Pathways Health Insurance Premium Payment (HIPP) Program
A/Rs with access to Employer Sponsored Insurance (ESI) must enroll in the Pathways HIPP program if it is determined to be cost-effective for the State.
Cost-effectiveness is defined as a savings of $1.00 or more per year for the State. It takes into account the cost to the State paying the A/R’s cost-sharing obligations, including premiums, for the employer’s insurance compared to the cost of paying Medicaid capitation rates. Cost-effectiveness will be determined by the Third-Party Liability (TPL) vendor using their proprietary formulas and processes.
If the A/R is determined eligible for Pathways but is determined not to be cost-effective to enroll in ESI, the A/R will receive an approval notice from Gateway for Pathways and be enrolled into a CMO.
HIPP Referral Process - An A/R who reports having access to or reports being currently enrolled in ESI at application will be referred to the TPL vendor Health Management Systems (HMS) for an ESI cost-effectiveness determination if they are identified as potentially eligible for Pathways. The A/R will receive a notice informing them of this referral. The eligibility determinations for Pathways and for ESI cost-effectiveness will occur concurrently in order to remain within the 45-day standard of promptness requirement for eligibility determination. Gateway will determine eligibility for Pathways while the TPL vendor will determine cost-effectiveness for ESI. If the A/R is determined eligible for Pathways and is determined cost-effective to enroll in ESI, the A/R will receive an approval notice from Gateway outlining requirements for ongoing participation and next steps for enrollment with the TPL vendor. A/Rs enrolled in the Pathways HIPP program will have their ESI premium payments and cost-sharing obligations (including copayments & deductibles) made on their behalf by the State. The Pathways HIPP program was effective May 2024.