Most people eligible for Minnesota Health Care Programs (MHCP) are enrolled in managed care.
DHS contracts with managed care organizations (MCOs) (including counties or groups of counties known as county-based purchasing or CBP) to provide health care services for MHCP members. MHCP members in any of these programs must enroll in a managed care plan (unless excluded from enrollment):
Managed care organizations (MCOs) are organizations certified by the Minnesota Department of Health (MDH) to provide all defined health care benefits to people enrolled in an MHCP in return for a capitated payment. MCOs are also referred to as health plans or prepaid health plans (PPHP).
Except as described in this section, MCOs are not obligated to pay for services provided outside their networks. Providers must follow the member’s MCO policies and procedures, including for authorizations and referrals, to receive payment for services.
Each MCO establishes its own provider network. Providers interested in providing medical care to MHCP members through the MCO:
Providers also have the responsibility to:
All MHCP MA members must enroll in an MCO, except those who have a basis for exclusion. Some members who are not required to enroll with an MCO may voluntarily enroll. All MinnesotaCare members must enroll in an MCO. Verify member eligibility and the MCO enrollment status through the MN–ITS Eligibility (270/271) transaction prior to performing services. Call the MCO directly with questions about member MCO coverage.
Coverage for members in a prepaid MCO is effective the first day of the next available month. Depending on when a member applies and is made eligible, MA members may be placed on fee-for-service (FFS) for a short period of time before they are enrolled in an MCO. MinnesotaCare members are enrolled in prepaid MCOs effective the first day of the month after the month eligibility is approved and a first premium payment is received, if a premium is required. The premium must be paid by noon on the last business day of the month preceding enrollment to ensure coverage.
MA members who meet certain criteria are excluded from enrollment into an MCO. For example, members in the Refugee Assistance Program and the Emergency MA program are never enrolled into MCOs. Some members have a basis for exclusion but may voluntarily enroll.
MA members receive managed care education and enrollment from county staff. MinnesotaCare members receive education and enrollment materials through the mail. Members are:
For MSHO and SNBC, education is completed by mail, phone or in person. Members are enrolled through the state or MCO. Members may ask for help from the Senior Linkage Line (SLL) or Disability Hub MN about the various MCO options available.
In addition to their MHCP ID cards, members enrolled in an MCO also receive health plan member ID cards directly from their MCOs. Members are instructed to show both ID cards before receiving health care services. Members are also instructed to show the cards of any other health coverage they have, such as Medicare or private insurance.
Members may change MCOs in the following situations:
MSHO and SNBC members may change plans monthly.
The following guidelines apply when members transition from FFS coverage to MCO enrollment.
MHCP FFS covers both authorized services and services that do not require authorization only through the last day of a member's FFS eligibility.
• Must provide members medically necessary covered services that another MCO or MHCP FFS had authorized before enrollment in the MCO
• May require the member to receive the services from an MCO network provider if that would not create an undue hardship on the member
Inpatient Status at MCO Enrollment
If a member is an inpatient in the hospital on the day the MCO enrollment is effective, the inpatient stay and ancillary services will continue to be covered by the previous coverage (either FFS or the previous MCO). The previous MCO or FFS in effect at the time of admission remains financially responsible for the inpatient hospital stay and for any related ancillary services until discharge from the hospital. The new MCO will be responsible for the services not related to the inpatient hospital stay beginning on the effective date of the enrollment. The same policy applies when a member changes from an MCO to FFS.
Newborn MCO Enrollment
A newborn whose mother is enrolled in an MCO at the time of delivery is retroactively enrolled for the birth month. Unless the newborn meets an exclusion from managed care (refer to basis of exclusion) the following applies:
A newborn will be enrolled in the same MCO as the mother for MA for families and children if the MCO is available. If the health plan is not available, the baby will be FFS.
This policy also applies to a baby born to a woman enrolled in SNBC.
If a member is receiving ongoing medical services, such as mental health services, and the provider is not in the network of the member’s MCO, the provider must contact the member’s MCO for authorization to continue the service. Under some circumstances, the MCO may continue to authorize services by the non-participating provider, or may authorize a limited number of visits. Under some circumstances, the MCO will develop a transition plan, which will require the member to change to a provider in the MCO network.
Unless services are not included in the MCO contract (Carve-out Services) MCOs are required to provide all medically necessary health services covered under the contract, which include these access services:
For reimbursement for meals, lodging, parking, personal mileage and out-of-state transportation:
Managed care members may access services outside their MCO networks without authorization for the following services:
Some services are “carved-out” of MCO coverage and are covered through FFS MHCP. Bill the following services to MHCP directly:
For help resolving MCO or provider complaints, MCO members may contact:
A provider, acting on behalf of the member and with the member's written consent, may file an appeal with the MCO or request a State Appeal (State Fair Hearing. No written consent is needed if the provider is appealing a prior authorization or payment denial.
MCOs must notify their enrolled members with a written notice of denial of payment or the denial, termination or reduction (DTR) of services that the member or the member's health care provider requested. This notice contains the following information:
If the member disagrees with the MCO action, the member must appeal to the MCO before requesting a state appeal (State Fair Hearing), Member:
When an MCO reduces or terminates ongoing medical services that the member's MCO physician or another physician authorized by the MCO has ordered, and the member has filed an appeal with the MCO within 10 days after receiving notice, or before the date of the proposed action, whichever is later. Members may also continue benefits during the state appeal if they request a state appeal within 10 days from the date of the MCO appeal decision.
Minnesota Statutes 256B.69 Prepaid Health Plans
Minnesota Statutes 256D.03 Responsibility to Provide General Assistance
Minnesota Statutes 256L.12 Managed Care
Minnesota Statutes 62D Health Maintenance Organizations
Minnesota Statutes 62M Utilization Review of Health Care
Minnesota Statutes 62N Community Integrated Service Network
Minnesota Statutes 62Q Health Plan Companies
Minnesota Statutes 62T Community Purchasing Arrangements
Minnesota Rules 9500.1450 to 9500.1464 Administration of the Prepaid Medical Assistance Program
Minnesota Rules 9505.0285 Health Care Prepayment Plans or Prepaid Health Plans
Minnesota Rules 9506.0200 Prepaid MinnesotaCare Program; General
Minnesota Rules 9506.0300 Health Plan Services; Payment
Minnesota Rules 9506.0400 Other Managed Care Health Plan Obligations
42 CFR 431 State organization and general administration
42 CFR 438 Managed care