Skip To: Main content|Subnavigation|
Minnesota Department of Human Services Provider Manual
Advanced Search|  

MHCP Member Evidence of Coverage

Revised: 09-08-2017

This evidence of coverage is for people who have fee-for-service coverage* through a Minnesota Health Care Program. An “evidence of coverage” explains your health care coverage and how to use it.

*When you have Minnesota Health Care Program coverage, you can get services in one of two ways: 1) you can be enrolled in a health plan and get services through that health plan, or 2) you can have fee-for-service coverage. Having fee-for-service coverage means that we pay a fee to our enrolled health care providers for a service they provide to you. This evidence of coverage is only for fee-for-service Minnesota Health Care Program members. Members who get services through a health plan should see the evidence of coverage for their health plan.

Table of contents

  • Welcome to MHCP
  • Phone numbers and contact information
  • Important information about getting the care you need
  • Interpreter services
  • Service authorizations
  • Covered and noncovered services
  • Cost sharing
  • Paying providers
  • Other insurance
  • Private information
  • Restricted recipient program
  • HIV/AIDS program
  • Your explanation of benefits
  • When to call your worker
  • Provider information
  • Cancellation
  • Retroactive coverage
  • Your member rights
  • Your member responsibilities
  • Your member card
  • Cost sharing
  • Copays
  • Family deductible
  • Noncovered services
  • Covered services
  • Using your MHCP coverage with other insurance
  • Subrogation or other claim
  • Appeal process
  • Definitions
  • Welcome to MHCP

    Welcome to membership in Minnesota Health Care Programs (referred to as MHCP). MHCP includes MinnesotaCare and all Medical Assistance programs. Not all programs cover all services. Call your worker or the Member Help Desk if you are not sure whether a service or item is covered.

    MHCP (also “we,” “us” or “our”) is giving you this evidence of coverage, also called an EOC. An EOC explains your health care coverage and how to use it. This EOC includes the following:

  • • Contact information
  • • Information about how to get the care you need
  • • Your rights and responsibilities as a member of MHCP
  • • Information about copays
  • • A list of covered services (the list does not include all covered services)
  • • A list of services that are not covered (the list does not include all services that are not covered)
  • • Information about what to do if you have a complaint or want to appeal an action
  • • Definitions
  • • Legal resources
  • Coverage is available in every county in Minnesota. If you want to find our enrolled providers, go to our MHCP Provider Directory.

    When you have MHCP coverage, you can get services in one of two ways: 1) you can be enrolled in a health plan and get services through that health plan, or 2) you can have fee-for-service coverage, which means that we pay a fee to our enrolled providers for a service they provide to you. This EOC is only for fee-for-service MHCP members. Members who get services through a health plan should see the evidence of coverage for their health plan.

    Phone numbers and contact information

    Member help desk

    If you have questions or concerns, call our MHCP Member Help Desk. Member Help Desk hours of service are 8:00 a.m. to 5:00 p.m., Monday through Friday.

    Phone number: 651-431-2670 or 800-657-3739

    TDD/TTY: 711

    Appeals contact information

    If you do not agree with a decision we make, you have the right to appeal (example of a decision: a denial, reduction, suspension or termination of medical services). You have to ask for an appeal hearing in writing. You or someone who represents you must sign the request for an appeal. To request an appeal, fill out the Appeal to State Agency (DHS-0033) (PDF) form. For more information on appeals, go to our frequently asked questions about state appeal hearings.

    Phone number: 651-431-3600 or 800-657-3510

    TDD/TTY: 651-296-7385

    Fax number: 651-431-7523

    Fraud

    If you think a provider or another member is misusing MHCP benefits, MHCP payments or the system in general, please report this fraud. You do not have to give your name or contact information, but giving that information might help investigators if they have more questions. Go to our How to report fraud page to find examples of and report fraud by recipients, by child care providers or by health care providers. You can also contact the Office of Inspector General:

    Phone number: 651-431-2650 or 800-657-3750

    Form: Minnesota Fraud Hotline Form

    Other important contact information

    If you have a hearing loss or speech disability, call the following numbers to access the resources listed in this EOC:

  • • 7-1-1
  • • 800-627-3529 Minnesota Relay (TTY, voice ASCII, Hearing Carry Over)
  • • 877-627-3848 Minnesota Relay (speech-to-speech relay service)
  • Important information about getting the care you need

    Each time you get health services, check to make sure the provider is enrolled with MHCP. Make sure you show your MHCP ID card at every visit.

    Interpreter services

    If you need either a hearing interpreter or a spoken-language interpreter, let your health care provider know. You can also get an interpreter if you are the parent or guardian of a child patient who is under the age of 18. The provider cannot bill you for interpreter services.

    Service authorizations

    Our approval is needed for some services to be covered. This approval is called a service authorization. Providers have to get the approval before we pay for the service or item and, in some cases, before you get the service or item. Providers have to get these authorizations so we can make sure the services or items are medically necessary for you and that you are getting the right amount of these services or items. Some services, such as chiropractic care, have limits. Chiropractic visits are limited to six per month or 24 per calendar year. If you need more visits, the chiropractor has to ask for approval through an authorization.

    Some of the more common services and items that need authorization include the following:

  • • Adult rehabilitative mental health services and day treatment
  • • Augmentative communication devices and accessories
  • • Bath, shower and toileting equipment
  • • Children’s therapeutic services and supports
  • • Chiropractic care
  • • Dental implants
  • • Dialectical behavior therapy
  • • Early intensive developmental and behavioral intervention (became a covered service July 1, 2015)
  • • Enteral nutritional supplements
  • • Enclosed medical beds
  • • Home and community-based services
  • • Medication therapy management services
  • • Mobility devices
  • • Prosthetics and orthotics
  • • Specialized wound therapy
  • • Standers and accessories
  • • Temporomandibular joint disorder treatment
  • • Vision therapy
  • • Waiver services
  • The provider will send us documentation when asking for the authorization. After we review the documentation, your provider and you will get a letter letting you know whether the authorization was approved or denied. If the authorization was denied, you have the right to appeal that decision. Follow the process in the Appeal process section.

    Covered and noncovered services

    Having MHCP eligibility does not guarantee that certain services or items are covered. Some services, prescription drugs or medical equipment or supplies may not be covered. Read through the Covered services section in this EOC. You can also call the Member Help Desk with specific questions about coverage.

    Cost sharing

    You may have to pay an amount toward the cost of some medical services. This is called cost sharing. Cost sharing consists of copays and a family deductible for certain services. See the main Cost sharing section below for more information.

    Paying providers

    We cannot pay you back for medical bills that you paid. State and federal laws prevent us from paying you directly. If you paid for a service that you think we should have covered, call the Member Help Desk.

    You can get health services or items not covered by us if you agree to pay for them. Providers have to have you sign a form saying that you will be responsible for the bill before you get the service or item. Providers have to explain to you why the service or item is not covered and what services or items are covered that you could get.

    If you choose to get services from a provider who is not enrolled with MHCP, you may be responsible for the cost of the services.

