He-P 2500 Cat Ill Prog

CHAPTER He-P 2500 CATASTROPHIC ILLNESS PROGRAM

PART He-P 2501 PURPOSE

He-P 2501.01 Purpose. The purpose of the catastrophic illness program (CIP) is to assist residents of the state suffering from catastrophic illnesses in gaining access to needed diagnostic, curative, and rehabilitative health services when these individuals are unable to pay the entire cost of the medical care and treatment required on a continuing basis, despite the existence of various types of hospital and medical insurance, medicare, medicaid, and other governmental assistance programs and private charitable assistance programs.

Source. #4167, eff 11-6-86; ss by #4638, eff 6-26-89, EXPIRED: 6-26-95

New. #8864, eff 4-13-07

PART He-P 2502 DEFINITIONS

He-P 2502.01 Definitions.

(a) “Annual gross income” means the sum of all before-tax income received by the family as stated on the most recent IRS tax return, excluding the sale of property, house, or car, tax refunds, scholarships, or training stipends.

(b) “Applicant” means the person who makes application to the catastrophic illness program (CIP) and who becomes a recipient if determined eligible.

(c) “Catastrophic illness” means “catastrophic illness” as defined in accordance with RSA 137-G:2, II, namely “cancer, hemophilia, end-stage renal disease, spinal cord injury, cystic fibrosis, or multiple sclerosis, the treatment of which requires extensive medical care such as hospitalization, medication, diagnostic evaluation, surgery, dialysis, therapy, or other associated medical expenses such as transportation to and from medical facilities.”

(d) “Commissioner” means the commissioner of the department of health and human services.

(e) “Date of application” means the date on which the program receives the signed application.

(f) “Dependent” means a person who may legally be claimed on the federal income tax return of another person.

(g) “Department” means the New Hampshire department of health and human services (DHHS).

(h) “Family” means two or more persons related by birth, marriage, or adoption who live together, and all such related persons are considered to be members of one family.

(i) “Financial assistance” means a payment in whole or in part for services received for the treatment of the catastrophic illness.

(j) “Medicaid” means the Title XIX program administered by the department, which makes medical assistance available to eligible individuals who are age 19 or over.

(k) “Medical debt” means the combined out-of-pocket dollar amount paid or owed during the 12-month period for the entire family prior to the date of acceptance into the program for services provided by a licensed physician, nurse, therapist, hospital, clinic, or outpatient treatment center to include medical equipment, medications, dental care, ambulance services, home oxygen, and insurance premiums.

(l) “Recipient” means a person over 21 years of age who meets the standards for eligibility as set forth in these rules.

(m) “Third party” means any private insurer, health maintenance organization, hospital service organization, medical service or health services corporation, governmental agency, or any individual, organization, entity, or agency which is authorized or under legal obligation to pay for medical services for an eligible recipient.

(n) “Title XIX” means the joint federal-state program described in Title XIX of the Social Security Act and administered in New Hampshire under the program entitled medicaid.

Source. #2484, eff 9-26-83; ss by #4167, eff 11-6-86; ss by #4638, eff 6-26-89, EXPIRED: 6-26-95

New. #8864, eff 4-13-07

PART He-P 2503 APPLICATION PROCEDURE

He-P 2503.01 Application Procedure. The applicant shall submit the following as part of the application process, before any financial assistance is provided:

(a) A CIP application including:

(1) The applicant’s dated signature, authorizing the release of information and allowing the department to communicate with health care providers; and

(2) The applicant’s dated signature, authorizing the department to collect the applicant’s medical records;

(b) A signed statement verifying that the income information provided on the application in (a) above is correct; and

(1) The most recent income tax return of all those persons whose income is counted in determining family income;

(2) The applicant’s 4 most recent consecutive paycheck stubs, if tax returns are unavailable; or

(3) A letter from the applicant’s most recent employer indicating present gross salary or wages and expected changes during the next 12 months.

Source. #2484, eff 9-26-83; ss by #4167, eff 11-6-86; ss by #4638, eff 6-26-89, EXPIRED: 6-26-95

New. #8864, eff 4-13-07

He-P 2503.02 Commencement, Duration, Redetermination of Eligibility, and Reapplication.

(a) When the CIP determines that an applicant is eligible for financial assistance, the applicant shall remain eligible for the 12 months commencing with the date of application, or earlier for quality assurance purposes.

(b) The CIP shall re-determine eligibility for financial assistance prior to the expiration of the 12-month period described in (a) above, pursuant to He-P 2504.

(c) An applicant and/or family who has applied for financial assistance and has been determined to be ineligible may reapply, when and if their financial or medical status changes.

(d) The CIP shall notify the applicant or the applicant’s family in writing within 30 days of receiving the fully completed application that they are determined to be eligible or ineligible, and the amount, if applicable, of medical debt that must be incurred before receiving financial assistance.

