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.
(c)
“Applicant” means the person who makes application to the catastrophic
illness program (CIP) and who becomes a recipient if determined eligible.
(d)
“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.”
(e)
“Commissioner” means the commissioner of the department of health and
human services.
(f) “Date
of application” means the date on which the program receives the signed
application.
(g)
“Dependent” means a person who may legally be claimed on the federal
income tax return of another person.
(h)
“Department” means the
(i) “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.
(j)
“Financial assistance” means a payment in whole or in part for services
received for the treatment of the catastrophic illness.
(k)
“Medicaid” means the Title XIX program administered by the department,
which makes medical assistance available to eligible individuals who are age 19
or over.
(l) “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.
(m)
“Recipient” means a person over 21 years of age who meets the standards
for eligibility as set forth in these rules.
(n)
“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.
(o)
“Title XIX” means the joint federal-state program described in Title XIX
of the Social Security Act and administered in
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
(c)
Written documentation justifying the income information provided on the
application form are correct, including:
(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
(2) A
(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
(c)
Mileage reimbursement shall continue for one year after kidney
transplantation
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.
(c) Under
no circumstances shall payment be made for services rendered more than one year
from 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.