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Minnesota Department of Human Services Provider Manual
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Health Care Programs and Services Overview

Revised: 03-13-2014

The Minnesota Department of Human Services (DHS) ensures basic health care coverage for low-income Minnesotans through publicly subsidized Minnesota Health Care Programs (MHCP). This section outlines eligibility and coverage for these programs.

  • MHCP Recipient Eligibility
  • Minnesota Health Care Programs (MHCP)
  • Minnesota Restricted Recipient Program (MRRP)
  • Waiver Services Programs
  • Minnesota Children with Special Health Needs (MCSHN) Program
  • Incarcerated Recipients
  • Applying for MHCP Coverage
  • Newborn Coverage
  • Spenddown
  • Recipient ID Cards/Verification
  • MHCP Covered Services
  • MHCP Non-covered Services
  • Legal References
  • MHCP Recipient Eligibility

    The information below shows the major program codes that appear in the MN–ITS eligibility verification transaction, with a brief description of the program and a link to more information. MHCP recipient eligibility is generally approved on a monthly basis. Verify MHCP eligibility through the secure, online MN–ITS eligibility verification transaction before providing a service (or at least once per month if billing monthly or for multiple services provided in one calendar month). Review Billing the Recipient for information about recipient cost-sharing responsibilities.

    Minnesota Health Care Programs (MHCP)

    Major Program Code

    Brief Description of Program
    When mentioned, MinnesotaCare is the publicly subsidized program for Minnesota residents without access to affordable health care coverage, generally, whose employers do not offer or pay at least half the monthly cost of healthcare coverage.

    AC

    Alternative Care Program
    A state-funded cost-sharing program that provides home- and community-based services to prevent and delay transitions to nursing facility level of care for eligible Minnesotans age 65 and over.

    BB

    MinnesotaCare Plus One
    State-funded program for adults, age 21 years and older, not parents, not pregnant.

    EH

    Emergency MA
    State- and federally-funded emergency assistance for some non-citizens with a medical emergency; coverage before 1/9/12 does not include transplants, some drugs, preventive care, routine visits, and screenings; coverage on and after 1/9/12 includes only services provided in an emergency department or inpatient hospital when the admission is the result of an emergency admission and some limited services under a care plan (see EMA Provider FAQ).

    FP

    Minnesota Family Planning Program (MFPP)
    State- and federally-funded program that provides only family planning and related health care services for people 15-49 years, not pregnant and not enrolled in other MHCP.

    FF

    MinnesotaCare Basic Plus
    MinnesotaCare Basic Plus Two
    State- and federally-funded program for parents; income determines whether Basic Plus or Basic Plus Two benefit set applies.

    HH

    HIV/AIDS
    Federally-funded programs for HIV-positive people who meet eligibility guidelines; provides support for people to access case management, dental, insurance benefit, medication, mental health and nutrition services; see also Program HH Covered Services.

    IM

    Institution for Mental Disease (IMD)
    State-funded MA program for people residing in an IMD.

    JJ

    MinnesotaCare Basic Plus
    MinnesotaCare Basic Plus Two
    State-funded program for parents; income determines whether Basic Plus or Basic Plus Two benefit set applies

    KK

    MinnesotaCare Expanded
    State-funded program for children to age 21 and pregnant women.

    LL

    MinnesotaCare Expanded
    State- and federally-funded program for children to age 21 and pregnant women.

    MA

    Medical Assistance
    Minnesota’s Medicaid and largest state- and federally-funded health care program with more than half a million Minnesotans eligible, most enrolled in managed care organizations (MCOs).

    NM

    State-funded MA
    State-funded MA program covers certain noncitizens not eligible for federally-funded MA only because of their immigration status. Eligibility and covered services mirror MA.

    QM

    Qualified Medicare Beneficiary (QMB) (DHS-2087e) covers Medicare Part A & B copays, coinsurance, premiums and deductibles only.

    RM

    Refugee
    Federally-funded MA program available for the first 8 months after a refugee arrives in the USA; covered services are the same as MA.

    SL

    Service Limited Medicare Beneficiary will pay Medicare Part B premiums. There is no coverage for services or Medicare copays and deductibles.


    Some recipients may be eligible for more than one program at the same time. For these recipients, MHCP will pay services at the highest level of coverage. For example, a recipient has QM and MA coverage. MHCP will cover the recipient’s Medicare coinsurance and deductible based on QM coverage. However, because the recipient also has MA coverage, MHCP will cover services not covered by QM but are covered by MA. Program SL reimburses a recipient’s Medicare premium and does not include coverage for healthcare services. Recipients pending a long term care assessment are listed as unknown until the assessment has been completed.

