Skip to: Main content | Subnavigation |
Department of Human Services Department of Human Services  
MHCP Member Evidence of Coverage

Revised: 06-09-2014

Table of contents

Welcome to MHCP
Welcome as a member of 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 if a service or item is covered.

MHCP (also “we,” “us,” or “our”) is giving you this Evidence of Coverage, also called an EOC, and includes:

• Contact information
• Information about how to get the care you need
• Your rights and responsibilities as a member of MHCP
• Information about copays
• A listing of covered and non-covered services (not all inclusive lists)
• Information about what to do if you have a complaint or want to appeal an action
• Definitions
• Legal resources

We have coverage in every county in Minnesota. If you want to find our enrolled providers, go to our MHCP Provider Directory.

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

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 4:15 p.m., Monday through Friday.

Call: 651-431-2670 or 1-800-657-3739

TDD/TTY: 711

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

Call: 651-431-3600 or 1-800-657-3510

TDD/TTY: 651-296-7385

Fax: 651-431-7523

If you think a provider or another member is misusing MHCP benefits, payments or the system in general, please report this fraud. You do not have to give your name or contact information, but it 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:

Call: 651-431-2650 or 1-800-657-3750

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:

1-800-627-3529 Minnesota Relay (TTY, voice ASCII, Hearing Carry Over)
1-877-627-3848 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 or spoken language interpreter, let your health care provider know. You can also get an interpreter if you are the parent or guardian and the patient is a child under age 18. The provider cannot bill you for interpreter services.

Service authorizations
Our approval is needed for some services to be covered. This 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 have limits, such as chiropractic care: 6 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:

• 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
• 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 information, your provider and you will get a letter letting you know if 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 section.

Covered and non-covered services
Having MHCP eligibility does not guarantee that certain services or items are covered. Some services, prescription drugs, 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 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 may 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.

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 these services. 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 do this. 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. Restricted recipients or members may not pay out of pocket for services from providers to whom they are restricted.

You must get health services only from the designated provider or providers. You may be designated (assigned) to one doctor, one pharmacy, one hospital or other health service provider. You have to do this for at least 24 months of eligibility for MHCP. You may be assigned to a home health agency or other providers. You may not be allowed to use the personal care assistance choice or flexible use options or consumer directed services. The restricted program will stay with you if you enroll in a health plan or change health plans. You will not lose eligibility for MHCP because of being placed 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 program for an additional 36 months of eligibility. You have the right to appeal being placed in the restricted recipient program.

HIV/AIDS program
Members may be eligible for Program HH only 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 Program HH-only eligible members.

Go to HIV/AIDS Programs and services 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 rendered 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 contact information of this EOC.

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 it

When to call your worker
Call your worker to report these changes:

• Name or address changes
• Pregnancy begin and end dates
• Addition to 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 changes

Provider information
You do not have to give documentation for services to MCHP. 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.

Your fee-for-service coverage with us ends when you become ineligible for MHCP or if 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 their network of providers.

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 they 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.

Know that providers will 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. This is called a “health care directive.” It 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 to:
Read this EOC and know which services are covered and how to get them.

Show your MHCP member ID card every time you get health care. Also, show the cards of any other health coverage you have, such as Medicare or private insurance.

Establish a relationship with a primary care doctor before you become ill. This helps you and your primary care doctor understand your total health condition.

Give information asked by your doctor. Share information about your health history.

Follow all of your doctor’s instructions. If you have questions about your care, ask your doctor.

Work 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.

Practice preventive health care. Have tests, exams and shots recommended for you based on your age and gender.

Pay your copay, family deductible and spenddown, when they apply (see the table under cost sharing).

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 of 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:

CP Member ID card January 2003 through February 2006

MHCP Member ID cards issued before January 2003:

CP 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. You can also ask your worker for a new card.

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% of the federal poverty guidelines, you will pay no more than 5% 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:

• 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.

Some services never have copays and family deductibles applied to them, such as:

• Chemical dependency treatment
• Dental services
• Emergency services
• Eye glasses and repair of eyeglasses (except MinnesotaCare members not in a health plan)
• Family planning services
• Hearing aids
• Home care
• Immunizations
• Inpatient hospital stays (except MinnesotaCare members not in a health plan)
• 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)
• Tests such as blood work and x-rays
• 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

These are not a complete list. Call the Member Help Desk at the phone number in the first part of this EOC.

Also, the following providers cannot charge MHCP copays or family deductibles to American Indian members, regardless of whether they 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

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)
Non-preventive visit (such as for a sore throat, diabetes checkup, high fever, sore back, etc.) when provided by an advanced practice nurse, audiologist, chiropractor, doctor, nurse midwife, optician, optometrist, physician ancillary or podiatrist. This includes diagnostic procedures (such as colonoscopy, endoscopy, arthroscopy). No copays for mental health visits. $3.00 $3.00
Emergency room visit when it is not an emergency $3.50 $3.50
Prescription drugs No copays for certain mental health or family planning drugs $1.00 generic
$3.00 brand name
$12.00 max per month
Eyeglasses No copay $25.00
Inpatient hospital No copay or limit No copay or limit

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 of these services.

