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.
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.
Major Program Code
Brief Description of Program
Alternative Care Program
State and federally funded program for people age 21 years and older.
Emergency Medical Assistance
Minnesota Family Planning Program (MFPP)
Institution for Mental Disease (IMD)
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
Service Limited Medicare Beneficiary
Limited program for specified benefits that do not require MA basis of eligibility.
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.
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.
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.
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 are programs that have received federal approval for expanded coverage to MHCP members of services not usually covered by MA. These programs include:
Refer also to HCBS Waiver Services section of the MHCP Provider Manual for additional provider information about waiver and AC programs.
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.
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:
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.
People may apply online through MNsure.org, 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
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.
Members may pay spenddowns in one of four different ways, depending on the program they are eligible for:
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.
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.
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.
Verify recipient eligibility before each visit through MN–ITS.
Example of MHCP Member ID cards issued March 2006 through present:
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 by program, refer to the MHCP benefits at a glance chart.
MHCP does not cover:
Consult the appropriate section(s) of this manual for more specific information about other noncovered services.
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 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