CHAPTER He-W 500  MEDICAL ASSISTANCE

 

REVISION NOTE:

 

          Pursuant to RSA 161:4, VI, the Division of Human Services (Division) in December, 1993 and January, 1994 filed with the Office of Legislative Services renumbered and reorganized existing rules under Chapter He-W 500 governing the Division's medical assistance program.  The Director of the Office of Legislative Services (OLS) reviewed the changes pursuant to RSA 161:4, VI(b).  As certified by the agency, these changes in numbering and organization of existing rules pursuant to RSA 161:4, VI(b) were limited to title, chapter, part, section, and subsection changes and non-substantive changes in the text so as to conform to the renumbering and reorganization.

 

          The renumbered and reorganized Chapter He-W 500 supersedes all previous filings for rules in this chapter.  However, these certified changes by the Division do not affect the adoption, effective, or expiration dates of the text of the rules in Chapter He-W 500.  Pursuant to RSA 161:4, VI(b), the changes in numbering and organization were effective January 7, 1994 for citation purposes with a notice published in the New Hampshire Rulemaking Register.

 

          The Division with its certification filed a conversion index to relate the new rule numbering to the former rule numbering and section titles, and that index is included below.  The index also includes the most recent document numbers for rule filings under the former numbering, with the effective and expiration dates, so that the reader can examine the dates applicable to the respective rules in the renumbered and reorganized Chapter He-W 500.

 

New Part #

Old Section #

Old Section Title

Doc. #

Eff. Date

Exp. Date

 

 

 

 

 

 

520

501.01

General Program Information

5018

11/30/90

11/30/96

501

502.01

General Medical Eligibility (Int. Rule #93-011)

5749

12/1/93

3/31/94

502

502.02

Aid to the Needy Blind (ANB) Program

5019

11/30/90

11/30/96

502.04

502.02(d)

 

5272

11/15/91

11/15/97

503

502.03

Aid to the Permanently and Totally Disabled (Int. Rule #93-011)

5749

12/1/93

3/31/94

 

502.04

(Reserved)

 

 

 

505

502.05

Aid to Families with Dependent Children Program

5623

5/13/93

5/13/99

 

502.06

(Reserved) was: Notice Requirement - Medicaid (EXPIRED)

2918

11/30/84

11/30/90

507

502.07

Medical Assistance for Children with Severe Disabilities

4560-A

1/1/89

1/1/95

508

502.08

Medical Assistance for Home Care of Certain Children with Severe Disabilities

4681

10/4/89

10/4/95

521

503.01

General Payment Information

4488-a

9/13/88

9/13/94

521.01

503.01(a)

 

4560-B

1/1/89

1/1/95

521.02(c)(1)

503.01(b)(3)a

 

4560-B

1/1/89

1/1/95

521.02(c)(3)

503.01(b)(3)c

 

4560-B

1/1/89

1/1/95

521.02(c)(9)

503.01(b)(3)i

 

4560-B

1/1/89

1/1/95

519

503.02

Payments to Disproportionate Share Psychiatric Hospitals

5194

7/26/91

7/26/97

530

504.01

Service Limits, Non-Covered Services and Co-Payments

4863

7/12/90

7/12/96

530.03(d)

504.01(c)(4)

 

5714

10/1/93

10/1/99

533

504.02

Chiropractic Services

4817

6/1/90

6/1/96

531

504.03

Physician Services

4629

6/16/89

6/16/95

531.03

504.03(b)

 

4694

11/9/89

11/9/95

531.05(h)

504.03(d)(8)

 

4694

11/9/89

11/9/95

531.05(m)

504.03(d)(13)

 

4779

3/1/90

3/1/96

531.05(s)

504.03(d)(18)

 

4630

6/16/89

6/16/95

531.05(s)(1) and (2)

504.03(d)(18)a. and b.

 

4694

11/9/89

11/9/95

531.05(s)(4) through (6)

504.03(d)(18)d. through f.

Physician Services (cont'd)

4694

11/9/89

11/9/95

531.06

504.03(e)

 

4694

11/9/89

11/9/95

531.06(b)

504.03(e)(2)

 

4779

3/1/90

3/1/96

531.08(f) through (h)

504.03(g)(5) through (7)

 

5181

7/22/91

7/22/97

537

504.04

Rural Health Clinics

4884

8/1/90

8/1/96

532

504.05

Podiatrist Services

4818

6/1/90

6/1/96

542

504.06

Abortion Services

4968

11/7/90

11/7/96

536

504.07

Medical Services Clinic

4690

12/1/89

12/1/95

535

504.08

Psychologist Services

4794

3/30/90

3/30/96

535.05

504.08(e)

 

5182

7/22/91

7/22/97

541

504.09

Family Planning Services

4969

11/7/90

11/7/96

546

504.10

Early and Periodic Screening, Diagnosis and Treatment Services

5532

12/17/92

12/17/98

548

504.11

Extended Services to Pregnant Women

5578

2/11/93

2/11/99

 

504.12

(Reserved)

4771

3/1/90

 

543

504.13

Hospital Services

4488-a

9/13/88

9/13/94

543.01

504.13(a)

 

4560-B

1/1/89

1/1/95

543.04(i)

504.13(d)(8)

 

4695

11/9/89

11/9/95

543.07

504.13(g)

 

4560-B

1/1/89

1/1/95

543.11(a)

504.13(k)(1)

 

4560-B

1/1/89

1/1/95

543.11(c)

504.13(k)(3)

 

4560-B

1/1/89

1/1/95

543.11(i)

504.13(k)(9)

 

4560-B

1/1/89

1/1/95

 

504.14

(Reserved)

4773

3/1/90

 

 

504.15

(Reserved)

4774

3/1/90

 

565

504.16

Vision Care

4819

6/1/90

6/1/96

550

504.17

Adult Medical Day Care

4482

9/1/88

9/1/94

 

504.18

(Reserved)

4908

8/17/90

 

540

504.19

Private Duty Nursing Services

4691

12/1/89

12/1/95

552

504.20

Personal Care Attendant Services

4993

11/30/90

11/30/96

566

504.21

Dental Services

5639

6/17/93

6/17/99

576

504.22

Health Maintenance Organizations

4907

9/1/90

9/1/96

576.06

504.22(f)

 

5165

6/17/91

6/17/97

576.07

504.22(g)

 

5165

6/17/91

6/17/97

576.08

504.22(h)

 

5165

6/17/91

6/17/97

576.09

504.22(i)

 

5165

6/17/91

6/17/97

553

504.23

Home Health Services

5342

3/3/92

3/3/98

522

504.24

Interpreter Services

5735

11/12/93

11/12/99

568

504.25

Therapy Services

4995

11/30/90

11/30/96

569

504.26

Laboratory and Radiological Services

4886

8/1/90

8/1/96

569.08(f) through (h)

504.26(g)(5) through (7)

 

5183

7/22/91

7/22/97

 

504.27

(Reserved)

4887

8/1/90

 

570

504.28

Pharmaceutical Services

5742

12/1/93

12/1/99

567

504.29

Hearing Aid Services

4778

3/1/90

3/1/96

567.05(a)(4)

504.29(e)(4)

 

4888

8/1/90

8/1/96

571

504.30

Durable Medical Equipment, Prosthetic Devices and Medical Supplies

4712

1/1/90

1/1/96

572

504.31

Ambulance Services

5022

11/30/90

11/30/96

573

504.32

Wheelchair Van Services

5023

11/30/90

11/30/96

574

504.33

General Medical Transportation

4696

1/1/90

1/1/96

556

504.34

Supported Residential Care Services

5676

8/1/93

8/1/99

534

504.35

Advanced Registered Nurse Practitioner Services

4793

3/30/90

3/30/96

558

504.36

Home and Community-Based Care for the Elderly and Chronically Ill

4482

9/1/88

9/1/94

558.05(h), except (h) (1)a. and b.

504.36(e)(8), except (e)(8) a. 1. and 2.

 

4776

3/1/90

3/1/96

 

504.37

(Reserved) was: Preadmission Screening Program (EXPIRED)

4062

5/29/86

5/29/92

559

504.38

Case Management Services

4482

9/1/88

9/1/94

590

505.01

Nursing Facility Services

4908

8/17/90

8/17/96

590.01

505.01(a)

 

5085

3/5/91

3/5/97

590.16

505.01(m)

 

5085

3/5/91

3/5/97

590.02(d)(3)

505.01(b)(1) d. 3.

 

5164

6/12/91

6/12/97

593

505.02

Nursing Facility Reimbursement

5058

1/31/91

1/31/97

593.09(g)

505.02(b)(7) a. 7.

 

5268

11/1/91

11/1/97

593.22

505.02(b)(7) j. 5.

 

5268

11/1/91

11/1/97

593.27

505.02(b)(7)o.

Nursing Facility Reimbursement (cont'd)

5268

11/1/91

11/1/97

593.28

505.02(b)(7)p.

 

5268

11/1/91

11/1/97

593.37

505.02(b)(9)b.

 

5531

12/16/92

12/16/98

593.38

505.02(b)(9)c.

 

5531

12/16/92

12/16/98

593.39

505.02(b)(9) d. and e.

 

5531

12/16/92

12/16/98

591

505.03

Nursing Home Enforcement Remedies

4741

1/23/90

1/23/96

592

505.04

Nursing Assistant Training Reimbursement

5618

4/28/93

4/28/99

 

PART He-W 501  GENERAL MEDICAL ELIGIBILITY - EXPIRED

 

          He-W 501.01  Definitions.

 

Source.  (See Revision Note at chapter heading He-W 500); ss by #5806, eff 3-30-94; amd by #5941, eff 12-22-94, all EXPIRED: 3-30-00, except paragraph (c) EXPIRED: 12-22-02

 

          He-W 501.02

Source.  (See Revision Note at chapter heading He-W 500); ss by #5806, eff 3-30-94, EXPIRED: 3-30-00

 

          He-W 501.03

 

Source.  (See Revision Note at chapter heading He-W 500); ss by #5806, eff 3-30-94; amd by #5941, eff 12-22-94, all EXPIRED: 3-30-00, except paragraph (a)(3) EXPIRED: 12-22-02

 

          He-W 501.04 - 501.12

 

Source.  (See Revision Note at chapter heading He-W 500); ss by #5806, eff 3-30-94, EXPIRED: 3-30-00

 

PART He-W 502  AID TO THE NEEDY BLIND PROGRAM

 

          He-W 502.01  Definitions.

 

          (a)  “Aid to the Needy Blind (ANB)” means a category of assistance for which eligibility is determined by the New Hampshire department of health and human services, in accordance with RSA 167:6, IV.

 

          (b)  “Blindness” means “blindness” as defined in Sections 216(i)(1) and 1614(a)(2) of the Social Security Act, 42 USC 416 and 42 USC 1382c.

 

          (c)  “Department” means the New Hampshire department of health and human services.

 

          (d)  “Medicaid” means the Title XIX and Title XXI programs administered by the department, which makes medical assistance available to eligible individuals.

 

          (e)  “Recipient” means any individual who is eligible for and receiving medical assistance under the medicaid program.

 

          (f)  “Title XIX” means the joint federal-state program described in Title XIX of the Social Security Act and administered in New Hampshire by the department under the medicaid program.

 

          (g)  “Title XXI” means the joint federal-state program described in Title XXI of the Social Security Act and administered in New Hampshire by the department under the medicaid program.

 

Source.  (See Revision Note at chapter heading He-W 500); ss by #6112, eff 11-4-95; ss by #7132, eff 11-23-99; ss by #9011, eff 10-25-07; amd by #10139, eff 7-1-12; ss by #11027, eff 1-26-16

 

          He-W 502.02  Recipient Eligibility.  ANB shall be available to recipients who:

 

          (a)  Meet the financial, categorical, technical, and other eligibility requirements, pursuant to He-W 600 and He-W 800, as applicable; and

 

          (b)  Meet the definition of blindness in He-W 502.01(b).

 

Source.  (See Revision Note at chapter heading He-W 500); amd by #5272, eff 11-15-91; ss by #6112, eff 11-4-95; ss by #7132, eff 11-23-99; ss by #9011, eff 10-25-07; ss by #11027, eff 1-26-16

 

          He-W 502.03  Blindness Evaluation.