    Minnesota Restricted Recipient Program (MRRP)

    MRRP identifies MHCP recipients (any major program code) who have used services at a frequency or amount that is not medically necessary and/or who have used health services that resulted in unnecessary costs to MHCP. Once identified, such recipients are placed under the care of a designated primary care physician/other providers who coordinate their care for a 24-month period.

    The primary care provider must fax a Medical Referral for MRRP Recipient form (DHS-2978) to the MRRP office at 651-431-7475 no later than 90 days after the date of service of the referred-to provider service. This allows MHCP to process the referred-to provider’s claim. MHCP will deny claims if the referral is not received within 90 days of the referred-to provider’s date of service. Emergency health care services in response to a condition that, if not immediately diagnosed and treated, could cause a person serious physical or mental disability, continuation of severe pain, or death may be provided to a MRRP recipient without the authorization/referral of the primary care physician. The MRRP office may require documentation of the emergency situation to determine payment of the claim.

    For recipients enrolled in managed care organizations (MCO), primary care providers must fax all health plan MRRP referrals to the appropriate MCO.

    Applicants with Disabilities

    For MA applicants who indicate they may have a disability, the State Medical Review Team (SMRT) determines if they meet the criteria for disability status. Review the SMRT web page for information about the determination process, how the SMRT division coordinates to arrange services between the applicant and providers, and how providers are able to receive payment for services that SMRT requests for the disability determination.

    Waiver Services Programs

    Waiver services are programs that have received federal approval for expanded coverage to MHCP recipients of services not usually covered by MA. These programs include:

  • • Brain Injury (BI) Waiver
  • • Community Alternative Care (CAC) for chronically ill individuals
  • • Community Alternatives for Disabled Individuals (CADI)
  • • Developmental Disability(DD) waiver
  • • Elderly Waiver (EW)

  • Refer also to HCBS Waiver Programs and the AC Program for additional provider information about waiver services programs.

    Minnesota Children with Special Health Needs (MCSHN) Program

    MCSHN is no longer a funding resource for children with chronic illnesses or disabilities. Staff from this program is available to assist families of children with special health care needs throughout Minnesota to identify services and supports (including financial support) that might be available. Staff is also available to problem-solve with providers and county workers who are trying to locate resources for families. For assistance, call 651-215-8956 or 1-800-728-5420.

    Incarcerated Recipients

    In general, adults who are incarcerated in detention or correctional facilities are not eligible for MHCP. Recipients eligible under major program RM who meet all other eligibility requirements remain eligible for RM regardless of their living arrangement.

    MHCP applicants, regardless of age, are ineligible for coverage while they reside in the following correctional facilities:

  • • City, county, state and federal correctional and detention facilities for adults, including, inmates who are:
  • • In a work release program that requires they return to the facility during non-work hours
  • • Admitted to an acute care medical hospital for medical treatment or to give birth, but required to return to the facility when treatment or convalescence is completed
  • • Sent by the court or penal institution to a chemical dependency residential treatment program while serving a sentence and are required to return to the correctional facility after completing treatment
  • • Secure juvenile facilities licensed by the Department of Corrections (DOC) that are for holding, evaluation, and detention purposes
  • • State-owned and operated juvenile correctional facility
  • • Publicly-owned and operated juvenile residential treatment and group foster care facilities licensed by the DOC with more than 25 non-secure beds

  • Children who are placed by a juvenile court in certain juvenile programs may be eligible depending on the type of facility.

    Notification that a recipient is incarcerated may not be received by MHCP until after the recipient’s eligibility was determined. In those cases, MHCP will retroactively close out the recipients eligibility and recoup any reimbursements made to the provider for services performed during the recipients dates of incarceration.

    Providers should contact the appropriate county jail or correctional facility regarding how to bill for the services that were provided.

    Applying for MHCP Coverage

    Individuals may apply at their local tribal or county or MinnesotaCare agency for MHCP coverage.

    MinnesotaCare legislation mandates that application and informational materials be made available to provider offices, local human services agencies, and community health offices. Access and print online applications or have applications mailed to your office. Contact MinnesotaCare at:

    MinnesotaCare
    PO Box 64838
    St Paul MN 55164-0838
    651-297-3862 or 1-800-657-3672

    Newborn Coverage

    Children born to mothers covered by one of Minnesota’s health care programs during the month of birth are given automatic newborn coverage. If these children continue to live in Minnesota (regardless with whom), the automatic eligibility continues through the last day of the month in which the child turns one year of age.

    Spenddown

    MHCP recipients may be eligible with a spenddown or waiver obligation. Some people who have more income than the MA income limit allows may become eligible by spending down to the income limit. The spenddown dollar amount, similar to an insurance deductible, becomes the recipient’s financial responsibility before MHCP payment can be made.

