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Presumptive Eligibility for Breast/Cervical Cancer Services

Revised: 10-10-2012

The Sage Screening Program (formerly the Minnesota Breast and Cervical Cancer Control Program -MBCCCP), is a breast and cervical cancer control program, administered by the Minnesota Department of Health (MDH), that provides free screening to low or moderate income Minnesota women who are uninsured or underinsured.

Minnesota women screened through the MDH Sage Screening Program in need of treatment for breast or cervical cancer, including precancerous conditions and early stage cancer, may be eligible for Medical Assistance coverage (MA-BC (DHS-3525) (PDF).

Eligible Providers

Minnesota Health Care Program (MHCP) providers who have signed an agreement (DHS-4786) (PDF) with MDH to participate in the Sage Screening Program. The Sage provider agreement is subject to renewal with MDH every 5 years.

Participating providers who choose to become a presumptive eligibility (PE) provider must sign the Agreement to Conduct Medical Assistance Presumptive Eligibility for Clients of the Sage Screening Program (DHS-4786) (PDF) form with the Minnesota Department of Human Services (DHS) and complete training with MDH, using the Medical Assistance for Women with Breast or Cervical Cancer presentation located on this page at MDH.

Participating PE providers with MDH determine PE based on information provided on the Sage Enrollment Form and patient’s need for treatment.

Participating providers who do not determine PE must give applicants a copy of their Sage Screening Program form and an MA-BC Application/Renewal to submit to their county agency themselves, or the provider may forward the completed forms to the county agency to determine eligibility for program MA-BC.

Refer to the links below to obtain these forms.

Eligible Recipients

To be eligible for MA-BC recipient’s must:

  • • Use the Sage Screening Program
  • • Need breast or cervical cancer treatment
  • • Have a precancerous cervical condition (diagnostic services to determine the extent and course of treatment are included)
  • • Be uninsured for course of treatment
  • • Be under 65 years old
  • • Be ineligible for other Minnesota Health Care Programs (MHCP)
  • Presumptive Eligibility

    Before determining presumptive eligibility (PE), you must verify eligibility on MN–ITS. Recipients currently eligible for any MHCP are not eligible for PE.

    Participating PE providers with MDH determine PE based on information provided on the MHCP Breast and Cervical Cancer Application/Renewal form (DHS-3525) (PDF).

    Participating providers must complete, sign and give the applicant the enrollee copy of the Temporary Medical Assistance Authorization Form (DHS-3525B) (PDF). This serves as proof of eligibility until eligibility is updated and she receives an MHCP membership card. Individuals found presumptively eligible may immediately receive services.

    Fax to the county's designated MA-BC staff a copy of the recipient's:

  • • Signed consent form
  • • Completed Sage Screening Program form
  • Temporary Medical Assistance Authorization (DHS-3525B) (PDF)
  • MA-BC coverage for applicants with PE begins the first day of the month in which the provider determines PE. Coverage continues for a minimum of 30 days after the date of application.

    The applicant must also complete and return the MA-BC Application/Renewal (DHS-3525) (PDF) form to the county agency within 30 days to determine ongoing MA-BC eligibility.

    Recipient’s determined presumptively eligible may be approved for up to three months of retroactive coverage only after they are determined eligible for ongoing MA-BC. Applicants must meet all eligibility criteria in the retroactive months for MA-BC.

    Referrals to Other Providers

    Refer recipients only to MHCP-enrolled providers.

    The recipient must use the Temporary Medical Assistance Authorization Form (DHS-3525B) (PDF) as proof of MA-BC (DHS-3525) (PDF) presumptive eligibility until their recipient ID is available. After three business days (72 hours) MHCP providers can verify MA-BC (DHS-3525) (PDF) eligibility and obtain the recipient’s ID number using MN–ITS. MN–ITS will denote MA-BC eligibility with major program code BC.

    MA-BC coverage for applicants without PE

    Providers give applicants a copy of their Sage Screening Program form and the MA-BC Application/Renewal (DHS-3525) (PDF) to submit to their county agency. (Providers may also forward the completed forms to the county agency for the applicant).

    MA-BC coverage begins the first day of the month of application. Retroactive MA-BC is available up to three months prior to the application month, but cannot begin prior to the month the applicant was screened. Applicants must have met all eligibility criteria for MA-BC in the retroactive months.

    Breast/Cervical Cancer materials

  • • Refer to the links below for the following forms:
  • • MDH Enrollment and client consent for release of information form
  • • MDH Return Visit Form
  • • MDH Colonoscopy Program
  • MHCP Agreement to Conduct MA Presumptive Eligibility MA-BC Program (DHS-4786) (PDF)
  • Temporary Medical Assistance Authorization (DHS-3525B) (PDF)
  • Certification of Further Treatment Required (DHS-3525A) (PDF)
  • MN Medical Assistance Application/Renewal (DHS-3525) (PDF)
  • Genetic Mutation Testing

    BRCA Genetic Mutation Testing for Breast & Ovarian Cancer Susceptibility: Authorization Criteria

    Authorization

    All services are subject to normal prior authorization and other utilization requirements.

    Refer to the MHCP Provider Manual Authorization section for authorization criteria, and documentation requirements.

    Submit authorizations using MN–ITS or the MHCP Authorization Form (DHS-4695) (PDF).

    Covered Services

    All Medical Assistance covered services may be provided under this program.

    Noncovered Services

    For all Non-Covered services see Non-Covered Services for MA/ MinnesotaCare.

    Billing

  • • To receive payment, you must be an enrolled MHCP provider.
  • • Payment will be made at the MHCP allowed rate for covered Medical Assistance services only.
  • • The recipient’s ID number may not be available through MN–ITS (270/271) for three business days (72 hours) days. Do not bill electronic claims without the recipients ID number.
  • Definitions

    Participating PE Provider: MA providers, who participate in the MDH Sage Screening Program who choose to become a PE provider by completing training and signing an agreement with the Minnesota Department of Health (MDH)

    Presumptive eligibility (PE): A short-term period of eligibility that is determined at the point of service by the participating Sage Screening Program provider. At the time a presumptive eligibility determination is made, the participating provider gives the applicant the enrollee copy of the Temporary Medical Assistance Authorization Form (DHS-3525B) (PDF). This serves as proof of eligibility until her eligibility is updated and she receives a Minnesota Health Care Programs membership card. The presumptive eligibility period begins the first day of the month that the participating provider makes the presumptive eligibility determination and continues through a minimum of 30 days after the date of application. Individuals found presumptively eligible may receive services immediately.

    Legal References

    MS 256B.0625, subd. 13

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