 

          (a)  The recipient’s optometrist or ophthalmologist shall complete, sign, and date Form 901 “Report of Eye Examination” (April 2015) and submit the form to the department.

 

          (b)  The department shall review the information provided on Form 901 in (a) above, to determine if the criteria in He-W 502.02 have been met.

 

Source.  (See Revision Note at chapter heading He-W 500); ss by #6112, eff 11-4-95; ss by #7132, eff 11-23-99; ss by #9011, eff 10-25-07; ss by #11027, eff 1-26-16

 

PART He-W 503  AID TO THE PERMANENTLY AND TOTALLY DISABLED (APTD) PROGRAM - EXPIRED AND RESERVED

 

Source.  (See Revision Note at chapter heading He-W 500); ss by #5806, eff 3-30-94, EXPIRED: 3-30-00

 

PART He-W 504  MEDICAID FOR EMPLOYED ADULTS WITH DISABILITIES

 

Revision Note:

 

          Document #13215, effective 6-22-21, readopted with amendment Part He-W 504 titled “Medicaid for Employed Adults with Disabilities.”  Document #13215 replaces all prior filings for rules in Part He-W 504.

 

          The prior filings affecting the rules in the former Part He-W 504 include the following documents:

 

          He-W 504.01  Definition.

 

          #7644, eff 2-8-02

          #8292, eff 2-24-05

           #10321, eff 4-25-13

 

          He-W 504.02  Medical Eligibility.

 

          #7644, eff 2-8-02

          #8292, eff 2-24-05

          #10321, eff 4-25-13

          #13118, Emergency Rule, eff 10-29-20

          #13155, Statement for Repeal, eff 1-7-21

          #13156, Emergency Rule, eff 1-7-21

 

          Document #13118 was an emergency rule filed pursuant to RSA 541-A:18, I that amended He-W 504.02(b).  Document #13155 was a Statement for Repeal filed pursuant to RSA 541-A:18, VI to repeal the emergency rule in Document #13118.  Document #13156 was a second emergency rule which was immediately filed after Document #13155 pursuant to RSA 541-A:18, I to amend He-W 504.02(b) again.  Document #13156 was scheduled to expire 7-6-21, but Document #13215 readopted with amendments both He-W 504.01 and He-W 504.02, effective 6-22-21, before the second emergency rule expired.

 

          He-W 504.01  Definition.

 

          (a)  “Medicaid for employed adults with disabilities (MEAD)” means the medicaid eligibility category defined in 42 USC 1396a(a)(10)(A)(ii)(XV) and established by RSA 167:3-i.

 

Source. #13215, eff 6-22-21 (See Revision Note at part heading for He-W 504)

 

          He-W 504.02  Medical Eligibility.  To be medically eligible for MEAD:

 

          (a)  An individual shall have been determined eligible for aid to the permanently and totally disabled (APTD) according to RSA 167:6, VI, or aid to the needy blind (ANB) according to RSA 167:6, IV, within the 12 months prior to an application for MEAD unless the department terminated the individual’s APTD or ANB medical assistance due to medical improvement during the previous 12 months; or

 

          (b)  If an individual is not medically eligible for MEAD pursuant to paragraph (a), the department shall determine medical eligibility for MEAD in accordance with 42 CFR § 435.540 and 42 CFR  435.541 except that:

 

(1)  The department shall not consider substantial gainful activity (SGA) as described in 20 CFR 416.972 when determining medical eligibility for MEAD; and

 

(2)  The duration of the physical or mental impairment, or combination of impairments, shall have lasted, or might be expected to last for a continuous period of 48 consecutive months or result in death.

 

Source. #13215, eff 6-22-21 (See Revision Note at part heading for He-W 504)

 

PART He-W 505 - RESERVED

 

          He-W 505.01-505.04 - REPEALED

Source.  (See Revision Note at chapter heading He-W 500); ss by #5623, eff 5-13-93, EXPIRED: 5-13-99

 

New.  #7134, eff 11-23-99; rpld by #8973, eff 9-11-07

 

PART He-W 506  MEDICAID CARE MANAGEMENT (MCM)

 

          He-W 506.01  Purpose.  The purpose of this part is to prescribe the requirements of the New Hampshire medicaid care management program as they pertain to medicaid recipients, including individuals deemed eligible for medicaid coverage through the New Hampshire health protection program (NHHPP) in accordance with RSA 126-A:5 XXIII-XXV.

 

Source.  #10410, eff 9-13-13; ss by #10631, eff 7-1-14

 

          He-W 506.02  Scope.  This part shall apply to all medicaid recipients insofar as they are required to enroll in managed care.  Those recipients who are not enrolled in managed care shall receive medicaid services on a fee-for-service basis in accordance with applicable rules in He-W 500.

 

Source.  #10410, eff 9-13-13; ss by #10965, eff 11-1-15

 

          He-W 506.03  Definitions.

 

          (a)  “Action” means a managed care organization (MCO) activity including, but not limited to, the following activities identified in the definition of “adverse benefit determination” in 42 CFR 438.400(b):

 

(1)  The denial or limited authorization of a requested service, including the type or level of service, including determinations based on the type or level of service, requirements for medical necessity, appropriateness, setting, or effectiveness of a covered benefit;

 

(2)  The reduction, suspension, or termination of a previously authorized service;

 

(3)  The denial, in whole or in part, of payment for a service;

 

(4)  The failure to provide services in a timely manner, as described in the contracts between the department and the MCOs;

 

(5)  The failure of an MCO to act within the timeframes required for disposition of a grievance, standard resolution of an appeal, or expedited resolution of an appeal, as described in the contracts between the department and the MCOs; or

 

(6)  The denial of a member’s request to dispute a financial liability, including cost sharing, copayments, premiums, deductibles, coinsurance, or other enrollee financial liabilities.

 

          (b)  “Appeal” means a request to the MCO for the review of any action taken by the MCO.

 

          (c)  “Department” means the New Hampshire department of health and human services.

 

          (d)  “Enrollee” means a recipient who is enrolled in managed care and who has not yet selected an MCO.

 

          (e)  “Fair hearing” means an administrative appeal under He-C 200.

 

          (f)  “Fee-for-service” means the reimbursement method used by the department:

 

(1)  For all services to recipients who are not enrolled in managed care and to members whose MCO coverage has not yet begun; and

 

(2)  For those services excluded from managed care for all recipients.

 

          (g)  “Grievance” means an expression of dissatisfaction about any matter other than an action that is communicated to the MCO, such as with regard to the quality of care or services provided, and aspects of interpersonal interactions with the MCO employees.

 

          (h)  “Managed care organization (MCO)” means an entity that has a comprehensive risk-based contract with the department to provide managed medicaid health care services.

 

          (i)  “MCO grievance system” means the system through which members can complain, express dissatisfaction, or challenge an action made by the MCO, including:

 

(1)  An MCO grievance process;

 

(2)  An MCO appeal process; and

 

(3)  Access to the department’s fair hearing process after (i)(2) above has been exhausted.

 

          (j)  “Medicaid” means the Title XIX and Title XXI programs administered by the department which makes medical assistance available to eligible individuals.

 

          (k)  “Member” means a recipient who has selected or been auto-assigned to an MCO.

 

          (l)  “New Hampshire health protection program (NHHPP)” means the program established by SB 413 (Chapter 3, Laws of 2014), which authorizes medical assistance for adults up to 133% federal poverty levels under 42 USC §1396a(a)(10)(A)(i)(VIII).

 

          (m)  “Recipient” means any individual who is eligible for and is receiving medical assistance under the New Hampshire medicaid program.

 

          (n)  “Title XIX” means the joint federal-state program described in Title XIX of the Social Security Act and administered in New Hampshire by the department under the medicaid program.

 

          (o)  “Title XXI” means the joint federal-state program described in Title XXI of the Social Security Act and administered in New Hampshire by the department under the medicaid program.

 

Source.  #10410, eff 9-13-13; amd by #10631, eff 7-1-14; amd by #10965, eff 11-1-15; ss by #12537, eff 5-24-18

 

          He-W 506.04  Covered Services.

 

          (a)  Covered services provided through an MCO shall include:

 

(1)  All covered state plan services except the following:

 

a.  Dental services provided in the dental setting;

 

b.  Intermediate care facility for the mentally retarded (ICFMR);

 

c.  Medicaid to schools program;

 

d.  Skilled nursing facility;

 

e.  Skilled nursing facility atypical care;

 

f.  Inpatient hospital swing beds, intermediate care facility;

 

g.  Inpatient hospital swing beds, skilled nursing facility;

 

h.  Intermediate care facility nursing home;

 

i.  Intermediate care facility atypical care;

 

j.  Glencliff Home;

 

k.  Early supports and services;

 

l.  The following drugs when billed by a pharmacy:

 

1.  Drugs used for the teeatment of Hepatitis C;

 

2.  Durgs used for the treatment of hemophilia;

 

3.  Carbaglu; and

 

4.  Raviciti; and

 

m.  The following services which are only offered to children involved with the division for children, youth and families:

 

1.  Home based therapy;

 

2.  Child health support service;

 

3.  Placement services;

 

4.  Intensive home and community services;

 

5.  Private non-medical institutional care for children; and

 

6.  Crisis intervention; and

 

(2)  Community mental health services described in He-M 426.

 

          (b)  In addition to the covered services provided in accordance with (a) above, covered services for recipients eligible through the NHHPP shall also include:

 

(1)  Chiropractic services as described in He-W 512.05(a)(3); and

 

(2)  Early and periodic screening, diagnosis, and treatment (EPSDT) services, as defined in He-W 546, for NHHPP recipients who are under 21 years of age.

 

          (c)  The services excluded in (a)(1) above shall be covered by medicaid on a fee-for-service basis.

 

          (d)  Covered services shall be covered by the MCO starting the first day of the first month following a member’s selection of or auto-assignment to an MCO, or the first day of the managed care program, whichever is later.

 

          (e)  Covered state plan services provided through an MCO shall be furnished in an amount, duration, and scope that is no less than the amount, duration, and scope for the same services furnished to recipients under fee-for-service.

 

Source.  #10410, eff 9-13-13; ss by #10631, eff 7-1-14; amd by #11107, eff 7-1-16; amd by #12016, eff 10-25-16

 

          He-W 506.05  Enrollment in Managed Care.

 

          (a)  Enrollment in managed care shall be mandatory for all individuals who are eligible for medicaid through the NHHPP.

 

          (b)  All other medicaid recipients shall be enrolled in managed care unless the recipient is excluded from managed care as described in (c) below.

 

          (c)  The following individuals shall not be allowed to enroll in managed care:

 

(1)  Recipients receiving benefits from the U.S. Department of Veterans Affairs;

 

(2)  Recipients receiving in and out medically needy assistance in accordance with 42 CFR 435.301 and He-W 678.01;

 

(3) Individuals who have qualified medicare beneficiary/specified low-income medicare beneficiary (QMB/SLMB) benefits only, and are not eligible for medicaid service coverage; and

 

(4) Individuals receiving only the family planning expansion category of services (FPEC) in accordance with 1902(a)(10)(A)(ii) of the Social Security Act, 42 U.S.C. 1396a(a)(10)(A)(ii) and He-W 509.

 

          (d)  Any recipient not enrolled in managed care shall receive medicaid services on a fee-for-service basis.

 

Source.  #10410, eff 9-13-13; ss by #10631, eff 7-1-14; ss by #10965, eff 11-1-15

 

          He-W 506.06  Selection of a Managed Care Organization.

 

          (a)  The department shall send a notice of managed care enrollment and MCO selection to all recipients not excluded from managed care per He-W 506.05(c).

 

          (b)  Recipients shall have 60 days from the date of the notice in (a) above select an MCO by responding to the department, via writing, telephone, or by utilizing the on-line NH Electronic Application System (NH EASY).

 

          (c)  If a recipient fails to select an MCO as required by (b) above, an MCO shall be auto-assigned to the recipient.