  • • Medical spenddown: Recipients pay for medical services, including prescriptions, generally on a monthly basis
  • • Institutional/long-term care (LTC) spenddown: Recipient pay a portion or all of their institutional per diem charges
  • • Designated provider spenddown: Recipients pay a specific provider, selecting the provider using the Request for Designated Provider Agreement (DHS-3161) form. Providers agree to:
  • • Make sure the recipient’s spenddown is applied to the provider’s claims for each month the provider renders services to the recipient
  • • Contact the county agency if:
  • • The information on the form is incorrect
  • • The spenddown is not applied to claims appropriately
  • • The provider stops rendering services to the named recipient
  • • The provider no longer renders services that equal or exceed the spenddown amount reported on the monthly designated provider notice
  • • The provider continues to receive the designated provider notices after it has stopped providing services

  • MHCP may collect any overpayments if the provider does not take appropriate steps.

    The spenddown designated provider must bill services shortly after rendering the service, as the recipient will remain ineligible for other services until the designated providers claim is processed.

  • • Client option spenddown: Recipients prepay their spenddowns to DHS
  • • Elderly waiver (EW) obligation: Recipients pay a portion or all of their EW service costs

  • Providers who are owed spenddown amounts generally see base rate reason code PR142 on their remittance advices with a dollar amount, indicating the recipient’s spenddown amount. See Billing the Recipient.

    Recipient ID Cards/Verification

    Each recipient approved for MHCP is assigned an 8-digit member number that is printed on his/her ID card. Members of an eligible household receive their own ID cards, and may have different versions of the card, depending on when they became eligible.

  • • MHCP ID numbers do not change, regardless of changes in program, eligibility or address
  • • MHCP ID cards do not include eligibility information

  • Verify recipient eligibility before each visit through MN–ITS.

    MHCP Member ID cards issued March 2006 through present:

    DHS image

    MHCP Member ID cards issued January 2003 through February 2006:

    DHS image

    MHCP Member ID cards issued before January 2003:

    DHS image

    MHCP Covered Services

    In order to be covered by MHCP, a health service must be determined by prevailing community standards or customary practice and usage to be:

  • • Medically necessary
  • • Appropriate and effective for the medical needs of the of the patient
  • • Able to meet quality and timeliness standards
  • • Able to represent an effective and appropriate use of program funds
  • • Able to meet specific limits outlined in rules adopted by DHS and explained in the service-specific MHCP Provider Manual sections
  • • Personally rendered by a provider, except as specifically authorized in the MHCP Provider Manual

  • For covered services at a glance by program, refer to the MHCP Benefits Chart.

    MHCP Non-covered Services

    MHCP does not cover:

  • • Health services:
  • • For which a physician’s order is required but not obtained
  • • Not documented in the recipient’s health/medical record
  • • Not in the recipient’s plan of care, individual treatment plan, IEP, or individual service plan
  • • Not provided directly to the recipient unless the service is identified as a covered service in MHCP Provider Manual
  • • Of a lower standard of quality 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 an emergency health service, provided to a recipient in a long-term care facility that are not in the recipient’s plan of care and have not been ordered, in writing, by a physician when an order is required
  • • Other than emergency health services, provided without the full knowledge and consent of the recipient or the recipient’s legal guardian
  • • Paid for directly by the recipient or other source, except when the recipient made the payment for services incurred during the recipient’s retroactive eligibility period. Refer to Billing Policy and Billing the Recipient
  • • That do not contain documentation of supervision, if supervision is required
  • • Missed appointments (do not bill MHCP recipients for missed appointments)
  • • Non-U.S. (out-of country) care
  • • Reversal of voluntary sterilizations
  • • Surgery primarily for cosmetic purposes
  • • Vocational or educational services, including functional evaluations or employment physicals, except as provided under IEP-related services

  • Consult the appropriate section(s) of the MHCP Provider Manual which may list other non-covered services.

    Legal References

    MS 256B.02 Definitions
    MS 256B.03
    , subd. 4 Prohibition on payments to providers outside of the United States
    MS 256B.055 to 26B.061
    MA; Eligibility categories & requirements
    MS 256B.0625
    Covered Services
    MS 256D.03
    Responsibility to provide general assistance
    MS 256L
    MinnesotaCare
    Minnesota Rules 9505.0010 to 9505.0140
    Health Care Programs, Medical Assistance Eligibility
    Minnesota Rules 9505.0170 to 9505.0475
    Health Care Programs, Medical Assistance Payments
    Minnesota Rules 9505.2160 to 9505.2245
    Health Care Programs, Surveillance and Integrity Review Program
    Minnesota Rules 9506.0010 to 9506.0400
    MinnesotaCare
    42 CFR 435
    MA Eligibility
    42 CFR 440
    MA Services
    42 CFR 456
    MA Utilization Control

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    Updated: 11/20/14 1:02 PM | Accessibility | Terms/Policy | Contact DHS | Top of Page | Updated: 11/20/14 1:02 PM