| (a) Purpose. The Medicaid Health Insurance Premium
Payment (HIPP) program is established under §1906 of the Social
Security Act (42 U.S.C. §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 (42 U.S.C. §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 §§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.
Cont'd... |
