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Health Insurance Premium Payment (HIPP) Program / Cost Avoidance

The Health Insurance Premium Payment (HIPP) program is a voluntary program for qualified beneficiaries with full scope Medi-Cal coverage.  HIPP approved Medi-Cal eligible beneficiaries shall receive services that are unavailable from third party coverage and offered by Medi-Cal.  Beneficiaries with restricted Medi-Cal coverage are not eligible for the HIPP program.

Requirements for HIPP:

Any existing, medically confirmed, medical condition determined by the Department of Health Care Services (DHCS) to be a cost-effective condition is deemed to meet the cost-effectiveness criteria for the HIPP program.  If this does not apply, then the following requirements will be used to determine cost-effectiveness:

  1. Enrollment in an individual or group health insurance plan shall be considered cost-effective when the cost of paying premiums, coinsurance, deductibles, other cost-sharing obligations, and administrative costs, are projected to be less than the amount paid for an equivalent set of Medi-Cal services.
    • The confirmed medical condition must be covered under the individual or group health insurance plan upon date of application.
  2. When determining cost-effectiveness of individual or group health insurance plans, DHCS shall consider the following information:
    • The cost of the insurance premium, coinsurance, deductible;
    • The average yearly anticipated Medi-Cal utilization for the confirmed medical condition;
    • The specific health-related circumstances of the persons covered under the insurance plan; and
    • Annual administrative expenditures.
  3. In any month that a HIPP enrollee has not met his/her monthly spend-down obligation, the enrollee will not be reimbursed.
  4. In order to meet the cost-effectiveness criteria, HIPP enrollees are required to be in fee-for-service (FFS) Medi-Cal.

 You are NOT eligible for HIPP if you are eligible for or enrolled in the following:

  • Medicare
  • TRI-CARE (formerly known as CHAMPUS)
  • Medi-Cal Managed Care


Quick Reference Links

HIPP Application Form - Fillable

HIPP Application and Forms (PDF)
Solicitud y Formas para el Programa HIPP

Frequently Asked Questions (FAQ)

HIPP State Plan Amendment (PDF)



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Last modified on: 4/21/2015 8:43 AM