    Other insurance

    If you have other health or dental insurance, tell your worker right away. Tell your provider about the other insurance. Your provider will have to bill the other insurance before they bill us. If your provider does not bill the other insurance, we may try to collect from the other insurance.

    If you have Medicare, you need to get most of your prescription drugs through the Medicare Part D plan. You have to enroll in Medicare Part D to get that prescription-drug coverage. We do not pay for prescriptions that are covered by Medicare Part D.

    Private information

    We and the health care providers who take care of you have the right to see information about your health care. When you enrolled in MHCP, you gave your consent for us to see this information. We will keep your information private according to law.

    Restricted recipient program

    The Minnesota Restricted Recipient Program (MRRP) is a program for members who have not followed the rules for getting medical care or have misused services. If you are a restricted recipient or member, you may not pay out of pocket for services from providers to whom you are restricted.

    You must get health services only from the provider or providers we designate (assign for you). You may be designated (assigned) one doctor, one pharmacy, one hospital or one other health service provider. You must remain in the MRRP for at least 24 months of eligibility for MHCP. You may be designated a home health agency or other providers. You may be prohibited from using the personal-care-assistance choice, flexible-use options or consumer-directed services. You will remain in the MRRP if you enroll in a health plan or change health plans. You will not lose eligibility for MHCP because you are in this program.

    At the end of the 24 months, we will review your use of health care services. If you still did not follow the rules, you will be placed in the MRRP for an additional 36 months of eligibility. You have the right to appeal your placement in the MRRP.

    HIV/AIDS programs (Program HH)

    You may be eligible for only Program HH or for other Minnesota health care programs and Program HH, such as Medical Assistance and Program HH.

    The information in this EOC does not apply to people who are eligible only for Program HH and are ineligible for other Minnesota health care programs.

    Go to Minnesota HIV/AIDS programs or Program HH Covered Services for more information about Program HH benefits.

    Your explanation of benefits

    After MHCP makes payments to providers for services they provided to you, you will get an explanation of benefits (EOB). The EOB will show the name of the provider or provider group we paid, the amount we paid and the dates of service. If you did not get services from the provider listed on the EOB, contact the DHS Fraud Hotline. (See the Phone numbers and contact information section of this EOC for the DHS Fraud Hotline number.)

    Some services are confidential. EOBs do not show when we pay for the following services:

  • • Child welfare targeted case management
  • • Family planning, when you ask us not to show this service
  • When to call your worker

    Call your worker to report these changes:

  • • Name or address change
  • • Pregnancy begin and end dates
  • • Addition or loss of a household member
  • • Lost or stolen MHCP member ID card
  • • Insurance or Medicare start and end dates
  • • New job or change in income
  • • Disability status change
  • Provider information

    You do not have to give documentation for services to MHCP. The provider has to keep medical records of the services you get and the reason you get the services. If we need documentation, the provider will give it to us. The provider has to ask for authorization when it is required and bill us for services. We can pay only providers, not you.

    Cancellation

    Your fee-for-service coverage with us ends when you become ineligible for MHCP or when you enroll in a health plan. If you enroll in one of our prepaid health plans, the health plan will give you an evidence of coverage. You will have to follow the health plan’s rules and use the plan’s network of providers.

    Retroactive coverage

    You may be able to get coverage for health care services you received in past months. This is called retroactive coverage. You can get retroactive coverage for several reasons, including these:

  • • On your application you asked for coverage to help you pay for health care services you received up to three months before the month in which you applied.
  • • Your application was processed and coverage was approved in a month after the month in which you applied.
  • You must tell your health care providers as soon as possible when you receive retroactive eligibility for any reason.

    Also see the Paying providers section above.

    Your member rights

    You have the right to:

  • • Be treated with respect, dignity and consideration for privacy.
  • • Get the services you need 24 hours a day, seven days a week. This includes emergencies.
  • • Be told about your health problems.
  • • Get information about treatments, your treatment choices and how treatments will help or harm you.
  • • Participate with providers in making decisions about your health care.
  • • Refuse treatment and get information about what might happen if you refuse treatment.
  • • Refuse care from specific providers.
  • • Have providers keep your records private according to law.
  • • Ask for and get a copy of your medical records. You also have the right to ask to correct the records.
  • • Get notice of our decision if we deny, reduce or stop a service, or deny payment for a service.
  • • File an appeal with us.
  • • Get a clear explanation of covered nursing home and home care services.
  • • Give written instructions that tell others your wishes about your health care. These instructions are called a “health care directive.” A health care directive allows you to name a person to decide for you if you are not able to decide or if you want someone else to decide for you.
  • • Choose where you will get family planning services.
  • • Get a second opinion for medical, mental health and chemical dependency services.
  • • Be free of restraints or seclusion used as a means of coercion, discipline, convenience or retaliation.
  • • Exercise the rights listed here.
  • Your member responsibilities

    You are responsible for these things:

  • • Reading this EOC and knowing which services are covered and how to get them.
  • • Showing your MHCP member ID card every time you get health care. You are also responsible for showing the cards for any other health coverage you have, such as Medicare or private insurance.
  • • Establishing a relationship with a primary care doctor before you become ill. This helps you and your primary care doctor understand your total health condition.
  • • Giving information your doctor asks you for. Share information about your health history.
  • • Following all of your doctor’s instructions. If you have questions about your care, ask your doctor.
  • • Working with your doctor to understand your total health condition. It is important to know what to do when a health problem happens, when and where to get help and how to prevent health problems.
  • • Practicing preventive health care. Have the tests, exams and shots that are recommended for you based on your age and gender.
  • • Paying your copay, family deductible and spenddown, when they apply (see the table under the Cost sharing section below).
  • • Finding out whether a provider is enrolled with MHCP before getting services from the provider. If you choose to get services from a provider who is not enrolled with MHCP, you may be responsible for the cost of the services.
  • Your member card

    Each member gets his or her own MHCP Member ID card. It looks like one of the cards below. Always carry your member ID card with you.

    Show your member card every time you see a provider. Also, show the cards for any other health coverage you have, such as Medicare or private insurance.

    MHCP Member ID cards, March 2006 through present:

    MHCP Member ID card March 2006 thorugh present

    MHCP Member ID cards, January 2003 through February 2006:

    MHCP Member ID card January 2003 through February 2006

    MHCP Member ID cards issued before January 2003:

    MHCP ID card before January 2003

    If you have an old card from before March 2006, ask your worker or the Member Help Desk for a replacement card. Older cards may have old phone numbers for members and providers.

    Cost sharing

    Cost sharing refers to your responsibility to pay an amount toward your medical costs. Cost sharing includes copays and a monthly deductible.

    If your income is at or below 100 percent of the federal poverty guidelines, you will pay no more than 5 percent of your monthly family income for cost sharing. This may reduce the copay amount to less than the amounts listed below.

