Medical Assistance

2.1.1.2.1.3.1 Cost Effective Insurance (Archive)

A Medical Assistance (MA) enrollee with access to health insurance from another source may be eligible for assistance in paying the premiums, deductibles, and copays, if it is cost effective. Cost effective means that paying for the other plan would be less costly than the amount for an equivalent set of services paid for by MA.

When the other available health insurance is determined by the county, tribal or state servicing agency to be cost effective, the enrollee may receive a reimbursement for premiums paid for the policy or they may have the cost of the premium paid directly to the employer or insurance provider. The county, tribal or state servicing agency must process the reimbursement or premium payment within 30 days of receiving verification from the enrollee or employer. Only the portion of the premium payment that covers MA enrollees is reimbursed.

Cost effective coverage could include, but is not limited to, coverage through:

• Group health care coverage, including COBRA

• Individual health care coverage

• Long-term care insurance (group or individual coverage)

• Medicare

Enrollee responsibilities

MA enrollees must:

• Maintain or enroll in a group health plan, if determined to be cost effective and premiums are paid by the county, tribal or state servicing agency or if there is no cost to the enrollee.

• An MA enrollee currently enrolled in a group health plan is not required to maintain enrollment during the cost effective evaluation process.

• Adult enrollees who choose to disenroll from the group health plan during the evaluation process must reenroll in the group health plan at the earliest opportunity if the coverage is determined to be cost effective.

• Children who disenroll from the group health plan during the evaluation process must be reenrolled in the coverage the next possible month if the coverage is determined to be cost effective.

• Cooperate in determining the cost effectiveness of Medicare supplemental policies or group health care coverage. Enrollees have 10-day notice to provide information about other health care coverage to maintain MA eligibility. MA coverage ends when the enrollee fails to cooperate.

• Enroll in cost effective Medicare or group health care coverage at the earliest possible date.

• Report when the cost effective insurance ends or changes.

• Enrollees are not required to cooperate with cost-effective coverage determinations when they are Safe at Home (SAH) Address Confidentiality program participants and the policyholder is their probable assailant.

MA enrollees who cannot enroll in cost effective group health care coverage on their own behalf, do not have MA coverage end due to non-cooperation. See the MA Cooperation policy for more information.

MA enrollees may choose to enroll in or maintain individual health care coverage that is cost effective, with premiums reimbursed or paid directly to the insurance provider. MA enrollees are not required to enroll in or maintain individual policies.

Pregnant women, eligible for CHIP-funded MA, are not required to pursue other health care coverage.

Premiums not reimbursable

The following policies are not cost effective:

• Medicare Supplements

• Medicare Part C (Medicare Advantage)

• Long-term care and hospital indemnity policies that provide cash payments for each day in a hospital or nursing facility and the MA enrollee is not currently collecting benefits

Managed care exclusions

Enrollees with cost effective private health care coverage are excluded from participation in managed care. These enrollees receive health care through fee-for-service (FFS).

Enrollees with non-cost effective private health care coverage through a Health Maintenance Organization (HMO) licensed under Minnesota Statutes §62D may enroll on a voluntary basis if they select the same MHCP managed care organization as their private HMO.

Legal Citations

Code of Federal Regulations, title 42, section 435.1015

Minnesota Rules, part 9505.0430

Minnesota Statutes, section 256B.056

Social Security Act, title 19, section 1906

United States Code, title 26, section 5000

Published:  June 1, 2016

Archived: June 1, 2017