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Employer-Based Health Insurance Premium Payment (EB-HIPP) Program Client Checklist

The Employer-Based Health Insurance Premium Payment (EB-HIPP) program is a subsidy program that provides premium assistance for an AIDS Drug Assistance Program (ADAP) client's portion of their employer-based insurance premiums. Individuals who are enrolled in EB-HIPP are also eligible for the medical out-of-pocket (MOOP) cost benefit, which covers outpatient MOOP costs that count towards the client's health insurance policy's annual out-of- pocket maximum.

This checklist provides all the necessary information for potential clients to apply to the EB-HIPP Program.

Program Eligibi​lity

  1. ​ Be actively enrolled in ADAP.
  2.  Enrolled in employer-based insurance.
  3. Employed by the employer (i.e., the client cannot be on a spouse's employer-based health insurance plan).
  4. Employer must agree to participate in the EB-HIPP program. (Please Note: If the employer does not consent to this program by filling out the Participation Agreement Form, the client will not be eligible to enroll in EB-HIPP.)
  5. Submit all required EB-HIPP program documentation.

New Enrollment: Required Documents

  1. A signed ADAP Client Attestation Form - CDPH 8723 (PDF)​.
  2. A signed and completed Participation Agreement Form by client and their employer.
  3. A full month of consecutive paystubs, confirming premium amount (must be within the last 3 months). If a new premium is not reflected yet on the paystubs, then a Benefit Enrollment Form, Benefit Statement or Benefit Summary Letter (refer to the Benefit Summary Letter Requireme​nts section below for details) can be submitted. For retirees: In lieu of paystubs, a Benefit Enrollment Form, Benefit Statement or Benefit Summary Letter may be submitted.

Application Process to Enroll in EB-HIPP

  1. ​Retrieve the Participation Agreement Form from the Enrollment Site by email, fax or in- person.
  2. Client and their employer must complete the Participation Agreement Form for the client to enroll in OA's EB-HIPP.
  3. Client will submit all required documents to an ADAP Enrollment Worker or to CDPH directly.
  4. CDPH will enroll the client into EB-HIPP. Please Note: With the first successful payment, the employer will receive a letter stating that the client has successfully enrolled in the program.

Re-Enrollment in EB-HIPP

For ADAP to continue paying premiums towards the client's health plans, clients are required to re-enroll into ADAP and EB-HIPP annually on their birthday.

Re-Enrollment: No Changes

If re-enrolling into EB-HIPP without changes to the client's premium amount, health plan and employer, please submit the following documents:

  1. ​One paystub from the last 3 months (to confirm employer and premium amounts). If the premium is not reflected on the paystubs, then a Benefit Enrollment Form, Benefit Statement or Benefit Summary Letter (refer to the Benefit Summary Letter Requirements section below for details) can be submitted.
  2. Signed ADAP Attestation Form.

    Re-Enrollment: With Changes​

    If the client's premium or employer has changed, see Changes in Premiums, Employer, Health Insurance ​Policies section below.

    Changes in Premium, Employer, Health Insurance Policies

    EB-HIPP clients must report changes about their employer, employer's information, employment status, health plan and premium amount at any time during the year to their ADAP Enrollment Worker. The client must provide the following documentation to an ADAP Enrollment Worker:

    1. New Client Attestation Form - CDPH  8723 (PDF)
    2. New Participation Agreement Form
    3. A full month of consecutive paystubs (within the last 3 months).

    If paystubs do not provide medical and dental deductions, clients should submit a Benefit Enrollment form, Benefit Statement or Benefit Summary Letter (refer to the Benefit Summary Letter Requireme​nts section below for details) to confirm premium amounts.

    Example: If a client submits their January 2023 EB-HIPP documents to show the premium change but their paystubs no longer show deductions, the client can submit a Benefit Statement or Benefit Summary Letter for 2023. This document can be re-submitted when the client is due for their annual ADAP and EB-HIPP re-enrollment.

    For retirees: A benefit enrollment form, benefit statement or benefit summary letter in lieu of paystubs (to verify premium amount).

    Family Plans

    A family plan is defined as a married couple or registered domestic partnership and any dependent children who are included on the health insurance policy along with the ADAP client. Clients who have a family plan are not required to submit any additional supporting documentation when enrolling or re-enrolling in EB-HIPP.

    For clients who have a family plan, EB-HIPP will pay family premiums for medical, dental and bundled vision plans. However, the client's spouse and/or dependents will not have access to MOOP benefits as part of EB-HIPP.

    Please Note: EB-HIPP will only pay the primary policy holder's plan. Additionally, if the client's spouse and/or dependents are enrolled in OA's Spousal / Dependent MOOP Benefit, they will have access to MOOP benefits through the Spousal / Dependent MOOP Benefit. For more information on the Spousal / Dependent MOOP Benefit, please contact your Enrollment Worker or ADAP Advisor.

    Communication with​ Employer

    The client should be aware that Pool Administrators Inc. (PAI) is the contracted vendor for the State of California and may contact the client's employer to get updated premium and payment information. The information will be considered confidential but may be exchanged with the employer as necessary to determine client's eligibility and for purposes of administering the program. PAI's phone number is 877-804-5524.

    Benefit Summary Lette​​r Requirements

    If paystubs do not provide medical and dental deductions, clients can submit a Benefit Enrollment Letter to confirm premium amounts.

    The Benefit Summary Letter must include the following:

    • On company letterhead or state the name of the company
    • Signed by the employer (wet or approved digital signature)
    • Must be no older than 45 days from the date received by ADAP
    • Name of employer or company
    • Name and title of person writing the letter
    • Employer or company address
    • Employer or company phone number
    • Date of the letter
    • Client's name
    • Insurance plan start date or premium change effective date
    • Medical and dental monthly premium amount client is responsible for.​

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