(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 Sections 409.9122(14) and 409.977(4), F.S. This includes the recipient’s share of the ESI premiums, copayments, deductibles, coinsurance and other cost sharing obligations for Medicaid services and items 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.
    (a) The recipient’s health care services will be covered through their ESI primary coverage. Medicaid will cover the lesser of the ESI required copayments, deductibles, or coinsurance, up to the Medicaid fee when the recipient’s ESI provider is also a Medicaid enrolled provider. Medicaid will deduct any applicable Medicaid copay for covered state plan services. If a recipient chooses to utilize non-Medicaid providers, only the ESI coverage will apply and the recipient may be subject to ESI required copayments, deductibles, or coinsurance.
    (b) Medicaid will cover any state plan services that are not provided by the recipient’s ESI when those services are provided by an enrolled Medicaid provider.
    (2) Participation in the HIPP program.
    (a) Recipients must enroll in or be enrolled in and maintain their ESI coverage during the period of participation. Recipients will be identified by AHCA, or its designee, and will be sent an enrollment package.
    (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) HIPP premium payments.
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 receipt of the proper documentation. Recipients must pay their ESI premium and submit a request with supporting documentation for reimbursement to AHCA, or its designee.
Rulemaking Authority 409.919 FS. Law Implemented 409.977(4) FS. History-New 3-30-15.