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Effective: December 1, 2006 |
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15.10.05.20ar1 - Cost-Effective Reimbursement (Archive) |
Archived: June 1, 2009 |
The county agency must pay health insurance premiums if DHS determines the premiums are cost-effective and the client meets all of the reimbursement requirements.
Pay premiums directly to the insurance provider or as a reimbursement to the client.
County of Financial Responsibility.
Retroactive Reimbursement Requirements.
Medical Support Reimbursements.
Mail Order Prescription Drug Reimbursement.
County of Financial Responsibility
Counties financially responsible for a client living in another county (for example, excluded time) are responsible for reimbursing the premiums. The servicing county should send payment recommendations to the financially responsible county.
Reimbursements for premiums may be paid to the client, the employer or the insurance provider directly.
Reimburse a client for the cost-effective health insurance premiums if all of the following are met:
l The client or a financially responsible relative, other than a non-custodial parent who is court ordered to provide medical support, paid the premium. Verify payment of the premium.
l The premiums were not used to meet one of the following:
Note: If only part of a premium was used to meet a spenddown, obligation or asset reduction, the client is eligible for reimbursement of the difference between the total amount paid for premiums in the application and retroactive months and the amount used to meet the spenddown or asset reduction.
Example:
Pete applies for MA in April requesting retroactive coverage for March. He has health insurance which is determined to be cost-effective. He paid his health insurance premium of $80 per month for March and April. $60 of the March premium was used to meet his spenddown.
Action:
Reimburse Pete for $20 of the March premium and all of the April premium.
When issuing reimbursements:
l Verify the monthly premium amount to be paid.
Note: See the MMIS User Manual for information on how to determine the payment amount of the monthly premium and how to enter cost-effective information in the TPL subsystem.
l The premium may be paid directly to the employer or the insurance provider after any initial reimbursements to the client.
n If the county elects to reimburse clients, reimburse clients in the same month the client pays the premium.
n Reimburse the initial retroactive premiums within 30 days of the decision to approve MA or GAMC.
l Pay only the portion of the premium that covers family members enrolled in MA or GAMC.
Exception: Consider paying premiums for other family members only if their enrollment is a condition of the MA or GAMC family members' eligibility for the health plan and it is cost-effective.
l Premiums may be reimbursed retroactively for up to 12 months in cases where the cost-effective determination was not completed due to either agency or client delay.
Example:
Lila applies for MA for herself and her children in March and is approved eligible retroactively back to January. A cost-effective review was requested but Lila did not return the paper work. Lila’s MA eligibility was closed.
Lila returns the cost-effective referral information at the children’s MA renewal in July. The insurance is cost-effective.
Action:
Reimburse premiums paid, according to reimbursement requirements, back to January.
Example:
Sara is eligible for MA using the TEFRA waiver. She lives with her parents and her brother, none of whom receive MA or GAMC. Her father has health insurance through his employer at no charge for the employee. The cost of dependent coverage for Sara, her mother, and her brother is $96 per month.
Action:
One-third of the cost of dependent coverage will be reimbursed to the family or paid directly to the provider because it is one-third of the cost of dependent coverage.
Example:
Mary is eligible for MA for herself and her two daughters. Her husband John, the children's stepfather, does not receive MA or GAMC. Mary has health insurance through her employer at a cost of $300 per month for Mary and all dependents. Mary would pay $30 for employee-only coverage. The insurance is determined to be cost-effective.
Action:
$30 is considered to be Mary's share of the $300 premium. $270 is considered to be the cost of dependent coverage for John and the children. Each dependent’s share of the cost of the premium is $90. ($270 divided by 3)
$210 of the premium will be reimbursed to Mary or will be directly paid to the insurance provider ($30 for Mary’s share + $90 for each child).
Example:
Bill applies for MA for his two sons. He is not eligible for MA for himself. He has health coverage through his employer at a cost of $50 for the employee and $100 for dependent coverage. He cannot enroll his sons in the health plan unless he is enrolled. The cost of the covered medical expenses for the year exceeds the annual premium amount based on the $150 per month premium.
