10 Colo. Code Regs. § 2505-10-8.066

Current through Register Vol. 47, No. 16, August 25, 2024

Section 10 CCR 2505-10-8.066 - HEALTH INSURANCE BUY-IN

The purpose of the Department of Health Care Policy & Financing (Department)'s Health Insurance Buy-In (HIBI) program is to reduce, or shift, Medicaid liability by paying the cost of private health insurance premiums and out-of-pocket expenses for Medicaid clients, when it is cost-effective for Medicaid to do so. The health insurance premiums, deductibles, coinsurance, or other cost-sharing obligation for services, of Medicaid clients who are enrolled in a group or individual health insurance plan, will be paid by the Department, when it is cost-effective to do so. Payment of said services shall be treated as payment for medical assistance. This program is in addition to a client's regular Medicaid benefits.

.1ELIGIBILITY/CONDITIONS FOR ENROLLMENT

.11 In order to be eligible to participate in the HIBI program, the following criteria must be met:

A. Client must be eligible for Medicaid during the time period for which premium or cost-sharing payment is requested.

B. Client must be covered by, or have access to, a cost-effective group or individual health insurance plan.

C. Client must comply with the requirements of their health insurance plan.

D. Client must provide documentation required by the Department, sufficient to verify eligibility, continuing coverage, and to permit accurate reimbursement.

.12 Once shown to be cost-effective, enrollment in a group or individual health insurance plan shall be required of clients as a condition of obtaining or retaining Medicaid. A client who is a policyholder shall be required to enroll his or her dependents in the insurance plan, if the dependents are Medicaid-eligible and also eligible to enroll in the cost-effective health insurance plan. However, Medicaid for such dependents shall not be discontinued if a policyholder fails to enroll the Medicaid-eligible dependent.

8.066.2COST-EFFECTIVENESS

.21 The determination of cost-effectiveness shall be in accordance with applicable state and federal guidelines.

.22 A Medicaid client's enrollment in a group or individual health plan is cost-effective when the amount paid for premiums and other cost-sharing obligations plus the State's administrative costs are less than Medicaid's expenditure for an equivalent set of services for the average person in the same category of service.

.23 If a plan is determined not to be cost-effective using average Medicaid costs in the above process, the specific client's known historical medical costs may be substituted for the average Medicaid costs in the above formula.

.24 If a Medicaid client has access to more than one health insurance plan, a cost-effectiveness evaluation shall be performed on each. The client shall be informed as to which plan(s), if any, are likely to be cost-effective to Medicaid. The Medicaid client shall be required to enroll in the health plan that indicates the greatest cost savings to Medicaid. If multiple health plans are equally cost-effective, the client may choose which plan to enroll in.

.25 Written notification shall be mailed to the Medicaid client upon approval for participation in HIBI. The notification will include the effective date, participation requirements, and applicable instructions.

.26 The enrollment in, or continuation of, a health insurance plan determined not to be cost-effective shall be the client's decision. The client shall be required to notify the county of any plan change or termination. The disposition of such non-cost-effective health insurance plan shall not affect a client's Medicaid eligibility.

8.066.3PAYMENT OF PREMIUMS

.31 Premiums and cost-sharing will be paid by the Department, from the date the Department receives a premium claim or an approved referral.

A. Up to three (3) months of premium back-payments will only be considered in the following circumstances:

(1) Consolidated Omnibus Budget Reconciliation Act (COBRA) invoice, which may cover one to three months.

(2) The first invoice of any new plan, which may cover more than one month.

(3) Reinstatement of an insurance plan in arrears, if shown to be cost-effective to Medicaid.

(4) In certain cases, if it is cost-effective to Medicaid, and good cause is shown. The term "good cause" is defined as conditions outside the control of the individual such as, but not limited to, sudden illness, fire, theft, or acts of God.

B. For pregnant women, premiums will be paid by the Department through the end of the month following the birth of the baby.

.32 Premium payment will be made to an insurance carrier, employer, COBRA administrator, or directly to the client or policyholder, if circumstances warrant.

.33 Only the portion of the premium that covers the Medicaid client will be paid (i.e., the amount the policyholder would save if he/she were to drop the Medicaid client from coverage). This amount shall be obtained from the premium cost breakdown supplied by the employer or insurance company.

.34 The portion of the premium covering plan members who are not Medicaid-eligible will be paid if paying the full premium amount is necessary to obtain coverage for the Medicaid-eligible client(s).

.35 If payment is made in error, the Department has the right to recover the funds paid in error. If a Medicaid client fails to return monies received, participation in the HIBI program may terminate, and the client's county technician may be notified of undeclared income, which may jeopardize Medicaid eligibility.

8.066.4CRITERIA FOR EXCLUSION

.41 Criteria for exclusion from the HIBI program are as follows:

A. Medicaid payment of the client's health insurance premium is not found to be cost-effective.

B. Client is no longer eligible for Medicaid.

C. Eligibility for, or access to, the health insurance plan has ended.

D. Payment of the Medicaid client's health insurance premium cannot be made because the insurance coverage is a court-ordered obligation.

E. Health Insurance is provided at no cost to either the client or policyholder.

F. Policyholder intends to continue premium payment and does not want to participate in HIBI.

G. Client has not provided documentation required by the Department.

H. Client does not comply with the requirements of their health insurance plan.

.42 Written notification of denial or discontinuation shall be mailed to the Medicaid client upon determination that the Medicaid client is not eligible for participation in the HIBI program. The notification will include the effective date and reason for denial or discontinuation.

.5 USE OF/NON-MEDICAID PROVIDERS

The Medicaid client can continue to use his/her own medical provider that participates in the cost-effective health insurance plan. If the provider is not an approved Medicaid provider, the cost of deductibles, coinsurance, and other cost-sharing amounts will be paid by the Department, if it would still be cost-effective to do so.

.6 CLIENT APPEAL RIGHTS

If a Medicaid client is denied or discontinued from participation in the HIBI program, he/she may appeal the decision to the Department of Health Care Policy and Financing. The aggrieved Medicaid client shall file his or her written appeal within sixty (60) days of the mailing date of the adverse action to the HIBI program, the Department of Health Care Policy & Financing. The written appeal will be reviewed by the HIBI officer and manager. A written response to the appeal will be sent to the appellant within 60 calendar days of receipt of the written appeal. A cost-effectiveness evaluation may be resubmitted to the Department with additional information for consideration. Denial or discontinuation at one point in time does not preclude future participation.

10 CCR 2505-10-8.066