Health Insurance Premium Payment 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 or who are no longer covered under the same existing commercial health insurance plan they were on at the time they enrolled into Medi-Cal 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:
- Enrollment in an existing 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.
When determining cost-effectiveness of existing individual or group health insurance plans, DHCS shall consider the following information:
- The confirmed medical condition must be covered under the existing individual or group health insurance plan upon date of application.
In any month that a HIPP enrollee has not met his/her monthly spend-down obligation, the enrollee will not be reimbursed.
In order to meet the cost-effectiveness criteria, HIPP enrollees are required to be in fee-for-service (FFS) Medi-Cal.
- 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.
You are NOT eligible for HIPP if you are eligible for or enrolled in the following:
- TRI-CARE (formerly known as CHAMPUS)
- Medi-Cal Managed Care
If you are transitioning from the HIPP program into a Medi-Cal Managed Care program and are in need of assistance, please contact the HIPP program using one of the methods below:
Fax (916) 440-5676
Address Third Party Liability and Recovery Division
HIPP Program- MS 4719
P.O. Box 997425
Sacramento, CA 95899-7425
The HIPP staff will assist with putting you in contact with your selected Managed Care program staff.
Additional information about Medi-Cal Managed Care can be found using the link below:
Medi-Cal Managed Care
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