 

          (d)  Auto-assignments shall be based on the following criteria:

 

(1)  MCO participation of a primary care provider with whom the enrollee has a pre-existing relationship as demonstrated by past claims history;

 

(2)  MCO participation of a specialty care provider with whom the enrollee has a pre-existing relationship as demonstrated by past claims history;

 

(3)  MCO selection by a household family member of the enrollee;

 

(4)  MCO previously selected prior to a loss of medicaid eligibility; or

 

(5)  If no assignment can be made utilizing (1)-(4) above, assignment shall be based on an algorithm, which has been contractually agreed to by the department and the MCO, that ensures equitable enrollment of enrollees across all MCOs.

 

          (e)  A member may request to change his or her MCO selection without cause, by making a written or oral request to the department at any of the following times:

 

(1)  During the 90 days following the date of the member’s initial selection of or the auto-assignment to the MCO, or the date the department sends the member confirmation of the member’s selection or auto-assignment, whichever is later;

 

(2)  At any time for members who are auto-assigned to the MCO and who have an established relationship with a primary care provider that is only in the network of a non-assigned MCO;

 

(3)  During annual open enrollment periods;

 

(4)  For 60 days following an automatic re-enrollment if the temporary loss of medicaid eligibility causes the member to miss the annual re-enrollment/disenrollment opportunity.  This provision shall apply to redeterminations only and shall not apply when an individual is completing a new application for medicaid eligibility; and

 

(5)  When the department imposes an intermediate sanction specified in 42 CFR 438.702(a)(3).

 

          (f)  A member may request to change his or her MCO selection with cause, by making a written or oral request to the department at any time for any of the following reasons:

 

(1)  The member requires related services simultaneously that are not available in the MCO’s network and bifurcation of the care creates unnecessary risk to the member as determined by the member’s treating provider;

 

(2)  The member wants to select the same managed care plan as a household family member;

 

(3)  Poor quality of care;

 

(4)  Lack of access to covered services;

 

(5)  The member has experienced a violation of his or her member rights, as established in 42 CFR 438.100; or

 

(6)  The MCO’s network providers are not experienced in the member’s unique healthcare needs.

 

          (g)  If a request made pursuant to (e) or (f) above does not include the selection of a different MCO, the department shall not act on the request unless there are only 2 MCOs.

 

          (h)  A member may request a department fair hearing of a denial of (e) or (f) above in accordance with He-C 200 without first exhausting the MCO appeal process.

 

          (i)  A member shall be locked into the selected or auto-assigned MCO for a period of 12 months or until the next open enrollment period, whichever comes first, unless the member changes his or her MCO selection in accordance with (e)(1), (2), (5), or (f) above.

 

          (j)  A member shall disenroll from an MCO when the member has moved out of state and is no longer NH medicaid eligible.

 

          (k)  An MCO may request the department to disenroll a member who is threatening or abusive such that the health or safety of other members, MCO staff, or providers is jeopardized.

 

          (l)  The department shall approve a request for disenrollment in (k) above when no other option is available that would ensure the health and safety of other members, MCO staff, or providers.

 

          (m)  If the department approves an MCO request for involuntary disenrollment, the member may request a department fair hearing of the disenrollment in accordance with He-C 200 without first exhausting the MCO appeal process.

 

          (n)  Members appealing involuntary disenrollment may request a continuation of services pending appeal as outlined in 42 CFR 431.230.

 

Source.  #10410, eff 9-13-13; ss by #10965, eff 11-1-15

 

          He-W 506.07  MCO Grievance Process.

 

          (a)  A member who is dissatisfied with any matter other than an action, as defined in He-W 506.03(a), shall utilize the MCO grievance process exclusively.

 

          (b)  The MCO grievance process shall address members’ expression of dissatisfaction about any matter other than an action including, but not limited to:

 

(1)  The quality of care or services provided;

 

(2)  Aspects of interpersonal interactions with providers or MCO employees; or

 

(3)  Failure to respect the member’s rights. 

 

          (c)  Actions, as defined in He-W 506.03(a), shall be subject to the MCO appeal process but not subject to the MCO grievance process.

 

          (d)  A member, or the member’s authorized representative, appointed in accordance with He-W 603.01, shall file a grievance with the MCO either orally or in writing.

 

          (e)  Members shall be notified of the disposition of grievances as follows:

 

(1)  Either orally or in writing for grievances not involving clinical issues; and

 

(2)  In writing for grievances involving clinical issues.

 

          (f)  Members shall not have the right to a department fair hearing in regard to the disposition of a grievance.

 

          (g)  The MCO grievance process shall not preclude a member’s ability to pursue client rights protection under He-M 204.

 

Source.  #10410, eff 9-13-13

 

          He-W 506.08  MCO Appeal Process.

 

          (a)  The MCO appeal process shall address members’ requests for the appeal of any adverse benefit determination or action taken by the MCO.

 

          (b)  A member who wants to appeal an action taken by the MCO shall utilize the MCO appeal process.

 

          (c)  A member, the member’s authorized representative, the member’s legal guardian appointed in accordance with He-W 803.01, or the member’s provider acting on behalf of the member and with the member’s written consent may file an appeal with the MCO.  However, a provider acting as an authorized representative shall not request continuation of benefits pending the appeal even with written consent.

 

          (d)  All requests for appeals shall be made within 60 calendar days of the date on the MCO’s notice of action.

 

          (e)  All requests for appeals shall be made either orally or in writing. An oral request for an appeal shall be followed by a written request, unless the request is for expedited resolution as described in (g) below.

 

          (f)  The MCO shall resolve standard appeals within 30 calendar days from the day the MCO receives the appeal.

 

          (g)  A person in (c) above may request an expedited resolution of an appeal when taking the time needed for a standard resolution could seriously jeopardize the member’s life, physical or mental health, or ability to attain, maintain, or regain maximum function. 

 

          (h)  The MCO shall resolve an expedited appeal within 72 hours of receiving the appeal.

 

          (i)  The MCO may extend the timeframes to resolve standard and expedited appeals up to 14 calendar days if:

 

(1)  The member requests the extension; or

 

(2)  The MCO demonstrates that there is a need for additional information in order to resolve the appeal and the extension is in the member’s interest.

 

          (j)  If the MCO extends the timeframes not at the request of the member in accordance with (i)(2) above, then the MCO shall:

 

(1)  Make reasonable efforts to give the member prompt oral notice of the delay by providing a minimum of 3 oral attempts to contact the member at various times of the day, on different days within 2 calendar days of the MCO’s decision to extend the timeframe;

 

(2)  Within 2 calendar days of the MCO’s decision to extend, give the member written notice of the reason for the decision to extend the timeframe and inform the member of the right to file a grievance if he or she disagrees with that decision; and

 

(3)  Resolve the appeal as expeditiously as the member’s health condition requires and no later than the date the extension expires.

 

          (k)  A member’s benefits shall be continued during an appeal if:

 

(1)  The member requests a continuation of benefits on or before the later of the following:

 

a.  Within 10 calendar days of the date the MCO mails the notice of action; or

 

b.  The intended effective date of the MCO’s proposed action; 

 

(2)  The appeal involves the termination, suspension, or reduction of previously authorized services;

 

(3)  The services were ordered by an authorized provider; and

 

(4)  The period covered by the original authorization has not expired.

 

          (l)  If the MCO’s action is upheld in a hearing, the MCO may institute recovery procedures against the member to recoup the cost of any continued benefits furnished to the member.

 

          (m)  The MCO grievance process shall not preclude a member’s ability to pursue client rights protection under He-M 204.

 

Source.  #10410, eff 9-13-13; ss by #12537, eff 5-24-18

 

          He-W 506.09  Department Fair Hearing Process.

 

          (a)  A member shall exhaust the MCO appeal process prior to filing a request for a fair hearing with the department, subject to the following:

 

(1)  Grievances shall not be the subject of a department fair hearing; and

 

(2)  The MCO shall have resolved an appeal under He-W 506.08 and provided notice of that resolution prior to the member requesting a fair hearing with the department; except that a member is deemed to have exhausted the MCO’s appeal process if the MCO fails to adhere to the notice and timing for expedited and standard appeals as described in He-W 506.08(f), (h), and(j).

 

          (b)  If the member does not agree with the MCO’s resolution of an appeal, the member may file a request, in accordance with He-C 200, for a department fair hearing.

 

          (c)  Requests for a department fair hearing shall be made in writing within 120 calendar days of the date of the MCO’s notice of the resolution of the appeal.

 

          (d)  A member in (b) above may request an expedited resolution of a department fair hearing if the department determines that the time otherwise permitted for a hearing could seriously jeopardize the member’s life, physical or mental health, or ability to attain, maintain, or regain maximum function, and:

 

(1)  The MCO adversely resolved the member’s appeal, wholly or partially; or

 

(2)  The MCO failed to resolve the appeal within 72 hours and failed to extend the 72-hour deadline in accordance with 42 CFR 438.408(c) and He-W 506.08(i).

 

          (e)  The department shall notify the member as expeditiously as possible as to whether the request for an expedited department fair hearing is granted or denied.  If oral notice is provided, the department shall follow up with written notice, which may be made through electronic means.

 

          (f)  If the department denies the member’s request for an expedited department fair hearing, the department shall schedule a department fair hearing within 90 days from the date the member filed an MCO appeal not including the number of days the member took to subsequently file for a department fair hearing.

 

          (g)  If the department grants the member’s request for an expedited department fair hearing, then the department shall resolve the appeal within 3 business days after the department receives from the MCO the case file and any other necessary information.  The MCO shall have no more than 3 days from the date the department notifies the MCO that it has granted the member’s expedited appeal, to provide the case file to the department.

 

          (h)  A member’s benefits shall be continued during a department fair hearing if:

 

(1)  The member received benefits pending the MCO appeal; and

 

(2) The member requests a department fair hearing and continuation of benefits within 10 calendar days of the date the MCO sends the notice of adverse decision of an MCO appeal to the member.

 

          (i)  If the member did not receive benefits pending the MCO appeal, then a member’s benefits shall be continued during a department fair hearing if:

 

(1)  The member requests a department fair hearing within 10 calendar days of the date the MCO mails the notice of decision adverse to the member;

 

(2)  The member requests continuation of benefits pending the department fair hearing;

 

(3) The department fair hearing involves the termination, suspension, or reduction of a previously authorized service;

 

(4)  The service was ordered by an authorized provider; and

 

(5)  The original authorization period for the service has not expired.

 

          (j)  Only the member, the member’s authorized representative, or the member’s legal guardian may request benefits pending a department fair hearing of a MCO decision. 

 

          (k)  Providers acting as an authorized representative shall not request continuation of benefits pending the appeal even with written consent.

 

          (l)  If the MCO’s adverse decision is upheld in a department fair hearing, the MCO may institute recovery procedures against the member to recoup the cost of any continued benefits furnished to the member.

 

Source.  #10410, eff 9-13-13; ss by #12537, eff 5-24-18

 

PART He-W 507  MEDICAL ASSISTANCE FOR CHILDREN WITH SEVERE DISABILITIES

 

          He-W 507.01  Definitions.

 

          (a)  “Department” means the New Hampshire department of health and human services.

 

          (b)  “Medical review team (MRT)” means a team of medical professionals, comprised of physicians and registered nurses with expertise in the care of children with special health care needs, developmental disabilities and behavioral issues, who determine medical eligibility for healthy kids-gold medical assistance in accordance with the criteria set forth in He-W 507 and He-W 508.

 

          (c)  “Medicaid” means the Title XIX and Title XXI programs administered by the department which makes medical assistance available to eligible individuals.

 

          (d)  “Recipient” means any individual who is eligible for and receiving medical assistance under the medicaid program.

 

          (e)  “Title XIX” means the joint federal-state program described in Title XIX of the Social Security Act and administered in New Hampshire by the department under the medicaid program.

 

          (f)  “Title XXI” means the joint federal-state program described in Title XXI of the Social Security Act and administered in New Hampshire by the department under the medicaid program.

