Section 210-RICR-30-05-3.10 - Methodology for Determining Cost-EffectivenessA. The RIte Share Unit uses the information about the ESI plan to compare the cost of the employee's share, for the ESI to the cost of enrollment in Medicaid managed care. An ESI plan is determined to be cost-effective when, on the aggregate, the total cost of medical coverage through RIte Share is less than the cost of coverage if enrolled in a Medicaid managed care plan. RIte Share participants receive coverage comparable in scope, amount, and duration to coverage provided in a Medicaid managed care plan. 1. Cost-effectiveness test - To be cost-effective, the policy holder's monthly ESI premium share, deductibles, co-insurance plus any Medicaid covered services not covered by the ESI plan (such as services covered under the RIte Care Health Plan contract but not under the ESI plan) must be less than the average capitation payment for an average individual/family enrolled in a Medicaid managed care plan. These average costs must be actuarially determined at such intervals as deemed appropriate by EOHHS.2. There are three cost effectiveness determinations for each employer plan: a. Family coverage where all family members are Medicaid eligible (income less than or equal to one hundred thirty six percent (136%) of the federal poverty guidelines (FPL));b. Family coverage where only children and/or pregnant women in the family are Medicaid eligible (for families, income greater than one hundred and thirty-six percent (136%) and less than or equal to, two hundred and sixty one percent (261%); for pregnant women, income greater than one hundred and thirty six percent (136%), and less than or equal to two hundred fifty three percent (253%) of FPL); andc. Individual coverage where only the employee is Medicaid eligible (133% FPL) (Medicaid Expansion).d. All the above listed FPL guidelines are not inclusive of the five percent (5%) income disregard to allow for minor fluctuation in income.B. The figures used as the basis for assessing cost-effectiveness shall be made available, upon request, by EOHHS.210 R.I. Code R. 210-RICR-30-05-3.10
Amended effective 8/6/2019