Section 405IAC10-5-3. Maintaining services

   (a) This subsection applies to an aggrieved member requesting an administrative appeal under section 1 or 2 of this rule as follows:

(1) If an aggrieved member requests an administrative hearing as provided in the notice of adverse action, prior to the effective date of the adverse action, plan coverage shall continue without change until an administrative law judge issues a decision after the hearing under 405 IAC 1.1-1-6. If POWER account contributions were required for that member to receive services, the member shall continue to make contributions to the member's POWER account during the appeal in order to continue coverage.

(2) If the administrative law judge sustains the action, the member shall be responsible for repaying the cost of any services furnished by reason of this section, minus any POWER account contributions made for coverage during the pendency of the appeal.

(3) If the action under appeal is overturned, the state or the insurer shall make coverage available effective to the date the overturned action was taken. However, unless the member is not required to make POWER account payments to maintain coverage, the individual shall make any POWER account payments that became due during the appeal within sixty (60) days of the insurer's date of invoice in order to continue participating in the plan.

(4) A member shall not receive continued benefits pending the outcome of an administrative hearing if:

(A) the action is the result of the member's nonpayment of POWER account contributions; or

(B) the member requests in writing that plan benefits not be maintained pending the administrative appeal.

  (b) This subsection applies to an applicant requesting an administrative appeal under section 1 or 2 of this rule. If an applicant was determined ineligible but receives a favorable decision on appeal, coverage begins as follows:

(1) For an applicant who made either a fast track prepayment as provided under 405 IAC 10-3-3(c) or initial POWER account contribution, the first day of the month in which the individual made either the fast track prepayment or the initial POWER account contribution.

(2) For an applicant who made neither a fast track prepayment nor an initial POWER account contribution prior to the date of the appealable action, such individual shall be given a period of time to make either a fast track prepayment or an initial POWER account contribution. This period of time shall be equal to the amount of time remaining in the applicant's payment period from the date of the office's erroneous action. Such period begins on the date of the insurer's new invoice issued after the favorable decision on appeal. If the individual makes either a fast track prepayment or POWER account contribution within this period, the individual shall receive a coverage start date intended to put such individual in the position the applicant would have been in but for the office's erroneous determination.

  (c) An aggrieved applicant requesting an administrative appeal under section 1 or 2 of this rule who receives a favorable determination and is enrolled in either HIP Plus or HIP State Plan Plus in accordance with subsection (b) shall make the required POWER account contributions that accrued during the appeal within sixty (60) days of the date of the invoice in order to continue to be eligible to receive HIP Plus or HIP State Plan Plus coverage. An individual who does not make the required contributions within sixty (60) days of the date of invoice shall:

(1) be transferred to HIP Basic or HIP State Plan Basic if the individual is at or below one hundred percent (100%) of the FPL; or

(2) become ineligible for participation in the plan if such individual is above one hundred percent (100%) of the FPL.

(Office of the Secretary of Family and Social Services; 405 IAC 10-5-3; filed May 18, 2015, 12:34 p.m.: 20150617-IR-405140339FRA)