 

Source.  (See Revision Note at chapter heading He-W 500); ss by #5941, eff 12-22-94, EXPIRED: 12-22-02

 

New.  #7867, eff 4-10-03; ss by #9866, eff 2-11-11; amd by #10139, eff 7-1-12

 

          He-W 507.02  Recipient Eligibility.  Title XIX services shall be available to children with disabilities who:

 

          (a)  Are under the age of 19;

 

          (b)  Meet the requirements of He-W 641.04;

 

          (c)  Are chronically ill or impaired, whose illness or disability does not require the level of care provided in an inpatient facility, but whose condition requires ongoing and regular medical monitoring and treatment; and

 

          (d)  Have a severe disability which includes at least one of the following:

 

(1)  A developmental disability as defined in RSA 171-A:2,V;

 

(2)  A chronic, degenerative, progressive, or life-threatening condition causing impairment of a vital organ function which requires ongoing and regular medical monitoring;

 

(3)  A sensory impairment which is expected to continue indefinitely, including a hearing loss established by audiometry which functionally impacts the child;

 

(4)  A mental illness, emotional disturbance or behavioral disorder which functionally impacts his or her psychosocial adjustment and the diagnosis for which is recognized by the American Psychiatric Association;

 

(5)  An acquired childhood disease which functionally impacts the child; or

 

(6)  A genetic disorder or congenital anomaly requiring ongoing medical monitoring.

 

Source.  (See Revision Note at chapter heading He-W 500); ss by #5941, eff 12-22-94, EXPIRED: 12-22-02

 

New.  #7867, eff 4-10-03; ss by #9866, eff 2-11-11

 

          He-W 507.03  Continued Eligibility.

 

          (a)  The MRT shall conduct periodic redeterminations of medical eligibility for Title XIX benefits based on current evidence of the child’s disability.

 

          (b)  At the time of redetermination, the MRT shall first determine whether the recipient meets the eligibility criteria in accordance with He-W 507.02.

 

          (c)  The department shall issue a written notice to the recipient when a medical eligibility determination is made.

 

          (d)  If an adverse eligibility determination is made, the written notice to the recipient shall include the following information:

 

(1)  The recipient’s identifying information;

 

(2) A listing of the medical and non-medical reports considered during the disability determination process;

 

(3)  A statement of the department’s action;

 

(4)  The reasons for the department’s action;

 

(5)  Citations from federal and state statutes and regulations supporting the department’s actions; and

 

(6)  An explanation of the individual’s rights to appeal the department’s disability determination and to reapply for medical assistance.

 

          (e)  The department shall continue the recipient’s medical eligibility after an adverse medical eligibility determination is made when the recipient:

 

(1)  Submits a hearing request to the local district office within 30 days from the date on the written notice of adverse decision; and

 

(2)  Submits a request to the local district office for a continuation of benefits during the appeal process within 10 days of the date on the written notice of adverse decision.

 

Source.  (See Revision Note at chapter heading He-W 500); ss by #5941, eff 12-22-94, EXPIRED: 12-22-02

 

New.  #7867, eff 4-10-03; ss by #9866, eff 2-11-11

 

          He-W 507.04  Termination of Medical Eligibility.  The department shall terminate medical eligibility after an adverse medical eligibility determination is made when:

 

          (a)  The MRT determines that the recipient no longer meets the eligibility criteria specified in He-W 507.02; and

 

          (b)  The recipient fails to submit a continuation of benefits request to the local district office within 10 days from the date of written notice of adverse decision.

 

Source.  #7867, eff 4-10-03; ss by #9866, eff 2-11-11

 

          He-W 507.05  Appeals.

 

          (a)  Individuals may appeal an adverse disability determination, pursuant to RSA 541-A:31, III and He-C 200.

 

          (b)  Individuals must submit the written request for a hearing to the local district office pursuant to RSA 541-A:31, III and He-C 200 within 30 days from the date of the notice of decision.

 

Source.  #7867, eff 4-10-03; ss by #9866, eff 2-11-11

 

PART He-W 508  MEDICAL ASSISTANCE FOR HOME CARE OF CERTAIN CHILDREN WITH SEVERE DISABILITIES

 

          He-W 508.01  Purpose.  The purpose of family centered community-based home care shall be to support, but not supplant, the recipient’s family as the primary caregiver.

 

Source.  (See Revision Note at chapter heading He-W 500); ss by #5941, eff 12-22-94, EXPIRED: 12-22-02

 

New.  #8196, INTERIM, eff 10-29-04, EXIRED: 7-1-05

 

New.  #9291, eff 7-1-09

 

          He-W 508.02  Definitions.

 

          (a)  “Degree of care” means the level of intensity or extent of medical care, treatment, or intervention required by the child as determined by the medical setting in which the child is being evaluated.

 

          (b)  “Department” means the New Hampshire department of health and human services.

 

          (c)  “Family centered community-based home care” means an organized network of integrated and coordinated services delivered at the local level which promotes normal patterns of living and which recognizes the pivotal role of families with respect to the provision of services for their children.

 

          (d)  “Joint medical review team (MRT)” means a team of medical professionals, comprised of physicians and registered nurses with expertise in the care of children with special health care needs, developmental disabilities, and behavioral issues, that determines if home care services are medically appropriate in accordance with RSA 167:3-f, VI, and the most appropriate level of care under which to evaluate the child in accordance with RSA 167:3-g, III–VI.

 

          (e)  “Medicaid” means the Title XIX and Title XXI programs administered by the department which makes medical assistance available to eligible individuals.

 

          (f)  “Recipient” means any individual who is eligible for and receiving medical assistance under the medicaid program.

 

          (g)  “Title XIX” means the joint federal-state program described in Title XIX of the Social Security Act and administered in New Hampshire by the department under the medicaid program.

 

          (h)  “Title XXI” means the joint federal-state program described in Title XXI of the Social Security Act and administered in New Hampshire by the department under the medicaid program.

 

Source.  (See Revision Note at chapter heading He-W 500); ss by #5941, eff 12-22-94; amd by #6198, eff 2-28-96, all EXPIRED: 12-22-02 except (b)(3) EXPIRED: 2-28-04

 

New.  #8196, INTERIM, eff 10-29-04, EXIRED: 7-1-05

 

New.  #9291, eff 7-1-09 (from He-W 508.01); amd by #10139, eff 7-1-12

 

          He-W 508.03  Recipient Eligibility.

 

          (a)  In accordance with RSA 167:3-e, III, and RSA 167:3-f, III (a)–(f), recipients shall be eligible for medical assistance for home care of children with severe disabilities (HC-CSD), if the recipient:

 

(1)  Resides in a place maintained as the recipient’s home community;

 

(2)  Is able to receive services in the home as defined in 45 CFR 233.90(c)(1)(v)(B);

 

(3)  Meets the program criteria described in Section 1902(e)(3) of the Social Security Act;

 

(4)  Meets the criteria described in He-W 641.04, except that, pursuant to the prohibition in Section 1614(f)(2)(B) of the Social Security Act, the criteria described in He-W 641.04(b)-(e) on the deeming of parental income shall not apply;

 

(5)  Has an impairment, or combination of impairments, that meets, medically equals, or functionally equals the criteria for an impairment as described in 20 CFR, Part 404, Subpart P, App. 1;

 

(6)  Meets the medical criteria pursuant to RSA 167:3-f, III(e); and

 

(7)  Requires the same degree of care that is typically provided in a hospital, psychiatric hospital, nursing facility, or intermediate care facility for the mentally retarded (ICF-MR), in accordance with He-W 508.04.

 

          (b)  In addition to (a) above, recipients shall be eligible only if the services proposed for the recipient are:

 

(1)  Medically appropriate in accordance with He-W 508.05; and

 

(2)  Cost effective in accordance with He-W 508.06.

 

Source.  (See Revision Note at chapter heading He-W 500); ss by #5941, eff 12-22-94, EXPIRED: 12-22-02

 

New.  #8196, INTERIM, eff 10-29-04, EXIRED 7-1-05

 

New.  #9291, eff 7-1-09 (from He-W 508.02)

 

          He-W 508.04  Degree of Care.  The most appropriate degree of care under which to evaluate the recipient’s eligibility per He-W 508.03(a)(7) above shall be determined as follows:

 

          (a)  The MRT shall review, in accordance with RSA 167:3-g, II, the recipient’s medical condition and community care needs; and

 

          (b)  Based upon the review in (a) above, the MRT shall:

 

(1)  Determine that the degree of care provided by a hospital is appropriate for the recipient, if all of the criteria in RSA 167:3-g, III, are met;

 

(2)  Determine that the degree of care provided by a psychiatric hospital is appropriate for the recipient, if all of the criteria in RSA 167:3-g, IV, are met;

 

(3)  Determine that the degree of care provided by a nursing facility is appropriate for the recipient, if any one of the criteria in RSA 167:3-g, V, is met; or

 

(4)  Determine that the degree of care provided by an ICF-MR is appropriate for the recipient, if all of the criteria in RSA 167:3-g, VI, are met.

 

Source.  #9291, eff 7-1-09 (from He-W 508.03)

 

          He-W 508.05  Medically Appropriate Services.

 

          (a)  The medical services proposed for a recipient shall be medically appropriate if the MRT, upon certification by the recipient’s physician, determines in accordance with (b) below, that it is medically appropriate for the recipient to receive family centered, community-based home care as opposed to institutional care.

 

          (b)  In accordance with RSA 167:3-f, VI, family centered, community-based home care shall be medically appropriate if each of the following conditions is met:

 

(1)  The care can be provided in the home without jeopardizing the medical needs of the recipient;

 

(2)  Medical and psychological support services are available in the community;

 

(3)  The recipient’s treating physician recommends home care and certifies the safety of home placement in accordance with (c) below;

 

(4)  The recipient’s family or guardian has expressed a willingness and desire to assume responsibility as the primary caregiver for the recipient in order to maintain the recipient at home; and

 

(5)  The family and household members have been trained to support the recipient’s needs in the home and have the ability to be primary caregivers.

 

          (c)  The treating physician’s recommendation of home care and certification of the safety of home placement shall be submitted in writing by mail, electronic mail, or facsimile to the department or via direct telephone conversation with the MRT.

 

          (d)  The written certification in (c) above, or MRT documentation of direct telephone conversation with the treating physician as per (c) above, shall be maintained in the recipient’s case file at the department.

 

Source.  #9291, eff 7-1-09

 

          He-W 508.06  Monitoring and Determination of Cost Effectiveness.

 

          (a)  In accordance with RSA 167:3-e, IV, the medical services proposed for a recipient shall be cost effective if the estimated cost of care outside an institution is no higher than the estimated medicaid cost of appropriate institutional care.

 

          (b)  For each recipient, cost effectiveness shall be monitored monthly and determined annually by the department as follows:

 

(1)  The department shall obtain Title XIX payment data on the costs paid by Title XIX for the recipient’s home care from the department’s cost reports generated for each recipient from the Medicaid Management Information System (MMIS);

 

(2)  For each recipient, the items or services included in the home care cost data in (1) above shall include only those items or services listed in (c) below;

(3)  The items or services included in (d) below shall not be included in home care cost data for (1) above, or in institutional cost of care data in (c) below;

 

(4)  The department shall utilize, as institutional cost of care data, the most recently published inpatient per diem Title XIX rates for hospitals, psychiatric hospitals, nursing facilities, or ICF-MR;

 

(5)  The department shall determine the per diem rate to use as the recipient’s institutional cost of care by selecting the rate for the facility in (4) above that most closely corresponds to the degree of care determined and utilized for the recipient’s eligibility determination pursuant to He-W 508.04; and

 

(6)  The department shall compare the costs of the recipient’s home care to the recipient’s institutional cost of care, as determined in He-W 508.06(b)(1)–(b)(5).

