Cost-Effectiveness and Eligibility


What does it mean to have a case that is cost-effective?
A case is cost-effective if it is determined that the State will save money by paying for a Health First Colorado (Colorado’s Medicaid Program) member’s portion of the monthly commercial health insurance premium. Your case is cost-effective if the annual cost of your commercial health insurance premiums is less than the annual cost that Health First Colorado would otherwise pay for the member’s medical care.

Do I need to have a catastrophic illness to be eligible for HIBI?
No. Any Health First Colorado member with a high-cost medical condition will be considered for the HIBI Program.

Will you give me some examples of a high-cost medical condition?
When a pre-eligible applicant has a high-cost medical condition, there is a good chance their case will be cost-effective. An applicant with high medical costs may have a catastrophic illness, but high costs may also be associated with other types of conditions, including:

  • Pregnancy
  • Asthma
  • Kidney disease
  • Autism
  • Cancer
  • Cerebral palsy
  • Diabetes
  • Lou Gehrig’s disease
  • Low birth weight babies
  • Muscular dystrophy

Will HIBI find my case to be cost-effective if I am on Medicare?
Typically, premiums for Medicare supplements and Medicare HMO plans are not cost-effective for the State to pay.