    The following members do not have to pay copays or family deductibles for medical services:

  • • Members who are pregnant women (if you become pregnant, tell your county worker right away)
  • • Members under age 21
  • • Members who get hospice care
  • • Members who live in a nursing home, hospital or other long-term-care facility for more than 30 days
  • • Effective January 1, 2015, American Indians enrolled in a federally recognized tribe pay no MinnesotaCare cost-sharing at any provider
  • Some services never have copays and family deductibles applied to them. These services include the following:

  • • Chemical dependency treatment
  • • Dental services
  • • Emergency services, if you have Medical Assistance
  • • Eyeglasses and repair of eyeglasses, if you have Medical Assistance
  • • Family planning services
  • • Hearing aids
  • • Home care
  • • Immunizations
  • • Inpatient hospital stays, if you have Medical Assistance
  • • Interpreter services
  • • Medical equipment and supplies
  • • Mental health services
  • • Oxygen
  • • Preventive care visits, like physicals
  • • Rehabilitation therapies
  • • Services covered by Medicare, except for Medicare Part D drugs
  • • Some mental health drugs (antipsychotics)
  • • Laboratory tests such as blood work
  • • Medical transportation
  • The following services also do not have family deductibles applied to them:

  • • Any service that has an MHCP copay applied to it
  • • Emergency services provided in a hospital, clinic, office or other facility
  • • Chiropractic services
  • The lists above are not complete lists. If you have questions about whether a copay or family deductible applies to a service, call the Member Help Desk at the phone number in the Phone numbers and contact information section.

    Also, the following providers cannot charge copays to MHCP or family deductibles to American Indian members, regardless of whether the members are enrolled in a health plan:

  • • Tribal health care providers
  • • Federal Indian Health Service (IHS)
  • • Urban Indian Organizations
  • • IHS-contracted health services (CHS) when IHS has referred the member
  • Copays

    Some services have copays. A copay is an amount you are responsible to pay your provider.

    Fee-for-service copays

    Medical Assistance and other programs

    MinnesotaCare (when not enrolled in a health plan)

    Nonpreventive visit (such as for a sore throat, diabetes checkup, high fever, sore back, etc.) when services are provided by an advanced practice nurse, audiologist, chiropractor, doctor, nurse midwife, optician, optometrist, physician ancillary or podiatrist. These services include diagnostic procedures (such as a colonoscopy, endoscopy or arthroscopy).

    No copays are required for mental health visits.

    $3.00

    $15.00

    Emergency room visit when it is an emergency

    $0.00

    $50.00

    Emergency room visit when it is not an emergency

    $3.50

    $50.00

    Prescription drugs

    No copays are required for certain mental health or family planning drugs.

    $1.00 generic
    $3.00 brand name
    $12.00 maximum per month

    $6.00 generic
    $20.00 brand name
    $60.00 maximum per month

    Eyeglasses

    No copay

    $25.00

    Inpatient hospital

    No copay or limit

    $150.00 per admission

    Outpatient hospital

    No copay

    $25.00 per visit

    Ambulatory surgery

    No copay

    $50.00 per surgery

    Radiology services

    No copay

    $25.00 per visit


    If you have Medicare, you have to get most of your prescription drugs through a Medicare prescription drug plan known as Medicare Part D. You may have different copays with no monthly limit for some prescriptions through Medicare Part D.

    Pay your copay directly to your provider. Some providers may ask you to pay the copay when you arrive for the medical service. Other providers, like a hospital, may bill you after your visit. For example, a hospital may bill you for your nonemergency visit to the emergency room after the visit.

    If you are enrolled in Medical Assistance and are unable to pay the copay, the provider still has to provide the service. This is true even if you have not paid your copay to that provider in the past or you have other debts to that provider. The provider may still bill you for the unpaid copays.

    Family Deductible

    A family deductible is an amount adult family members have to pay each month toward health care costs. A deductible is separate from a copay. The family deductible amount is $3.10 per month in 2017. This amount is adjusted yearly.

    Noncovered services

    MHCP does not cover:

  • • Health services or items that need a doctor’s written order but do not have one
  • • Services or items at a lower standard of quality than the leading community standard
  • • Health services or items you get outside the United States
  • • Reversal of voluntary sterilizations
  • • Missed appointments (providers cannot bill you for missed appointments)
  • • Surgery mostly for cosmetic reasons
  • • Vocational or educational services, including functional evaluations or employment physicals, except as stated in the Individualized education program (IEP)-related services section below
  • • Autopsies
  • • Services provided by providers who are not enrolled in MHCP
  • See the specific services below for more information about covered and noncovered services.

    Covered services

    This section describes the major services that MHCP covers. Most of the lists below are not complete lists of all covered services. Covered services must meet MHCP rules and guidelines. In general, for MHCP to cover a service, the service, according to leading community standards and usage, must be:

  • • Medically necessary
  • • Appropriate and effective for your medical needs
  • • Able to meet quality and timeliness standards
  • • Able to represent an effective and appropriate use of program funds
  • • Personally rendered by an MHCP-enrolled provider, except as specifically authorized by MHCP
  • • Documented in your health or medical record. The documentation must include supervision requirements
  • • Provided directly to you unless the service is otherwise described as covered
  • • In your plan of care
  • • Provided with your or your legal guardian’s full knowledge and consent, except for emergency health services
  • For covered services at a glance, refer to the MHCP Benefits Chart.

    Some services have limits or need an authorization. Those services are marked with an asterisk (*).

    Bariatric* (weight loss surgery) services

    Bariatric services are a covered service with authorization, doctor’s orders and a mental health evaluation. You may need to meet other specific conditions. Talk to your doctor about whether you meet the required conditions for this service.

    Noncovered services include excess skin excision.

    Acupuncture services

    Acupuncture services are covered for the following:

  • • Acute and chronic pain
  • • Depression
  • • Anxiety
  • • Schizophrenia
  • • Post-traumatic stress syndrome
  • • Insomnia
  • • Smoking cessation
  • • Restless legs syndrome
  • • Menstrual disorders
  • • Xerostomia associated with the following:
  • • Sjogren’s syndrome
  • • Radiation therapy
  • • Nausea and vomiting associated with the following:
  • • Postoperative procedures
  • • Pregnancy
  • • Cancer care
  • Chemical dependency* services

    Covered services include the following:

  • • Assessment and diagnosis
  • • Outpatient (group and individual) treatments
  • • Hospital-based residential treatment
  • • Non-hospital-based residential treatment
  • • Medication-assisted treatment
  • • Medication-assisted treatment plus (additional nine hours of treatment services per week)
  • • Medication-assisted treatment plus (methadone and all other drugs)
  • • Detoxification (only if needed for medical treatment and part of a licensed program of care)
  • • Room and board determined necessary by chemical dependency assessment
  • Child and Teen Checkups (C&TC)

    C&TC is a health care program of well-child visits for members under the age of 21. C&TC visits help find and treat health problems early. How often a C&TC visit is needed depends on age:

  • • Birth to 2 years: Visit at 0–1, 2, 4, 6, 9, 12, 15, 18 and 24 months
  • • 3 to 21 years: Visit at 3, 4, 5, 6, 8, 10, 12, 14, 16, 18 and 20 years
  • Covered services in C&TC preventive health visits include the following:

  • • Growth measurements
  • • Health education
  • • Health history, including mental health, nutrition and chemical use
  • • Developmental screening
  • • Mental health screening
  • • Physical exam
  • • Immunizations
  • • Lab tests
  • • Vision checks
  • • Hearing checks
  • • Regular dental checks
  • Chiropractic* care

    Covered services are as follows:

  • • One evaluation or exam per year
  • • Manual manipulation (adjustment) of the spine to treat subluxation of the spine (24 per year; no more than six per month)
  • • X-rays when needed to support a diagnosis of subluxation of the spine
  • Noncovered services from a chiropractor include other adjustments, vitamins, medical supplies, therapies and equipment.