 

          (c)  The costs associated with the following categories of service, which are included in an institution’s per diem rate, shall be the only costs utilized in determining the costs incurred for the recipient’s home care in accordance with He-W 508.06(b)(1) and (2) above:

 

(1)  Mental health services, including psychotherapy and community mental health center services;

 

(2)  Family planning services;

 

(3)  Drugs which are included in the per diem of the institution in (b)(4) above that is utilized in the calculation in (b)(6) above;

 

(4)  Durable medical equipment;

 

(5)  Medical supplies;

 

(6)  Dental services;

 

(7)  Private duty nursing services;

 

(8)  Physical therapy;

 

(9)  Occupational therapy;

 

(10)  Speech therapy;

 

(11)  Care provided through the Home and Community Based Care for the Developmentally Disabled waiver in accordance with He-M 517, with the exception of assistive technology support services, environmental modifications, employment services, respite and specialty services that would not otherwise be included in the institutional per diem rate;

 

(12)  Home and community-based care provided through the In Home Supports Waiver for Children with Developmental Disabilities in accordance with He-M 524, with the exception of environmental modifications, respite, and consultative services not otherwise included in the institutional per diem rate;

 

(13)  Case management services;

 

(14)  Home health; and

 

(15)  Early supports and services.

 

          (d)  Costs associated with the following categories of service, which are not included in an institution’s per diem rate, shall not be included in home care cost data in (b)(1) above or in institutional cost of care data in (c) above:

 

(1)  Inpatient services, including acute psychiatric admissions;

 

(2)  Outpatient services;

 

(3)  Laboratory services;

 

(4)  X-ray services;

 

(5)  Medical assistance services provided by education agencies in accordance with He-M 1301;

 

(6)  Ambulance services;

 

(7)  Wheelchair van services;

 

(8)  Audiology services;

 

(9)  Ophthalmology services;

 

(10)  Podiatry services;

 

(11)  Chiropractic services;

 

(12)  Physician services, including services of a psychiatrist;

 

(13)  Advanced registered nurse practitioner services;

 

(14)  DCYF/DJSS medicaid funded services to include private non-medical institutional placement services (PNMI) and residential placement;

 

(15)  Youth development center or other youth detention center placements;

 

(16)  Rural health clinics and federally qualified health centers;

 

(17)  Short term stays of 30 days or less in an intermediate care facility for the mentally retarded or in a nursing facility;

 

(18)  Services provided on an acute or short-term basis, in response to an illness or injury, rather than care for the chronic condition which is the basis for the home care;

 

(19)  Mileage reimbursement; and

 

(20)  Medicaid health insurance premium payments.

 

Source.  #9291, eff 7-1-09

 

          He-W 508.07  Recipient Notification of Cost Effectiveness Monitoring and Determination Results.

 

          (a)  When the department’s monthly monitoring of cost effectiveness results in an estimated, projected annual home care cost for a recipient which is higher than the appropriate type of institutional care cost, the department shall notify the recipient in writing.

 

          (b)  The notification in (a) above shall include:

 

(1)  A reminder of the requirement to maintain annual home care costs at or below the cost of care for the appropriate type of institution pursuant to state and federal law in order to maintain HC-CSD eligibility;

 

(2)  Medicaid payment data showing the recipient’s monitored home care costs and estimated, projected annual home care costs, including a copy of the report used;

 

(3)  The calculated cost of care in an appropriate type of institution for the same time period as in (2) above and the projected annual institutional costs, including identification of the appropriate type of institution; and

 

(4)  Contact information for the department’s care coordination services unit.

 

          (c)  Upon receipt of the notification in (a) above, the recipient’s family or guardian may contact the department:

 

(1)  For an explanation of the information included in the notification pursuant to (b) above;

 

(2)  To report costs they believe the department should not include in the home care costs; and

 

(3)  To request assistance with reducing the costs of home care or achieving cost effectiveness pursuant to He-W 508.06(a).

 

          (d)  For each state fiscal year ending June 30, the department shall complete an annual determination of cost effectiveness for each recipient pursuant to He-W 508.06(b).

 

          (e)  If the department’s annual determination of cost effectiveness indicates that home care costs are higher than the costs of the appropriate type of institutional care, the department shall provide written notice to the recipient within 30 days of the determination.

 

          (f)  The written notice pursuant to (e) above shall include:

 

(1)  A statement that annual cost effectiveness has not been demonstrated;

 

(2)  A statement that the recipient is required to reduce and maintain annual home care costs at or below the cost of care for the appropriate type of institution pursuant to state and federal law in order to maintain HC-CSD eligibility;

 

(3)  Medicaid payment data showing the recipient’s annual home care costs and a copy of the report used;

 

(4) The calculated annual cost of care in an appropriate type of institution, including identification of the appropriate type of institution;

 

(5)  A statement that the recipient’s family or guardian shall submit and implement a written plan for reducing costs in accordance with (f)(2) within 3 months of the date of the notice in (e) above;

 

(6)  Contact information for the department’s care coordination services unit which the recipient’s family or guardian may use for assistance in identifying any billing errors and in developing the cost reduction plan in (5) above; and

 

(7)  Information that a fair hearing on the requirement to reduce costs may be requested within 30 calendar days of the date on the cost effectiveness annual determination notice, in accordance with He-C 200.

 

          (g)  If the recipient’s family or guardian requests assistance in accordance with (f)(6) above, the department shall assign a care coordination manager to assist the recipient’s family or guardian.

 

Source.  #9291, eff 7-1-09

 

          He-W 508.08  Cost Reduction Plans.

 

          (a)  The department shall continue to monitor cost effectiveness monthly and determine it annually in accordance with He-W 508.06, for recipients who submit and implement a cost reduction plan in accordance with He-W 508.07(f)(5).

 

          (b)  The department shall terminate a recipient’s medical eligibility for HC-CSD if:

 

(1)  The recipient submits a cost reduction plan that does not demonstrate cost effectiveness in accordance with He-W 508.07(f)(2);

 

(2)  The recipient submits a cost reduction plan that demonstrates cost effectiveness, but does not implement the cost effectiveness plan in accordance with He-W 508.07(f)(5); or

 

(3)  The recipient does not submit a cost reduction plan in accordance with He-W 508.07(f)(5).

 

          (c)  A recipient’s termination of medical eligibility for HC-CSD, in accordance with (b) above, shall be effective 30 days after the due date of the written plan in He-W 508.07(f)(5).

 

          (d)  The recipient shall receive a written notice of termination of medical eligibility on department Form 272hc, “Termination of Medical Eligibility for HC-CSD,” including:

 

(1)  The reason for, and legal basis of, the termination;

 

(2)  Information that a fair hearing on the termination may be requested within 30 calendar days of the date on the notice of termination, in accordance with He-C 200.

 

          (e)  The department shall continue the recipient’s medical eligibility after the termination date of medical eligibility in accordance with (b) above when the recipient submits to the local district office both a request for a fair hearing and for a continuation of benefits during the appeal process not later than 10 calendar days from the date on the written notice of termination.

 

Source.  #9291, eff 7-1-09

 

          He-W 508.09  Continued Medical Eligibility for HC-CSD.

 

          (a)  The MRT shall conduct reviews of continued medical eligibility for Title XIX benefits based on current evidence of the recipient’s disability or based upon changes in eligibility.

 

          (b)  At the time of medical eligibility review, the MRT shall determine whether the recipient meets the eligibility standards in accordance with He-W 508.03 and He-W 508.04.

 

          (c)  The department shall issue a written notice to the recipient when a denial of continued medical eligibility is made following a medical eligibility review.

 

          (d)  The written notice in (c) above shall include:

 

(1)  The recipient’s identifying information:

 

(2)  A listing of the medical and non-medical reports used for consideration during the medical eligibility review process;

 

(3)  A description of the impairments used for consideration during the medical eligibility review process;

 

(4)  The reasons for the department’s decision;

 

(5)  The legal basis supporting the department’s decision(s);

 

(6)  Information that a fair hearing on the denial of continued medical eligibility may be requested within 30 calendar days of the date on the notice of denial, in accordance with He-C 200; and

 

(7)  Information on how to reapply for medical assistance.

 

          (e)  The department shall continue the recipient’s medical eligibility after a denial of continued medical eligibility in accordance with (c) above when the recipient submits to the local district office both a request for a fair hearing and for a continuation of benefits during the appeal process not later than 10 calendar days from the date on the written notice of denial.

 

Source.  #9291, eff 7-1-09

 

          He-W 508.10  Denial or Termination of Medical Eligibility for HC-CSD.  The department shall deny or terminate medical eligibility for HC-CSD if:

 

          (a)  The MRT, in accordance with He-W 508.09(b), determines that the recipient does not meet the eligibility criteria specified in He-W 508.03 and 508.04; or

 

          (b)  Both the following occur:

 

(1)  A cost reduction plan is not acceptable in accordance with He-W 508.08(b); and

 

(2)  The recipient fails to submit a request for a fair hearing and for a continuation of benefits during the appeals process to the local district office within 10 calendar days from the date of written notice of adverse decision or termination.

 

Source.  #9291, eff 7-1-09

 

PART He-W 509  FAMILY PLANNING EXPANSION CATEGORY (FPEC)

 

          He-W 509.01  Purpose.  The purpose of this part is to describe the family planning and family planning-related services and supplies available to individuals who are determined eligible, in accordance with He-W 626, for this expanded Title XIX eligibility category.  In accordance with Section 1902(a)(10)(A)(ii) of the Social Security Act, 42 U.S.C. 1396a(a)(10)(A)(ii), FPEC recipients shall not be eligible for any other Title XIX services, except as provided for in this part.

 

Source.  #10357, eff 7-1-13

 

          He-W 509.02  Definitions.

 

          (a)  “Department” means the New Hampshire department of health and human services.

 

          (b)  “Family planning expansion category” means a category of recipients who meet the technical eligibility requirements established by the department for the family planning services and/or family planning-related services specified in this part, but who are not eligible for any other Title XIX services not specified in He-W 509.

 

          (c)  “Family planning-related services” means certain medical diagnosis and treatment services and pharmaceutical supplies that are provided pursuant to a family planning service in a family planning setting and that do not receive an enhanced rate of 90% federal match.

 

          (d)  “Family planning services” means family planning services and supplies described in section 1905(a)(4)(c) of the Social Security Act, 42 U.S.C. 1396d(a)(4)(c), including medical services, medical procedures, and pharmaceutical supplies and devices provided by or under the supervision of a physician or other health professional that allow an individual to prevent or delay pregnancy or to otherwise control family size, and which receive an enhanced match rate of 90% federal match.

 

          (e)  “Hysterectomy” means a surgical procedure for the purpose of removing the uterus.

 

          (f)  “Institutionalized individual” means “institutionalized individual” as defined in 42 CFR 441.251.

 

          (g)  “Mentally incompetent individual” means “mentally incompetent individual” as defined in 42 CFR 441.251.

 

          (h)  “Sterilization” means any medical procedure, treatment, or surgical procedure which is intended to render an individual permanently incapable of reproducing.

 

          (i)  “Title XIX program” means the joint federal-state program described in Title XIX of the Social Security Act.

 

Source.  #10357, eff 7-1-13

 

          He-W 509.03  Eligibility.

 

          (a)  Individuals shall be eligible for family planning services and family planning-related services, as described in He-W 509.06(b) and (c) below, respectively, and in accordance with He-W 509 if the individual:

 

(1)  Meets the division of family assistance eligibility requirements specified in He-W 626;

 

(2)  Once determined eligible in accordance with (1) above, the FPEC recipient has reached reproductive maturity; and

 

(3)  If female, is not known to be pregnant.

 

          (b)  Acceptance of any family planning services shall be voluntary on the part of the individual.

 

          (c)  FPEC recipients shall not be considered to be Title XIX recipients for the purposes of receipt of services other than those as described in He-W 509.

 

Source.  #10357, eff 7-1-13

 

          He-W 509.04  Provider Participation.  All participating family planning providers shall be:

 

          (a)  Licensed by the state in which s/he practices or be a NH certified midwife; and

 

          (b)  A New Hampshire enrolled Title XIX provider.

 

Source.  #10357, eff 7-1-13

 

          He-W 509.05  Service Limits.  Family planning services and family planning-related services for FPEC recipients shall be subject to the limits described in He-W 530.

 

Source.  #10357, eff 7-1-13

 

          He-W 509.06  Covered Services.

 

          (a)  The services in (b) and (c) below shall be covered as family planning services and family planning-related services, respectively, only if the services, supplies, and procedures are clearly provided or performed for family planning purposes.