(e) The CIP shall notify the applicant or the applicant’s family in writing of any other action that the CIP has decided to take which affects the applicant’s eligibility, including termination of eligibility or change in the amount of medical debt. This written notification shall be sent to the applicant at least 30 days prior to the effective date of the proposed action.

Source. #2484, eff 9-26-83; ss by #4167, eff 11-6-86; ss by #4638, eff 6-26-89, EXPIRED: 6-26-95

New. #8864, eff 4-13-07

PART He-P 2504 ELIGIBILITY

He-P 2504.01 Residency.

(a) An applicant shall be:

(1) A resident of the state of New Hampshire; and

(2) A United States citizen or a legal alien.

(b) Visitors or persons arriving in the state for special treatment shall not be considered to meet the requirement in (a) above.

Source. #2484, eff 9-26-83; 83; ss by #4167, eff 11-6-86 ss by #4638, eff 6-26-89, EXPIRED: 6-26-95

New. #8864, eff 4-13-07

He-P 2504.02 Medical Eligibility.

(a) An applicant shall be considered medically eligible if he or she is diagnosed as having a catastrophic illness as defined in RSA 137-G:2, II.

(b) An applicant with cancer shall be considered eligible if he or she:

(1) Has undergone active cancer treatment within the last 12 months, defined as undergoing chemotherapy or radiation treatment or cancer surgery; and

(2) Requires oncology monitoring post-active treatment, up to 5 years after undergoing active cancer treatment.

(c) Applicants with a spinal cord injury shall be considered eligible if they are non-ambulatory as a result of the injury.

Source. #2484, eff 9-26-83; ss by #4167, eff 11-6-86; ss by #4638, eff 6-26-89, EXPIRED: 6-26-95

New. #8864, eff 4-13-07

He-P 2504.03 Financial Eligibility.

(a) Financial assistance shall be available to:

(1) Single persons with annual gross incomes of $13,500 or less; and

(2) A family of 2 persons with annual gross incomes of $14,500 or less.

(b) For each additional dependent, the amount of allowed income described in (a)(2) above shall increase by $1,000.

(c) Financial assistance shall be available to applicants whose annual gross income is above the allowed income described in (a) and (b) above when the family’s level of medical debt meets or exceeds 80% of the difference between the annual gross income and the allowed income.

(d) The following special considerations shall be made in determining financial eligibility:

(1) Applicants living with adult married children shall be considered a single person family if the applicant is not claimed as a dependent, otherwise, if the applicant is a dependent, gross income of the family household shall be considered; and

(2) If there has been a significant change in family income due to unemployment, decrease in wages, illness, accident, loss due to fire and so forth, income shall be determined on current available financial resources.

(e) Applicants shall be notified in writing as to the amount of medical debt they shall accrue before the CIP can provide assistance.

(f) Applicants shall be ineligible to receive medical assistance if their savings and/or investments exceed $30,000.

Source. #2484, eff 9-26-83; ss by #4167, eff 11-6-86; ss by #4638, eff 6-26-89, EXPIRED: 6-26-95

New. #8864, eff 4-13-07

He-P 2504.04 Eligibility Determination. An applicant shall be eligible if the applicant meets the eligibility requirements described in He-P 2504.01 through He-P 2504.03.

Source. #2484, eff 9-26-83; ss by #4167, eff 11-6-86; ss by #4638, eff 6-26-89, EXPIRED: 6-26-95

New. #8864, eff 4-13-07

PART He-P 2505 FINANCIAL ASSISTANCE PROVIDED

He-P 2505.01 Recipients with End-Stage Renal Disease. Recipients with end-stage renal disease shall receive financial assistance as follows:

(a) Mileage reimbursement at $0.21 per mile, including tolls, for transportation to and from the nearest dialysis service facility;

(b) Monthly reimbursement for mileage shall not exceed $208.33; and

Source. #2484, eff 9-26-83; ss by #4167, eff 11-6-86; ss by #4638, eff 6-26-89, EXPIRED: 6-26-95

New. #8864, eff 4-13-07

He-P 2505.02 Recipients with Other Catastrophic Illnesses.

(a) Recipients with a diagnosis of cancer, cystic fibrosis, spinal cord injury, hemophilia, or multiple sclerosis shall receive financial assistance for the following:

(1) Outpatient hospital services including diagnostic x-ray, radiotherapy, and diagnostic and therapeutic services;

(2) Physician services, including:

a. Surgical and medical services, including routine pre- and post-operative care, provided in a hospital, in a hospital outpatient department, in a physician’s office, or in the individual’s home;

b. Services provided by an assisting physician in connection with an operative procedure;

c. Services provided by an anesthesiologist, if anesthesia is administered by an individual other than the surgeon or assisting surgeon; and

d. Consultation services when requested by the attending physician; and

(3) Other services, including:

a. Ambulance services provided to the nearest hospital when medically justified;

b. Durable medical equipment, including, mastectomy prosthesis(es), wigs, ostomy supplies, or catheters, where medically indicated by a physician for the treatment of the catastrophic illness;

c Drugs and medications when prescribed by a physician, including over-the-counter pharmacy items needed for the recipient’s treatment; and

d. Related services including payment of COBRA insurance premiums, and home health care as requested in writing by the recipient and as required to meet the recipient’s unique needs, subject to the program budget.