    Dental* services

    Covered services include the following:

  • • Diagnostic services, including the following:
  • • Comprehensive exam (once every five years for nonpregnant adults)
  • • Periodic exam (once per calendar year for nonpregnant adults)
  • • Exam focused on a limited problem (once per day per facility for nonpregnant adults)
  • • X-rays. X-rays are limited to:
  • • Bitewing X-rays (once per calendar year for nonpregnant adults)
  • • Single X-rays for diagnosis of problems
  • • Panoramic X-rays (once every five years for nonpregnant adults, as medically necessary for diagnosis and follow-up of oral and maxillofacial conditions and trauma; once every two years in limited situations)
  • • Full-mouth X-rays (once every five years for nonpregnant adults, only when provided in an outpatient hospital or freestanding ambulatory surgical center)
  • • Preventive services, including the following:
  • • Cleaning (once per 365 days for nonpregnant adults; authorization is required for additional cleanings performed up to a maximum of three additional cleanings within the same 365-day span)
  • • Fluoride varnish (once per calendar year for nonpregnant adults; once every six months for pregnant members and members under the age of 21)
  • • Oral hygiene instruction (only for members under the age of 21 and pregnant members, once per lifetime; additional oral hygiene instruction services allowed in limited situations)
  • • Sealants (only for members under the age of 21, once every five years per permanent molar)
  • • Restorative services, including the following:
  • • Fillings (once per 90 days on the same tooth)
  • • Sedative filings for relief of pain
  • • Individual crowns (only for pregnant members and members under the age of 21; crowns must be made of prefabricated stainless steel or resin, unless medically necessary in specific situations)
  • • Endodontics (root canal) (for nonpregnant adults: once per lifetime, on anterior teeth and premolars only; retreatment is not covered) (for members under the age of 21 and pregnant members: once per lifetime, on anterior, premolars and molars; retreatment is not covered) (for members under the age of 21 and pregnant members: pulp therapy on primary teeth or root canal on permanent teeth)
  • • Periodontics, including the following:
  • • Gross removal of plaque and tartar (once every five years for nonpregnant adults)
  • • Scaling and root planing (once every two years for nonpregnant adults, only when provided in an outpatient hospital or freestanding ambulatory surgical center)
  • • Dental-implant-related service (only when medically necessary and for very limited conditions, not covered for nonpregnant adults). Limited conditions include bone and tooth loss that compromises chewing or breathing. The implants must be medically necessary and cost-effective. A complete treatment plan, including a prosthesis and all related services, must be approved before start of treatment
  • • Prosthodontics, including the following:
  • • Removable prostheses (dentures and partials) (for nonpregnant adults: once every six years per dental arch; for members under the age of 21 and pregnant members: once every three years per dental arch)
  • • Oral surgery (for nonpregnant adults; limited to extractions, biopsies and incision and drainage of abscesses)
  • • Orthodontics (only for members under the age of 21 and only when medically necessary for very limited conditions)
  • • Additional general services, including the following:
  • • Treatment for pain (once per day for nonpregnant adults)
  • • General anesthesia (for nonpregnant adults, only when provided in an outpatient hospital or freestanding ambulatory surgical center)
  • • Relines, repairs and rebases of removable prostheses (dentures and partials)
  • • Replacement of lost, stolen, or damaged and unrepairable prostheses in certain situations
  • • Replacement of partial prostheses if the existing partial cannot be altered to meet dental needs
  • Diagnostic* services

    Covered services are as follows:

  • • Lab tests and X-rays
  • • Other medical diagnostic tests ordered by your doctor
  • Doctor, clinic, and other health services

    Covered services include the following:

  • • Doctor visits, including the following:
  • • Care for pregnant women and delivery, including anesthesia if medically necessary
  • • Family planning (open-access service)
  • • Lab tests and X-rays*
  • • Physical exams
  • • Preventive exams
  • • Preventive office visits
  • • Visits to specialists
  • • Telemedicine consultation
  • • Vaccines, immunizations and drugs administered in a doctor’s office
  • • Visits for illness or injury
  • • Visits in the hospital or nursing home
  • • Acupuncture for chronic pain management provided by a licensed acupuncturist or within the scope of practice by a licensed provider with acupuncture training or credentialing
  • • Services provided by an advanced-practice nurse (nurse practitioner, nurse anesthetist, nurse midwife or clinical nurse specialist)
  • • Allergy immunotherapy and allergy testing
    Blood and blood products
  • • Cancer screenings, including the following:
  • • Mammography
  • • Pap test
  • • Prostate cancer screening
  • • Colorectal cancer screening
  • • Casting in a doctor’s office
  • • Circumcision (male) only when medically necessary with service authorization
  • • Clinical trial coverage: routine care that 1) is provided as part of the protocol treatment of a cancer clinic trial; 2) is usual, customary and appropriate to your condition; and 3) would be typically provided outside of a clinical trial. This care includes services and items needed for the treatment of effects and complications of the protocol treatment.
  • • Community health worker care coordination and patient education services
  • • Community paramedic services
  • • Counseling and testing for sexually transmitted diseases (STDs) and AIDS and other HIV-related conditions (open-access service)
  • • Health education and counseling, including the following:
  • • Diabetes education
  • • Nutrition counseling
  • • Smoking cessation
  • • In-reach community-based service coordination (to reduce emergency room use)
  • • Podiatry services (debridement of toenails, infected corns and calluses, and other nonroutine foot care)
  • • Respiratory therapy
  • • Services provided by a certified public health nurse or a registered nurse practicing in a public health nursing clinic under a governmental unit
  • • Surgical services (some surgeries must have approved service authorizations)
  • • Treatment for AIDS and other HIV-related conditions (not an open-access service)
  • • Treatment for STDs (open-access service)
  • • Tuberculosis care management and direct observation of drug intake
  • Noncovered services include artificial ways to get pregnant (artificial insemination, including in-vitro fertilization and related services; fertility drugs; and related services).

    Early intensive developmental and behavioral intervention

    Early intensive developmental and behavioral intervention becomes a covered service as of July 1, 2015.