 

(b)  The following services shall be covered as family planning services:

 

(1)  Those physician services in accordance with He-W 531, certified midwife services in accordance with He-W 538, and advanced registered nurse practitioner services in accordance with He-W 534, provided for family planning purposes;

 

(2)  Contraceptive devices or drugs, both prescription and non-prescription, in accordance with He-W 570;

 

(3)  Pregnancy tests and screening for a sexually transmitted disease (STD) only when performed routinely as part of an initial, regular, or follow-up family planning visit; and

 

(4)  Sterilization, in accordance with 42 CFR 441.253 and 42 CFR 441.254, as follows:

 

a.  The FPEC recipient shall be at least 21 years old at the time consent is obtained;

 

b.  The FPEC recipient shall not be a mentally incompetent individual;

 

c.  The FPEC recipient shall not be an institutionalized individual;

 

d.  The FPEC recipient shall voluntarily give informed consent in accordance with the requirements at 42 CFR 441.257 through 42 CFR 441.258;

 

e.  The provider shall submit a sterilization consent form meeting the requirements of 42 CFR 441, Subpart F, to the department prior to the department’s payment for the sterilization claim;

 

f.  At least 30 days, but not more than 180 days, shall have passed between the date of informed consent and the date of sterilization, with the exception of cases of premature delivery or emergency abdominal surgery as described in g. below;

 

g.  A FPEC recipient may consent to be sterilized at the time of an emergency abdominal surgery if at least 72 hours have passed since he or she gave informed consent for the sterilization; and

 

h.  Treatment of surgical or anesthesia-related complications resulting from or during a covered sterilization procedure shall be covered; and

 

(5)  Family planning-related services that were provided as part of, or as follow-up to, a family planning visit in which a sterilization procedure took place.

 

          (c)  The following services shall be covered as family planning-related services: 

 

(1)  Services to treat adverse reactions to, or medical complications of, family planning procedures, services, treatments, or therapies including, but not limited to:

 

a.  Treatment of perforated uterus due to an intrauterine device insertion; and

 

b. Treatment of severe menstrual bleeding caused by Depo-Provera injection;

 

(2)  Drugs, in accordance with the following:

 

a.  Drugs shall be for the treatment of STDs, except for HIV/AIDS and hepatitis, when the STD is identified or diagnosed during a routine or periodic family planning visit; and

 

b. Title XIX providers shall comply with the provisions of He-W 570 regarding pharmaceutical services when prescribing or dispensing drugs covered in a. above;

 

(3)  A follow-up visit after prescribing drugs for the treatment of an STD, including a re-screen for the STD;

 

(4)  Drugs and other treatment for lower genital tract and genital skin infections/disorders, and urinary tract infections, when the infection/disorder is identified/diagnosed during a routine/periodic family planning visit;

 

(5)  A follow-up visit for drugs and other treatment of the lower genital tract and genital skin infections or disorders where the infections or disorder is identified during a family planning visit; and

 

(6)  Vaccinations to prevent cervical cancer that are routinely provided pursuant to a family planning service in a family planning setting.

 

Source.  #10357, eff 7-1-13

 

          He-W 509.07  Non-Covered Services.  The following services shall not be covered as family planning or family planning-related services:

 

(a)  Sterilizations which do not meet the requirements of He-W 509.06(b)(4) above;

 

(b)  Hysterectomies;

 

(c)  Abortions;

 

(d)  Medical, surgical, or pharmaceutical treatment for the purpose of enhancing, promoting, or restoring fertility;

 

(e)  Diagnostic examination of the cervix or vagina by means of a special microscope, colposcopy, biopsy, or cryotherapy of the cervix or vagina; and

 

(f)  Any medical service, procedure, or pharmaceutical supply or device provided to a FPEC recipient who is known to be pregnant.

 

Source.  #10357, eff 7-1-13

 

          He-W 509.08  Transportation.

 

          (a)  FPEC recipients shall be ensured assistance with locating or being reimbursed for transportation to Title XIX providers in order to access necessary family planning and family planning-related services described in He-W 509.

 

          (b)  FPEC recipients who wish to be reimbursed for transportation shall:

 

(1)  Enroll in the transportation provider system in accordance with He-W 574.10(b)–(e); and

 

(2)  Be known as a recipient driver only for enrollment and payment purposes.

 

          (c)  FPEC recipients shall only be reimbursed for transportation under the following circumstances:

 

(1)  Transportation shall be to in-state or border Title XIX enrolled providers, except as described in (2) below;

 

(2)  Transportation to out-of-area providers shall be authorized in advance in accordance with He-W 574.08;

 

(3)  There is no transportation available free of charge or payable by any other agency;

 

(4)  Only one trip per day, whether one-way or round-trip, shall be covered; 

 

(5)  Only the actual number of miles driven from the individual’s residence to the Title XIX provider and return to individual’s residence shall be reimbursed; and

 

(6)  Transportation shall be to the nearest available  provider of the necessary covered family planning services or family planning-related services via the shortest, most economical route, as described in He-W 574.14(b).

 

          (d)  FPEC recipients shall submit transportation claims in accordance with He-W 574.06.

 

          (e)  The above transportation claims shall be paid in accordance with He-W 574.07.

 

          (f)  The provisions of He-W 574.12 and He-W 574.14 regarding hearings and utilization review and control shall apply to FPEC recipients.

 

          (g)  FPEC recipients who request transportation assistance via wheelchair van in order to access family planning services or family planning-related services shall qualify for wheelchair van transportation if they meet the requirements in He-W 573.02(a)(1) and (2), except that eligibility as an FPEC recipient shall be substituted for the requirements in He-W 573.02(a) to be a Title XIX recipient.

 

          (h)  FPEC recipients utilizing wheelchair van transportation shall be subject to the provisions of He-W 573.04, He-W 573.10, He-W 573.11, and He-W 573.12 regarding service limits, prior authorization to exceed service limits, utilization review and control, and third party liability.

 

          (i)  FPEC recipient shall utilize Title XIX enrolled wheelchair van providers who meet the requirements of He-W 573.

 

          (j)  FPEC recipients shall be eligible to be transported by volunteer drivers in accordance with He-W 574 only for the purpose of accessing family planning services or family planning-related services.

 

Source.  #10357, eff 7-1-13

 

          He-W 509.09 Co-Payments.  Co-payments for family planning pharmaceutical products shall not be required.

 

Source.  #10357, eff 7-1-13

 

He-W 509.10  Utilization Review and Control.  The department’s surveillance and utilization review of subsystems unit (SURS) shall monitor utilization of family planning services in accordance with 42 CFR 455 and 42 CFR 456.

 

Source.  #10357, eff 7-1-13

 

          He-W 509.11  Third Party Liability.  All third party obligations shall be exhausted before Title XIX shall be billed, in accordance with 42 CFR 433.139.

 

Source.  #10357, eff 7-1-13

 

          He-W 509.12  Payment for Services.

 

          (a)  Rates of payment for family planning and family planning-related services shall be established by the department in accordance with RSA 161:4, VI(a).

 

          (b)  The provider shall submit claims for payment to the department’s fiscal agent.

 

          (c)  The provider shall maintain supporting records, in accordance with He-W 520.

 

Source.  #10357, eff 7-1-13

 

PART He-W 510 - RESERVED

 

PART He-W 511  HEALTH INSURANCE PREMIUM PAYMENT PROGRAM (HIPP)

 

          He-W 511.01  Purpose.  The purpose of this part is to describe the requirements for enrollment in the health insurance premium payment program (HIPP), which uses medicaid funds to purchase group health plan coverage on behalf of a medicaid recipient, as allowed by 42 USC §1396e.

 

Source.  #10632, eff 7-1-14

 

          He-W 511.02  Scope.  This part shall apply only to newly eligible adults for whom enrollment in HIPP is a condition of medicaid eligibility under 42 USC §1396a(a)(10)(A)(i)(VIII) and RSA 126-A:5, XXIII. Enrollment in HIPP shall be voluntary for all other medicaid recipients.

 

Source.  #10632, eff 7-1-14

 

          He-W 511.03  Definitions.

 

          (a)  “Cost effective” means that the cost to enroll an individual in a group health plan is likely to be less than the medicaid expenditures for an equivalent set of services.

 

          (b)  “Cost effectiveness test” means the method by which the department determines if a recipient’s group health plan costs less than the expected medicaid expenditure.

 

          (c)  “Department” means the New Hampshire department of health and human services.

 

          (d)  “Group health plan” means any plan of, or contributed to by, an employer, including a self-insured plan, to provide health care to the employer’s employees, former employees, or the families of employees or former employees, and which meets S. 5000(b)(1) of the Internal Revenue Code of 1986, and includes continuation coverage pursuant to Title XXII of the Public Health Services Act, S. 4980B of the Internal Revenue Code of 1986, or Title VI of the Employee Retirement Income Security Act of 1974.

 

          (e)  “Health insurance premium payment program (HIPP)” means a premium assistance program administered by the department consistent with section 1906 of the Social Security Act, which permits the use of medicaid funds to purchase group health plan coverage on behalf of eligible medicaid recipients.

 

          (f)  “Medicaid” means the Title XIX and Title XXI programs administered by the department, which makes medical assistance available to eligible individuals.

 

          (g)  “New Hampshire health protection program (NHHPP)” means the program established by SB 413 (Chapter 3, Laws of 2014), which authorizes medical assistance for adults up to 133% federal poverty levels under 42 USC §1396a(a)(10)(A)(i)(VIII).

 

          (h)  “Newly eligible adult” means adults who are eligible for medicaid under the New Hampshire health protection program and the provision of section 1902(a)(10)(A)(i)(VIII) of the social security act of 1935 as amended, 42 USC §1396a(a)(10)(A)(i)(VIII).

 

          (i)  “Wrap-around services” means to the extent that a group health plan does not cover a benefit contained in the NH state medicaid benefit package for newly eligible adults, the service is covered by traditional medicaid so that the individual has access to the same services to which they are entitled if they were covered directly through the state’s medicaid program.

 

Source.  #10632, eff 7-1-14

 

          He-W 511.04  Recipient Participation.

 

          (a)  Participation in HIPP shall be mandatory when a newly eligible adult has access to a group health plan and the department determines, in accordance with He-W 511.05 below, that it is cost effective for the individual to enroll in the group health plan.

 

          (b)  Pending the determination of cost effectiveness, the newly eligible adult shall be eligible to receive medicaid covered services through the medicaid fee-for-service program.

 

          (c)  Premium assistance through the HIPP program shall not be available when:

 

(1)  The insurance plan is an indemnity plan that pays only a predetermined amount for covered services, such as dental or vision only plans, or long-terms care plans;

 

(2)  The insurance plan is a school-based plan offered based on attendance or school enrollment;

 

(3)  The individual is only eligible for medicaid through in and out medical assistance in accordance with He-W 678.01;

 

(4)  The insurance plan is only offered for a temporary time period;

 

(5)  The eligible individual does not qualify for full medicaid benefits;

 

(6)  The insurance plan is through New Hampshire’s high-risk pool;

 

(7)  The insurance plan is a medicare supplemental policy, if the HIPP application was filed after March 1, 1996;

 

(8)  The insurance plan is COBRA; or

 

(9)  The newly eligible adult is eligible for, but is not enrolled in Medicare Part B.

 

          (d)  The newly eligible adult shall inform the department if he or she has access to group health plan coverage, at the time of application, and within 10 days of any other such time as coverage becomes available.

 

          (e)  Within 30 days of receiving a written request from the department or the department’s vendor, the newly eligible adult shall provide information necessary to establish the cost effectiveness of the group health plan, including the following:

 

(1)  Health plan information, such as the plan name and policy number;

 

(2)  Premium liability, which is the portion of the premium that is paid by the policy holder;

 

(3)  Co-insurance, which is the policy holder’s share of the cost of a covered health care services, and is generally calculated as a percentage of the total charge for the service;

 

(4)  Deductibles, which is the amount the policy holder must pay for health care services before the group health plan begins to pay;

 

(5)  Co-pay liability, which is a fixed amount the policy holder pays for a health care service, and generally paid for at the time the services are rendered;

 

(6)  Covered benefits and services;

 

(7)  Any service limits applied to the benefit and service use by the health plan; and

 

(8)  Demographic information relative to other individuals on the policyholder’s plan, including gender and age.

