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CODE OF STATE REGULATIONS 1 ROBIN CARNAHAN (10/31/05) Secretary of State Rules of Department of Social Services Division 70Division of Medical Services Chapter 97Health Insurance Premium Payment (HIPP) Program Title Page 13 CSR 70-97.010 Health Insurance Premium Payment (HIPP) Program ...................................3

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Page 1: Rules of Department of Social Services · Rules of Department of Social Services ... stances of the persons covered under the insurance plan. The HIPP Medical History Questionnaire,

CODE OF STATE REGULATIONS 1ROBIN CARNAHAN (10/31/05)Secretary of State

Rules of

Department of Social ServicesDivision 70�Division of Medical Services

Chapter 97�Health Insurance Premium Payment(HIPP) Program

Title Page

13 CSR 70-97.010 Health Insurance Premium Payment (HIPP) Program...................................3

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Title 13�DEPARTMENT OFSOCIAL SERVICES

Division 70�Division of MedicalServices

Chapter 97�Health Insurance PremiumPayment (HIPP) Program

13 CSR 70-97.010 Health Insurance Pre-mium Payment (HIPP) Program

PURPOSE: This rule establishes guidelinesfor the health insurance premium paymentprogram in accordance with section 1906 ofthe Social Security Act, P.L. 101-508 ofNovember 5, 1990, as amended. The Depart-ment of Social Services, Division of MedicalServices shall pay for the cost of enrolling aneligible Medicaid recipient in a group healthinsurance plan when the Division of MedicalServices determines it is cost-effective to doso.

(1) Definitions. Group health insurance shallmean any plan of, or contributed to by, anemployer (including a self-insured plan) toprovide health care (directly or otherwise) tothe employer�s employees, former employees,or the families of the employees or formeremployees. A group health plan must meetsection 5000(b)(1) of the Internal RevenueCode of 1986, as amended, and include con-tinuation coverage pursuant to Title XXII ofthe Public Health Service Act, section 4980Bof the Internal Revenue Code of 1986, orTitle VI of the Employee Retirement IncomeSecurity Act of 1974, as amended. Participa-tion in a health insurance plan that is notgroup health insurance as defined in this sec-tion is not a condition of Medicaid eligibility.

(2) Condition of Eligibility. An individual eli-gible for Medicaid, or a person acting on therecipient�s behalf, shall cooperate in provid-ing information necessary for the Division ofMedical Services to establish availability andcost-effectiveness of group health insuranceby completing the Application for HealthInsurance Premium Payment (HIPP) Pro-gram, Form MO886-3179(6-94), includedherein. As a condition of Medicaid eligibility,persons who are not enrolled in an availablegroup insurance plan which the division hasdetermined is cost-effective, and who are oth-erwise eligible for Medicaid, shall apply forenrollment in the plan.

(A) The Department of Social Services,Divisions of Medical Services shall pay allenrollee premiums and deductibles, coinsur-ance and other cost-sharing obligations foritems and services otherwise covered underthe Medicaid program. Payment of theseitems is considered as payment for medical

assistance; the group health insurance is theprimary payor to Medicaid. Only coverage ofservices not provided under the group healthplan, but to which the individual is entitledunder the Medicaid program, shall be pro-vided under Medicaid as wrap-around cover-age.

(B) When an applicant, recipient, parent,guardian or caretaker fails to provide infor-mation necessary to determine availabilityand cost-effectiveness of group health insur-ance, Medicaid benefits of the applicant,recipient, parent, guardian or caretaker shallbe denied unless good cause for failure tocooperate is established. If an applicant,recipient, parent, guardian or caretaker failsto enroll in a group health insurance plan thathas been determined cost-effective, or disen-rolls from a group health insurance plan thedepartment has determined cost-effectiveMedicaid benefits of the applicant, recipient,parent, guardian or caretaker shall be termi-nated unless good cause for failure to coop-erate is established. Good cause for failure tocooperate shall be established when the appli-cant, recipient, parent, guardian or caretakerdemonstrates one (1) or more of the follow-ing conditions exist:

1. There was a serious illness or death ofthe applicant, recipient, parent, guardian orcaretaker or a member of the applicant�s,recipient�s, parent�s, guardian�s or caretak-er�s family.

2. There was a family emergency orhousehold disaster such as a fire, flood ortornado;

3. The applicant, recipient, parent,guardian or caretaker offers a good causebeyond the applicant�s, recipient�s, parent�s,guardian�s or caretaker�s control; and

4. There was a failure to receive thedepartment�s request for information or noti-fication for a reason not attributable to theapplicant, recipient, parent, guardian or care-taker. Lack of a forwarding address isattributable to the applicant, recipient, par-ent, guardian or caretaker.

(C) Medicaid benefits of a child shall notbe denied or terminated due to the failure ofthe parent, guardian or caretaker to cooper-ate. Additionally, the Medicaid benefits of thespouse of the employed person shall not bedenied or terminated due to the employedperson�s failure to cooperate when the spousecannot enroll in the plan independently of theemployed person.

