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.
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.
Major Program Code
Brief Description of Program
Alternative Care Program
MinnesotaCare Plus One
Minnesota Family Planning Program (MFPP)
MinnesotaCare Basic Plus
Institution for Mental Disease (IMD)
MinnesotaCare Basic Plus
Qualified Medicare Beneficiary (QMB) (DHS-2087e) covers Medicare Part A & B copays, coinsurance, premiums and deductibles only.
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.
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.
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 are programs that have received federal approval for expanded coverage to MHCP recipients of services not usually covered by MA. These programs include:
Refer also to HCBS Waiver Programs and the AC Program for additional provider information about waiver services programs.
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.
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:
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.
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:
PO Box 64838
St Paul MN 55164-0838
651-297-3862 or 1-800-657-3672
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.
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.
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.
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.
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.
Verify recipient eligibility before each visit through MN–ITS.
MHCP Member ID cards issued March 2006 through present:
MHCP Member ID cards issued January 2003 through February 2006:
MHCP Member ID cards issued before January 2003:
In order to be covered by MHCP, a health service must be determined by prevailing community standards or customary practice and usage to be:
For covered services at a glance by program, refer to the MHCP Benefits Chart.
MHCP does not cover:
Consult the appropriate section(s) of the MHCP Provider Manual which may list other non-covered services.
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