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, like for your non-emergency visit to the emergency room.

If you are not able 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 if 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 $2.75 per month in 2014, and is adjusted yearly.

Non-covered 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 under IEP-related services
• Autopsies

See the specific services below for more information about covered and non-covered services.

Covered services
This section describes the major services that MHCP covers. Covered services have to follow MHCP rules and guidelines. This is not a complete list. In general, for MHCP to cover a service, the service, according to leading community standards and usage, has to be:

• Medically necessary
• Appropriate and effective for the medical needs of the member
• Able to meet quality and timeliness standards
• Able to represent an effective and appropriate use of program funds
• Personally rendered by a provider, except as specifically authorized by MHCP
• Documented in the member’s health or medical record, including supervision requirements
• Provided directly to the member unless the service is otherwise described as covered
• In a member’s plan of care
• Provided with the member’s or his or her 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
Covered service with authorization, doctor’s orders and a mental health evaluation. Members may need to meet other specific conditions. Talk to your doctor about whether you meet the required conditions for this service.

Not covered services include excess skin excision

Chemical dependency* services
Covered services:

• 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 9 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 age 21. C&TC visits help find and treat health problems early. How often a C&TC is needed depends on age:

• Birth to 2 years: at 0-1, 2, 4, 6, 9, 12, 15, 18, and 24 months
• 3 to 21 years: 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:

• 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)
• Acupuncture for chronic pain management within the scope of practice by chiropractors with acupuncture training or credentialing
• X-rays when needed to support a diagnosis of subluxation of the spine

Not covered services from a chiropractor include other adjustments, vitamins, medical supplies, therapies and equipment.

Dental* services
Covered services:

• Diagnostic services, including:
• Comprehensive exam (every five years for non-pregnant adults)
• Periodic exam (once per calendar year for non-pregnant adults)
• Limited problem focused exam (once per day per facility for non-pregnant adults)
• X-rays are limited to:
• Bitewing (once per calendar year for non-pregnant adults)
• Single x-rays for diagnosis of problems
• Panoramic (for non-pregnant adults – once every five years, 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 (for non-pregnant adults – once every five years only when provided in an outpatient hospital or freestanding ambulatory surgical center)
• Preventive services, including:
• Cleaning (once per 365 days for non-pregnant 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 non-pregnant adults and once every six months for pregnant women and members under age 21)
• Oral hygiene instruction only for members under age 21 and pregnant women, once per lifetime; additional oral hygiene instruction services allowed in limited situations.
• Sealants only for members under age 21, once every five years per permanent molar
• Restorative services, including:
• Fillings (once in 90 days on the same tooth)
• Sedative filings for relief of pain
• Individual crowns only for pregnant women and members under age 21, must be made of prefabricated stainless steel or resin, unless medically necessary in specific situations
• Endodontics (root canal) (for non-pregnant adults – on anterior teeth and premolars only and once per lifetime, retreatment is not covered) (pulp therapy on primary teeth or root canal on permanent teeth) (for members under age 21 and pregnant women – on anterior, premolars and molars once per lifetime, retreatment is not covered)
• Periodontics, including:
• Gross removal of plaque and tartar (once every five years for non-pregnant adults)
• Scaling and root planing (for non-pregnant adults – once every two years only when provided in an outpatient hospital or freestanding ambulatory surgical center)
• Dental implant-related service (only covered when medically necessary and for very limited conditions, not covered for non-pregnant 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 prosthesis and all related services, must be approved before start of treatment
• Prosthodontics, including
• Removable prostheses (dentures and partials) once every three years per dental arch (for non-pregnant adults – once every six years per dental arch; for members under age 21 and pregnant women – once every three years per dental arch)
• Oral surgery (for non-pregnant adults – limited to extractions, biopsies, and incision and drainage of abscesses)
• Orthodontics only for members under age 21 and only when medically necessary for very limited conditions
• Additional general services, including:
• Treatment for pain (once per day for non-pregnant adults)
• General anesthesia (for non-pregnant 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:

• Lab tests and x-rays
• Other medical diagnostic tests ordered by your doctor

Doctor, clinic, and other health services
Covered services (not an all-inclusive list):

• Doctor visits, including:
• 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
• 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 by licensed acupuncturist or within the scope of practice by a licensed provider with acupuncture training or credentialing
• Advanced practice nurse services: services provided by a nurse practitioner, nurse anesthetist, nurse midwife or clinical nurse specialist
• Allergy immunotherapy – allergy testing
• Blood and blood products
• Cancer screenings (including mammography, pap test, prostate cancer screening, colorectal cancer screening)
• Casting in a doctor’s office
• Circumcision (male) only when medically necessary with service authorization
• Clinic trial coverage: routine care that is 1) 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 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), AIDS and other HIV-related conditions – open access service
• Health education and counseling, including:
• 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 non-routine foot care)
• Respiratory therapy
• Services of 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

Not covered services include artificial ways to get pregnant (artificial insemination, including in-vitro fertilization and related services, fertility drugs and related services).