    As of July 1, 2015, covered services are as follows:

  • • Comprehensive multidisciplinary evaluation (CMDE)
  • • Coordinated care conference
  • • Applied behavior analysis (ABA) intervention
  • • Developmental and behavioral intervention (DBI)
  • • Family and caregiver training and counseling
  • • Development and monitoring of individual treatment plan (ITP)
  • • Observation and direction of treating providers
  • As of July 1, 2015, noncovered services are as follows:

  • • Services provided by a parent, legal guardian or legally responsible person
  • • A service that is primarily a respite, custodial, educational or daycare service
  • • Any other service that does not fall under covered services
  • Emergency medical services and post-stabilization care

    Covered services include the following:

  • • Emergency room services
  • • Post-stabilization care
  • • Ambulance (air or ground)
  • • Nonemergency medical transportation (NEMT) (for covered services only)
  • Noncovered services include emergency care, urgent care and other health care services you get from providers located outside the United States.

    In an emergency that needs treatment right away, either call 911 or go to the closest emergency room. Show your member ID card and ask to call your primary care doctor.

    In all other cases, call your primary doctor, if possible. The doctor or nurse will tell you what to do.

    If you are out of town, go to the nearest emergency room. Show your member ID card and ask to call your primary care doctor.

    Eye care and eyeglass* services

    Covered services are as follows:

  • • Eye exams
  • • Eyeglasses (frames, lenses, eyeglass case), every two years, including identical replacement due to damage, loss or theft. Eyeglasses must be chosen from those specified in the MHCP volume-purchase contract. Providers can give you frames and lenses not specified in the contract only if you have Medicare or other insurance and Medicare and the other insurance will pay for the eyeglasses. If you want us to pay for eyeglasses that Medicare or the other insurance would or could deny, you have to choose from those specified in the contract. If you choose noncontract eyeglasses and Medicare or the other insurance denies the claim, the provider may bill you for the eyeglasses if the provider told you that MHCP would not cover noncontract eyeglasses if Medicare or the other insurance denied the claim
  • • Repairs to frames and lenses for eyeglasses covered by us
  • • Tints and polarized lenses, when medically necessary
  • • Contact lenses, when medically necessary for the following:
  • • Aphakia
  • • Keratoconus
  • • Aniseikonia
  • • Bandage lenses, when medically necessary
  • Noncovered services include the following:

  • • Extra pair of glasses
  • • Eyeglasses more often than every two years, unless medically necessary
  • • Bifocal or trifocal lenses without lines and progressive bifocals or trifocals
  • • Contact lens supplies
  • Family planning services

    Under federal and state law, family planning services are open-access services. “Open access” means you can choose any physician, clinic, hospital, pharmacy or family planning agency to get these services. You can get the family planning services in the first list below from any provider.

    Some people are eligible for only family planning services and not any other services MHCP offers. Check with your worker or the Member Help Desk if you are unsure whether you are eligible for only family planning services.

    Covered services are as follows:

  • • Family planning exam and medical treatment
  • • Family planning lab and diagnostic test
  • • Family planning methods (birth control pills, patch, ring, intrauterine device [IUD], injections, implant)
  • • Family planning supplies (condom, sponge, foam, film, diaphragm, cap), with prescription
  • • Counseling for and diagnosis of infertility, including related services
  • • Counseling and testing for STDs, AIDS and HIV-related conditions
  • • Treatment of STDs
  • • Voluntary sterilization. You must be 21 years of age or older and sign a federal sterilization consent form. At least 30 days, but not more than 180 days, must pass between the date you sign the form and the date of the surgery
  • • Genetic counseling
  • Covered services that are not open-access services:
  • • Treatment for medical conditions of infertility. This service does not include artificial ways to get pregnant
  • • Treatment of AIDS and other HIV-related conditions
  • • Genetic testing
  • • Nonemergency medical transportation (NEMT) (for covered services only)
  • Hearing aids

    Covered services are as follows:

  • • Hearing aids and batteries. Hearing aids must be chosen from those specified in the MHCP volume-purchase contract unless your provider receives authorization
  • • Personal communicators, FM systems and cochlear implants with approved authorization
  • • Repair and replacement of hearing aids, with limits
  • Home and community-based waiver* services

    Home and community-based waiver services are not covered service for MinnesotaCare members.

    If you are a Medical Assistance member, you must be approved to get waiver services. Depending on the type of waiver you are approved for, the following are some services MHCP can cover with an approved authorization:

  • • 24-hour emergency assistance
  • • Adult day care
  • • Customized living and 24-hour customized living
  • • Assistive technology
  • • Behavioral support
  • • Caregiver living expenses
  • • Caregiver training and education
  • • Case management
  • • Chore services
  • • Companion services—adult
  • • Crisis respite
  • • Consumer-directed community supports
  • • Day training and habilitation (DT&H)
  • • Environmental accessibility adaptations
  • • Extended personal care assistance
  • • Extended home care services
  • • Family training and counseling
  • • Foster care
  • • Home-delivered meals
  • • Homemaker services
  • • Housing access coordination
  • • Independent living skills training and therapies
  • • Night supervision
  • • Personal support
  • • Prevocational services
  • • Residential care
  • • Residential habilitation
  • • Respite care
  • • Specialized supplies and equipment
  • • Structured day program
  • • Supported employment
  • • Transitional services
  • Home care services

    Home care services are a covered service under the following programs:

  • • Medical Assistance
  • • MinnesotaCare (benefit sets differ depending on the service)
  • • Waivered services programs
  • Covered services are as follows:

  • • Skilled nursing
  • • Rehabilitation therapies to restore function (such as physical, occupational and speech therapies)
  • • Home health aide
  • • Home care nursing
  • • Personal care assistance
  • Hospice

    Covered services are as follows:

  • • Doctor, nurse and other professional services
  • • Medical social services
  • • Medical equipment and supplies
  • • Physical, occupational and speech therapies
  • • Short-term inpatient care, including respite care
  • • Counseling, including dietary counseling
  • • Home health aide and homemaker services
  • • Outpatient drugs for symptom management and pain relief
  • • Other items and services included in the plan of care that are otherwise covered medical services
  • You must elect hospice benefits to get hospice services.

    If you are under the age of 21 and getting hospice services, you can get services related to treatment of the terminal condition.

    Hospital—inpatient*

    Covered services are as follows:

  • • Inpatient hospital stay
  • • Your semiprivate room and meals
  • • Private room when medically necessary
  • • Tests and X-rays
  • • Surgery
  • • Drugs
  • • Medical supplies
  • • Therapy services (such as physical, occupational, speech and respiratory therapies)
  • Noncovered services for inpatient stays include personal comfort items, such as TV, phone, barber or beauty services and guest service.

    Hospital—outpatient

    Covered services are as follows:

  • • Urgent care for conditions that are not as serious as an emergency
  • • Outpatient surgical center
  • • Tests and X-rays*
  • • Dialysis
  • • Emergency room services
  • • Post-stabilization care
  • Individualized education program (IEP) services

    IEP services are available for members under the age of 21 if the services are specified in the IEP or individualized family service plan (IFSP).

