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In situations of dual processing, it is important to inform the applicant/AR that HIP coverage will not be removed for prior approved and fully open (not conditional) coverage. For applicants that are in a nursing facility or are in the process of being approved for a waiver, it is best practice to pursue the MA D process as opposed to processing for HIP coverage.

If a recipient is in a nursing home and was on HIP, a deviation can be completed for medical expenses incurred in a retro month that the recipient was eligible for HIP coverage, if the claim was not a HIP covered service. See IHCPPM 3455.15.10.

It is the provider’s responsibility to work with the Managed Care Entity (MCE) regarding billing issues, up to and including obtaining prior authorization. If a provider was denied prior authorization or a bill was denied by the MCE, the provider must exhaust all grievances and appeals with the MCE before requesting the HIP removal. If the provider disagrees with the MCE determination, then this should be appealed with the MCE, not with the DFR.

If a request to remove pre-existing HIP coverage is received, then the removal will be reviewed on a case-by-case basis. If an actual provider generated bill, or copy of such a bill, is submitted that clearly shows that the provider has billed the Managed Care Entity (if applicable), that the claim was denied, and that the provider has exhausted all appeals and grievances with the MCE, then these can be reviewed by PAL for possible HIP removal; HIP removal is not guaranteed. Please send to PAL for a policy determination.

2220.10.00 CHANGES REPORTED UNTIMELY YET VERIFIED TIMELY

If a change is not reported within 10 days yet is verified within 13 days following the report date, action is taken as indicated below.

When the change results in an increase in benefits or other positive action, the change is effective the month following the date reported and verified.

Example 1: An individual who is required to pay a premium for health coverage is fired from his job on 6/3 and received his last paycheck on 6/23. He called to report the change on 6/28. On 7/3 he faxes in his last paycheck stub. The caseworker verifies by phone that his last day was 6/3 and his last pay was 6/23. The loss of earnings is reflected 7/1 with a supplemental benefit of either a lower premium or no premium for health coverage beginning 7/1.

When the change results in a decrease in benefits or the AG becomes ineligible, the change is effective the month following the expiration of timely notice.

Example 2: An individual begins a job on 5/26 which he reports on 7/19. His earnings require the payment of a premium for health coverage effective 9/1. Recovery is pursued for July and August. Refer to Chapter 4600.00.00.