(3) Cost-effectiveness. Enrollment in a healthinsurance plan is considered cost-effectivewhen the cost of paying the premiums, coin-sure, deductibles and other cost-sharing obli-gations, and additional administrative costs is

likely to be less than the amount paid for anequivalent set of Medicaid services. Whendetermining the cost-effectiveness of thehealth insurance plan, the following data shallbe considered:

(A) The cost of the insurance premium,coinsurance and deductible.

(B) The scope of services covered underthe insurance plan, including exclusions forpre-existing conditions, exclusions to enroll-ment and lifetime maximum benefitsimposed;

(C) The average anticipated Medicaid uti-lization, by age, sex, geographic location andcoverage group, for persons covered underthe insurance plan;

(D) The specific health-related circum-stances of the persons covered under theinsurance plan. The HIPP Medical HistoryQuestionnaire, Form MO886-3178(6-94)shall be used to obtain this information; and

(E) Annual administrative expenditures ofan amount determined by the Division ofMedical Services per Medicaid recipient cov-ered under the health insurance policy.

(4) Coverage of Non-Medicaid-Eligible Fam-ily Members. When is is determined to becost-effective, the department shall pay forhealth insurance premiums for non-Medi-caid-eligible family members if a non-Med-caid-eligible family member must be enrolledin the health plan in order to obtain coveragefor the Medicaid-eligible family members.However, the needs of the non-Medicaid-eli-gible family members shall not be taken intoconsideration when determining cost-effec-tiveness, and payments for deductibles, coin-surances or other cost-sharing obligationsshall not be made on behalf of family mem-bers who are not Medicaid-eligible.

(5) Exceptions to Payment. Premiums shallnot be paid for health insurance plans underany of the following circumstances:

(A) The insurance plan is designed to pro-vide coverage only for a temporary period oftime (for example, thirty to one hundredeighty (30�180) days);

(B) The insurance plan is a school planoffered on the basis of attendance or enroll-ment at the school;

(C) The premium is used to meet a spend-down obligation when all persons in thehousehold are eligible or potentially eligibleonly under the spenddown program. Whensome of the household members are eligiblefor full Medicaid benefits, the premium shallbe paid if it is determined to be cost-effectivewhen considering only the persons receivingfull Medicaid coverage. In those cases, thepremium shall not be allowed as a deduction

CODE OF STATE REGULATIONS 3ROBIN CARNAHAN (10/31/05)Secretary of State

Chapter 97�Health Insurance Premium Payment (HIPP) Program 13 CSR 70-97

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to meet the spenddown obligation for thosepersons in the household participating in thespenddown program. As long as the healthinsurance premium is not used as a deductionto income when determining client participa-tion in the Medicaid program, then spend-down coverage shall not exclude a Medicaideligible individual from participating in theHIPP program;

(D) The insurance plan is an indemnitypolicy which supplements the policyholder�sincome or pays only a predetermined amountfor services covered under the policy (forexample, fifty dollars ($50) per day for hos-pital services instead of eighty percent (80%)of the charge); or

(E) The persons covered under the plan arenot Medicaid-eligible on the date the decisionregarding eligibility for the HIPP program ismade.

(6) Duplicate Policies. When more than one(1) health insurance plan or policy is avail-able, the Department of Social Services,Division of Medical Services shall pay onlyfor the most cost-effective plan. However, insituations where the department is buying-into the cost of Medicare Part A or Part B foreligible Medicare beneficiaries, the cost ofpremiums for a Medicare supplemental insur-ance policy may also be paid if the depart-ment determines it is likely to be cost-effec-tive to do so.

(7) Discontinuance of Premium Payments.When all Medicaid-eligible members coveredunder the health insurance plan lose Medi-caid eligibility, premium payments shall bediscontinued as of the month of Medicaidineligibility. When only some of the Medi-caid-eligible members covered under thehealth insurance plan lose Medicaid eligibili-ty, a review shall be completed in order toascertain whether payment of the healthinsurance premium continues to be cost-effective.

(8) Effective Date of Premium Payment. Theeffective date of premium payments for cost-effective health insurance plans shall bedetermined as follows:

(A) Premium payments for cost-effectivehealth insurance plans shall begin with themonth the HIPP program application isreceived by the department, or the effectivedate of eligibility, whichever is later. If theperson is not currently enrolled in the cost-effective health insurance plan, premium pay-ments shall begin in the month in which thefirst premium payment is due after enroll-ment occurs; and

(B) In no case shall payments be made forpremiums which are used as a deduction to

income when determining client participationin the Medicaid program.

(9) Method of Premium Payment. Paymentsof health insurance premiums will be madedirectly to the insurance carrier except as fol-lows:

(A) The department may arrange for pay-ment to the employer to circumvent a payrolldeduction;

(B) When the employer will not agree toaccept premium payments from the depart-ment in lieu of a payroll deduction to theemployee�s wages, the department shall reim-burse the policyholder directly for payrolldeductions or for payments made directly tothe employer for the payment of health insur-ance premiums:

(C) When premium payments occurthrough an automatic withdrawal from a bankaccount by the insurance carrier, the depart-ment may reimburse the policyholder for saidwithdrawals; and

(D) When the department is otherwiseunable to make direct premium paymentsbecause the health insurance is offeredthrough a contract that covers a group of per-sons identified as individuals by reference totheir relationship to the entity, the departmentshall reimburse the policyholder for premiumpayments made to the entity.

