Section 75-02-02.1-12.1 - Cost-effective health insurance coverage1. For purposes of this section:a. "Cost effective" means that medicaid payments for a set of medicaid-covered services are likely to exceed the cost of paying the health plan premium, coinsurance charges, and deductibles for those services.b. "Health plan" means any plan under which a third party is obligated by contract to pay for health care provided to an applicant for or recipient of medicaid.2. Any recipient of medicaid benefits who is enrolled in a cost-effective health plan may have the health plan premium paid by medicaid.3. Applicants for and recipients of medicaid benefits must provide the information necessary to determine if a health plan is cost effective.4. Recipients with a health plan the department has determined is cost effective must cooperate with all of the conditions and requirements of the health plan. Applicants and recipients must take any optional coverage provided through the plan when it is cost effective to do so. Failure to cooperate with plan requirements, or to select cost-effective options of the plan, will: a. Result in termination of payments for health plan premiums; andb. Result in nonpayment for services, by medicaid, which the health plan would pay, or would have paid, had the recipient conformed to the requirements of the health plan.5. If an applicant for or recipient of medicaid benefits is eligible for enrollment, but is not enrolled in medicare part B, enrollment in any other health plan is not considered cost effective.6. The department shall determine, using information provided by or at the direction of a medicaid applicant or recipient, guidelines established by the department, and other information at its disposal, whether a health plan is cost effective. The department may make determinations under this subsection on a case-by-case basis, on a plan-by-plan basis, or both.N.D. Admin Code 75-02-02.1-12.1
General Authority: NDCC 50-06-16, 50-24.1-04
Law Implemented: NDCC 50-24.1-02; 42 USC 1396 e