Emergency medical services and post-stabilization care
Covered services:

• Emergency room services
• Post-stabilization care
• Ambulance (air or ground)

Not covered services include emergency care, urgent care, or 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:

• Eye exams
• Eyeglasses (frames, lenses, eyeglass case), every two years, including identical replacement due to damage, loss or theft. Eyeglasses have to be chosen from the MHCP volume purchase contract. Providers can give you frames and lenses not from the contract vendor only if you have Medicare or other insurance and Medicare and the other insurance would 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 the contract eyeglasses. If you choose non-contract eyeglasses and Medicare or the other insurance deny the claim, the provider may bill you for the eyeglasses if the provider told you that MHCP would not cover non-contract eyeglasses if Medicare or the other insurance deny 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:
• Aphakia
• Keratoconus
• Aniseikonia
• Bandage lenses

Not covered services:

• Extra pair of glasses
• Eyeglasses more often than every 24 months, unless medically necessary
• Bifocal/trifocal lenses without lines and progressive bifocals/trifocals
• Contact lens supplies

Family planning services
Federal and state laws allow you to choose any physician, clinic, hospital, pharmacy or family planning agency to get open access services. You can get open access services from any provider for the following family planning covered services.

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 not sure.

Covered services:

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

Hearing aids
Covered services:

• Hearing aids and batteries. Hearing aids have to be chosen from the MHCP volume purchase contract unless your provider receives authorization.
• Repair and replacement of hearing aids due to normal wear and tear, with limits

Home and community-based services waiver* services
Not a covered service for MinnesotaCare members.

Medical Assistance members have to be approved to get waiver services. Depending on the type of waiver a member gets, 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 (PCA)
• 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
Not a covered service for MinnesotaCare members.

Covered services for Medical Assistance:

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

Covered services:

• 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

You have to elect hospice benefits to get hospice services.

Members under age 21 getting hospice services can get services related to treatment of the terminal condition.

Hospital – inpatient*
Covered services:

• Inpatient hospital stay
• Your semi-private room and meals
• Private room when medically necessary
• Test and x-rays
• Surgery
• Drugs
• Medical supplies
• Therapy services (such as physical, occupational, speech and respiratory therapies)

Not covered services for inpatient stays include personal comfort items, such as TV, phone, barber or beauty services, guest service.

Hospital – outpatient
Covered services:

• 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 age 21 and have to be in the individualized education plan (IEP) or individualized family service plan (IFSP). Services may include:

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

Interpreter services
Covered services:

• 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 in the Minnesota Department of Health’s Spoken Language Health Care Interpreter Roster.

Medical equipment and supplies*
Covered services:

• Prosthetics or orthotics
• Durable medical equipment (such as wheelchair, hospital bed, walker, crutches, 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/enteral products when in certain situations
• Incontinence products
• Family planning supplies – open access service; see family planning services

Not covered services:

• Constructive modifications to home, vehicle, or workplace, including bathroom grab bars
• Environmental products (such as air filters, purifiers, conditioners, dehumidifiers)
• Exercise equipment

You need a prescription or doctor’s order for medical equipment and supplies to be covered.

Mental health* services
Covered services:

• Crisis response services, including:
• Assessment
• Intervention
• Stabilization
• Community intervention (for members age 18 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 age 18 or older in some situations)
• Inpatient psychiatric hospital stay
• Subacute psychiatric level of care (for members under age 21)
• Outpatient mental health services, including:
• Explanation of findings
• Mental health medication management
• Neuropsychological services
• Psychotherapy
• Psychotherapy for crisis
• Psychological testing
• Rehabilitative mental health services, including:
• Assertive community treatment (ACT) (for members age 18 or over)
• Adult day treatment (for members age 18 or over)
• Adult rehabilitative mental health services (ARMHS) (for members age 18 or over)
• Certified peer specialist support services in some situations
• Children’s mental health residential treatment services (for members under age 21)
• Children’s therapeutic services and supports (CTSS), including children’s day treatment (for members under age 21)
• Intensive residential treatment services (IRTS) (for members age 18 or over)
• Partial hospitalization program
• Youth assertive community treatment (Youth ACT) (for members ages 16 – 20)
• Physician mental health services, including:
• Health and behavior assessment/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.

