2912.2 Cost-Effectiveness Determination

Upon receipt of all information from the client, employer, and insurance company, the fiscal agent will determine if there is a likelihood that paying for the coverage would be cost-effective to the agency. This will be based on specific criteria which will analyze such things as the type of coverage available, the total cost of that coverage including all cost-sharing requirements, and any waiting period restrictions along with limitations on pre-existing medical conditions. This will then be compared with the historical claims data on a sample group which have like characteristics such as age, sex, type of coverage, etc. In addition, any medical expenses associated with known pre-existing and chronic illnesses are factored in. Based on this analysis, including both automated and manual procedures conducted by the HIPPS Unit, the coverage will be either approved or denied for health insurance purchase.

The client as well as the case worker, will be informed of the results by the HIPPS Unit. A copy of the approval or denial letter to the client will be provided to the eligibility worker to include in the case file. On-line screens in the MMIS system are also available to provide this information.

The employer will be notified of an approval only when enrollment needs to take place or payment will be made directly to the employer. The insurance company would also be notified of an approval if payment will be made directly to the company. If denied, the employer and/or insurance company will only be notified if there was a reevaluation of a policy currently being paid that will be discontinued.

Once cost-effectiveness has been determined it will not be reevaluated unless there are changes in circumstances. This would include such things as loss of eligibility, loss or change in employment, change in the health insurance plans offered or in the cost, and changes in family composition. The HIPPS Change Report Form should be used to communicate any such changes in insurance/employment status to the fiscal agent as they become known.

If a person does not initially meet cost-effectiveness guidelines and staff become aware of changes in his or her situations that might lead to a different decision, a new referral should be sent to the fiscal agent for a new determination. The form should indicate that is a redetermination and what the event was that changed in the specified section of this form.