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Billing the Recipient

Revised: 03-06-2014

State and federal laws require MHCP recipients to share in the costs of their health care. Cost-sharing includes copays and deductibles. MHCP allows providers to bill recipients under certain circumstances. MHCP does not allow providers to request or accept payments from MHCP recipients, their families, or others on behalf of the recipient for any of the following:

• Base rate changes made by MHCP (except copays and spenddowns)
• Missed appointments
• The difference between insurance allowed amounts and usual and customary charges (provider contract reductions)
• Services otherwise covered by MHCP, unless an MHCP copay or cap applies

If a provider has obtained a judgment against a recipient, the provider may not enforce the judgment against the recipient until at least six months after all public assistance for which eligibility existed has been terminated.

MHCP allows providers to request and accept payments from MHCP recipients for the following limited cost-sharing instances (more details below):


Also review Use of Collection Agencies and Waiving Recipient Cost-sharing below.


Copays and Family Deductible
Effective October 1, 2011, MHCP has the following copays:

Fee-for-service Copays
  FP, MA, NM RM BB, FF, JJ, XX
  Adults Parents Adults without children
Non-preventive* visit $3.00; no copays for mental health visits $3.00; no copays for mental health visits $3.00; no copays for mental health visits
Emergency room when not an emergency** $3.50 $3.50 $3.50
Prescriptions $1.00 generic
$3.00 brand name
$12.00 max per month
No copays for certain mental health drugs
$3.00 $3.00
Eyeglasses No copay $25.00 $25.00
Inpatient hospital No copay or limit $10,000 annual limit for parents with income over 215% FPG
Recipient is responsible for costs over $10,000;
10% copay up to $1,000 for BB
10% copay up to $1,000, $10,000 annual limit
Recipient is responsible for copay and costs over $10,000

Items or services provided by a volume purchase contract are exempt from subscriber copays and deductibles.

*Non-preventive visits are defined as visits that are the result of a recipient’s symptoms, diagnosis, or established illness and delivered in an ambulatory setting by one of the following:

• Advanced practice nurse
• Audiologist
• Chiropractor
• Nurse midwife
• Optician
• Optometrist
• Physician
• Physician ancillary
• Podiatrist
** Effective January 1, 2014, hospital emergency rooms providing care must conduct appropriate medical screening to determine that the recipient does not need emergency services. Before providing non-emergency services the hospital must:

• Notify the recipient of the copay
• Give the recipient the name and location of an available and accessible alternative non-emergency provider
• Determine the non-emergency provider can provide the services in a timely manner
• Provide a referral to coordinate scheduling the recipient’s treatment by the non-emergency provider

Family Deductible
Effective January 1, 2014, the family deductible of $2.75 applies to:

• Major program codes IM, NM, MA, BB, FF, JJ
• Fee-for-Service recipients
• Adults only
• A case only once per month, regardless of the number of adults in a case

MCO enrollees are no longer subject to the family deductible due to contract changes effective Jan. 1, 2013.

The family deductible amount changes annually.

MHCP deducts the family deductible amount from the first claim it receives in a month that is processed for payment. The deductible amounts appear on provider RAs with adjustment reason code PR1. Providers may collect the deductible from the adult recipient after you see the amount on your RA.

Copay and Family Deductible Exclusions
Copays and deductibles do not apply to the following:

• Children under 21 years of age
• Copays that exceed one per day per provider for non-preventive visits and non-emergency visits to a hospital-based emergency department
• Emergency services
• Family planning services and prescriptions
• Pregnant women for services that relate to the pregnancy or any other medical condition that may complicate the pregnancy
• Recipients expected to reside for at least 30 days in a hospital, nursing facility, or ICF/DD
• Recipients receiving hospice care
• Services paid by Medicare, resulting in MHCP payment of coinsurance and deductible
• 100% federally funded services provided by an IHS

In addition, the family deductible does not apply to the following:

• Access services (access and special transportation services and interpreter services)
• Chiropractic services
• Dental services
• Inpatient claims based on an emergency admission
• Prescription drugs
• Recipients residing or expected to reside more than 30 days in medical institutions (hospitals, nursing facilities and ICF/DDs)
• Transportation services authorized through the home and community based waiver or Alternative Care (AC) programs
• Volume purchase contracted items (eyeglasses, hearing aids, oxygen)

You may collect a copay at the time of the visit or bill the recipient for the copay. MHCP deducts copays from the provider payment and shows the deduction with adjustment reason code PR3. You may bill the copay to the recipient before or after you receive your RA. If the recipient paid the copay amount and you later find out the recipient was not liable for the copay, you must refund the copay amount to the recipient.

Copay and Family Deductible Limitations
MA recipients with countable income of less than 100% of the Federal Poverty Guidelines (FPG) have their copays limited to 5% of their monthly (family) gross income.

• Some of these MA recipients (with a 5% of income copay max) may not have a copay or family deductible amount
• MHCP will continue to reduce a provider’s payment by the copay or family deductible amount (if any)
• MHCP will show the copay or family deductible amount the provider may collect (if any) on the provider’s remittance advice

The ARRA prohibits the following providers from charging MHCP copays to American Indian recipients, regardless of whether or not the recipients are enrolled in an MCO:

• Tribal health care providers
• Federal Indian Health Service (IHS)
• Urban Indian Organizations
• IHS-contracted health services (CHS) when there is an IHS referral

Spenddowns and Copays
MHCP applies copays to claims after the spenddown has been met. If a copay and spenddown apply to service you provide, you may bill the recipient for both. MHCP deducts copays and spenddowns from the provider payment and reflects the deductions on RAs with appropriate adjustment codes.

TPL and Copays
If a recipient with private health insurance primary to MHCP also has an MHCP copay, bill the recipient for the MHCP copay. Bill the claim to MHCP in the usual manner, reporting the insurance payment on the claim with the balance due. If the MHCP allowable covers all or part of the balance billed, MHCP will pay up to the maximum MHCP allowable, minus any applicable MHCP copay. MHCP will deduct the copay from its payment amount to the provider and report it as the copay amount on the provider’s RA.

MCO Enrollment and Copays
For recipients enrolled in a managed care organization (MCO), the MCO will notify providers of copay and deductible amounts. Copay amounts for MA recipients enrolled in MCOs are generally based on FFS MHCP copay guidelines. Copay amounts for MinnesotaCare enrollees may differ from MA copay amounts. Contact the MCO about your contractual requirements.

Recipient Inability to Pay Copay & Deductible
Recipients eligible for the following programs are protected from denial of service based on inability to pay their copays or deductible as long as they inform you that they are unable to pay the copay or deductible:

• Federally-funded MA
• Federally-funded MinnesotaCare

Providers must continue to accept a recipient’s assertion of inability to pay their copays or deductible. State-funded MA and state-funded MinnesotaCare programs are not affected by these state and federal laws.

If a federally-funded MA or MinnesotaCare recipient cannot pay the copay at the time of their visit, follow the steps below:

• Provide services for the current visit
• Inform the recipient of their debt and give them the opportunity to pay using your standard office policies and procedures
• Do not deny future or ongoing service to the recipient

If a state-funded MA/MinnesotaCare recipient cannot pay the copay at the time of the visit, follow the steps below:

• Provide services for the current visit
• Inform the recipient of their debt and give them the opportunity to pay using standard office policies and procedures
• If it is your standard office policy to refuse services to patients who have debt, you may refuse to provide ongoing services because of the recipient’s inability to pay their copay

Non-covered Services
You may bill a recipient for a service only when all the following conditions apply:

• MHCP never covers the service or the recipient does not meet MHCP criteria for the service
• You reviewed with the recipient:
• Service limits
• Reason(s) the service/item/prescription is not covered
• Available covered alternatives
• You inform the recipient before you deliver the services that the recipient is responsible for payment
• You obtain a recipient signature on the appropriate form (listed below)
• You or an authorized health care representative completes the appropriate forms and provider fields and signs the forms:

