Common use of Individual Cost-Sharing Obligations Clause in Contracts

Individual Cost-Sharing Obligations. As detailed in Section 6.16, the Contractor shall ensure that member cost sharing as set forth in this Section 4.1 does not exceed 5% of family income as calculated on a quarterly basis, except that all HIP Plus or HIP State Plan Plus members whose household income is at or below five percent (5%) of the FPL will be required to contribute, at a minimum, monthly one dollar ($1.00) POWER account contributions. The Contractor will work with the State to consider all contributions made by the household in the calculation and monitoring of the 5% contribution limit. The Contractor will have the ability to identify members who have reached the maximum contribution and to cease that member’s cost sharing obligations in accordance with the HIP MCE Policies and Procedure Manual. While the Contractor has the primary responsibility for tracking member’s cost sharing, the Contractor shall also have a process in place that allows a member to self-report on their expenditures and have a process in place to end cost sharing based on member provided documentation. In addition to the cost-sharing set forth below, all HIP members (with the exception of members exempt from cost-sharing as described in Section 4.1.4) will be required to make an $8.00 copayment for non-emergent use of hospital emergency departments, as further described in Section 6.6.2. 4.1.1 HIP Plus Member Cost-Sharing In order to participate in HIP Plus or HIP State Plan Plus, members are required to help fund their $2,500 deductible by contributing to their POWER Account on a monthly basis. Required contributions will be calculated based on a tiered contribution structure. The tier contribution structure assigns a specific POWER Account contribution amount, roughly equivalent to 2% of income, based on the member’s FPL. For married couples participating in HIP Plus, the State will divide the monthly contribution between the two HIP eligible married adults, and each member will be responsible for half of the calculated amount on a monthly basis. Individuals who have indicated they are tobacco users will be required to pay an increased contribution amount beginning in the second calendar year benefit period as part of the tiered structure. In no event will a member’s base monthly POWER account contribution be less than one dollar ($1.00). Base HIP Plus member required contribution tiers based on 2% of income range from $1 to $20 per month. These amounts may be split between spouses, increased for tobacco surcharges, or reduced due to member rollover. <22% $1.00 $1.00 $1.50 $1.00 & $1.50 $1.50 23-50% $5.00 $2.50 $7.50 $2.50 & $3.75 $3.75 51-75% $10.00 $5.00 $15.00 $5.00 & $7.50 $7.50 76-100% $15.00 $7.50 $22.50 $7.50 & $11.25 $11.25 101-138% $20.00 $10.00 $30.00 $10.00 & $15.00 $15.00 The State will determine the member’s required monthly POWER Account contribution and will notify the Contractor of this amount. The Contractor will be responsible for applying any tobacco surcharge or rollover credits or discounts to the POWER Account contribution amount determined by the state. In calendar year 2018 the Contractor must track members’ tobacco use indicator. For calendar year 2019 the Contractor must begin applying the surcharge to the POWER Account invoice. The POWER Account contribution will change only when a member has a FPL change that moves the member to a different tier. Members may prepay their POWER account contribution amounts and the Contractor is responsible for refunding any member overpayments. 4.1.2 HIP Basic Member Cost-Sharing Members enrolled in HIP Basic or HIP State Plan Basic are not required to make monthly contributions to their POWER Account, but are required to pay the following copayments at the time services are rendered: ▪ No copayment is required for preventative care, maternity services or family planning services. ▪ Four dollar ($4.00) copayment is required for outpatient services. ▪ Seventy-five dollar ($75.00) copayment is required for inpatient services. ▪ Four dollar ($4.00) copayment is required for preferred drugs. ▪ Eight dollar ($8.00) copayment is required for non-preferred drugs. The Contractor shall also establish education and policies and procedures for its contracted providers to collect copayments for HIP Basic members at the time of service. 4.1.3 HIP State Plan Member Cost-Sharing Other than individuals exempt from cost-sharing as set forth in Section 4.1.4, all members receiving HIP State Plan benefits shall either pay POWER Account contributions in the amounts set forth in Section 4.1.1 if the member is enrolled in HIP State Plan Plus, or copayments for services as set forth in Section 4.1.2 if the member is enrolled in HIP State Plan Basic. Members that qualify as medically frail under Section 3.3.2 may be subject to both HIP Plus contributions and copayments when their income is over 100% of the FPL and they have not made their POWER account contributions.

