason not
attributable to the applicant, participant, parent, guardian, or caretaker.
Lack of a forwarding address is attributable to the applicant, participant,
parent, guardian, or caretaker.
(C) MO HealthNet benefits of a child shall
not be denied or terminated due to the failure of the parent, guardian, or
caretaker to cooperate. Additionally, the MO HealthNet benefits of the spouse
of the employed person shall not be denied or terminated due to the employed
person's failure to cooperate when the spouse cannot enroll in the plan
independently of the employed person.
(3) Cost-effectiveness. Enrollment in a
health insurance plan is considered cost-effective when the cost of paying the
premiums, coinsurance, deductibles, and other cost-sharing obligations, and
additional administrative costs is likely to be less than the amount paid for
an equivalent set of MO HealthNet services. When determining the
cost-effectiveness of the health insurance plan, the following data shall be
considered:
(A) The cost of the insurance
premium, coinsurance, and deductible;
(B) The scope of services covered under the
insurance plan;
(C) The average
anticipated MO HealthNet utilization, by age, sex, geographic location, and
coverage group, for persons covered under the insurance plan;
(D) The specific health-related circumstances
of the persons covered under the insurance plan; and
(E) Annual administrative expenditures of an
amount determined by the MO HealthNet Division per MO HealthNet participant
covered under the health insurance policy.
(4) Coverage of Non-MO HealthNet-Eligible
Family Members. When it is determined to be cost-effective, the department
shall pay for health insurance premiums for non-MO HealthNet-eligible family
members if a non-MO HealthNet-eligible family member must be enrolled in the
health plan in order to obtain coverage for the MO HealthNet-eligible family
members. When the department determines the health insurance plan or policy not
to be cost-effective due to the cost of paying for non-MO HealthNet-eligible
family members, the department shall consider the cost of the insurance
premiums for the policyholder and MO HealthNet-eligible family members only in
the determination. This exception shall only apply if the option is available
with the health insurance plan. However, the needs of the non-MO
HealthNet-eligible family members shall not be taken into consideration when
determining cost-effectiveness, and payments for deductibles, coinsurances, or
other cost-sharing obligations shall not be made on behalf of family members
who are not MO HealthNet-eligible.
(5) Exceptions to Payment. Premiums shall not
be paid for health insurance plans under any of the following circumstances:
(A) The insurance plan is designed to provide
coverage only for a temporary period of time (for example, thirty to one
hundred eighty (30-180) days);
(B)
The insurance plan is a school plan offered on the basis of attendance or
enrollment at the school;
(C) The
premium is used to meet a spend-down obligation when all persons in the
household are eligible or potentially eligible only under the spenddown
program. When some of the household members are eligible for full MO HealthNet
benefits, the premium shall be paid if it is determined to be cost-effective
when considering only the persons receiving full MO HealthNet coverage. In
those cases, the premium shall not be allowed as a deduction to meet the
spenddown obligation for those persons in the household participating in the
spenddown program. As long as the health insurance premium is not used as a
deduction to income when determining client participation in the MO HealthNet
program, then spenddown coverage shall not exclude a MO HealthNet eligible
individual from participating in the HIPP program;
(D) The insurance plan is an indemnity policy
which supplements the policyholder's income or pays only a predetermined amount
for services covered under the policy (for example, fifty dollars ($50) per day
for hospital services instead of eighty percent (80%) of the charge);
(E) CHIP-eligible participants;
(F) Medicare;
(G) Court-ordered health insurance;
(H) The persons covered under the plan are
not MO HealthNet-eligible on the date the decision regarding eligibility for
the HIPP program is made; or
(I)
The participant is enrolled in a MHD managed care plan.
(6) Duplicate Policies. When more than one
(1) health insurance plan or policy is available, the Department of Social
Services, MO HealthNet Division shall pay only for the most cost-effective
plan.
(7) Discontinuance of Premium
Payments. When all MO HealthNet-eligible members covered under the health
insurance plan lose MO HealthNet eligibility, premium payments shall be
discontinued as of the month of MO HealthNet ineligibility. When only some of
the MO HealthNet-eligible members covered under the health insurance plan lose
MO HealthNet eligibility, a review shall be completed in order to ascertain
whether payment of the health insurance premium continues to be
cost-effective.
