Cost Effective Calculation - Health Care Expense Review
If the policy is not determined to be cost effective (box A is less than box B plus box C), proceed to the third step of the Cost Effective Insurance Review Worker Steps (DHS-2841E) and send out the Cost Effective Insurance Referral Applicant/Enrollee (DHS-2841B). This form requests information about the client’s medical history from the last 12 months and asks for copies of Explanations of Benefits (EOBs). EOBs are sometimes referred to as Explanation of Medical Benefits (EOMB). These are statements from DHS, an insurance company, or a health plan reporting amounts paid, reduced, or denied for the client’s health care expenses.
Review any returned copies of EOBs. Approve for cost effective premium reimbursement if benefits paid by the policy are more than two times the cost of the prorated premium for the same period.