(b) Recipients with a diagnosis of cancer, cystic fibrosis, spinal cord injury, hemophilia, or multiple sclerosis shall not receive financial assistance for the following services:

(1) Services which are experimental or considered alternative therapies by current medical practice;

(2) In-patient hospital and emergency room visits;

(3) Funeral expenses;

(4) Dental care; and

(5) Supplemental payment for medicare part B and D.

Source. #2484, eff 9-26-83; ss by #4167, eff 11-6-86; ss by #4638, eff 6-26-89, EXPIRED: 6-26-95

New. #8864, eff 4-13-07

PART He-P 2506 PAYMENT FOR SERVICES

He-P 2506.01 Eligibility.

(a) A recipient shall be eligible for financial assistance if he or she meets the requirements set forth in He-P 2504.

(b) Applicants shall not be eligible for financial assistance if they are covered by any hospital, surgical, medical insurance plan, or health maintenance organization, or would be entitled to such coverage but for any assistance available through the department, to the extent that there are funds or services available through any medical insurance program or policy.

Source. #2484, eff 9-26-83; ss by #4167, eff 11-6-86; ss by #4638, eff 6-26-89, EXPIRED: 6-26-95

New. #8864, eff 4-13-07

He-P 2506.02 Payment Rates and Levels for Recipients with Other Catastrophic Illnesses.

(a) The maximum level of assistance in any fiscal year shall not exceed $2,500.00 for any recipient.

(b) All payments shall be paid at 50% of the amount billed, except for medications and medical supplies purchased through a pharmacy or from a durable medical equipment supplier, which shall be paid at the average wholesale price.

(c) Where commercial insurance or medicare is involved, payment by CIP shall not exceed the percentage necessary to bring the combined benefit to 50% of the original charge, except for medications.

(d) Medicaid payments shall not be supplemented.

Source. #4167, eff 11-6-86; ss by #4638, eff 6-26-89, EXPIRED: 6-26-95

New. #8864, eff 4-13-07

He-P 2506.03 Retroactive Payment.

(a) Applicants shall be eligible for payment for services beginning on the date of application.

(b) Nothing in this provision shall prohibit payment for services rendered prior to the date of application.

Source. #8864, eff 4-13-07

He-P 2506.04 Catastrophic Illness Program as Payor of Last Resort.

(a) With respect to medicaid, medicare, or any medical insurance program or policy, the CIP shall be the payor of last resort. Nothing contained in these rules shall authorize or require the CIP to provide payment for drugs or services, which would otherwise be paid for by medicaid, medicare, or any other medical insurance program or policy.

(b) Payment for services shall not be made by the CIP until all third party resources are fully utilized. Providers shall file a claim with the third party insurer prior to billing the CIP. Upon receipt of the third party payment, the provider may forward a bill to CIP if a balance remains. Bills shall be itemized and submitted in duplicate.

(c) Each recipient shall notify CIP in writing within 30 days of any change in the recipient’s medical insurance coverage, which results in coverage for drugs or medical services which are currently being paid for by the CIP.

Source. #8864, eff 4-13-07

He-P 2506.05 Limitation of Services. Financial assistance to which these rules apply shall be subject to the availability of funds.

Source. #8864, eff 4-13-07

PART He-P 2507 APPEAL PROCESS

He-P 2507.01 Case Review and Appeal Process.

(a) If an applicant or recipient is dissatisfied with a determination, the applicant or recipient may request a case review conference within 30 working days of the date upon which the notice of determination was received. The CIP shall notify the applicant or recipient within 14 days after the reconsideration of the determination.

(b) If the applicant or recipient is aggrieved by the results of the consideration, he or she may request an adjudicative proceeding in accordance with He-C 200.

Source. #8864, eff 4-13-07

APPENDIX

RULE	STATUTE

He-P 2501	RSA 137-G:1
He-P 2502	RSA 137-G:2; RSA 541-A:7
He-P 2503	RSA 137-G:5; RSA 137-G:5-a, I
He-P 2504	RSA 137-G:5, I; RSA 137:G-5-a, I
He-P 2505	RSA 137-G:5-a, III
He-P 2506	RSA 137-G:5, I; RSA 137-G:5-a
He-P 2507	RSA 541-A:16

APPENDIX II

SAMPLE CALCULATIO FOR HE-P 2404.03, FINANCIAL ELIGIBILITY

For example, if a family consists of a husband, wife, and one child, the allowed family income shall be $15,500. If the annual gross income for the entire family is $20,000, the difference of $4,500 shall be multiplied by 80% to determine the amount of medical debt that shall be incurred before the family shall be deemed eligible for financial assistance. Therefore, in this case, $3,600 shall be the amount of medical debt necessary before any CIP funds shall be used to assist.