The purpose of new rule 59G-7.007 is to implement the Health Insurance Premium Payment Program to reimburse recipients for premiums paid to employer health coverage 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 is to implement the Health Insurance Premium Payment Program to reimburse recipients for premiums paid to employer health coverage plans.

SUBJECT AREA TO BE ADDRESSED: Health insurance premium payment program; participation; cost effectiveness determination; premium payments.

RULEMAKING AUTHORITY: 409.919 FS.

LAW IMPLEMENTED: 409.977(4) FS.

IF REQUESTED IN WRITING AND NOT DEEMED UNNECESSARY BY THE AGENCY HEAD, A RULE DEVELOPMENT WORKSHOP WILL BE NOTICED IN THE NEXT AVAILABLE FLORIDA ADMINISTRATIVE REGISTER.

THE PERSON TO BE CONTACTED REGARDING THE PROPOSED RULE DEVELOPMENT AND A COPY OF THE PRELIMINARY DRAFT IS: Lee Peacock, Third Party Liability, 2727 Mahan Drive, Mail Stop 19, Tallahassee, Florida 32308-5407, telephone: [phone], e-mail: [e-mail]

 

THE PRELIMINARY TEXT OF THE PROPOSED RULE DEVELOPMENT IS:

59G-7.007 Health Insurance Premium Payment Program.

(1) Under the Health Insurance Premium Payment (HIPP) program the Agency for Health Care Administration (Agency) shall provide financial assistance to pay for the cost of health care premiums, pursuant to subsection 409.977(4), Florida Statutes. This would include wrap around services such as coinsurance, deductibles, and non-covered Medicaid required services. 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 Employer Sponsored Insurance (ESI) or other insurance coverage during the period of participation.

(b) Participation in the program shall be subject to a determination by the Agency of cost effectiveness and subsequent re-determinations at least annually.

1. For Medicaid recipients with access to ESI for whom the Agency has made a determination of cost effectiveness, participation shall be mandatory.

2. For Medicaid recipients with access to ESI through a spouse or other family member or other insurance for whom the Agency has made a determination of cost effectiveness, participation shall be voluntary.

(c) Medicaid recipients with access to ESI or other insurance for whom the Agency has made a determination of non-cost effectiveness may choose to voluntarily participate and receive a partial reimbursement of their ESI or other insurance premium.

(d) HIPP participation may terminate upon any of the following events:

1. Loss of Medicaid eligibility.

2. Loss of access to ESI or other insurance.

3. A determination of non-cost effectiveness.

(3) 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 monthly ESI or other insurance premium reimbursement.

3. The amount of the wrap around services determined by the average monthly fee for service expenditures for recipients with other comparable insurance coverage.

4. The amount of the monthly administrative cost.

(b) The calculation used to determine cost effectiveness shall be: a ≥ (b+c+d). The Medicaid Managed Care Premium (a), must be greater than or equal to the recipient’s share of the ESI or other insurance premium reimbursement (b), plus the amount of the cost for wrap around services (c), plus the amount of any administrative cost (d).

(c) The calculation used to determine the amount of a partial payment of a recipient’s ESI or other insurance premium when it is determined that participation is not cost effective shall be: a-(c+d) = b. The Medicaid Managed Care Premium (a), minus the amount of the cost for wrap around services (c), plus the amount of any administrative cost (d), equals the amount of the partial ESI or other insurance monthly premium that can be paid (b).

(4) Premium payments.

(a) Any financial assistance provided towards the payment of a recipient’s ESI or other insurance premium shall be in the form of a reimbursement issued after the Agency’s receipt of the proper documentation. Recipients must pay their ESI or other insurance premium and file a claim, with supporting documentation, for reimbursement.

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