Medi-Cal/HIPP: Frequently Asked Questions

Disability Benefits 101: working with a disability in California

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1) What is the Medi-Cal/HIPP program?

2) Is Medi-Cal/HIPP known by another name?

3) What does Medi-Cal/HIPP provide and how long will it last?

4) Who is eligible for Medi-Cal/HIPP?

5) What is a high-cost medical condition?

6) What can I use Medi-Cal/HIPP for?

7) Are there any medical eligibility requirements to enroll in Medi-Cal/HIPP?

8) Does what I have in the bank and/or what I own affect my eligibility for Medi-Cal/HIPP?

9) How do I apply for Medi-Cal/HIPP?

10) How soon will I be eligible for benefits from Medi-Cal/HIPP?

11) Can I qualify for the Medi-Cal/HIPP program while I am eligible for the Supplemental Security Income (SSI) program?

12) Can I qualify for Medi-Cal/HIPP while I am eligible for the Social Security Disability Insurance (SSDI) program?

13) How do I stay enrolled/eligible in Medi-Cal/HIPP?

14) Are there rules for immigrants to qualify for Medi-Cal/HIPP?

15) What is the difference between Medi-Cal and Medi-Cal/HIPP?

16) Does working affect Medi-Cal/HIPP benefits?

1) What is the Medi-Cal/HIPP program?
HIPP stands for Health Insurance Premium Payment. The Medi-Cal/HIPP program pays private health insurance premiums so that individuals with high cost medical conditions may continue their private health coverage rather than relying solely on Medi-Cal.

2) Is Medi-Cal/HIPP known by another name?

Yes. The Medi-Cal/HIPP program is also referred to as the HIPP Program or HIPP. Technically, Medi-Cal/HIPP pays premiums for people who are already enrolled in private coverage. If you have private coverage available, but are not yet enrolled, the program is known as Employee Group Health Plan (EGRP). Besides this difference, the programs are identical, and are usually referred to simply as Medi-Cal/HIPP.

3) What does Medi-Cal/HIPP provide and how long will it last?
The Medi-Cal/HIPP program pays for private health insurance premiums. Benefits from the HIPP program last as long as you continue to meet the eligibility requirements.

4) Who is eligible for Medi-Cal/HIPP?

To be eligible for the Medi-Cal/HIPP program you must:

be enrolled in a Medi-Cal eligibility category (aid code) that does not have a share of cost OR has a share of cost that does not exceed $200 per month;
have a high-cost medical condition such as HIV/AIDS, cancer, pregnancy and organ transplantation; and
be insured under a private health insurance policy that does not exclude the individual’s high-cost medical condition. The policy can be individual, group, continuation coverage such as COBRA, Cal-COBRA or OBRA (for self-insured trusts) or COBRA conversion policy.

Individuals who have a share of cost that exceeds $200 per month may still be eligible for Medi-Cal/HIPP. To qualify you must either:

Pay for the private insurance premium during the month you apply for the HIPP program; or
Use unpaid medical bills to be applied towards a future share of cost. This can be done with Hunt v. Kizer case law that allows individuals to use unpaid medical bills towards a Medi-Cal share of cost during the initial application process.

Those ineligible for the HIPP program include individuals enrolled in:

Medi-Cal Managed Care program;
Medi-Cal prepaid health plan;
County Organized Health System (COHS);
County Health Initiative;
Geographic Managed Care Program of the County Medical Services Program (CMSP); and
California’s Major Risk Medical Insurance Pool (MRMIP).

5) What is a high-cost medical condition?
A high-cost medical condition is one that results in average monthly medical expenses that equal or exceed twice the monthly health insurance premium. Some of the conditions that fall into this category include, but are not limited to, HIV/AIDS, pregnancy, cancer and organ transplants.

6) What can I use Medi-Cal/HIPP for?
You can use Medi-Cal/HIPP to cover the cost of private health insurance premiums. Medi-Cal will cover services that are not available under the private policy in addition to deductibles and co-payments. If you have a share of cost it must be met before you can use Medi-Cal services.

7) Are there any medical eligibility requirements to enroll in Medi-Cal/HIPP?
Yes. To qualify for Medi-Cal/HIPP you must have a high-cost medical condition that is verified by your physician.

8) Does what I have in the bank and/or what I own affect my eligibility for Medi-Cal/HIPP?
Yes. To be eligible for the Medi-Cal/HIPP program, you must first meet the income and asset requirements for Medi-Cal. The income and assets requirements you are responsible for meeting depend on which Medi-Cal eligibility category you are enrolled in.

9) How do I apply for Medi-Cal/HIPP?

To apply for the HIPP program you must submit the following:

Medi-Cal/HIPP Department of Health Care Service Form 6155 (Health Insurance Questionnaire);
Medi-Cal/HIPP Department of Health Care Service Form 6172 (HIPP application);
An insurance policy or description of benefits from the insurer or employer;
A physician letter of diagnosis of high-cost medical condition; and
A premium payment notice or election form from COBRA or Cal-COBRA.

10) How soon will I be eligible for benefits from Medi-Cal/HIPP?
Medi-Cal/HIPP applications can take up to 90 days to process. Once approved, you should plan on at least 8-12 weeks before premium payments are made on your behalf.

11) Can I qualify for the Medi-Cal/HIPP program while I am eligible for the Supplemental Security Income (SSI) program?
Yes. If you qualify for Supplemental Security Income (SSI), you automatically qualify for Medi-Cal. If you meet the eligibility requirements for Medi-Cal/HIPP then you can have your private health insurance premiums paid too.

12) Can I qualify for Medi-Cal/HIPP while I am eligible for the Social Security Disability Insurance (SSDI) program?
Yes. If you qualify for a Medi-Cal eligibility category without a share of cost OR a share of cost below $200, you may also be eligible for the Medi-Cal/HIPP program.

13) How do I stay enrolled/eligible in Medi-Cal/HIPP?
To continue receiving Medi-Cal/HIPP benefits you must continue to meet the eligibility requirements. Your status will need to be redetermined on an annual basis.

14) Are there rules for immigrants to qualify for Medi-Cal/HIPP?
Yes. To qualify, you must meet Medi-Cal’s rules for residency.

15) What is the difference between Medi-Cal and Medi-Cal/HIPP?

Medi-Cal is the state Medicaid program that provides health coverage for low-income and medically needy individuals, including those with disabilities. Medi-Cal/HIPP is a program under Medi-Cal that pays for private health insurance premiums for individuals with high-cost medical conditions.

A major difference between Medi-Cal and Medi-Cal/HIPP is that Medi-Cal will pay health care costs billed up to three months before the application date, while Medi-Cal/HIPP only covers insurance premiums and does not make retroactive payments.

16) Does working affect Medi-Cal/HIPP benefits?

Yes. Working may affect your Medi-Cal coverage as well as Medi-Cal/HIPP eligibility. If your earned income increases while you are working, you may incur either a share of cost or a higher share of cost.

To avoid a share of cost or higher share of cost, you may want to consider enrolling in the 250% California Working Disabled Program (250% CWD) and pay a small premium instead. This will allow you to continue using private health insurance and Medi-Cal coverage.

Note: You will need to continue to meet the asset requirements under your Medi-Cal eligibility category.

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