Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 75 - Conditions of Eligibility › Rule 441-75.21 - Health Insurance Premium Payment (HIPP) Program

Current through Register Vol. 47, No. 3, July 24, 2024
Under the HIPP program, the department shall pay for the cost
				  of premiums, coinsurance, copayments, and deductibles for Medicaid-eligible
				  individuals when the department determines that those costs will be less than
				  the cost of paying for the individual's care through Medicaid including managed
				  care capitation fees. Payment shall include only the cost to the
				  Medicaid-eligible individual or household.
(1)
Definitions.
"Absentparent"
means a noncustodial parent,
				  or a parent who is not living with the member.
"Authorized representative"
means an
				  individual or organization authorized by a competent applicant or member,
				  authorized by a responsible person acting for an incompetent applicant or
				  member pursuant to 441-subrule 76.9(2), or with other legal authority to
				  represent the applicant or member in the application process, renewal of
				  eligibility and other ongoing communications with the department.
"Capitation payment"
means a monthly payment
				  to the managed care contractor on behalf of each member for the provision of
				  health services under the managed care entity contract. Payment is made by the
				  department regardless of whether the member receives services during the month.
				  The managed care capitation payment varies based on the eligible member's sex,
				  age, and eligibility aid type.
"Cost-effective "
means a determination has
				  been made that a savings will accrue to the department by paying the insurance
				  premium, cost sharing, wrap benefits, and administrative cost.
"Cost sharing"
means the member's portions
				  of in-network health care costs not covered by an insurance plan. "Cost
				  sharing" includes copayments, coinsurance and deductibles, which vary among
				  health care plans.
"Custodian "
means the person recognized as
				  representing the interests of the member for Medicaid assistance. When the
				  member reaches the age of 18 and the custodian is not used in determining
				  Medicaid eligibility, there shall be legal documentation in place that the
				  custodian is now the responsible person or authorized representative.
"Department"
means the Iowa department of
				  human services.
"Employer-sponsored insurance "
or
"ESI"
means any health insurance plan paid for by a business
				  on behalf of its employees.
"High-deductible health plan "
or
"HDHP "
means a health insurance plan that meets the
				  definition found in Section 223(c)(2) of the Internal Revenue Code.
"HIPP-eligible member"
means a person whose
				  Medicaid eligibility is calculated in the cost-effective determination for
				  HIPP. "HIPP-eligible member" is also referred to as HIPP enrollee.
"Household"
means the group of people who
				  are used in the budgeting and size when determining Medicaid
				  eligibility.
"Individualplan"
means an insurance plan
				  purchased through a government-run health insurance marketplace or through a
				  local broker or agent.
"Insurance plan"
means major medical
				  comprehensive health coverage provided through an employer, the Consolidated
				  Omnibus Budget Reconciliation Act of 1985 (COBRA), a government-run health
				  insurance marketplace, or a local broker or agent. Dental and vision plans are
				  not considered to be insurance plans for purposes of this definition.
"Member"
means an individual who has been
				  determined eligible for Medicaid assistance and is enrolled to receive
				  assistance.
"Policyholder "
means the person in whose
				  name an insurance policy is registered.
"Responsible person "
means an individual
				  recognized by the department pursuant to 441-subrule 76.9(1) as acting for an
				  applicant or member who is unable to act on the applicant's or member's own
				  behalf because the applicant or member is a minor or is incompetent,
				  incapacitated, or deceased.
"Wrap benefits "
means the services covered
				  under the Medicaid state plans that are not paid for by insurance plans (i.e.,
				  waiver services, transportation).
(2)
Insurance plans.
Participation in an insurance plan is not a condition of Medicaid eligibility.
				The department shall pay for the cost of the insurance plan premiums,
				coinsurance, copayment, and deductibles of an insurance plan for a member if:
a. A member is enrolled in or can be added to
				the insurance plan; and
b. The
				insurance plan is cost-effective as defined in subrule 75.21(3).