 

          (f)  In addition to the information listed in (e)(1)-(8) above, the newly eligible adult shall also provide employer and employment information to the department within the 30-day timeframe described in (e) above, to include:

 

(1)  The employer’s business name;

 

(2)  The number of hours worked by the employee per week; and

 

(3)  Contact information for the employer's human resource department.

 

          (g)  The newly eligible adult shall be granted an additional 15 days to provide the information required in (e) and (f) above when the individual informs the department or the department’s vendor that the failure to comply with (e) above was due to one of the following reasons:

 

(1)  There was a serious illness or death in the individual’s family;

 

(2)  There was a family emergency or household disaster, such as a fire, flood, or tornado;

 

(3)  The individual offers a cause beyond the individual’s control, such as the individual has made multiple unsuccessful attempts to obtain the information; or

 

(4)  There was a failure to receive the department’s request for information or notification for a reason not attributable to the individual’s lack of a forwarding address.

 

          (h)  Except as allowed by (i) below, if the department or the department’s vendor determines that the group health plan is cost effective, the newly eligible adult shall:

 

(1)  Enroll in the health plan within 15 days of receiving notification from the department or the department’s vendor that the plan is cost effective; and

 

(2)  Upon enrollment, provide the department or the department’s vendor with confirmation of the start date of coverage.

 

          (i)  In the event that the newly eligible adult is already enrolled in cost effective group health plan prior to applying for medicaid, then the HIPP premium payments will begin in the month following HIPP approval notification.

 

          (j)  If the department or the department’s vendor determines that the group health plan is not cost effective, the newly eligible adult shall be enrolled in the medicaid care management program in accordance with He-W 506.

 

          (k)  Enrollment in a group health plan shall not change the individual’s eligibility for medicaid benefits.

 

Source.  #10632, eff 7-1-14

 

He-W 511.05  Cost Effectiveness Determination.  Cost effectiveness shall be determined by the department applying the methodology set forth in Chapter 3, Section 3910, Medicaid Payments for Recipients under Group Health Plans, of the federal Centers for Medicare and Medicaid Services (CMS), State Medicaid Manual, available as noted in Appendix A.

 

Source.  #10632, eff 7-1-14

 

          He-W 511.06  Cost Effectiveness Redetermination.

 

          (a)  Cost effectiveness shall be redetermined annually concurrent with the recipient’s annual enrollment in the group health plan, or any time there is a change in the group health plan.

 

(b)  The newly eligible adult shall submit the current group health plan, as described in He-W 511.04(e) and (f) above, within 30 days of having receiving a notice of redetermination from the department.

 

Source.  #10632, eff 7-1-14

 

          He-W 511.07  Wrap Around Coverage.

 

          (a)  If the group health plan does not cover the full range of medicaid services, the newly eligible adult shall receive wrap-around services.

 

          (b)  Non-medicaid eligible family members shall not be eligible to receive wrap around services.

 

Source.  #10632, eff 7-1-14

 

          He-W 511.08  Payment of Cost Sharing.

 

          (a)  Recipient cost sharing obligations shall be either paid directly by medicaid or reimbursed to the recipient if the recipient paid out of pocket, such as for mail order prescription medications.

 

          (b)  If a non-medicaid family member is enrolled in the group health plan, then medicaid funds shall be expended for payment of premiums, but not for any other cost sharing expenses attributable to the non-medicaid family members.

 

          (c)  The HIPP program shall pay for the minimum coverage option that allows the medicaid-eligible person/persons to be covered.

 

          (d)  When more than one cost effective group health plan is available, the department shall pay the premium for only one plan, but the newly eligible adult may choose the cost effective plan in which to enroll.

 

          (e)  If the newly eligible adult’s health plan offers more services than what is covered under medicaid, the newly eligible adult shall be responsible for any deductibles, coinsurance, and other cost sharing obligations attributable to those services not covered by medicaid.

 

          (f)  The newly eligible adult shall be responsible for payment of any nominal cost sharing amounts permitted under section 1916 of the SSA.

 

Source.  #10632, eff 7-1-14

 

          He-W 511.09  Loss of Eligibility and Discontinuation of Premium Payments.

 

          (a)  Except as provided in (b) below, when the newly eligible adult loses medicaid eligibility, premium payments shall be discontinued as of the month of medicaid ineligibility.

 

          (b)  Premium payments shall continue for 6 months from the date the department determines that the group health plan is cost effective, even if the newly eligible adult loses medicaid eligibility within that 6-month period.

 

          (c)  Coverage of any medicaid benefits provided outside the group health plan, including any wrap around services, shall end on the date the newly eligible adult loses medicaid eligibility.

 

          (d)  If the department determines that the health plan is no longer cost effective, HIPP premium payment shall be discontinued pending timely and adequate notice, made in accordance with 42 CFR 431.211.

 

          (e)  If the newly eligible adult fails to provide the information necessary to determine the availability and cost effectiveness of group health insurance in accordance with the timeframes set forth in He-W 511.04(e) or (f) above, he or she shall be terminated from the medicaid program within 15 days following the failure to comply.

 

          (f)  If the newly eligible adult fails to provide the information necessary to establish ongoing eligibility in accordance with the timeframes set forth in He-W 11.06(b), he or she shall be terminated from the medicaid program within 15 days for failure to comply.

 

          (g)  If the newly eligible adult provides the necessary documentation within the 15 day advance notice period stipulated in (e) or (f) above, his or her termination from the medicaid program shall be voided and a HIPP cost effective calculation shall be performed.

 

          (h)  If the newly eligible adult disenrolls from their cost effective group health plan, the newly eligible adult shall lose eligibility for medicaid until such time as the newly eligible adult recipient re-enrolls in the cost effective group health plan and reapplies for medicaid.

 

          (i)  If the health plan is no longer available or the policy has lapsed, premium payments shall be discontinued as of the effective date of the termination of the coverage.

 

Source.  #10632, eff 7-1-14

 

          He-W 511.10  Third Party Liability.  All third party obligations shall be exhausted before claims shall be submitted to the department’s fiscal agent in accordance with 42 CFR 433.139.

 

Source.  #10632, eff 7-1-14

 

          He-W 511.11  Utilization Review & Control.  The department’s provider program integrity unit shall monitor utilization of services to identify, prevent, and correct potential occurrences of fraud, waste and abuse in accordance with in accordance with He-W 520, 42 CFR 455, and 42 CFR 456.

 

Source.  #10632, eff 7-1-14

 

PART He-W 512  ALTERNATIVE BENEFIT PLAN (ABP) AND PREMIUM ASSISTANCE PROGRAM

 

          He-W 512.01  Purpose.  The purpose of this part is to describe the alternative benefit plan (ABP) services and the premium assistance program (PAP) available through the medicaid program to the newly eligible population in accordance with the New Hampshire Health Protection Program, RSA 126-A:5, XXIV.

 

Source.  #10656, eff 8-15-14; ss by #11012, INTERIM, eff 1-1-16, EXPIRES: 6-29-16; ss by #11119, eff 6-29-16

 

          He-W 512.02  Definitions.

 

          (a)  “Alternative benefit plan (ABP)” means the medicaid benchmark or benchmark equivalent coverage described in section 1937 of the Social Security Act.

 

          (b)  “Department” means the New Hampshire department of health and human services.

 

          (c)  “Medicaid” means the Title XIX and Title XXI programs administered by the department, which makes medical assistance available to eligible individuals.

 

          (d)  “Medically frail” means a newly eligible individual who is exempt from mandatory enrollment in the ABP or PAP in accordance with the conditions set forth in 42 CFR § 440.315(f).

 

          (e)  “Newly eligible adult” means adults who are eligible for medicaid under the New Hampshire health protection program and the provision of section 1902(a)(10)(A)(i)(VIII) of the Social Security Act of 1935 as amended, 42 USC §1396a(a)(10)(A)(i)(VIII).

 

(f)  “Premium Assistance Program (PAP)” means the Marketplace Premium Assistance Program, established by RSA 126-A:5 which requires that adults eligible for medical assistance under 42 USC § 1396a(a)(10)(A)(i)(VIII) enroll in a cost-effective Qualified Health Plan offered on New Hampshire’s federally facilitated Marketplace, authorized through the Section 1115(a) research and demonstration waiver, # 11-W-00298/1 by the Centers for Medicare and Medicaid Services on March 4, 2015.

 

(g)  “Premium Assistance Program participants (PAP participants)” means those newly eligible adults who are mandatorily required to enroll in a qualified health plan, and those who voluntarily enroll in a qualified health plan.

 

(h)  “Qualified Health Plan (QHP)” means an individual health insurance policy certified by the Centers for Medicare and Medicaid Services (CMS) for sale through New Hampshire’s individual health insurance Marketplace.

 

          (i)  “Subluxation” means an incomplete dislocation, off centering, misalignment, fixation, or abnormal spacing of the vertebrae.

 

          (j)  “Title XIX” means the joint federal-state program described in Title XIX of the Social Security Act and administered in New Hampshire by the department.

 

          (k)  “Title XXI” means the joint federal-state program described in Title XXI of the Social Security Act and administered in New Hampshire by the department.

 

          (l)  “Wrap benefits” means:

 

(1)  Non-emergency medical transportation;

 

(2)  Early Periodic Screening Diagnosis and Treatment (EPSDT) services as described in He-W 546, for individuals who are under the age of 21; and

 

(3)  Family planning services and supplies from a medicaid enrolled provider, and adult dental in accordance with He-W 566.04(e) and adult vision services in accordance with He-W 530.03(g).

 

Source.  #10656, eff 8-15-14; ss by #11012, INTERIM, eff
1-1-16, EXPIRES: 6-29-16; ss by #11119, eff 6-29-16

 

          He-W 512.03  Eligibility.

 

          (a)  All newly eligible individuals shall receive services under the ABP, unless they are medically frail or identify as pregnant after application and opt to receive Medicaid state plan services.

 

          (b)  Individuals who are eligible for medicaid through the New Hampshire Health Protection Program (NHHPP) shall be in the PAP unless the individual is exempt or voluntary as described in He-W 512.04(b) and (c) below.

 

Source.  #10656, eff 8-15-14; ss by #11012, INTERIM, eff
1-1-16, EXPIRES: 6-29-16; ss by #11119, eff 6-29-16

 

          He-W 512.04  Enrollment.

 

          (a)  For individuals who are eligible for PAP, enrollment in a QHP shall be mandatory unless the individual is determined to be exempt as described in (b) below or voluntary as described in (c) and (d) below.

 

          (b)  Individuals who are determined to be medically frail as defined in 42 CFR § 440.315(f) shall be exempt from mandatory enrollment with a QHP.

 

          (c)  The following individuals shall be considered voluntary for enrollment with a QHP:

 

(1)  Individuals who are members of a federally recognized Indian tribe or Alaskan natives; and

 

(2)  Individuals who are enrolled in PAP who identify as pregnant after the point of application for medicaid.

 

          (d)  The following shall apply to voluntary individuals described in (c) above:

 

(1)  Voluntary individuals shall be enrolled in a QHP unless the individual identifies to the department that he or she is in a voluntary eligibility group as noted in (c) above; and

 

(2)  If, after identifying as being in a voluntary eligibility group, a voluntary individual chooses not to enroll in a QHP, the individual shall be notified by the department and required to choose a medicaid managed care organization (MCO) as described in He-W 506.

 

          (e)  The department shall send a notice of QHP plan selection to all individuals eligible for PAP enrollment as indicated in (a) above except those who are exempted from enrollment.

 

          (f)  PAP participants shall have 30 days from the date of the QHP plan selection notice in (e) above to select a QHP and to respond to the department’s notice by using the on-line portal NH Electronic Application System (NH EASY) at www.nheasy.nh.gov, calling via telephone at 1-888-901-4999, or contacting the department in person.

 

          (g)  Except for voluntary individuals described in (c) and (d) above, PAP participants who fail to select a QHP within 30 days from the date of the notice in (f) above shall be auto-assigned to a QHP.

