Page 12

3540.05.00 POWER ACCOUNT CONTRIBUTION AMOUNT DETERMINATION

All HIP members are initially required to help fund the $2,500 deductible by contributing to the POWER account, established by the member’s health plan, and jointly funded by the member and the State, unless the person is an American Indian/Alaska Native.13

The amount of the required member contribution is determined based on the person’s countable household income using MAGI methodology. The difference between the amount of the deductible and the member’s annual contribution is paid by the State. If an individual (at or below 100% FPL) does not make the fast-track prepayment nor the initial POWER account contribution for HIP Plus, the client will begin HIP Basic or HIP State Plan Basic benefits, as applicable, on the first day of the month in which the sixty (60) day payment period expires.14

A member’s monthly POWER Account contribution (PAC) amounts will be tiered, based on the Federal Poverty level (FPL) percentage ranges. The PAC will change only when a member’s income change moves them to a different FPL percentage range. Table 1 defines the required PAC amounts associated with each tier of FPL percentages.15

HIP will implement a tobacco use surcharge on PAC amounts for all tobacco users effective 1/1/2019. The MCE and/or Maximus will oversee assessing and maintaining the member’s tobacco use. None of the tobacco use information will be kept in the State Eligibility System, the DFR will merely pass the information on to the MCEs when the member indicates tobacco use or non-use on new applications. The tobacco use surcharge will be equal to a 50% increase in a member’s required PAC. PAC amounts for spouses who are tobacco users will also be assessed as a tobacco surcharge. See table 1 for the surcharge amounts associated with each PAC tier.

Table 1 – Monthly PAC amounts based on FPL percentages and tobacco surcharges. FPL% Individual PAC Amount Individual PAC with Tobacco Surcharge ≤ 22% $1.00 $1.50 23-50% $5.00 $7.50 51-75% $10.00 $15.00 76-100% $15.00 $22.50 101-138% $20.00 $30.00

An employer or health care provider or provider-related entity may contribute up to one hundred percent (100%) of a member's annual POWER account obligation.16A health care provider or provider-related entity may contribute to a member’s POWER account provided the following:

• The provider or provider-related entity establishes criteria for aiding that do not distinguish between individuals based on whether they receive or will receive services from the contributing provider or providers or class of providers