Not covered services:
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 intensive residential treatment services (IRTS)
• Room and board associated with IRTS

Medication therapy management services (MTMS)
You can get medication therapy management services to help you better understand and use your medications. You have to be taking three or more prescriptions to treat or prevent one or more chronic conditions, not in a hospital, and not on Medicare. Pharmacists can monitor and give you the training to get the best results from you medications. You can get the service at a clinic or pharmacy.

Nursing facilities
Not a covered service for MinnesotaCare members.

For a Medical Assistance member to be placed in a nursing facility:

• A county public health nurse or social worker has to screen you and determine you need nursing facility care
• A doctor has to certify, up to 30 days before the admission to the nursing facility, that you need that level of care

Covered services include (not an all-inclusive list):

• 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, shaving cream)
• Over-the-counter drugs or supplies as needed (such as aspirin, antacids, cough syrups)

Not covered services include special services. Some members have to pay their spenddown to the nursing facility.

Obstetrics and gynecology (OB/GYN) services
Covered services:

• 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 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:
• 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
• Medically necessary for other health/therapeutic reasons or to prevent impairment of a major bodily function

Personal care assistance* (PCA) services
Not covered for MinnesotaCare members.

All personal care assistance 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:

• Activities of daily living (ADLs)
• Health-related procedures and tasks
• Observation and redirection of behaviors
• Instrumental activities of daily living (IADLs)

Not covered services include:

• 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:

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

Not covered services:

• 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

The drug has to be in our covered drug list. We will cover a non-covered drug if your doctor shows us that 1) the drug that is normally covered has caused you a harmful reaction; 2) there is a reason to believe the drug that is normally covered would cause you a harmful reaction; or 3) the drug prescribed by your doctor is more effective for you than the drug that is normally covered. The drug has to be in a class of drugs that is covered.

We will cover an antipsychotic drug, even if it is not in our drug list, if your doctor certifies this is best for you. You do not have to pay a copay for antipsychotic drugs. In some cases, we will also cover other drugs used to treat a mental illness or emotional disturbance even if the drug is not in our approved drug list. We will do this for up to one year if your provider certifies the drug is best for you and you have been treated with the drug for 90 days before we removed the drug from our drug list.

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:

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

Not covered services:

• 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

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:

• Rehabilitation therapies to restore function: physical, occupational and speech therapy
• Audiology services, including hearing tests

Not covered services:

• Vocational rehabilitation
• Health clubs and spas

Covered services:

• 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)

Not covered services:

• Cosmetic surgery
• Sex reassignment surgery

Covered services:

Organ and tissue transplants, including:

• 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:

• Preoperative evaluation
• Member and live donor surgery and follow-up care

Transplants have to be done at transplant centers meeting United Network for Organ Sharing (UNOS) standards or be Medicare approved transplant centers. Stem cell transplant centers have to meet standards set by the Foundation for the Accreditation of Cellular Therapy (FACT).

Transportation to or from medical services
Covered services:

• Emergency ambulance (air or ground)
• Non-emergency ambulance
• Special transportation (for members who cannot safely use a common carrier because of physical or mental impairment and do not need an ambulance); requires a level of need assessment by MNET
• Common carrier (access) transportation (such as bus, cab, or through volunteer driver programs), only to get covered health services. Members have to call their local county or tribe.

Not covered services:

For common carrier (access) 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. This 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 them. This is called “coordination of benefits.” Examples of other insurance include:

• 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
This first paragraph applies to some noncitizens:

You may have other sources of payment for your medical care. They might be from another person, group, insurance company or other 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.

This second paragraph applies to MHCP members, except some noncitizens:

You may have other sources of payment for your medical care. They might be from another person, group, insurance company or other 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. The 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).

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.

Personal care assistance 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.

The following are the meanings of some words in this Evidence of Coverage.

Action: an action includes:

• 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 exam that is done on 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 age 21.

Child and Teen Checkups (C&TC): A special health care program of well-child visits for members under age 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
• Sponsored by a clinical research program that meets federal and state rules and approved standards
• Whose true results are 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 for that MHCP can pay 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:

• 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. It tells you our rights and responsibilities.

Experimental services: 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. These decisions include choosing to have a child, when to have a child or not to have a child.

Fee-for-service: A method of payment for health services. The medical provider bills MHCP directly. MHCP pays 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: Care that is appropriate for the condition. This 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 age 65 or older. It is also for some people under age 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, a service, or any other action taken by us.

Open access services: Federal and state laws allow you to choose any physician, clinic, hospital, pharmacy or family planning agency to get these services.

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 conditions 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 providers: 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.

© 2014 Minnesota Department of Human Services Online
North Star is led by the Office of Enterprise Technology
Updated: 6/9/14 1:34 PM | Accessibility | Terms/Policy | Contact DHS | Top of Page |