    Covered services include the following:

  • • Therapies: physical, occupational, speech
  • • Audiology services
  • • Mental health services
  • • Nursing services
  • • Personal care assistance services
  • • Assistive technology
  • • Special transportation
  • Interpreter services

    Covered services are as follows:

  • • Spoken-language interpreter services—available for any language
  • • Hearing (American sign language) interpreter services
  • Interpreter services are available to help you get services. Face-to-face spoken-language interpreter services are covered only if the interpreter is listed on the Minnesota Department of Health’s Spoken Language Health Care Interpreter Roster.

    Medical equipment and supplies*

    Covered services include the following:

  • • Prosthetics or orthotics
  • • Durable medical equipment (such as wheelchairs, hospital beds, walkers, crutches and wigs [for people with alopecia areata])
  • • Repairs of medical equipment
  • • Batteries for medical equipment
  • • Some shoes, when part of a leg brace or when custom molded
  • • Oxygen and oxygen equipment (provided under a volume purchase contract)
  • • Medical supplies you need to take care of your illness, injury or disability
  • • Diabetic equipment and supplies
  • • Nutritional and enteral products, in certain situations
  • • Incontinence products
  • • Family planning supplies (open-access service; see Family planning services)
  • Noncovered services include the following:

  • • Constructive modifications to home, vehicle or workplace, including bathroom grab bars
  • • Environmental products (such as air filters, purifiers, conditioners and dehumidifiers)
  • • Exercise equipment
  • You need a prescription or doctor’s order for medical equipment and supplies to be covered.

    Mental health* services

    Covered services include the following:

  • • Crisis response services, including the following:
  • • Assessment
  • • Intervention
  • • Stabilization
  • • Community intervention (for members 18 years of age or older)
  • • Diagnostic assessments, including screening, for the presence of co-occurring mental illness and substance-use disorder
  • • Mental health targeted case management (MH-TCM)
  • • Dialectical behavioral therapy (DBT) (for members 18 years of age or older, in some situations)
  • • Inpatient psychiatric hospital stay
  • • Subacute psychiatric level of care (for members under the age of 21)
  • • Outpatient mental health services, including the following:
  • • Explanation of findings
  • • Mental health medication management
  • • Neuropsychological services
  • • Psychotherapy
  • • Psychotherapy for crisis
  • • Psychological testing
  • • Rehabilitative mental health services, including the following:
  • • Assertive community treatment (ACT) (for members 18 years of age or older)
  • • Adult day treatment (for members 18 years of age or older)
  • • Adult rehabilitative mental health services (ARMHS) (for members 18 years of age or older)
  • • Certified peer specialist support services, in some situations
  • • Children’s mental health residential treatment services (for members under the age of 21)
  • • Children’s therapeutic services and supports (CTSS), including children’s day treatment (for members under the age of 21)
  • • Intensive residential treatment services (IRTS) (for members 18 years of age or older)
  • • Partial hospitalization program
  • • Youth assertive community treatment (Youth ACT) (for members 16–20 years of age)
  • • Physician mental health services, including the following:
  • • Health and behavior assessment and intervention
  • • Inpatient visits
  • • Psychiatric consultations to primary care providers
  • • Physician consultation, evaluation and management
  • • Treatment services at children’s residential mental health treatment facilities (Rule 5). Treatment services do not include coverage for room and board. Room and board may be covered by your county. Call your county for information.
  • Noncovered services include the following:
    The following services are not covered but may be available through your county. Call your county for information.

  • • Treatment at Rule 36 (adult mental health residential) facilities that are not licensed as providers of IRTS
  • • Room and board associated with IRTS
  • Medication therapy management services

    You can get medication therapy management services to help you better understand and use your medications.

    To get this service, you must:

  • • Be taking a prescription to treat or prevent one or more chronic conditions,
  • • Not be in a hospital and
  • • Not be on Medicare.
  • You can get this service at a clinic or pharmacy. A pharmacist can monitor your medications and give you the training to get the best results from them.

    Moving Home Minnesota (MHM)

    The services listed below are covered and available in addition to the Medical Assistance or MinnesotaCare services and any waiver services you are eligible to receive. The services listed below can be delivered without affecting your waiver budget. MHM services are not meant to duplicate, take the place of or extend services that are already covered by your Medical Assistance or MinnesotaCare benefit set or your waiver benefit set. If a service is already available under your waiver, it is not available under MHM.

    Covered services are as follows:

  • • Pre-discharge and post-discharge case consultation
  • • Comprehensive community supports
  • • Certified peer specialist (CPS) services for people with mental illness
  • • Psycho-educational services for children with mental illness
  • • Youth assertive community treatment
  • • Family memory care intervention
  • • Costs associated with finding housing and employment
  • • Membership fees for health clubs or fitness centers
  • • Supported employment services (if you are under 65 years of age)
  • • Overnight assistance
  • The following services are also covered, but only if you are not on a waiver:

  • • MHM demonstration case management
  • • Respite services for children with mental illness
  • • Environmental modifications
  • • Durable Medical Equipment
  • • Person emergency response systems
  • • Tools, clothing and equipment needed for employment (if you are under 65 years of age)
  • Refer to the Moving Home Minnesota Demonstration and Supplemental Services Table (PDF) for a complete list of MHM services and waiver interactions.

    Nursing facilities

    Nursing facilities are not a covered service for MinnesotaCare members.

    If you are a Medical Assistance member, to be placed in a nursing facility, both of the following conditions must be met:

  • • A county public health nurse or social worker must screen you and determine you need nursing facility care.
  • • A doctor must certify, up to 30 days before your admission to the nursing facility, that you need that level of care.
  • Covered services include the following:

  • • Room and board
  • • Nursing services
  • • Laundry and linen services
  • • Dietary services
  • • Personal hygiene items needed for daily personal care (such as soap, toothpaste, toothbrush, shampoo and shaving cream)
  • • Over-the-counter drugs or supplies as needed (such as aspirin, antacids and cough syrup)
  • Noncovered services include special services. Some members must pay their spenddown to the nursing facility.

    Obstetrics and gynecology (OB/GYN) services

    Covered services are as follows:

  • • Prenatal, delivery and postpartum care
  • • Childbirth classes (for at-risk patients)
  • • Hospital services for newborns (circumcisions for newborns are not covered)
  • • HIV counseling and testing for pregnant women (open-access service)
  • • Treatment for HIV-positive pregnant women
  • • Treatment for newborns of HIV-positive mothers
  • • Testing for and treatment of STDs (open-access service)
  • • Services provided by a licensed health professional at licensed birth centers, including services of certified professional midwives and licensed traditional midwives
  • • Abortion and abortion-related services only when one of the following conditions applies:
  • • The pregnancy is the result of rape.
  • • The pregnancy is the result of incest.
  • • The continuation of the pregnancy would endanger the woman’s life, as certified by a physician.
  • • An abortion is medically necessary for other health or therapeutic reasons or to prevent impairment of a major bodily function.
  • Personal care assistance* (PCA) services

    PCA services are not covered services for MinnesotaCare members.

