Section 405IAC10-2-1. Definitions

   The following definitions in this rule apply throughout this article:

(1) "Alternative benefit plan" means an alternative benefit plan approved by the Centers for Medicare and Medicaid Services.

(2) "American Indian/Alaskan Native" means any individual defined in 25 U.S.C. 1603(13) or 25 U.S.C. 1603(28) or whom the division has determined eligible as an American Indian/Alaskan Native under 42 CFR 136.12.

(3) "Applicant" means an individual for whom coverage under the plan is requested.

(4) "Benefit period" means the continuous period of plan eligibility. Subject to any exceptions listed in this article, the period of plan eligibility is twelve (12) months.

(5) "Conditionally eligible" or "conditionally eligible individual" means a plan applicant who:

(A) has been determined eligible for the plan by the division; and

(B) is not yet able to receive coverage under HIP Basic, HIP Plus, HIP State Plan Basic, or HIP State Plan Plus.

(6) "Copayment" means a fixed amount charged to a member by the provider for certain services at the time the services are provided.

(7) "Covered service" means a service provided to a member for which payment is available under the plan, subject to the limitations set forth in this article.

(8) "Deductible" means the amount of covered medical services for which the member is responsible. The amount of the deductible for the plan is two thousand five hundred dollars ($2,500) for the benefit period.

(9) "Designated enrollment center" means a center authorized by the division to:

(A) accept applications; and

(B) complete initial intake processing on applications.

(10) "Division" means the division of family resources or its designee.

(11) "Early and periodic screening, diagnostic, and treatment services" means those services defined in 42 U.S.C. 1396d(r).

(12) "Emergency medical condition" means a medical condition as set forth in 42 U.S.C. 1395dd.

(13) "Emergency services" means covered services, including inpatient and outpatient services, that are needed to evaluate or stabilize an emergency medical condition.

(14) "Enrollment broker" means an entity that contracts with the state to:

(A) inform applicants and members about; and

(B) enroll applicants and members with;

insurers participating in the plan.

(15) "Family planning services" means services provided to individuals of childbearing age to temporarily or permanently prevent or delay pregnancy including, but not limited to, birth control pills and nonoral contraceptives. The term also includes sexually transmitted disease testing. Elective abortions and abortifacients are excluded from the definition of family planning services.

(16) "Family planning services program" means the Medicaid category set forth at IC 12-15-46-1.

(17) "Fast track prepayment" means an optional ten dollar ($10) POWER account contribution, which, upon the division's eligibility determination, is either:

(A) refunded to a pending applicant determined ineligible for the plan; or

(B) applied toward the member's required POWER account contribution in the case of a pending applicant determined eligible for the plan.

(18) "Federal income poverty level" or "FPL" means the poverty guidelines updated periodically in the Federal Register by the U.S. Department of Health and Human Services under the authority of 42 U.S.C. 9902(2).

(19) "Federal marketplace" means an American health benefit exchange or online marketplace for health insurance operating in Indiana under 42 U.S.C. 18041.

(20) "Healthy Indiana Plan Basic" or "HIP Basic" means the alternative benefit plan, subject to copayments as set forth in 405 IAC 10-10-3(b), that is provided to individuals with household income at or below one hundred percent (100%) of the FPL when such individuals do not make the required contributions to their POWER account as set forth in 405 IAC 10-10-3(a).

(21) "Healthy Indiana Plan Plus" or "HIP Plus" means the enhanced alternative benefit plan available to individuals with household income up to and including one hundred thirty-three percent (133%) of the FPL who make the required POWER account contributions as set forth in 405 IAC 10-10-3(a).

(22) "Healthy Indiana Plan State Plan" or "HIP State Plan" means the benefits that are, at a minimum, no less than the benefits offered in the Medicaid state plan or HIP Plus, and that are available to the following members who are enrolled in the plan:

(A) Medically frail.

(B) Section 1931 parents and caretaker relatives.

(C) Members eligible for transitional medical assistance.

(D) Low income dependents.

(23) "HIP State Plan Basic" means the benefits, subject to copayments as set forth in 405 IAC 10-10-3(b), available to HIP State Plan members with household income at or below one hundred percent (100%) of the FPL when such individuals do not make the required contributions to their POWER account as set forth in 405 IAC 10-10-3(a).

(24) "HIP State Plan Plus" means the benefits available to HIP State Plan members with household income up to and including one hundred thirty-three percent (133%) of the FPL who make the required POWER account contributions as set forth in 405 IAC 10-10-3(a).

(25) "Household" means the composition and family size of a household as set forth in 42 CFR 435.603(f).

(26) "Household income" means the sum of the MAGI of every individual included in the individual's household as set forth in 42 CFR 435.603.

(27) "Insurer" means a health insurer or health maintenance organization that has contracted with the office to provide a high deductible health plan and POWER account to individuals enrolled in the plan.

(28) "Low income dependent" means a dependent either nineteen (19) or twenty (20) years of age who maintains primary residence in the home of a parent or caretaker relative and meets the Section 1931 parent and caretaker relative income criteria.

