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Effective: December 1, 2006 |
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15.10.05.05ar1 - Steps in Cost Effective Determination (Archive) |
Archived: November 1, 2009 |
Follow these steps when a client has or is eligible for other health insurance coverage:
1. Review the application/renewal for health insurance information.
2. Request the client complete the Health Insurance Premium Cost Effectiveness Review Form (DHS-2841) and provide any additional information that is needed.
Note: Clients who do not provide requested information are not eligible for MA or GAMC.
3. Determine if the coverage meets any of the coverage for never cost effective. If the coverage:
l Meets one of the never cost effective criteria, stop and go to Step 6.
l Does not meet one of the criteria for never cost effective, go to Step 4.
4. Determine if the coverage meets any of the criteria for always cost effective. If the coverage:
l Meets one of the always cost effective criteria, go to Step 6.
l Does not meet one of the always cost effective criteria, go to Step 5.
5. Make a referral for cost effective review to the Benefit Recovery Section (BRS) of DHS.
Note: If a policy will lapse before the DHS-2841 can be reviewed, call the Benefit Recovery Section for an oral decision.
Include the following information when referring to BRS:
l Three copies of a completed Health Insurance Premium Cost Effectiveness Review Form (DHS-2841).
Note: Pay particular attention to Section 4.
l A copy of the health care policy.
l Include the prorated cost of the health care premium amount for all family members who are applying for or receiving MA.
l Available payment reports or Explanation of Medical Benefits (EOMB).
6. Notify the client of the cost effective determination.
l If approved, notify the client using the appropriate MAXIS SPEC/ LETR. Go to Step 7 and Step 8.
n If the client is not enrolled in the cost effective coverage he or she must enroll within 30 days.
Note: Determine if a special enrollment period is available.
n If the client is enrolled in the cost effective coverage the client must maintain that coverage.
l If denied, notify the client of the decision and the right to appeal the action using the appropriate MAXIS SPEC/LETR. The steps are complete.
n BRS will reconsider denials if the client provides additional information to support a finding of cost effectiveness within 30 days.
n Clients are not required to maintain private or group coverage that is not determined to be cost effective. If they do maintain non-cost-effective coverage, they must continue to assign their rights and to cooperate with the county agency and BRS in providing information about the coverage.
n Clients who continue to pay for enrollment in a non-cost-effective policy may use the premium payment to meet a medical spenddown. Go to Step 7 only.
7. Update the TPL Subsystem in MMIS with the cost effective policy information.
8. Determine which one of the following options the client chooses:
l The client will continue to pay the premium and be reimbursed.
l The client will continue to pay the premium, and have the amount applied to their medical spenddown.
l The premium will be paid by MA directly to the provider.
See Cost Effective Reimbursement for more information.
Clients must continue to maintain other health care coverage which is found to be cost effective. Deny or close eligibility for a client who does not enroll in or maintain this coverage.
Exception: Do not deny or close eligibility for children whose parents or other caretakers refuse or fail to maintain enrollment in cost effective plans.