1. (a) Cost effectiveness shall be determined by the department utilizing managed care rates.

2. (b) The cost effectiveness calculation shall be determined as follows:

   1. (1) The average medicaid cost which is the managed care capitation payment at the time a completed HIPP application is received for the category of assistance, age, and gender of the medicaid recipient in the employer group health plan; and

   2. (2) Any additional cost added for the conditions in a. through d. below, paid for under fee for service or additional managed care rates:

      1. a. Blood disorders;
      2. b. Hepatitis C;
      3. c. Disorder of urea cycle metabolism; and
      4. d. Maternity and newborn.
3. (c) The condition(s) listed in (b)(2)a. through d., above shall be present at the time of the HIPP application review.
4. (d) The medicaid cost for included services shall be the percent of the managed care capitation payment, as determined by the actuarial vendor and noted in (b)(1) above, for medicaid only covered services included in the employer group health plan.
5. (e) Adjustment of coinsurance and deductible shall be 30% of the managed care capitation payment after the reduction for the medicaid only covered services in (b)(2) above.
6. (f) An employer group health plan shall be considered cost effective when the cost of the employer group health plan is lower than the cost under the medicaid managed care program.
7. (g) The employer group health plan cost shall be the employee’s share of the premium plus the coinsurance and deductible amount calculated in (e) above.
8. (h) The medicaid cost shall be determined by the managed care capitation payment in (b)(2) above.

Source. #10632, eff 7-1-14; ss by #14075, eff 9-20-24, EXPIRES: 9-20-34