    All PCA services for Medical Assistance members need to have approved authorization. You will receive a letter letting you know the amount of PCA services you can get. If we deny the services or you disagree with the amount of services you can get, you can appeal. See the Appeals section.

    Covered services include the following:

  • • Activities of daily living (ADLs)
  • • Health-related procedures and tasks
  • • Observation and redirection of behaviors
  • • Instrumental activities of daily living (IADLs)
  • Noncovered services include the following:

  • • Applying constraints or other procedures that are aversive or depriving
  • • Home maintenance or chore services
  • • Homemaker services
  • • Injections of fluid or drugs into veins, muscles or skin
  • • Services that are provided by a residence or program under license
  • • Child care or babysitting services
  • • Staffing options in a residential or child care setting
  • • Sterile procedures
  • Prescription drugs* for members who do not have Medicare

    Covered services include the following:

  • • Prescription drugs
  • • Medication therapy management services
  • • Certain over-the-counter drugs when prescribed by a doctor or pharmacist
  • • Home infusion therapy services
  • Noncovered services include the following:

  • • Drugs used to treat impotence or erectile dysfunction
  • • Drugs used to enhance fertility
  • • Drugs used for cosmetic purposes, including drugs to treat hair loss
  • • Drugs or products to promote weight loss
  • • Drugs not clinically proven to be effective
  • • Investigational or experimental drugs
  • • Medical cannabis
  • The drug has to be in our drug formulary. For a drug to be included in the drug formulary, the manufacturer must participate in the federal Centers for Medicare & Medicaid Services (CMS) drug rebate program.

    You do not have to pay a copay for antipsychotic drugs used for the treatment of mental illness. You also do not have to pay a copay for drugs used for family planning or to help you stop smoking.

    If a pharmacy person tells you the drug is not covered and asks you to pay, ask the person to call your doctor. Your doctor may need to prescribe a different drug that is covered. Your doctor may need to submit a special request, called a prior authorization, if your doctor thinks only a certain drug is right for you and that drug is not usually covered by your MHCP benefits. If the pharmacy will not call, you can call your doctor or the MHCP Member Help Desk.

    Prescription drugs* for members who have Medicare

    Covered services include the following:

  • • Some over-the-counter products
  • • Some prescription cough and cold products
  • • Some vitamins not covered by the Medicare Prescription Drug Program (Medicare Part D)
  • Noncovered services include the following:

  • • Prescription drugs that could be covered by Medicare Part D
  • • Drugs used to treat impotence or erectile dysfunction
  • • Drugs used to enhance fertility
  • • Drugs used for cosmetic purposes, including drugs to treat hair loss
  • • Drugs or products to promote weight loss
  • • Drugs not clinically proven to be effective
  • • Investigational or experimental drugs
  • • Medical cannabis
  • Medicare pays for most of your prescription drugs through Medicare Part D. You have to enroll in a Medicare prescription drug plan to get most of your prescription drug services. You will get your prescription drug services through your Medicare prescription drug plan. You may have to pay a copay for prescription drugs covered by your Medicare prescription drug plan.

    Rehabilitation* services

    Covered services include the following:

  • • Rehabilitation therapies to restore function: physical, occupational and speech therapy
  • • Audiology services, including hearing tests
  • • Augmentative communication or speech generating devices
  • Noncovered services include the following:

  • • Vocational rehabilitation
  • • Health clubs and spas
  • Surgery*

    Covered services include the following:

  • • Office visits, clinic visits and surgery
  • • Removal of port wine stain birthmarks
  • • Reconstructive surgery (such as after a mastectomy, after surgery for in injury, illness or other disease; for birth defects)
  • • Anesthesia services
  • • Circumcision* when medically necessary (prior authorization required)
  • • Gender reassignment surgery
  • Noncovered services include the following:

  • • Cosmetic surgery
  • Transplants*

    Covered services are as follows:

    Organ and tissue transplants, including transplants of the following:

  • • Autologous pancreatic islet cell (after pancreatectomy)
  • • Cornea
  • • Heart (artificial heart transplants are not covered)
  • • Heart-lung
  • • Intestine
  • • Intestine-liver
  • • Kidney
  • • Liver
  • • Lung
  • • Pancreas
  • • Pancreas-kidney
  • • Stem cell
  • Transplant coverage includes the following:

  • • Preoperative evaluation
  • • Your and your live donor’s surgery and follow-up care
  • A transplants must be done at a transplant center meeting United Network for Organ Sharing (UNOS) standards or a Medicare-approved transplant center. Stem cell transplant centers must meet standards set by the Foundation for the Accreditation of Cellular Therapy (FACT).

    Transportation to or from medical services

    Covered services are as follows:

  • • Emergency ambulance (air, ground and water)
  • • Nonemergency ambulance
  • • State-administered nonemergency medical transportation (NEMT) for members who cannot safely use a local county or tribal agency NEMT service (common carrier) because of physical or mental impairment and do not need an ambulance
  • • Coverage of these transportation services requires a level-of-service (LOS) assessment completed by a state identified medical review agent
  • • Local-agency administered NEMT (bus, cab, volunteer driver and client mileage reimbursement). You must call your local county or tribal agency to access these transport services
  • • NEMT services are only available to get to and from covered health services
  • Noncovered services include the following:

    For nonemergency medical transportation to the following services, because the services include transportation:

  • • Adult day care
  • • Day training and habilitation
  • • Residential care
  • • Supported employment
  • Urgent care

    Urgent care is a covered service. An urgent condition is not as serious as an emergency. Urgent care is care for a condition that needs prompt treatment to stop the condition from getting worse. Urgent care is available 24 hours a day.

    Using your MHCP coverage with other insurance

    If you have other insurance, tell your worker before you get care. We will coordinate our payments with the other insurance. This is called “coordination of benefits.” Examples of other insurance include the following:

  • • No-fault car insurance
  • • Workers’ compensation
  • • Medicare
  • • HMO or other managed care organization coverage
  • • Other commercial insurance
  • When you become an MHCP member, you agree to:

  • • Let us send bills to your other insurance
  • • Let us get information from your other insurance
  • • Let us get payments from your other insurance instead of payments going to you
  • • Help us get payments from your other insurance
  • If your insurance changes, call your worker.

    Subrogation or other claim

    The following paragraph applies to some noncitizens:

    You may have other sources of payment for your medical care. These sources might include another person, a group, an insurance company or another organization. If you have a claim against another source for injuries, we will make a claim for medical care we covered for you. State laws require you to help us do this. We may recover the claim from any settlement or judgment you receive from another source. This is true even if you did not get full payment of your claim. The amount of the claim will not be more than state laws allow.

    The following paragraph applies to MHCP members, except some noncitizens:

    You may have other sources of payment for your medical care. These sources might include another person, a group, an insurance company or another organization. Federal and state laws provide that MHCP benefits pay only if no other source of payment exists. If you have a claim against another source for injuries, we will make a separate claim for medical care we covered for you. Laws require you to help us do this. The claim may be recovered from any source that may be responsible for payment of the medical care we covered for you. The amount of the claim will not be more than federal and state laws allow.

