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

Revised: 05-16-2018

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

  • MHCP Member Eligibility
  • Minnesota Health Care Programs (MHCP)
  • Minnesota Restricted Recipient Program (MRRP)
  • Hospital Presumptive Eligibility
  • Waiver Services Programs
  • Minnesota Children with Special Health Needs (MCSHN) Program
  • Incarcerated Members
  • Applying for MHCP Coverage
  • Newborn Coverage
  • Spenddown
  • Member ID Cards and Verification
  • MHCP Covered Services
  • MHCP Noncovered Services
  • Legal References
  • MHCP Member 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 member 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 member cost-sharing responsibilities.

    Minnesota Health Care Programs (MHCP)

    Major Program Code

    Brief Description of Program
    When mentioned, MinnesotaCare is the program for Minnesota residents without access to affordable health care coverage.


    Alternative Care Program
    A state- and federally 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.



    State and federally funded program for people age 21 years and older.


    Emergency Medical Assistance
    State-funded and federally funded emergency assistance for some people with a medical emergency; 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 certified care plan.


    Minnesota Family Planning Program (MFPP)
    State and federally funded program that provides only pre-pregnancy family planning and related health care services for people of any age.


    State and federally funded program for people age 21 years and older.


    Federally funded program for people with HIV or AIDS 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.


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


    State and federally funded program for people age 21 years and older.


    State-funded program for children under age 21.


    State and federally funded program for children under age 21.


    Medical Assistance
    Minnesota’s Medicaid program with more than a million Minnesotans eligible, most enrolled in managed care organizations (MCOs).


    MA program that is mostly federally funded under the Children’s Health Insurance Program (CHIP), which covers pregnant women and infants under age 2. NM also covers a small number of adults age 21 and over who are not covered by CHIP. Eligibility and covered services mirror MA.


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


    Refugee Medical Assistance
    Federally funded MA program available for the first eight months after a refugee arrives in the United States; covered services are the same as MA.


    Service Limited Medicare Beneficiary
    Medicare Savings Program that covers Medicare Part B premiums. There is no coverage for services or Medicare copays and deductibles. See Service Limited Medicare Beneficiaries (DHS-2087G) (PDF)


    Limited program for specified benefits that do not require MA basis of eligibility.
    Essential Community Supports (ECS)

    Group Residential Housing (GRH) Supplemental Services


    State-funded program for people age 21 or older.

    Some people may be eligible for more than one program at the same time. For these people, MHCP will pay services at the highest level of coverage. For example, if a person has QM and MA coverage, MHCP will cover the person’s Medicare coinsurance and deductible based on QM coverage. However, because the person also has MA coverage, MHCP will cover services that are not covered by QM, but are covered by MA. Program SL reimburses a person’s Medicare premium and does not include coverage for health care services. People 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 (members) (any major program code) who have used services at a frequency or amount that is not medically necessary or who have used health services that resulted in unnecessary costs to MHCP. Once identified, these people are placed under the care of a designated primary care physician or 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) (PDF) 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 or referral of the primary care physician. The MRRP office may require documentation of the emergency situation to determine payment of the claim.

    If you have any questions about a referral or the referral form, call MRRP at 651-431-2648 or 800-657-3674.

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

    Hospital Presumptive Eligibility

    The Hospital Presumptive Eligibility (HPE) program was established by the Affordable Care Act. It allows participating hospitals to determine eligibility for temporary Medical Assistance (MA) using preliminary information from applicants. A hospital can enroll as a qualified HPE provider at any time.

    A qualified HPE hospital must help people it approves for HPE complete and submit the full MA application. Hospitals can provide direct assistance to complete the application, or help people connect with a navigator organization or certified application counselor. A hospital qualified to determine eligibility for HPE must comply with all policies and procedures and meet the HPE performance metrics established. See the HPE: Policies, forms and notices for more information.

    A person who is approved for HPE is eligible to receive full MA benefits under the adults and families with children benefit set. HPE helps people get needed health care coverage and helps hospitals receive payments for services they provide before a full MA determination can be made.

    To make HPE determinations, a hospital must be an enrolled MHCP provider and agree to comply with the DHS HPE policy and procedures. Hospitals must sign and submit the Hospital Presumptive Eligibility Applicant Assurance Statement (DHS-3887) (PDF). Hospitals must also submit to DHS the name of two members of the hospital’s staff who have passed the DHS HPE training.

    Refer to Hospital Presumptive Eligibility webpages for more information.

    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. Refer to the SMRT webpage for more information.

    Waiver Services Programs

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

  • Brain Injury (BI) Waiver
  • Community Alternative Care (CAC) for chronically ill individuals
  • Community Access for Disability Inclusion (CADI)
  • Developmental Disability(DD) Waiver
  • Elderly Waiver (EW)
  • Refer also to HCBS Waiver Services section of the MHCP Provider Manual for additional provider information about waiver and AC 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 are available to help 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 help, call 651-215-8956 or 800-728-5420.

    Incarcerated Members

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

    A person incarcerated in a state or local correctional facility may qualify for MA payment for inpatient hospital services only. Refer to the Inpatient Hospital Services section for more information.

    MHCP members, 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.

