Cost-effectiveness Determination 510-03-20-20

(New 7/1/2014 ML #3404)

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(N.D.A.C. Section 75-02-02.1-12.1)

Health plans requiring a formal cost-effective determination should be submitted to the Medicaid Eligibility Division on SFN 817, "Health Insurance Cost-Effectiveness Review," along with any other information the worker feels is pertinent (i.e. a copy of the health plan, available payment reports, information regarding pre-existing conditions . . .). The form asks for information about the policy coverage, the individuals covered, and the premium. The Medicaid Eligibility Division will obtain or request any additional information needed and will make a timely determination (within 15 days) of cost-effectiveness. The county agency will be notified of that determination. An application for assistance should not be held up beyond the standard of promptness pending a cost-effective determination.

When an individual has more than one health plan, both plans may be considered cost-effective if they do not provide duplicate coverage.

If an individual is eligible for Medicare Part B, but is not enrolled in Part B, enrollment in any other health plan is not considered cost-effective.

Premium payments normally are only allowed for eligible Medicaid recipients. A family policy, however, may cover ineligible members. Payment of the full premium amount is allowed when it is determined that the health plan is cost-effective. The needs of the ineligible family members are not taken into consideration when determining cost-effectiveness.

The following health plans are usually not considered to be cost-effective.

Medicare supplement policies for individuals with routine medical needs (the exceptions are recipients with higher medical needs and the recipient's covered costs exceed the premium);

Hospital indemnity policies if the recipient is not currently collecting benefits;

Policies where the absent parent is the policy holder;

Specific illness policies (i.e. cancer ins.) if the individual covered does not have the illness;

Accident insurance policies, if the recipient is not currently collecting benefits; or

Policies where all of the members of the ACA Medicaid Household, who are covered by the health plan, have a client share (recipient liability).

If the cost-effectiveness of any of these policies is questionable, the policy should be submitted to the Medicaid Eligibility Division for a formal determination.

All cost-effective health plans must be reviewed at least annually.

Changes in a plan’s, premium, coverage or individuals included in the plan must be reported to the Medicaid Eligibility Division.

Cost-effective health plan premiums will be paid effective with the month in which the information is sent to the Medicaid Eligibility Division for approval or is required to maintain the health plan.