 

          (h)  Auto-assignments with a QHP shall be based on the following criteria:

 

(1)  Personal or family affiliation to a QHP or MCO, if the MCO offers a complementary QHP;

 

(2)  Primary care provider affiliation with a QHP; or

 

(3)  If no assignment can be made utilizing (1)-(2) above, assignment shall be equally distributed among the available QHPs.

 

          (i)  PAP participants may request to change the QHP selection without cause, by making a written or oral request to the department at any of the following times:

 

(1)  During the first 30 days following the date of the member’s initial selection of or the auto-assignment to the QHP, or the date the department sends the member confirmation of the individual’s selection or auto-assignment, whichever is later; and

 

(2)  During annual open enrollment.

 

          (j)  PAP participants may request to change the QHP selection for cause, by making a written or oral request to the department within 60 days of the occurrence of one of the following events:

 

(1)  PAP participant loses access to the QHP he or she is currently enrolled in because of a permanent move to a county where that QHP is not available;

 

(2)  PAP participant gains or becomes a dependent through marriage, birth, adoption, foster care, child support order, or court order;

 

(3)  PAP participant loses a dependent or is no longer considered a dependent through divorce or legal separation as defined by state law in the state in which the divorce or legal separation occurs, or if the enrollee’s dependent dies;

 

(4)  The department confirms based on a PAP participant’s complaint that the QHP in which the PAP participant is enrolled violated a material provision of its contract in relation to the PAP participant; or

 

(5)  PAP participant’s enrollment or non-enrollment in a QHP is unintentional, inadvertent, or erroneous and is the result of the error, misrepresentation, misconduct, or inaction of an officer, employee, or agent of the department, its instrumentalities, or a non-departmental entity providing enrollment assistance or conducting enrollment activities.

 

          (k)  PAP participants shall be dis-enrolled from the PAP program if they identify as medically frail after they were previously determined eligible.

 

          (l)  Medically frail individuals shall have the option to enroll with a medicaid MCO to receive the ABP benefit or the state plan medicaid benefit.

 

          (m)  Individuals who are voluntary as described in (c) and (d) above shall be enrolled as follows:

 

(1)  Individuals who are enrolled in PAP and identify as pregnant after the point of application for medicaid shall elect to receive either state plan medicaid benefits delivered through a medicaid MCO or remain enrolled in the PAP with a QHP; and

 

(2)  Individuals who are members of a federally recognized Indian tribe or Alaskan natives who elect to dis-enroll from their QHP shall receive ABP benefits delivered through a medicaid MCO.

 

          (n)  For PAP participants eligible for medicaid after October 1, 2015, the PAP participant shall receive coverage through fee-for-service medicaid from the date of the eligibility determination until the individual’s enrollment in the QHP becomes effective. 

 

          (o)  If a PAP participant selects or is auto-assigned to a QHP on or before the 15th of the month, coverage in the QHP shall be begin the first day of the month following the month in which the selection or auto-assignment was made.

 

          (p)  If a PAP participant selects or is auto-assigned to a QHP any time after the 15th of the month, coverage in the QHP shall be begin the first day of the second month following the month in which the selection or auto-assignment was made.

 

Source.  #10656, eff 8-15-14; ss by #11012, INTERIM, eff
1-1-16, EXPIRES: 6-29-16; ss by #11119, eff 6-29-16

 

          He-W 512.05  Covered Services.

 

          (a)  ABP services for NHHPP participants who are medically frail or identify as members of federally recognized Indian tribes or Alaskan natives who choose to opt-out of the PAP shall include the following:

 

(1)  Services described in He-W 506.04(a) and (b);

 

(2)  Substance use disorder (SUD) services as described in He-W 513; and

 

(3)  Chiropractor services, which shall be provided as follows:

 

a.  Chiropractic services shall consist of spinal manipulation and manual medical intervention services, including:

 

1.  Office visits for:

 

(i)  Assessment;

 

(ii)  Evaluation;

 

(iii)  Spinal adjustments;

 

(iv)  Manipulation; and

 

(v)  Physiological therapy before or in conjunction with spinal adjustments; and

 

2.  Medically necessary diagnostic laboratory and x-ray tests;

 

b.  Chiropractic services shall not include wellness care; and

 

c.  Chiropractic services shall be limited to 12 visits per recipient, per state fiscal year.

 

          (b)  Covered services for PAP participants enrolled with a QHP shall include the following categories of services from a QHP:

 

(1)  Ambulatory patient services;

 

(2)  Emergency services;

 

(3)  Hospitalization;

 

(4)  Maternity and newborn care;

 

(5)  Mental health and substance use disorder services, including behavioral health treatment;

 

(6)  Prescription drugs;

 

(7)  Rehabilitative and habilitate services and devices;

 

(8)  Laboratory services;

 

(9)  Preventive and wellness services and chronic disease management; and

 

(10)  Pediatric services including oral and vision care.

 

          (c)  PAP participants shall receive benefits described in (b) above from a QHP, and shall be restricted to using the QHP provider networks except that PAP participants shall not be restricted in their choice of family planning providers if the family planning provider is enrolled with medicaid.

 

          (d)  PAP participants shall receive fee for service wrap benefits as defined in He-W 512.02(l) above.

 

Source.  #10656, eff 8-15-14; ss by #11012, INTERIM, eff
1-1-16, EXPIRES: 6-29-16; ss by #11119, eff 6-29-16

 

          He-W 512.06  Co-payments.

 

          (a)  Except as prohibited by 42 USC § 1396o-1(b)(3)(B), newly eligible individuals who have an income greater than 100 percent of the FPL and are PAP participants shall be subject to the following co-payments:

 

(1)  A co-payment in the amount of $8.00 for each non-preferred drug prescription and refill dispensed;

 

(2)  A co-payment in the amount of $4.00 for each preferred drug prescription and refill dispensed;

 

(3)  A co-payment in the amount of $5.00 for each primary care provider visit to treat illness or injury;

 

(4)  A co-payment in the amount of $125.00 for each inpatient mental health admission, inpatient substance use disorder treatment admission or hospital admission, excluding maternity admissions;

 

(5)  A co-payment in the amount of $50.00 for high-cost imaging such as CT/PET scans, and MRIs;

 

(6)  A co-payment in the amount of $5.00 for each mental health outpatient visit;

 

(7)  A copayment in the amount of $5.00 for each substance use disorder outpatient visit;

 

(8)  A co-payment in the amount of $8.00 for each physical therapy visit;

 

(9)  A co-payment in the amount of $8.00 for each occupational therapy visit;

 

(10)   A co-payment in the amount of $8.00 for each speech therapy visit;

 

(11)  A co-payment in the amount of $5.00 for each chiropractor visit;

 

(12)  A co-payment in the amount of $8.00 for each specialty physician visit;

 

(13)  A co-payment in the amount of $5.00 for each visit to other medical professionals such as an advanced practice registered nurse or a physician’s assistant; and

 

(14)  A co-payment in the amount of $5.00 for each laboratory outpatient visit.

 

          (b)  Co-payment obligations shall be suspended for the remainder of the calendar year quarter when the total co-payments made out of pocket by the newly eligible individual reach 5 percent of the individual’s household income for that quarter. Co-payment obligations shall resume at the beginning of the next quarter. “Quarter” means one of 4 calendar periods ending March 31, June 30, September 30, and December 31.

 

Source.  #10656, eff 8-15-14; ss by #11012, INTERIM, eff
1-1-16, EXPIRES: 6-29-16 (from He-W 512.05); ss by #11119, eff 6-29-16; ss by #12438, eff 1-1-18

 

He-W 512.07  Appeals Process for the Premium Assistance Program.

 

(a)  The appeals process for the PAP shall address PAP participants’ requests for the appeal of any adverse decisions made by the QHP related to a PAP participant’s QHP covered benefits and decisions made by the department related to eligibility or wrap benefits related to the PAP.

 

(b)  PAP participants who want to appeal a decision made by the QHP regarding a QHP’s covered benefits shall exhaust all private market appeals processes applicable under RSA 420-J:5 and RSA 420-J:5-a through 5-e prior to requesting a state fair hearing with the department.  The private market appeals processes include internal review conducted by the QHP under RSA 420-J:5 with respect to both medical necessity and coverage issues, and an independent external review conducted by an independent review organization (IRO) under RSA 420-J:5-a through 5-e with respect to medical necessity issues only.

 

(c)  PAP participants shall have the right to a state fair hearing in accordance with (d) and (e) below when the enrollee has exhausted the private market appeals processes without having the issue under appeal resolved in his or her favor. PAP enrollees shall file a request for a fair hearing in accordance with He-C 200.

 

(d)  PAP participants shall have the right to a state fair hearing for the following issues:

 

(1)  For medical necessity issues, at the conclusion of the external review process as provided in RSA 420-J:5-a-5-e;

 

(2)  For issues not related to medical necessity, at the conclusion of a QHP internal review process as provided in RSA 420-J:5; and

 

(3)  For decisions related to eligibility for medicaid or decisions made regarding wrap benefits made by the department, without first exhausting any private market appeals processes.

 

          (e)  Requests for a department fair hearing shall be made in writing within 30 calendar days of the date of the notice of the resolution of the appeal through the private market appeals process.

 

          (f)  A PAP participant’s benefits shall be continued during a department fair hearing if:

 

(1)  The individual requests a department fair hearing within 10 calendar days of the notice of the disposition of the private market appeals process or the notice of the department’s decision on eligibility or wrap benefits;

 

(2)  The individual requests continuation of benefits; and

 

(3)  The individual identifies a medicaid enrolled provider to provide the benefit requested.

 

          (g)  If the QHP’s adverse decision is upheld in a department fair hearing, the member shall be liable for the cost of continued benefits.

 

Source.  #10656, eff 8-15-14; ss by #11012, INTERIM, eff 1-1-16, EXPIRES: 6-29-16; ss by #11119, eff 6-29-16

 

          He-W 512.08  Utilization Review and Control.  The department’s provider program integrity unit shall monitor utilization of ABP services to identify, prevent, and correct potential occurrences of fraud, waste and abuse in accordance with in accordance with He-W 520, 42 CFR 455, and 42 CFR 456.

 

Source.  #11012, INTERIM, eff 1-1-16, EXPIRES: 6-29-16 (from He-W 512.06); ss by #11119, eff 6-29-16

 

He-W 512.09  Third Party Liability.  All third party obligations shall be exhausted before claims shall be submitted to the department’s fiscal agent in accordance with 42 CFR 433.139.

 

Source.  #11012, INTERIM, eff 1-1-16, EXPIRES: 6-29-16 (from He-W 512.07); ss by #11119, eff 6-29-16

 

PART He-W 513  SUBSTANCE USE DISORDER (SUD) TREATMENT AND RECOVERY SUPPORT SERVICES

 

He-W 513.01  Purpose.  The purpose of this part is to establish the procedures and requirements for age and clinically appropriate substance use disorders (SUDs) treatment and recovery support services that are provided to the individuals who are eligible for medicaid.

 

Source.  #10655, INTERIM, eff 8-15-14, EXPIRES: 2-11-15; ss by #10779, eff 2-11-15; ss by #10922, eff 9-1-15; ss by #11107, eff 7-1-16; ss by #12681, eff 11-27-18

 

          He-W 513.02  Definitions.

 

          (a)  “Collaborative service model” means a model whereby SUD treatment and recovery support services, health care services, and mental health services are provided by practitioners from different programs who work together via formalized relationships.

 

          (b)  “Comprehensive SUD program” means:

 

(1)  An agency under contract with or agreement with the department which provides specialty SUD treatment and recovery support services on a residential and outpatient basis and whose facility is:

 

a.  Licensed as a residential treatment and rehabilitation facility in accordance with He-P 807; or

 

b.  A state-owned SUD residential treatment and rehabilitation facility which is exempt from licensure in accordance with RSA 151:2, II (i)and He-P 807;

 

(2)  A hospital enrolled in medicaid both as a hospital in accordance with He-W 543 and as a comprehensive SUD program in accordance with He-W 513, which provides specialty SUD treatment and recovery support services on a res