    MHCP may not receive notification that a member is incarcerated until after the person’s eligibility was determined. In those cases, MHCP will retroactively close out the member’s eligibility and recoup any reimbursements made to the provider for services performed during the member’s dates of incarceration.

    Contact the appropriate county jail or correctional facility about how to bill for the services that were provided.

    Applying for MHCP Coverage

    People may apply online through, at their local tribal or county agency, or at the MinnesotaCare office at DHS 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:

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

    Newborn Coverage

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


    Members in MA, IM or EH 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 member’s financial responsibility before MHCP payment can be made.

  • Medical spenddown: Members pay for medical services, including prescriptions, generally on a monthly basis
  • Institutional or long-term care (LTC) spenddown: Members pay a portion or all of their institutional daily charges
  • Elderly waiver (EW) obligation: Members pay a portion or all of their EW service costs. For members enrolled in a senior managed care program, MCOs pay providers minus the waiver obligation and the provider bills the member. Members cannot use a designated provider for waiver obligations.
  • Spenddowns and Managed Care

  • • Members eligible for MA who are enrolled in a managed care plan for families and children (F&C) and Minnesota Senior Care Plus (MSC+) cannot be eligible with a medical spenddown. Members who become eligible with a medical spenddown while enrolled in F&C or MSC+ will be disenrolled from their managed care plan. Their eligibility will be fee for service for the next available month.
  • • Members cannot enroll in Minnesota Senior Health Options (MSHO) or Special Needs BasicCare (SNBC) if they have an existing medical spenddown. However, if someone was enrolled in MSHO or SNBC without a medical spenddown, and later become eligible with a medical spenddown, they can remain enrolled as long as they continue to pay their medical spenddown to DHS.
  • • If a member fails to pay three months of medical spenddowns to DHS they will be disenrolled from MSHO or SNBC.
  • • Once a member has been disenrolled from SNBC or MSHO, he or she has 90 days from the date of disenrollment to pay the outstanding balance to DHS and be reinstated into the health plan.
  • • If it has been more than 90 days since a member has been disenrolled from the SNBC or MSHO plan, the member cannot enroll into SNBC or MSHO until he or she no longer has an ongoing medical spenddown and has paid the outstanding balance of the previous spenddown.
  • Spenddown Payment Options

    Members may pay spenddowns in one of four different ways, depending on the program they are eligible for:

  • • Potluck spenddown: For members in FFS, the provider (or providers) who bills first, has all or a part of the medical spenddown amount deducted from their claims. The provider then bills the member for the spenddown amount that was deducted from the claims.
  • • DHS spenddown: For members in MSHO and SNBC, spenddowns are paid directly, in advance, to DHS.
  • Designated provider spenddown: FFS members pay a specific provider, selecting the provider using the Request for Designated Provider Agreement (DHS-3161) (PDF). Designated providers agree to make sure the member’s spenddown is applied to the provider’s claims for each month the provider renders services to the member.
  • • People enrolled in MSHO cannot have a designated provider; they must pay their spenddown to DHS.
  • • People enrolled in SNBC can have a designated provider as long as it is for services not covered by the health plan. Services covered by fee for service eligible for payment to a designated provider are HCBS for people with disabilities, PCA, or home care nursing.
  • 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 member named on the designated provider agreement
  • • 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; the member will remain ineligible for other services until the designated provider’s claim is processed.

  • Client option spenddown: Members prepay their spenddowns to DHS. The client option spenddown option is not available to people on MSHO.
  • Providers who are owed spenddown amounts see group and reason code PR142 on their remittance advices with a dollar amount that indicates the member’s spenddown amount. See Billing the Recipient.

    Member ID Cards and Verification

    Each member approved for MHCP is assigned an 8-digit member number that is printed on his or 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. (The look of the cards may change slightly from time to time.)
  • Verify recipient eligibility before each visit through MN–ITS.

    Example of MHCP Member ID cards issued March 2006 through present:

    DHS image

    MHCP Covered Services

    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 by program, refer to the MHCP benefits at a glance chart.

    MHCP Noncovered Services

    MHCP does not cover:

  • • Health services for any of the following:
  • • For which a physician’s order is required but not obtained
  • • Not documented in the member’s health or medical record
  • • Not in the member’s plan of care, individual treatment plan, IEP, or individual service plan
  • • Not provided directly to the member 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 member in a long-term care facility that are not in the member’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 member or the member’s legal guardian
  • • Paid for directly by the member or other source, except when the member made the payment for services incurred during the member’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 member 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 this manual for more specific information about other noncovered services.

    Legal References

    Minnesota Statute 256B.02 Definitions
    Minnesota Statute 256B.03
    , subd. 4 Prohibition on payments to providers outside of the United States
    Minnesota Statues 256B.055
    , subd. 14 Persons detained by law
    Minnesota Statute 256B.055 to 26B.061
    MA; Eligibility categories & requirements
    Minnesota Statute 256B.0625
    Covered Services
    Minnesota Statute 256D.03
    Responsibility to provide general assistance
    Minnesota Statute 256L
    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
    42 CFR 435
    MA Eligibility
    42 CFR 440
    MA Services
    42 CFR 456
    MA Utilization Control

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