The purpose of new Rule 59G-7.007 is to implement the Health Insurance Premium Payment (HIPP) program to reimburse recipients for premiums paid to Employer Sponsored Insurance plans.

 

AGENCY FOR HEALTH CARE ADMINISTRATION

Medicaid

RULE NO.:RULE TITLE:

59G-7.007Health Insurance Premium Payment Program

PURPOSE AND EFFECT: The purpose of new Rule 59G-7.007, F.A.C., is to implement the Health Insurance Premium Payment (HIPP) program to reimburse recipients for premiums paid to Employer Sponsored Insurance plans.

SUMMARY: This rule provides the criteria necessary to determine which Medicaid recipients may be required to participate in the HIPP program and which recipients may voluntarily choose to participate instead of enrolling in a Medicaid managed care plan. It also provides a formula to determine the cost effectiveness of providing financial assistance to recipients.

SUMMARY OF STATEMENT OF ESTIMATED REGULATORY COSTS AND LEGISLATIVE RATIFICATION: The Agency has determined that this will not have an adverse impact on small business or likely increase directly or indirectly regulatory costs in excess of $200,000 in the aggregate within one year after the implementation of the rule. A SERC has not been prepared by the Agency.

The Agency has determined that the proposed rule is not expected to require legislative ratification based on the statement of estimated regulatory costs or if no SERC is required, the information expressly relied upon and described herein: A checklist was prepared by the Agency to determine the need for a SERC. Based on this information at the time of the analysis and pursuant to Section 120.541, Florida Statutes, the rule will not require legislative ratification.

Any person who wishes to provide information regarding a statement of estimated regulatory costs, or provide a proposal for a lower cost regulatory alternative must do so in writing within 21 days of this notice.

RULEMAKING AUTHORITY: 409.919 FS.

LAW IMPLEMENTED: 409.977(4) FS.

IF REQUESTED WITHIN 21 DAYS OF THE DATE OF THIS NOTICE, A HEARING WILL BE HELD AT THE DATE, TIME AND PLACE SHOWN BELOW (IF NOT REQUESTED, THIS HEARING WILL NOT BE HELD):

DATE AND TIME: Monday, November 24, 2014, 10:00 a.m. ‒ 11:00 a.m.

PLACE: Agency for Health Care Administration, 2727 Mahan Drive, Building 3, Conference Room D, Tallahassee, Florida 32308-5407

Pursuant to the provisions of the Americans with Disabilities Act, any person requiring special accommodations to participate in this workshop/meeting is asked to advise the agency at least 48 hours before the workshop/meeting by contacting: Nikki Gordon. If you are hearing or speech impaired, please contact the agency using the Florida Relay Service, 1(800)955-8771 (TDD) or 1(800)955-8770 (Voice).

THE PERSON TO BE CONTACTED REGARDING THE PROPOSED RULE IS: Nikki Gordon, Bureau of Medicaid Services, 2727 Mahan Drive, Mail Stop 20, Tallahassee, Florida 32308-5407, telephone: [phone], e-mail: [e-mail]

Comments will be received until 5:00 p.m. on Tuesday, November 25, 2014.

 

THE FULL TEXT OF THE PROPOSED RULE IS:

 

59G-7.007 Health Insurance Premium Payment Program.

(1) Under the Health Insurance Premium Payment (HIPP) program, the Agency for Health Care Administration (AHCA) shall provide financial assistance to recipients in order to obtain or maintain Employer Sponsored Insurance (ESI) coverage pursuant to Section 409.977(4), F.S. This includes the recipient’s share of the ESI premiums, copayments, deductibles, coinsurance and other cost sharing obligations for items and Medicaid services covered under the State Plan. The amount of financial assistance provided for each recipient may not exceed the amount of the Medicaid managed care premium that would have been paid for that recipient.

(2) Participation.

(a) Recipients must enroll in or be enrolled in and maintain their ESI coverage during the period of participation.

(b) Participation in the program shall be subject to a cost effectiveness determination as defined in subsection (3) of this rule by AHCA and subsequent redeterminations, at least once every six months.

1. For non-pregnant adult Medicaid recipients with access to ESI for whom AHCA has made a determination of cost effectiveness, participation shall be mandatory.

2. For Medicaid recipients with proof of ESI through a spouse or other family member for whom AHCA has made a determination of cost effectiveness, participation shall be voluntary.

(c) Health Insurance Premium Payment program participation may terminate upon any of the following events:

1. Loss of Medicaid eligibility.

2. Loss of access to ESI coverage.

3. A determination of non-cost effectiveness.

(3) Health Insurance Premium Payment assistance cost effectiveness determination.

(a) When determining cost effectiveness, the following data elements shall be considered:

1. The amount of the Medicaid managed care premium that would have been paid for that recipient.

2. The amount of the recipient’s share of the ESI premium.

3. The amount of copayments, coinsurance, deductibles and other cost sharing obligations as determined by the average fee-for-service expenditures for recipients with other comparable insurance coverage.

4. The amount of AHCA’s administrative cost.

(b) The calculation used to determine whether a recipient qualifies for HIPP assistance shall be a = (b+c+d). The Medicaid managed care premium (a), must be greater than or equal to amount of the recipient’s share of the ESI premium (b), plus the amount for copayments, coinsurance, deductibles and other cost sharing obligations (c), plus the amount of any administrative cost (d).

(4) Premium payments.

(a) Any financial assistance provided towards the payment of a recipient’s share of the ESI premium shall be in the form of a reimbursement issued after AHCA’s receipt of the proper documentation. Recipients must pay their ESI premium and submit a request with supporting documentation for reimbursement.

Rulemaking Authority 409.919 FS. Law Implemented 409.977(4) FS. History–New__________.

 

NAME OF PERSON ORIGINATING PROPOSED RULE: Nikki Gordon

NAME OF AGENCY HEAD WHO APPROVED THE PROPOSED RULE: Elizabeth Dudek

DATE PROPOSED RULE APPROVED BY AGENCY HEAD: September 25, 2014

DATE NOTICE OF PROPOSED RULE DEVELOPMENT PUBLISHED IN FAR: May 13, 2013