(29) "Medically frail" means an individual who, in accordance with the process in 405 IAC 10-6-1, is determined to have any one (1) of the following:

(A) A disabling mental disorder.

(B) A chronic substance abuse disorder.

(C) A serious and complex medical condition.

(D) A physical, intellectual, or developmental disability that significantly impairs the individual's ability to perform one (1) or more activities of daily living.

(30) "Medically necessary service" means a covered service that, in a manner consistent with accepted standards of medical practice, is reasonably expected to:

(A) prevent or diagnose the onset of:

(i) an illness;

(ii) an injury;

(iii) a condition;

(iv) a primary disability; or

(v) a secondary disability;

(B) cure, correct, reduce, or ameliorate the:

(i) physical;

(ii) mental;

(iii) cognitive; or

(iv) developmental;

effects of an illness, an injury, or a disability; or

(C) reduce or ameliorate the pain or suffering caused by:

(i) an illness;

(ii) an injury;

(iii) a condition; or

(iv) a disability.

(31) "Member" means an individual:

(A) whom the division has determined to be eligible for the plan;

(B) who is able to receive coverage under HIP Basic, HIP Plus, HIP State Plan Basic, or HIP State Plan Plus; and

(C) who is not conditionally eligible.

(32) "Modified adjusted gross income" or "MAGI" means MAGI-based income as calculated in accordance with 42 CFR 435.603(e).

(33) "Nonemergency transportation services" means transportation services that are unrelated to an emergency medical condition as defined in subdivision (12).

(34) "Office" means the Indiana family and social services administration, and its offices, divisions, or designee.

(35) "Pending applicant" means an applicant whose application has been received by the division and who has not yet been determined eligible for the plan, but who has been determined by the division to meet the following initial criteria:

(A) Be at least nineteen (19) years of age and less than sixty-five (65) years of age.

(B) Not be a pregnant woman.

(C) Not be enrolled in the federal Medicare program.

(D) Not be a former foster youth.

(E) Not be determined disabled.

(F) Not be an American Indian/Alaskan Native.

(G) Not be subject to a six (6) month plan lockout under 405 IAC 10-10-12.

(36) "Plan" means the Healthy Indiana Plan or HIP as established by a U.S. Department of Health and Human Services approved Section 1115 demonstration waiver and IC 12-15-44.2 that provides health care benefit packages to eligible individuals through a high deductible health plan paired with a personal health spending account called a POWER account.

(37) "Plan reimbursement rate" means the amount of reimbursement insurers pay to providers participating in the plan. This amount shall be:

(A) established by the office; and

(B) based on a Medicaid reimbursement formula that is:

(i) comparable to the federal Medicare reimbursement rate for the service provided; or

(ii) one hundred thirty percent (130%) of the Medicaid reimbursement rate for a service that does not have a Medicare reimbursement rate.

(38) "POWER account" or "personal wellness and responsibility account" means a personal health spending account used to pay a member's deductible for plan covered benefits and services.

(39) "Pregnant woman" means a woman who is pregnant and who otherwise meets the HIP eligibility criteria set forth in 405 IAC 10-4-1.

(40) "Pregnant women Medicaid category" refers to the Medicaid benefits category under the state plan for which a pregnant woman is eligible.

(41) "Presumptive eligibility" means the process established pursuant to 42 CFR 435, Subpart L by which individuals can be determined presumptively eligible for the plan and receive temporary health coverage until official eligibility for the plan is determined by the division.

(42) "Preventive care services" means care that is provided to a member to:

(A) prevent disease;

(B) diagnose disease; or

(C) promote good health.

(43) "Prior authorization" or "PA" means the procedure for the insurer's prior review and authorization, modification, or denial of coverage for medical services and supplies within plan allowable limitations, based upon medical necessity and other criteria as established by one (1) of the following:

(A) The office.

(B) Insurers, subject to approval by the office.

(44) "Provider" means:

(A) an individual;

(B) a state or local agency; or

(C) a business entity;

that meets the requirements of 405 IAC 5-4-1. A provider enrolled as a Medicaid provider under 405 IAC 5-4 is eligible to participate in the plan.

(45) "Qualified presumptive eligibility provider" means a:

(A) hospital;

(B) federally qualified health center;

(C) rural health center;

(D) community mental health center; or

(E) health department;

authorized by the office to determine presumptive eligibility subject to the requirements of 42 CFR 435.1103 and 42 CFR 435.1110.

(46) "Section 1931 parent and caretaker relative" means an individual defined in 42 CFR 435.4 who meets the following income criteria:

Family Size	Monthly Income Amount
1	$152
2	$247
3	$310
4	$373
5	$435
6	$498
7	$561
Each additional	$63

(47) "State" means the executive branch of the state of Indiana.

(48) "Transitional medical assistance" means the extension of eligibility for medical assistance for Section 1931 parents and caretaker relatives in accordance with 42 U.S.C. 1396r-6.

(Office of the Secretary of Family and Social Services; 405 IAC 10-2-1; filed May 18, 2015, 12:34 p.m.: 20150617-IR-405140339FRA)