(10) Reviews of Cost-Effectiveness. Reviewsof cost-effectiveness will be completed atleast every six (6) months for employer-relat-ed group health plans and annually fornonemployer-related group health plans.Additionally, redeterminations shall be com-pleted whenever a predetermined premiumrate, deductible, or coinsurance increases,some of the persons covered under the policylose full Medicaid eligibility, loss of employ-ment when the insurance is through anemployer, or there is a decrease in the ser-vices covered under the policy. Recipientsshall report all changes concerning healthinsurance coverage to the local Division ofFamily Service�s office within ten (10) daysof the change.

(11) Notices.(A) Notice shall be provided to the house-

hold under the following circumstances:1. To inform the household of the initial

decision on cost-effectiveness and premiumpayment (Form MO886-3180(6-94) or FormMO886-3181(6-94));

2. To inform the household that premi-um payments are being discontinued becauseMedicaid eligibility has been lost by all per-sons covered under the policy (Form MO886-3182(6-94)); or

3. The policy is no longer available tothe family (for example, the employer dropsinsurance coverage or the policy is terminat-ed by the insurance company, Form MO886-3182(6-94)).

(B) A timely notice shall be provided to thehousehold informing them of a decision todiscontinue payment of the health insurancepremium because the department has deter-mined the policy is not longer cost-effective(Form MO886-3182(6-94)).

(C) Notice of appeal and hearing rights areas provided for in 208.080, RSMo.

(12) Premium or Rate Refunds. The depart-ment shall be entitled to any premium refunddue to overpayment of premium or paymentof an inactive policy for any time period forwhich the department paid the premium. Thedepartment shall be entitled to any raterefund made when the health insurance carri-er determines a return of premiums to thepolicyholder is due, because of lower thananticipated claims, for any time period forwhich the department paid the premium.

4 CODE OF STATE REGULATIONS (10/31/05) ROBIN CARNAHANSecretary of State

13 CSR 70-97�DEPARTMENT OF SOCIAL SERVICES Division 70�Division of Medical Services

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CODE OF STATE REGULATIONS 5ROBIN CARNAHAN (10/31/05)Secretary of State

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6 CODE OF STATE REGULATIONS (10/31/05) ROBIN CARNAHANSecretary of State

13 CSR 70-97�DEPARTMENT OF SOCIAL SERVICES Division 70�Division of Medical Services

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CODE OF STATE REGULATIONS 7ROBIN CARNAHAN (10/31/05)Secretary of State

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8 CODE OF STATE REGULATIONS (10/31/05) ROBIN CARNAHANSecretary of State

13 CSR 70-97�DEPARTMENT OF SOCIAL SERVICES Division 70�Division of Medical Services

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CODE OF STATE REGULATIONS 9ROBIN CARNAHAN (10/31/05)Secretary of State

Chapter 97�Health Insurance Premium Payment (HIPP) Program 13 CSR 70-97

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10 CODE OF STATE REGULATIONS (10/31/05) ROBIN CARNAHANSecretary of State

13 CSR 70-97�DEPARTMENT OF SOCIAL SERVICES Division 70�Division of Medical Services

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CODE OF STATE REGULATIONS 11ROBIN CARNAHAN (10/31/05)Secretary of State

Chapter 97�Health Insurance Premium Payment (HIPP) Program 13 CSR 70-97

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13 CSR 70-97�DEPARTMENT OF SOCIAL SERVICES Division 70�Division of Medical Services

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CODE OF STATE REGULATIONS 13ROBIN CARNAHAN (10/31/05)Secretary of State

Chapter 97�Health Insurance Premium Payment (HIPP) Program 13 CSR 70-97

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14 CODE OF STATE REGULATIONS (10/31/05) ROBIN CARNAHANSecretary of State

13 CSR 70-97�DEPARTMENT OF SOCIAL SERVICES Division 70�Division of Medical Services

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CODE OF STATE REGULATIONS 15ROBIN CARNAHAN (10/31/05)Secretary of State

Chapter 97�Health Insurance Premium Payment (HIPP) Program 13 CSR 70-97

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AUTHORITY: sections 208.153 and 208.201,RSMo 2000.* Original rule filed June 30,1994, effective Jan. 29, 1995. Amended:Filed June 1, 2005, effective Nov. 30, 2005.

*Original authority: 208.153, RSMo 1967, amended1973, 1989, 1990, 1991 and 208.201, RSMo 1987.

16 CODE OF STATE REGULATIONS (10/31/05) ROBIN CARNAHANSecretary of State

13 CSR 70-97�DEPARTMENT OF SOCIAL SERVICES Division 70�Division of Medical Services