- (a) Recipient cost sharing, co-pays, and deductible obligations shall be either paid directly by medicaid to the providers or reimbursed to the recipient or person who paid, if the recipient is a minor.
- (b) If the provider is a NH medicaid provider, then the provider shall be required to directly bill NH medicaid for any recipient obligation after the employer group health plan processes the claim in accordance with 42 CFR 433.139.
- (c) The recipient, or person who paid, if recipient is a minor, shall be directly reimbursed by the department for services provided by providers not enrolled in medicaid, but in network with the employer group health plan, in which the recipient was unable to obtain the service from a medicaid provider or prescriptions obtained from a mail order pharmacy required by the employer group health plan.
(d) The recipient, or person who paid, if recipient is a minor, shall not be reimbursed for services:
- (1) Not covered by NH medicaid; and
- (2) If the provider is not in either the medicaid network or employer group health plan network.
- (e) The HIPP program shall pay the premium for the minimum coverage group option that allows the medicaid-eligible recipient to be covered.
- (f) If a non-medicaid family member is enrolled in the employer group health plan, then medicaid funds shall be expended for payment of premiums, but not for any other cost sharing expenses attributable to the non-medicaid family members.
- (g) When more than one cost effective employer group health plan is available, the department shall pay the premium for only one plan, but the policyholder may choose the cost effective plan in which to enroll.
- (h) If the medicaid recipient’s health plan offers more services than what is covered under medicaid, the medicaid recipient shall be responsible for any deductibles, coinsurance, and other cost sharing obligations attributable to those services not covered by medicaid.
- (i) The medicaid recipient shall be responsible for payment of any nominal medicaid cost sharing amounts permitted under section 1916 of the Social Security Act (SSA).
Source. #10632, eff 7-1-14; ss by #14075, eff 9-20-24, EXPIRES: 9-20-34