Individual Cost-Sharing Obligations. As detailed in Section 6.16, the Contractor shall ensure that member cost sharing as set forth in this Section 4.1 does not exceed 5% of family income as calculated on a quarterly basis, except that all HIP Plus or HIP State Plan Plus members whose household income is at or below five percent (5%) of the FPL will be required to contribute, at a minimum, monthly one dollar ($1.00) POWER account contributions. The Contractor will work with the State to consider all contributions made by the household in the calculation and monitoring of the 5% contribution limit. The Contractor will have the ability to identify members who have reached the maximum contribution and to cease that member’s cost sharing obligations in accordance with the HIP MCE Policies and Procedure Manual. While the Contractor has the primary responsibility for tracking member’s cost sharing, the Contractor shall also have a process in place that allows a member to self-report on their expenditures and have a process in place to end cost sharing based on member provided documentation. In addition to the cost-sharing set forth below, all HIP members (with the exception of members exempt from cost-sharing as described in Section 4.1.4) will be required to make an $8.00 copayment for non-emergent use of hospital emergency departments, as further described in Section 6.6.2. 4.1.1 HIP Plus Member Cost-Sharing In order to participate in HIP Plus or HIP State Plan Plus, members are required to help fund their $2,500 deductible by contributing to their POWER Account on a monthly basis. Required contributions will be calculated based on a tiered contribution structure. The tier contribution structure assigns a specific POWER Account contribution amount, roughly equivalent to 2% of income, based on the member’s FPL. For married couples participating in HIP Plus, the State will divide the monthly contribution between the two HIP eligible married adults, and each member will be responsible for half of the calculated amount on a monthly basis. Individuals who have indicated they are tobacco users will be required to pay an increased contribution amount beginning in the second calendar year benefit period as part of the tiered structure. In no event will a member’s base monthly POWER account contribution be less than one dollar ($1.00). Base HIP Plus member required contribution tiers based on 2% of income range from $1 to $20 per month. These amounts may be split between spouses, increased for tobacco surcharges, or reduced due to member rollover. <22% $1.00 $1.00 $1.50 $1.00 & $1.50 $1.50 23-50% $5.00 $2.50 $7.50 $2.50 & $3.75 $3.75 51-75% $10.00 $5.00 $15.00 $5.00 & $7.50 $7.50 76-100% $15.00 $7.50 $22.50 $7.50 & $11.25 $11.25 101-138% $20.00 $10.00 $30.00 $10.00 & $15.00 $15.00 The State will determine the member’s required monthly POWER Account contribution and will notify the Contractor of this amount. The Contractor will be responsible for applying any tobacco surcharge or rollover credits or discounts to the POWER Account contribution amount determined by the state. In calendar year 2018 the Contractor must track members’ tobacco use indicator. For calendar year 2019 the Contractor must begin applying the surcharge to the POWER Account invoice. The POWER Account contribution will change only when a member has a FPL change that moves the member to a different tier. Members may prepay their POWER account contribution amounts and the Contractor is responsible for refunding any member overpayments. 4.1.2 HIP Basic Member Cost-Sharing Members enrolled in HIP Basic or HIP State Plan Basic are not required to make monthly contributions to their POWER Account, but are required to pay the following copayments at the time services are rendered: ▪  No copayment is required for preventative care, maternity services or family planning services. ▪  Four dollar ($4.00) copayment is required for outpatient services. ▪  Seventy-five dollar ($75.00) copayment is required for inpatient services. ▪  Four dollar ($4.00) copayment is required for preferred drugs. ▪  Eight dollar ($8.00) copayment is required for non-preferred drugs. The Contractor shall also establish education and policies and procedures for its contracted providers to collect copayments for HIP Basic members at the time of service. 4.1.3 HIP State Plan Member Cost-Sharing Other than individuals exempt from cost-sharing as set forth in Section 4.1.4, all members receiving HIP State Plan benefits shall either pay POWER Account contributions in the amounts set forth in Section 4.1.1 if the member is enrolled in HIP State Plan Plus, or copayments for services as set forth in Section 4.1.2 if the member is enrolled in HIP State Plan Basic. Members that qualify as medically frail under Section 3.3.2 may be subject to both HIP Plus contributions and copayments when their income is over 100% of the FPL and they have not made their POWER account contributions.