Section 471-30-003 - PARTICIPATION IN THE HEALTH INSURANCE PREMIUM PAYMENT (HIPP) PROGRAM003.01VOLUNTARY PARTICIPATION IN HEALTH INSURANCE PREMIUM PAYMENT (HIPP). Participation in the Health Insurance Premium Payment (HIPP) Program is voluntary. For Medicaid eligible clients, enrollment in the Health Insurance Premium Payment (HIPP) Program does not change the client's eligibility for benefits through the state plan or cost sharing obligations under the state plan.003.02PARTICIPATION DETERMINATION FOR HEALTH INSURANCE PREMIUMPAYMENT (HIPP).003.02(A)REQUIRED DOCUMENTATION. The Department may request any documentation from the client that it deems to be necessary to determine whether the client's enrollment in an available group health plan or individual market health plan is cost effective. Documentation that must be submitted includes, but is not limited to: (i) Signed application for enrollment in the Health Insurance Premium Payment (HIPP) Program;(ii) Summary of covered benefits from the group health plan or individual market health plan;(iii) If applicable, verification of the client's ongoing medical diagnosis. Verification must be provided by an appropriate physician or entity;(iv) Completed verification form for employer sponsored insurance; and (v) Monthly proof of health insurance premium payments.003.03EFFECTIVE DATE OF PARTICIPATION IN THE HEALTH INSURANCE PREMIUM PAYMENT (HIPP) PROGRAM. The effective date for Health Insurance Premium Payment (HIPP) participation is the first day of the month that the following criteria are met: (A) The client is enrolled in a group health plan or individual market health plan;(B) All documentation necessary for Medicaid to determine cost effectiveness has been submitted; and(C) The Department has determined that the client's participation in Health Insurance Premium Payment (HIPP) would be cost effective.003.04COST-EFFECTIVENESS DETERMINATION. The Department determines the cost-effectiveness for payment of qualifying group health insurance or individual market health insurance premiums. 003.04(A)COST-EFFECTIVE MEDICAL CONDITIONS. Any Medicaid-eligible client who has an existing, ongoing, medically confirmed medical condition determined by the Department to be considered a cost-effective condition, is deemed to meet the cost-effective criteria.003.04(B)COST-EFFECTIVENESS CALCULATION. When the criteria of 471 Nebraska Administrative Code (NAC) 30-003.03(A) are not met, cost-effectiveness will be calculated as follows: (i) Determine the annual anticipated cost for Medicaid services generally covered by the private health insurance based on the client's age, sex, and eligibility category;(ii) Total the results of each of the following calculations:(1) The portion of the group health insurance or individual market health insurance premium payable by the Health Insurance Premium Payment (HIPP) program;(2) A predetermined annual administration cost per participant; and(3) The expected cost to Medicaid for any deductibles, coinsurance, or copayments.(iii) Subtract the result of (ii) from the result of (i);(iv) If the result is greater than or equal to $10, the policy would be determined cost effective; and(v) If the result is less than $10, the policy would not be considered cost effective. 003.04(C)SUPPLEMENTAL INFORMATION. When the criteria of 471 NAC 30-003.04(A) and 471 NAC 30-004.03(B) are not met, specific information relating to the individual circumstances of the Medicaid-eligible client may be provided. On a case-by-case basis and at the sole discretion of the Department, a determination of cost effectiveness can be made if sufficient evidence is provided to demonstrate savings to Medicaid.003.04(D)EXCLUDED CASES. The Department will not make a determination of cost effectiveness in the following circumstances: (i) The client is eligible for or enrolled in Medicare;(ii) Payment of health insurance premiums have been fully reimbursed or offset by a third party, including, but not limited to:(2) An individual court-ordered to provide medical support.(iii) The recipient is only eligible for a medically needy, spend-down, program; or(iv) The group health insurance or individual market health insurance only provides catastrophic, limited benefit, limited duration, or indemnity coverage.003.04(E)MULTIPLE POLICIES. When more than one group or individual market health insurance policy is available, the Department shall pay only for the most cost-effective policy. 003.04(E)(i)EXCEPTION FOR SUPPLEMENTAL POLICIES. At the sole discretion of the Department, in the circumstance when an additional supplemental policy is available and that policy is found to provide coverage that does not duplicate coverage included in the primary health insurance plan, the Department may include both the primary health plan and supplemental policy in its cost-effectiveness calculation. If the Department finds that paying the costs described in 471 NAC 30-003.04 for both the primary and supplemental health policies is more cost effective than paying solely for the costs of the primary health policy, the Department may pay for the costs of both the primary and supplemental health policies.003.04(F)REDETERMINATIONS.003.04(F)(i)ANNUAL REDETERMINATION. The Department conducts a redetermination of participation annually for all clients enrolled in the Health Insurance Premium Payment (HIPP) Program. This redetermination includes: (1) Verification of eligibility for Medicaid; and(2) Completion of the cost-effective calculation as outlined in 471 NAC 30-004.03(A) through 30-004.03(C).003.04(F)(ii)CHANGES IN CIRCUMSTANCES. A redetermination of participation may be conducted at any point if: (1) The monthly premium of the group health insurance or individual market health insurance increases by more than $50;(2) There is a change in eligibility category or status for Medicaid;(3) The services offered by the group health insurance or individual market health insurance decrease;(4) There is a change in the deductible, co-insurance, or any other cost-sharing provisions of the group health policy or individual market health policy; or(5) There is reason to believe a change has occurred which may affect participation for Health Insurance Premium Payment (HIPP) enrollment. The client has an affirmative obligation to report any change in circumstances.
003.05TERMINATION OF HEALTH INSURANCE PREMUIM PAYMENT (HIPP) PARTICIPATION. Failure to provide requested documentation in accordance with 471 NAC 30-003.02(A), or failure to meet Health Insurance Premium Payment (HIPP) enrollment participation criteria as outlined in 471 NAC 30-004.01 and 30-004.03, may result in termination of participation in the Health Insurance Premium Payment (HIPP) Program.471 Neb. Admin. Code, ch. 30, § 003
Adopted effective 7/1/2019