***This version of the Health Care Programs Manual has been replaced and is no longer in effect. Please see the current Health Care Programs Manual for policy in effect as of December 1, 2006.***

The terminology used to describe people with disabilities has changed over time. The Minnesota Department of Human Services ("Department") supports the use of "People First" language. Although outmoded and offensive terms might be found within documents on the Department's website, the Department does not endorse these terms.

MDHS Health Care Programs Manual (Eligibility Policy through 11/30/06)

Chapter 0914 - Service Delivery

All chapters are numbered beginning with 09. The first chapter is 0901 (Table of Contents).

Chapter 0914

0914

SERVICE DELIVERY

PDF(s): Oct 03 | Dec 02

0914.03

SERVICE DELIVERY - PEOPLE W/OTHER COVERAGE

PDF(s): Jul 00

0914.03.03

MANAGED CARE EXCLUSIONS

PDF(s): Apr 06 | Jan 06 | Jan 05 | Oct 03 | Jan 03 | Dec 02

0914.03.03.03

MANAGED CARE VOLUNTARY ENROLLMENT

PDF(s): Apr 06 | Jan 06 | Oct 03 | Dec 02

0914.03.05

MANAGED CARE ENROLLMENT PROCESS

PDF(s): Jan 05 | Oct 03

0914.03.05.01

MANAGED CARE ENROLLMENT PROCESS -- MA/GAMC

PDF(s): Jan 05 | Feb 00

0914.03.05.03

MANAGED CARE ENROLLMENT PRESENTATIONS

PDF(s): Jan 05 | Dec 02

0914.03.07

HEALTH PLAN CHANGES

PDF(s): Jan 06 | Oct 03

0914.03.09

MANAGED CARE RE-ENROLLMENT & REINSTATEMENTS

PDF(s): Jan 05 | Oct 03

0914.03.11

MANAGED CARE DISENROLLMENT

PDF(s): Oct 03

0914.03.13

ADDING/REMOVING PEOPLE FROM MANAGED CARE

PDF(s): Jan 05 | Oct 03

0914.03.15

MANAGED CARE ADJUSTMENTS

PDF(s): Jan 05 | Dec 02

0914.03.17

MANAGED CARE COUNTY TRANSFERS

PDF(s): Jan 05 | Dec 02

0914.03.21

MANAGED CARE COVERED SERVICES

PDF(s): Oct 03

0914.03.23

MANAGED CARE COMPLAINTS AND APPEALS

PDF(s): Feb 00

0914.03.25

MINNESOTA SENIOR HEALTH OPTION - MSHO

PDF(s): Apr 06 | Jan 06 | Jul 01

0914.03.27

MINNESOTA DISABILITY HEALTH OPTIONS (MNDHO)

PDF(s): Apr 02

0914.03.29

MINNESOTA SENIORCARE AND SENIOR CARE PLUS

PDF(s): Jan 06

0914.05

FEE-FOR-SERVICE

PDF(s): May 05 | Aug 00

0914.07

MINNESOTA HEALTH CARE PROGRAMS CARD

PDF(s): May 05 | Jul 98

0914.09

ESTATE CLAIMS

PDF(s): Jul 04

0914.09.03

LIENS

PDF(s): Dec 01

0914.11

ACCESS SERVICES

PDF(s): Jan 05 | Jan 04 | Jan 03

0914.13

OUT OF STATE SERVICES

PDF(s): Apr 01

SERVICE DELIVERY 0914

People enrolled in Minnesota health care programs receive medical services in one of two ways:

• Managed care. In a managed care system, DHS contracts with a health plan to provide services to people enrolled in MA, GAMC, or MinnesotaCare. The health plan must provide most services covered by the program the person is enrolled in. DHS pays a fixed monthly fee, called a capitation payment, to the health plan. Enrollees must receive services through their health plans. MA services that are not covered in the managed care contract will be billed under fee-for-service.