    Appeal process

    If you disagree with a decision made by MHCP about a denial, reduction, suspension or termination of medical services, you can ask for a hearing. You have to ask for the hearing in writing. You or someone who represents you has to sign the request. You can request a hearing by filling out an Appeal to State Agency (DHS-0033) (PDF).

    You have to ask for the hearing within 30 days after getting written notice of the decision. If you show good cause for not appealing within this time limit, you may appeal up to 90 days after the notice.

    After we get your request, we will set a date for a hearing. We will tell you the exact date, time and place. The hearing might be in person or by telephone. You can call the human services judge and tell him or her that you want a face-to-face hearing if you have been scheduled for a telephone hearing. You can also call the human services judge and tell him or her that you want a telephone hearing if you have been scheduled for a face-to-face hearing. The human services judge may have to schedule the hearing for a different day and time.

    If we are stopping or reducing a service, you can ask to keep getting the service if you file an appeal within 10 days after we send you the notice, or before the service is stopped or reduced, whichever comes later. The treating provider has to agree the service should continue. The service can continue until the appeal is resolved. If you lose the appeal, you may be billed for these services.

    If you decide to file an appeal or ask for a hearing, it will not affect your eligibility for medical services.

    Your provider may file an appeal or ask for a hearing on your behalf. You have to give the provider your written consent.

    You can have a relative, friend, advocate, provider or lawyer help with your appeal or hearing.

    There is no cost to you for filing an appeal with us.

    PCA services during appeal

    If we are stopping or reducing your PCA services, you can ask to keep getting the same amount of services when you file an appeal. You have to file within 10 days of the date of the notice, or before the service is stopped or reduced, whichever is later. The services can continue until the appeal is resolved. If you lose the appeal, you may be billed for these services.

    Definitions

    The following are the meanings of some words in this EOC.

    Action: an action includes the following:

  • • Denial or limited authorization of the type or level of service
  • • Reduction, suspension or stopping of a service that was approved before
  • • Denial of all or part of payment for a service
  • • Not providing services in a reasonable amount of time
  • Anesthesia: Drugs that make you fall asleep for a surgery.

    Appeal: Your written request to us for review of an action.

    Autopsy: An examination of the body of someone who died. It is done to find out what caused the person’s death.

    Chemical dependency: Using alcohol or drugs in a way that harms you.

    Child: Members under the age of 21.

    Child and Teen Checkups (C&TC): A special health care program of well-child visits for members under the age of 21. It includes screening to check for health problems. It also includes referrals for diagnosis and treatment, if needed.

    Clinical trial: A qualified medical study test that:

  • • Is subject to a defined peer review
  • • Is sponsored by a clinical research program that meets federal and state rules and approved standards
  • • Has its true results reported
  • Copay: An amount that you may have to pay to the provider for specific medical services. Copays are usually paid at the time services are provided.

    Cost sharing: Amounts you may have to pay toward your medical care. Cost sharing amounts include deductibles and copays.

    Covered services: The health care services that MHCP can pay for when conditions are met.

    Durable medical equipment: Equipment that can withstand repeated use. It is used for medical purposes. The equipment has to be medically necessary and ordered by a doctor.

    Emergency: A condition that needs treatment right away. It is a condition that a prudent person believes needs prompt care, and without prompt care, it could cause one or more of the following:

  • • Serious physical or mental harm
  • • Continuing severe pain
  • • Serious damage to body functions, organs or parts
  • • Death
  • Labor and childbirth can sometimes be an emergency.

    Evidence of Coverage: The name of the document you are reading. This document tells you what services we cover. It tells you what you have to do to get covered services. It also tells you your rights and responsibilities and ours.

    Experimental service: A service that has not been proven to be safe and effective.

    Family deductible: An amount that adult family members may have to pay each month toward medical services.

    Family planning: Information, services and supplies that help a person decide about having children. Family planning decisions include choosing whether to have a child and choosing when to have a child.

    Fee-for-service: A method of payment for health services. Under this method, the medical provider bills MHCP directly, and we pay the provider for the medical services he or she provided. This method is used when you are eligible for MHCP but are not enrolled in a prepaid health plan.

    Hospice: A special program for members who are terminally ill and not expected to live more than six months. It offers special services for the member and his or her family.

    Inpatient hospital stay: A stay in a hospital or treatment center that usually lasts 24 hours or more.

    Investigative service: A service that has not been proven to be safe and effective.

    Medically necessary: Appropriate for the condition. Medically necessary care includes care related to physical conditions and mental health. It includes the kind and level of service. It also includes the number of treatments. It includes where you get the service and how long it continues. Medically necessary care has to:

  • • Be the service that most other providers would usually order
  • • Help you get better or stay as well as you are
  • • Help stop the condition from getting worse
  • • Help prevent and find health problems
  • Medicare: The federal health insurance program for people 65 years of age or older. It is also for some people under the age of 65 with disabilities and people with end-stage renal disease.

    Medicare Prescription Drug Plan: An insurance plan that offers Medicare Prescription Drug Program (Medicare Part D) drug benefits.

    Notice of action: A form or letter we send you telling you about a decision on a claim or a service or about any other action taken by us.

    Open-access services: Services for which federal and state law allows you to choose any physician, clinic, hospital, pharmacy or family-planning agency to provide them.

    Outpatient hospital services: Services provided at a hospital or outpatient facility that are not at an inpatient level of care. These services may also be available at your clinic or other health facility.

    Post-stabilization care: A hospital service needed to help a person’s condition stay stable after having emergency care.

    Prescriptions: Medicines and drugs ordered by a medical provider.

    Preventive services: Services that help you stay healthy, such as routine physicals, immunizations and well-person care. These services help find and prevent health problems. Follow-up care on conditions that have been diagnosed (like a diabetes check-up) are not preventive.

    Primary care doctor or provider: The doctor or other health professional you choose to see for your routine care. This person manages your health care.

    Provider: A health care professional or facility approved by state law to provide health care.

    Service authorization: Our approval that is needed for some services before you get them.

    Subrogation: Our right to collect money in your name from another person, group or insurance company. We have this right when you get medical services that are covered by us and by another source or third-party payer.

    United States: For the purposes of this Evidence of Coverage, the United States includes the 50 states, the District of Columbia, the Commonwealth of Puerto Rico, the Virgin Islands, Guam, American Samoa and the Northern Mariana Islands.

    Urgent care: Services you get for a condition that needs prompt treatment to stop the condition from getting worse. An urgent condition is not as serious as an emergency. Urgent care is available 24 hours a day.

    Rate/Report this pageReport/Rate this page

    © 2017 Minnesota Department of Human Services
    Minnesota.gov is led by MN.IT Services
    Updated: 9/8/17 1:50 PM | Accessibility | Terms/Policy | Contact DHS | Top of Page | Updated: 9/8/17 1:50 PM