Section 405IAC10-11-2. Definitions

   For the purposes of this rule, the following definitions apply:

(1) "Affordable" means an ESI plan with a cost structure approved by the Centers for Medicare and Medicaid Services (CMS) in which HIP Link members are predicted by the office to have sufficient funding for premiums and other potential out-of-pocket medical expenses within the HIP Link POWER account limit.

(2) "Employer" means an entity that is the sponsor of a health insurance or a group health insurance plan.

(3) "Employer-sponsored insurance" or "ESI" means an applicable group health insurance plan offered to employees by an employer or a multi-employer plan.

(4) "HIP Employer Benefit Link" or "HIP Link" means an optional defined contribution premium assistance program for HIP-eligible individuals with access to an ESI and meeting the HIP Link eligibility criteria in accordance with section 3 of this rule.

(5) "HIP Link eligible ESI plan" means an ESI plan that the office determines meets the requirements of section 10(d) of this rule.

(6) "HIP Link member" means an individual who meets the HIP Link eligibility criteria and is receiving benefits under section 5 of this rule.

(7) "Medicaid recipient" means an individual who is receiving benefits under any Medicaid category.

(8) "Special enrollment" means the period of time in which an employee is able to enroll for coverage under an ESI as outlined under 26 U.S.C. 9801(f)(3)(A)(ii).

(9) "Wraparound services" means the following health care services not included in the HIP Link eligible ESI plan:

(A) Services provided by a federally qualified health center as defined in 42 U.S.C. 1395x(aa)(2).

(B) Services provided by a rural health clinic as defined in 42 U.S.C. 1395x(aa)(4).

(C) Seventy-two (72) hour emergency prescription supply in accordance with 42 U.S.C. 1396r-8(d)(5)(B)(2).

(D) Family planning services.

(E) Nonemergency transportation services for the following groups:

(i) Transitional medical assistance as defined under 405 IAC 10-2-1(48).

(ii) A HIP Link member who is pregnant at the end of her benefit period and chooses to remain in HIP Link at her redetermination.

(iii) Section 1931 parents and caretaker relatives as defined under 405 IAC 10-2-1(46).

(F) Services required under the state's essential health benefits requirements under the HIP Link alternative benefit plan pursuant to 42 CFR 440.347, if:

(i) said services are not covered by the HIP Link employer's ESI plan after the HIP Link member exhausts all appeal processes under section 13 of this rule; and

(ii) the office determines said services should be covered pursuant to the state's essential health benefits requirements set forth in the HIP Link alternative benefit plan.

(Office of the Secretary of Family and Social Services; 405 IAC 10-11-2; filed Apr 6, 2016, 11:20 a.m.: 20160504-IR-405150325FRA)