Action:
The insurance is cost-effective. The entire premium will be paid as cost-effective coverage because the children cannot be enrolled in the health plan unless Bill is enrolled.
Retroactive Reimbursement Requirements
An MA client is eligible for cost-effective reimbursement in the retroactive months if both of the following are met:
l The client meets all of the reimbursement requirements.
l The client is eligible for MA during the retroactive months.
When issuing a retroactive reimbursement:
l Verify the amount to be reimbursed.
l Issue a check within 30 days of the decision to approve MA or GAMC.
Do not reimburse or pay premiums for non-custodial parents who are court-ordered to provide medical support.
Exception: If all of the following conditions are met, pay the employer or the custodial parent directly, if the custodial parent makes payments to the employer directly, for the cost of the premiums:
n The non-custodial parent leaves a job and has continued dependent coverage available through COBRA.
n The child support officer determines that the non-custodial parent is no longer financially able to keep the coverage in effect.
n The coverage is cost-effective.
Do not reimburse the non-custodial parent directly for the cost of premiums.
The child support officer may pursue repayment of the premiums from the non-custodial parent at a later date.
Example:
Brent receives MA for his son Jerod. Jerod's mother, Susan, is court-ordered to provide health insurance for Jerod. She has dependent coverage available through her employer at a cost of $75 per month. Susan contacts the county and requests reimbursement of the $75 premium because Jerod receives MA.
Action:
Do not reimburse or pay the premium regardless of whether the policy is cost-effective.
Several months later, Susan is laid off. She can continue coverage for Jerod for up to 18 months under COBRA at a cost of $150 per month. The child support officer determines that Susan is unable to pay the premium and requests a cost-effectiveness determination. The policy is determined to be cost-effective.
Action:
Pay the $150 premium directly to the employer or insurance company.
Mail Order Prescription Drug Reimbursement
Some employer-sponsored and private health plans offer prescription drug benefits only through mail order companies such as CareMark, ExpressScripts, and Merck-MedCo. These mail order companies refuse to enroll as MA/GAMC providers and will not bill enrollee co-payments to Minnesota Health Care Programs.
DHS may reimburse enrollees directly for out-of-pocket payments to these mail order companies if all of the following conditions are met:
l The co-payments were not used to meet an MA spenddown
l The enrollee receives MA or GAMC through fee-for-service.
l The benefits are determined cost-effective by the Benefit Recovery Section (BRS) of DHS.
Note: In this instance, "cost-effective" means it is less costly to reimburse the client for the mail order co-payments using 100% state funding than to pay the full cost of the drug through MA at a retail pharmacy.
Contact Benefit Recovery if an enrollee who receives MA or GAMC on a fee-for-service basis has a mail-order only drug benefit with co-payments.
Do not contact Benefit Recovery for enrollees who receive MA or GAMC from managed care plans. Refer the enrollee to the managed care plan for help with benefit coordination.
Reimburse the premiums paid for the following:
l Clients who have Medicare Part A determined cost-effective.
Note: DHS pays the premium directly to SSA through the automated Buy-In process if the client is active on QMB or QWD. No cost-effective referral is required.
Send the premium payment directly to:
HCFA Medicare Insurance.
Medicare Premium Collection Center.
PO Box 371384.
Pittsburgh, PA 15250-7384.
l Clients who have Medicare Part B determined cost-effective.
n Reimburse Part B premiums retroactive to the date of MA-EPD eligibility for MA-EPD enrollees who have Medicare Part B determined cost-effective.
n Also reimburse Part B premiums for IMD residents who would be eligible for QMB or SLMB but for their IMD residence.
See the following references for more information on Medicare Premiums and cost-effective coverage:
l Cost-Effective Health Care Coverage - MA and GAMC for information on cost-effective requirements and Medicare.
l Always Cost-Effective for more information on Medicare Part A, Medicare Part B and Medicare Supplement policies.
l Never Cost-Effective for more information on Medicare Part B and MA-EPD enrollees.
l MMIS User Manual II-37 (Medicare) for instructions on billing DHS for county-reimbursed Medicare payments.