The non-pharmacy provider must also meet the following conditions:

• You must request authorization and seek payment from the other insurance or Medicare before you request authorization or payment from MHCP or the recipient
• When a service or item requires authorization, request authorization through the MHCP medical review agent (see pharmacy conditions below). If the authorization is denied for other than a billing error or lack of documentation, you may bill the recipient
• Do not request payment from the recipient for:
• A service that requires authorization unless authorization was denied as not medically necessary and you have reviewed all other therapeutic alternatives with the recipient
• A service MHCP denied for reasons related to billing requirements
• Standard shipping or delivery and setup of medical equipment or medical supplies
• Services included in the recipient’s long term care per diem
• More than your usual and customary charge for the service/item
• The difference between what MHCP would pay for a less costly alternative service and the upgraded service provided
• A service when the recipient is enrolled in the Restricted Recipient Program and the provider is one of the provider types designated for the recipient’s health care services
• If MHCP makes any payment, you may bill the recipient only for amounts designated as cost-sharing or spenddown
• Do not use the DHS-3640 for controlled substance prescriptions, gabapentin or tramadol (see pharmacy conditions below)

Pharmacies must meet the applicable conditions above and the following:

• Do not accept payment from a recipient, or from someone paying on behalf of the recipient, for any MHCP-covered prescription
• Do not request payment from the recipient when the recipient is enrolled in the Restricted Recipient Program and the provider is one of a provider type designated for the recipient’s health care services

Prior approval

• A recipient may pay for a non-covered prescription for a controlled substance, gabapentin or tramadol with prior approval.
• The prescriber must call the MHCP Provider Call Center at (651) 431-2700 or 1-800-366-5411 and ask to speak with the pharmacist on call for prior approval
• If the approval is denied, you may not bill the recipient

Prior authorization

• Use NDC Search to find out if a drug is covered or requires authorization
• You must request authorization and seek payment from the other insurance before you request authorization or payment from MHCP
• When a prescription:
• Requires authorization, request authorization through the MHCP Prescription Drug PA Agent. If the authorization is denied, you may bill the recipient unless the prescription requested is a controlled substance, gabapentin, or tramadol
• Does not require authorization, bill MHCP. If MHCP denies the prescription for other than a billing error, you may bill the recipient unless the prescription is a controlled substance, gabapentin, or tramadol

MHCP does not cover the following:

• Health services:
• When a physician’s order is required but not obtained
• Not in the recipient’s plan of care, individual treatment, education or service plan
• That are of a lower quality standard than the prevailing community standard of the provider’s professional peers (providers of services that are determined to be of low quality must bear the cost of these services)
• Other than emergency health services, provided without the full knowledge and consent of the recipient or the recipient’s legal guardian
• Provided outside the United States or by providers whose financial institutions or entities are located outside the U.S.
• Provided by practitioners working outside their scope of practice or without appropriate credentials
• Missed appointments (do not bill MHCP recipients for missed appointments)
• Reversal of voluntary sterilizations
• Primarily for cosmetic purposes
• Vocational or educational services, including functional evaluations or employment physicals, except as provided under individual education plan-related services
• Drugs when indicated or used for erectile dysfunction
• Drugs used for:
• Fertility
• Weight loss or weight gain
• Any cosmetic purpose
• Symptomatic relief of cough and cold, except those listed in the MHCP Provider Manual
• Drugs determined to be less-than-effective (DESI) by the FDA and drugs identified as identical, related or similar to DESI drugs
• Drugs made by manufacturers that do not have a rebate agreement with CMS
• Drugs limited or excluded by the state as allowed by federal law (OBRA 90)
• Drugs dispensed after their expiration date
• The cost of shipping or delivering a drug
• Drugs lost in shipping or delivery
• Drugs, legend or OTC, prescribed by practitioners not licensed to prescribe or prescribed outside their scope of practice
• Drugs prescribed by practitioners not enrolled as MHCP providers
• Herbal or homeopathic products
• Nutritional supplements or vitamins, except those listed in the MHCP Provider Manual
• Compounded drugs, except those listed in the MHCP Provider Manual

Upgrade An upgrade is not a separate part of a service/item; a service/item that is an increased, newer or more advanced version of its base. For example, a power wheel chair is an upgrade of a manual wheel chair, or a CT scan is an upgrade of an x-ray.