(8) Effective Date
of Premium Payment. The effective date of premium payments for cost-effective
health insurance plans shall be determined as follows:
(A) Premium payments for cost-effective
health insurance plans shall begin with the month the HIPP program application
is received by the department, or the effective date of eligibility, whichever
is later. If the person is not currently enrolled in the cost-effective health
insurance plan, premium payments shall begin in the month in which the first
premium payment is due after enrollment occurs; and
(B) In no case shall payments be made for
premiums which are used as a deduction to income when determining client
participation in the MO HealthNet program.
(9) Method of Premium Payment. Payments of
health insurance premiums will be made directly to the insurance carrier except
as follows:
(A) The department may arrange for
payment to the employer to circumvent a payroll deduction;
(B) When the employer will not agree to
accept premium payments from the department in lieu of a payroll deduction to
the employee's wages, the department shall prospectively pay the policyholder
directly for payroll deductions or for payments made directly to the employer
for the payment of health insurance premiums;
(C) When premium payments occur through an
automatic withdrawal from a bank account by the insurance carrier, the
department may prospectively pay the policyholder for said
withdrawals;
(D) When the
department is otherwise unable to make direct premium payments because the
health insurance is offered through a contract that covers a group of persons
identified as individuals by reference to their relationship to the entity, the
department shall prospectively pay the policyholder for premium payments made
to the entity; and
(E) Participants
shall provide documentation to the department of the monthly premium paid by
payroll deduction or bank account auto-withdrawal. This documentation must be
received by the department on a monthly basis. Failure to provide this
documentation on a timely basis may result in non-payment of the HIPP premium
by the department or exclusion from the HIPP program.
(10) Reviews of Cost-Effectiveness. Reviews
of cost-effectiveness will be completed at least every six (6) months for
employer-related group health plans and annually for nonemployer-related group
health plans. Additionally, redeterminations shall be completed whenever a
predetermined premium rate, deductible, or coinsurance increases, some of the
persons covered under the policy lose full MO HealthNet eligibility, there is a
change in MO HealthNet eligibility, loss of employment when the insurance is
through an employer, or there is a decrease in the services covered under the
policy. Participants shall report all changes concerning health insurance
coverage to the local Family Support Division's office within ten (10) days of
the change.
(11) Notices.
(A) Notice shall be provided to the household
under the following circumstances:
1. To
inform the household of the initial decision on cost-effectiveness and premium
payment (Form MO886-3180(02/05) or Form MO886-3181(02/05));
2. To inform the household that premium
payments are being discontinued because MO HealthNet eligibility has been lost
by all persons covered under the policy (Form MO886-3182(02/05)); or
3. The policy is no longer available to the
family (for example, the employer drops insurance coverage or the policy is
terminated by the insurance company, Form MO886-3182(02/05)).
(B) A timely notice shall be
provided to the household informing them of a decision to discontinue payment
of the health insurance premium because the department has determined the
policy is no longer cost-effective (Form MO886-3182(02/05)).
(C) Notice of appeal and hearing rights are
as provided for in 208.080, RSMo.
(12) Premium or Rate Refunds. The department
shall be entitled to any premium refund due to overpayment of premium or
payment of an inactive policy for any time period for which the department paid
the premium. The department shall be entitled to any rate refund made when the
health insurance carrier determines a return of premiums to the policyholder is
due, because of lower than anticipated claims, for any time period for which
the department paid the premium.
(13) Administration. HIPP Program information
and forms are currently located and can be accessed on the MO HealthNet
Division's website at www.dss.mo.gov/mhd.
(14) Dental and Vision Benefits. Dental and
vision insurance policies will not be eligible for premium assistance unless
the benefits are part of the medical policy and cannot be separated from the
medical policy premium. Dental and vision benefits will be provided to
participants through wrap-around coverage.
(15) Cost Sharing. The department must be
notified three (3) weeks prior to a Medicaid-covered service to receive
prospective payment for any cost sharing obligation. Payment for cost sharing
related to services obtained without notice to the department will be
reimbursed. Documentation supporting the services occurred, and cost sharing
payment was made, must be submitted to the department by the end of the month
following the date of service.
Notes
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