Virginia Regulatory Town Hall View Comments

Department of Medical Assistance Services

Board of Medical Assistance Services

Administration of Medical Assistance Services [12 VAC 30 ‑ 20]

Action	Health Insurance Premium Payment (HIPP) Cost Effectiveness Methodology
Stage	Emergency/NOIRA
Comment Period	Ended on 11/25/2009

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11/17/09 9:02 pm

Commenter: Sue Ellen Carvil

Cost Determination

The following information is lifted from the appeal letter we sent to DMAS in response to their recent notification about terminating HIPP. It is hoped the following information will convey the concerns and issues we have with TH-13.

The rationale provided under DMAS letter dated October 23rd, 2009 stated, "A review of your health insurance coverage determined that your health plan is a family health plan. Effective October 5, 2009, HIPP Program regulations were implemented to include existing family health coverage as a factor in the cost effective determination. The HIPP program reviews health plan participants to determine who on the health plan is Medicaid eligible and who is not Medicaid eligible. Based upon the most recent HIPP application we have on file, your health plan is no longer cost effective for HIPP participation...."

The following information is provided for your consideration:

Cost could not have been used as the basis for the determination to terminate the HIPP services. The fact is that the family plan cost is the same whether we have only one child or more children. The Appendix 1, Ineligible Family Plan and Eligible Family Plan chart does not factor in the cost of the health insurance, but is a chart that appears to discriminate based on family configuration. The bottom-line is that if we had only one Medicaid family member (see line 5 of the Eligible Family Plan) and no other non-Medicaid Family members then we'd be eligible. However, because we have one family member that is a non-Medicaid family member (line 1 of Ineligible Family Plan) then we don't qualify. The costs are the same under either situation so I don't see how cost can be used as the rationale for DMAS's determination.

I would also like to call to your attention the extensive costs that our family insurance has covered over the last several years that if we had not had the insurance Medicaid would have borne the cost:

Dates of Service Final Bill

7/27/05 – 7/29/05 $39,384.

10/19/05 – 10/22/05 $36,284.

6/6/06 – 6/9/06 $93,122.

2/6/08 – 2/27/08 $27,152.

3/4/08 – 3/18/08 $113,070.

Total $269,628.

Our son has severe kyphoscoliosis (complex curvature of the spine) that requires periodic surgeries that take place in San Antonio, Texas. Surgeries typically are scheduled every 8 months to keep up with his growth. In 2009, his growth rate didn’t require surgery, but the surgeon(s) expect surgery will continue in 2010. As you can see these medical expenses are very expensive. Also, this probably doesn’t represent the total cost for our Medicaid qualified son as I am not privy to all the expenses the insurance company pays.

In conclusion, my appeal has three arguments:

1) DMAS’s claim that our family health plan is no longer cost effective for HIPP participation appears to be based only on a comparison of the last HIPP application on file to a Family Health Plan Eligibility Chart which could not have been developed based on cost. Our family health insurance premium cost is the same no matter the Medicaid / non-Medicaid configuration of my family, as explained above.

2) The DMAS letter statement, “…HIPP Program regulations were implemented to include existing family health coverage as a factor in the cost effective determination. The HIPP program reviews health plan participants to determine who on the health plan is Medicaid eligible and who is not Medicaid eligible…” I have not read this wording in the regulations.

3) Finally, if DMAS factors in the costs my insurance company has covered in recent years then I think DMAS will appreciate the cost savings benefit of our Medicaid qualified son continuing to receive the Health Insurance Premium Payment. Copies of those expenses are available upon request.

CommentID: 10110