Medical Assistance

2.1.1.2.1.3.1 Cost Effective Insurance (Archive)

A Medical Assistance (MA) enrollee with access to a group or individual health plan may be eligible for assistance in paying the premiums 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. If a plan is cost effective, MA reimburses the premium for the enrollee's health plan and provides coverage for all MA benefits not included in the plan.

When the health plan 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.

MA Cooperation Requirement to Enroll in a Cost Effective Group Health Plan

As a condition of ongoing MA eligibility, an adult enrollee with access to a group health plan must cooperate by enrolling in the plan and maintaining enrollment when the plan is determined to be cost effective. An MA enrollee may have access to a cost effective group health plan through their own employer, or through a family member's employer.

An MA enrollee who has an individual health plan may request a cost effective determination but is not required to enroll or maintain enrollment in the plan as a condition of MA eligibility. If the individual health plan is determined to be cost effective, the enrollee may receive premium reimbursement.

MA Enrollee Cost Effective Cooperation Requirements

MA enrollees must:

• Report access to a group health plan upon request at the time of application or any time access to a group health plan becomes available

• Maintain or enroll in a group health plan when notified of a determination that it is cost effective

• Cooperate in determining the cost effectiveness of group health care coverage. Enrollees have 10 days to provide information about group health care coverage to maintain MA eligibility. MA coverage ends when the enrollee fails to cooperate.

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

• Report when the cost effective insurance ends or changes

Exceptions to Cost Effective Cooperation Requirements

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.

Pregnant women who are eligible for Children's Health Insurance Program (CHIP) funded MA are not required to pursue other health care coverage.

Infants who are funded under CHIP cannot have other health insurance. If a CHIP-funded infant gains access to group health coverage or other health insurance they are moved to MA and the cost effective information in this section will apply.

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.

Managed care exclusions

Enrollees with cost effective group or individual health care coverage are excluded from participation in managed care. These enrollees receive health care through fee-for-service (FFS). Refer to the Prepaid Minnesota Health Care Programs Manual for more information.

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

Code of Federal Regulations, title 42, sections 433.147 and 433.148

Minnesota Rules, part 9505.0430

Minnesota Statutes, section 256B.056, subdivision 8

Minnesota Statutes, section 256B.0625, subdivision 15

Social Security Act, title 19, section 1905(a)

Social Security Act, title 19, section 1906

Published:  September 1, 2017

Archived:  June 1, 2018