230.09 NHHPP/NHHPP-M: Marketplace Premium Assistance Program (PAP) and the Bridge Program SR 16-03, 01/16 (MAM-A)

*Most NHHPP recipients are required to enroll in the Premium Assistance Program (PAP). Under PAP, DHHS purchases medical assistance coverage provided by Qualified Health Plans (QHPs) certified for sale on the federally facilitated Health Insurance Marketplace. NHHPP applicants and recipients enrolled in PAP shop for a QHP online through NH EASY or by phone or in person.

The following NHHPP recipients are not eligible for enrollment in PAP:

. NHHPP recipients participating in the NH Health Insurance Premium Payment (NH HIPP) program;

. NHHPP recipients who are medically frail (NHHPP-M); and

. NHHPP recipients in a period of presumptive eligibility (PE).

The following NHHPP recipients are considered voluntary participants in PAP:

. NHHPP applicants and recipients that are American Indian or Alaskan Native (AI/AN) may opt out of enrolling in PAP. AI/AN NHHPP recipients are enrolled in PAP unless the individual indicates he or she does not wish to enroll in PAP. AI/AN status is determined by self-attestation as part of the completion of DFA Form 800MA, Application for Health Coverage & Help Paying Costs. AI/AN NHHPP recipients may choose to enroll in PAP or opt out at any time by using NH EASY.

. NHHPP recipients who become pregnant while enrolled in a QHP through PAP may opt out of PAP. If a pregnant NHHPP recipient chooses to opt out of PAP, override the redetermination date to the current month and run the case in redetermination mode. The system will put the NHHPP recipient into the Pregnant Woman Medical Assistance (MA) category. Once complete, override the redetermination date back to what it was previously. Pregnant women who opt out of PAP cannot opt back into PAP. If a woman enrolled in PAP is pregnant at her regularly scheduled redetermination, transition her to Pregnant Woman MA per current policy.

Only NHHPP applicants and recipients must enroll in PAP. Applicants and recipients for all other Medicaid programs, including NHHPP-M, remain members of NH Medicaid Care Management (MCM).

QHPs cover the 10 essential health benefits required under the ACA, and Medicaid provides additional "wrap" benefits, such as coverage for non-emergency medical transportation, early periodic screening diagnostic and treatment (EPSDT) for *19 and 20 year olds, Family Planning services from any Medicaid enrolled provider outside of the QHP network, emergency dental extractions, and eyeglasses.

Once enrolled in PAP, two medical cards are issued:

. an insurance card specific to the QHP; and

. the usual Medicaid ID card that all NH medical assistance recipients receive.

Direct NHHPP recipients to provide both cards at all medical appointments to ensure proper service coverage and payment.

NHHPP recipients who are mandatory or voluntary opt-in have a 30 day window to choose a QHP. QHPs are auto-assigned if the individual is still open for Medicaid and has not self-selected a QHP by the end date of his or her initial selection window.

If a QHP is chosen or auto-assigned on or before the 15th of any month, the NHHPP recipient's QHP coverage begins on the first day of the next month. If a QHP is chosen or auto-assigned after the 15th of any month, the NHHPP recipient's QHP coverage begins on the first day of the second month following the selection. Between an NHHPP recipient's date of application and the start of QHP coverage, an NHHPP recipient receives fee-for-service (FFS) Medicaid.

When a Medicaid recipient enrolled in an MCO changes categories and moves to PAP, the enrollment in MCM stays effective until the begin date of the selected QHP. When an NHHPP recipient who is enrolled in a QHP cascades from NHHPP to another category of Medicaid, such as Parent/Caretaker Relative medical assistance (MA), the recipient remains with their QHP until the end of the month in which the change to the new category of Medicaid occurred. A Parent/Caretaker Relative recipient who was formerly enrolled in a QHP through PAP will have FFS coverage until their MCO enrollment begins after the end of the month in which the change occurred.

Copays

DHHS pays the QHP premiums for PAP enrollees. However, certain NHHPP recipients with income greater than 100% of the Federal Poverty Level (FPL) may be responsible for copays in amounts up to $147 per quarter for certain, but not all, services.

The following NHHPP recipients are exempt from copays:

. Pregnant women or women in a postpartum period;

. American Indians or Alaskan Natives;

. Recipients receiving hospice car; and

. Recipients with income at or below 100% FPL.

Copays are capped at $147 per quarter. Quarters are January 1-March 31, April 1-June 30, July 1-September 30, and October 1-December 31. Once a NHHPP recipient has paid or incurred $147 in copays in any quarter, the recipient is no longer subject to copays for the remainder of the quarter. Copays are paid at the point of service. Service Providers may not deny services to NHHPP recipients that fail to pay copays. Failure to pay copays will not affect an NHHPP recipient's eligibility for NHHPP.

Copays for NHHPP recipients who are subject to copays are as follows:

Services not included above are not subject to copays.

See DFA SR 14-04 or visit www.healthcare.gov for more information about the federally-facilitated Health Insurance Marketplace.

Per RSA 126-A:5,XXV(e)(3), *PAP is subject to cancellation upon notice.

References: He-W 511-512, He-W 841.01, He-W 841.08, RSA 126-A:5, XXIV-XXVI, RSA 126-A:5-b, RSA 126-A:67, 42 CFR 435.119, Section 1902(a)(10)(A)(i)(VIII) of the Social Security Act (SSA) [42 USC 1396a(a)(10)(A)(i)(VIII)], Section 1906 of the SSA [42 USC 1396e], Section 1937 of the SSA [42 USC 1396u-7]