Section 405IAC10-11-5. HIP Link coverage

   (a) For purposes of this rule, the member's HIP Link benefit period shall align with the employer's benefit period.

  (b) Once a HIP Link member is approved for HIP Link coverage and begins receiving benefits under this rule, such member shall continue to receive benefits in accordance with HIP Link eligible ESI plan and wraparound services. A HIP Link member shall not transfer to HIP during the HIP Link benefit period except upon the occurrence of a qualifying event in accordance with section 7 of this rule.

  (c) For an individual who is not a HIP member or Medicaid recipient, HIP Link coverage shall begin as follows:

(1) Once the division verifies that an individual is enrolled in a HIP Link eligible ESI plan, HIP Link coverage shall begin as follows:

(A) If the division verified that the individual was receiving HIP Link eligible ESI coverage on the first of the month in which eligibility was determined, the first of that month.

(B) If the division verified that the individual shall be receiving HIP Link eligible ESI coverage on the first of the following month, then the first day of the following month.

(C) If the division verified that the individual shall be receiving HIP Link eligible ESI coverage on a date after the first of the following month, the first date of the month following the date that the individual begins receiving ESI coverage. While awaiting HIP Link coverage, such individual shall be subject to conditional enrollment in accordance with 405 IAC 10-3-2.

(2) If the division cannot verify that an individual shall be enrolled in a HIP Link eligible ESI plan, the individual shall be subject to conditional enrollment in HIP Plus in accordance with 405 IAC 10-3-2.

  (d) For a HIP member, HIP Link coverage shall begin on the later of the following:

(1) The first day of the month following the division's verification that the individual was receiving HIP Link eligible ESI coverage.

(2) The first of the month following the beginning date of the HIP Link eligible ESI coverage.

A HIP member pending verification or enrollment in HIP Link shall remain enrolled in the HIP category of benefits the member was receiving.

  (e) For purposes of this subsection, a Medicaid recipient shall not be eligible to begin HIP Link coverage during any month in which the individual is receiving Medicaid coverage. For a Medicaid recipient, HIP Link coverage shall begin as follows:

(1) If the division verifies that a recipient is enrolled in HIP Link eligible ESI coverage, HIP Link coverage shall begin on the first of the month following the division's verification. If an individual is receiving Medicaid coverage during the month of verification or the month following verification, the first of the month following the month in which Medicaid coverage ends.

(2) For any individual not described in subdivision (1), HIP Link coverage shall begin in accordance with subsection (c)(1) or (c)(2) as applicable.

  (f) HIP Link coverage shall be limited to the following:

(1) Premiums, copayments, or other out-of-pocket expenses for covered services under the HIP Link eligible ESI plan up to the amount of the POWER account.

(2) Wraparound services to the extent not offered by the employer's ESI plan.

  (g) A HIP Link member who becomes pregnant and transfers to HIP shall receive benefits in accordance with 405 IAC 10-4-6. A HIP Link member who becomes pregnant and chooses to remain enrolled in HIP Link shall:

(1) receive wraparound services as defined in section 2(9) of this rule; and

(2) receive reimbursement for the entire amount of the cost of her portion of the ESI premium for the duration of the pregnancy and for a period of sixty (60) days after the pregnancy ends.

  (h) A HIP Link member may transfer to HIP if the member submits a written attestation to being medically frail on a form provided by the office pursuant to the process outlined in 405 IAC 10-6-1. A member who submits this attestation shall be transferred to HIP and receive HIP Plus benefits.

  (i) A HIP Link member who exhausts the POWER account funds established under section 8 of this rule shall be responsible for any copays or other cost sharing as set forth in 405 IAC 10-10-3(b) until such member's incurred expenses reach five percent (5%) of the member's quarterly household income as defined in 405 IAC 10-2-1(26). A HIP Link member described in this subsection may be subject to transfer under section 7(c)(3) of this rule. A HIP Link member's monthly two percent (2%) premium contribution shall count toward this five percent (5%) out-of-pocket contribution limit. (Office of the Secretary of Family and Social Services; 405 IAC 10-11-5; filed Apr 6, 2016, 11:20 a.m.: 20160504-IR-405150325FRA)