SFN 817, "Health Insurance Cost-Effectiveness Review" 510-03-100-80

(New 7/1/2014 ML #3404)

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This form is used by the county agency to refer Medicaid eligible cases with health insurance to the state Medicaid Eligibility unit to determine if the health insurance is cost-effective and can be paid by Medicaid.

This form is available through the Department of Human Services and may also be obtained electronically via E-Forms . (96 kb pdf)

E-Forms are presented in Adobe Acrobat and require the Adobe Acrobat reader. If you do not currently have Adobe Acrobat reader installed, you may download a free copy by clicking the Get Adobe Reader icon below.