Add-on An add-on is a separate part of a service/item; a service/item that is added to enhance a service/item. For example, a basket is an add-on to a walker, or an ultrasound modality is an add-on to a therapy.

Retroactive Eligibility
Some recipients may become retroactively eligible for MHCP. If a recipient notifies you that he or she became eligible for a retroactive period, and the recipient paid for an MHCP-covered service you provided during that retroactive period, you may do one of the following:

• Refund to the recipient the full amount he/she paid you and bill MHCP your usual and customary charge for the service(s)
• Keep the recipient’s payment to you and do not bill MHCP for the service(s)

If the service you provided during the retroactive eligibility period is a service or procedure that requires authorization, request authorization according to the guidelines for the procedure. Refer to Authorizations.

• If authorization is approved, refund the recipient’s payment and bill MHCP
• If authorization is denied, keep the recipient’s payment, as the service is considered a non-covered service and do not bill MHCP for the service

Spenddowns
You may bill a recipient for a spenddown after you receive the MHCP RA showing the amount of the spenddown. The RA will show adjustment reason code PR142 and the dollar amount the recipient is to pay.

If the amount of a recipient’s spenddown is later reduced, MHCP will automatically reprocess the previously paid claim. You will see the automatically adjusted claim on your RA. If you collected the spenddown, you may be required to pay back the recipient’s spenddown.

If a recipient does not pay their spenddown, and it is your standard office policy not to provide services to patients with unpaid debt, you may refuse to provide ongoing services to that recipient, regardless of the recipient’s program eligibility.

Refer to Spenddown in the Programs and Services section for additional information about:

• Spenddowns and eligibility
• Types of spenddowns

Use of Collection Agencies
Providers may hire a collection agency to attempt to get payment from an MHCP recipient with bad debt or sell the debt to a collection agency. The collection agency can call or mail, but cannot harass or engage in any other practices prohibited by Minnesota collection law.

The provider may also file a suit against the recipient, and the provider may get a judgment from the court. However, the provider/collection agency is not able to enforce the judgment against the recipient the recipient until the recipient has been off all public assistance for six (6) months.


Waiving Recipient Cost-sharing
Most providers cannot routinely waive recipient cost sharing without violating the federal Anti-Kickback law and the federal False Claims Act. MHCP does not enforce the Anti-Kickback law or the federal False Claims Act and there may be some situations that would allow providers to not violate the Anti-Kickback law and False Claims Act. Contact your own attorney to discuss and obtain legal advice, or contact the federal Office of the Inspector General (OIG).


Legal References
Minnesota Rules 9505.0210 Covered Services, General Requirements
Minnesota Rules 9505.0225
Request to Recipient to Pay
MS 256.045
, Administrative and Judicial Review of Human Service Matter
MS 256B.0625
,subd. 55 Payment for noncovered services
MS 256B.0631
Medical Assistance Copayments
MS 332.37
Prohibited Practices
MS 550.37
, subd. 14 Property Exempt, Public Assistance
MS 571.71
Garnishment; When Authorized
MS 571.912
Form of Exemption Notice
MS 571.914
Objection to Exemption Claim
Title XIX §1916(e)
42 CFR 447.54
Deductible, Coinsurance, Copayment or Similar Cost-sharing Charge; Maximum allowable and nominal charges
42 USC 1396o(e)
Prohibition of denial of services on basis of individual's inability to pay certain charges

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