Table of contents
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:
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.
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
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
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
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)
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.
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.
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:
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.
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.
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.
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.
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.
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.
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.
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.
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:
Call your worker to report these changes:
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 plans rules and use their network of providers.
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.
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 doctors 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).
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 cards January 2003 through February 2006:
MHCP Member ID cards issued 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 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:
Some services never have copays and family deductibles applied to them, such as:
The following services also do not have family deductibles applied to them:
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:
Some services have copays. A copay is an amount you are responsible to pay your provider.
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.
Emergency room visit when it is not an emergency
No copays for certain mental health or family planning drugs
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.
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.
MHCP does not cover:
See the specific services below for more information about covered and non-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:
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 (*).
Covered service with authorization, doctors 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
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:
Covered services in C&TC preventive health visits include the following:
Not covered services from a chiropractor include other adjustments, vitamins, medical supplies, therapies and equipment.
Covered services (not an all-inclusive list):
Not covered services include artificial ways to get pregnant (artificial insemination, including in-vitro fertilization and related services, fertility drugs and related services).
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.
Not covered 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.
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:
Not a covered service for MinnesotaCare members.
Covered services for Medical Assistance:
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.
Not covered services for inpatient stays include personal comfort items, such as TV, phone, barber or beauty services, guest service.
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:
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 Healths Spoken Language Health Care Interpreter Roster.
Not covered services:
You need a prescription or doctors order for medical equipment and supplies to be covered.
Not covered services:
The following services are not covered but may be available through your county. Call your county for information.
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.
Not a covered service for MinnesotaCare members.
For a Medical Assistance member to be placed in a nursing facility:
Covered services include (not an all-inclusive list):
Not covered services include special services. Some members have to pay their spenddown to the nursing facility.
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:
Not covered services include:
Not covered services:
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.
Not covered services:
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.
Not covered services:
Not covered services:
Organ and tissue transplants, including:
Transplant coverage includes:
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).
Not covered services:
For common carrier (access) transportation to the following services, because the services include transportation:
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.
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:
When you become an MHCP member, you agree to:
If your insurance changes, call your worker.
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.
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.
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:
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 persons 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:
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:
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:
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 persons 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.Report/Rate this page