All MinnesotaCare enrollees receive services through managed care. Some MA and GAMC enrollees receive services through managed care depending on the county they live in and whether they are excluded from managed care. See §0914.03.03 (Managed Care Exclusions).

The following are managed care counties for MA and GAMC as of 9-1-03:

Aitkin, Anoka, Becker, Benton, Big Stone, Blue Earth, Brown, Carlton, Carver, Chippewa, Chisago, Clay, Cook, Cottonwood, Dakota, Dodge, Douglas, Faribault, Fillmore, Freeborn, Goodhue, Grant, Hennepin, Houston, Isanti, Itasca, Jackson, Kanabec, Kandiyohi, Kittson, Koochiching, Lac Qui Parle, Lake, LeSueur, Lincoln, Lyon, Mahnomen, Marshall, Martin, McLeod, Meeker, Mille Lacs, Murray, Nicollet, Nobles, Norman, Olmsted, Otter Tail, Pennington, Pine, Pipestone, Pope, Ramsey, Red Lake, Redwood, Renville, Rice, Rock, Roseau, St. Louis, Scott, Sherburne, Sibley, Stearns, Steele, Stevens, Swift, Traverse, Wabasha, Waseca, Washington, Watonwan, Wilkin, Winona, Wright, Yellow Medicine, Mille Lacs Tribal TANF.

The following are managed care counties except for dental services. MA, GAMC and MinnesotaCare clients in these counties who are enrolled in managed care receive dental services through fee-for-service. The health plans are not responsible for dental services or transportation to dental appointments. The health plans provide all other managed care services:

Cass, Crow Wing, Morrison, Todd, Wadena

In most counties, managed care enrollees choose one of two or more health plans. If required, enrollees must also choose specific clinics within the health plan network. See §0914.03.05 (Managed Care Enrollment Process) and §0914.03.05.01 (Managed Care Enrollment Process--MA/GAMC).

Managed care enrollees receive a Minnesota Health Care Programs Identification Card and an identification card from the health plan. See §0914.07 (Minnesota Health Care Programs Card).

• Fee-for-service. MA and GAMC enrollees who are not enrolled in a managed care plan receive medical services on a fee-for-service basis. MinnesotaCare enrollees do not receive care through fee-for-service on an ongoing basis, but may be enrolled in fee-for-service for a limited period in some circumstances. See §0914.05 (Fee-for-Service). In a fee-for-service system, people may receive services from any provider who is enrolled as a Minnesota Health Care Programs provider. Providers bill DHS for each service provided. DHS makes payments for approved services at a predetermined rate.

Fee-for-service enrollees receive a Minnesota Health Care Programs Identification Card. See §0914.07 (Minnesota Health Care Programs Identification Card).

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SERVICE DELIVERY - PEOPLE W/OTHER COVERAGE 0914.03

People enrolled in Minnesota Health Care Programs (MHCP) who have other coverage must follow certain procedures to ensure proper payment for health services they receive. DHS sends "Your Notice About Third Party Liability" (DHS 2810) to enrollees annually. This notice contains information about health insurance and third party liability.

Enrollees who have insurance or HMO coverage must follow the plan’s policies and use providers that participate with that plan. They must use coverage through an insurance plan or HMO before MHCP will pay for any services

EXCEPTION:

Notify the Benefit Recovery Section (BRS) if enrollees are unable to use their primary coverage due to their distance from network providers. BRS applies a general standard of 30 miles to determine whether network providers are accessible.

MinnesotaCare:

Enrollees who have other health insurance must:

• Contact their MHCP prepaid health plan before receiving health care

AND

• Use the providers their MHCP prepaid health plan tells them to use.

MA/GAMC:

Follow MinnesotaCare for managed care enrollees who have other coverage.

Enrollees who receive coverage through fee-for-service must:

• Use their private insurance or HMO coverage first. MA or GAMC will not pay for services for enrollees who have not used the private coverage first. • Follow their insurance plan’s or HMO’s rules to get care covered by the plan or HMO. • Use providers who participate with MHCP and their private coverage, including following the plan’s policy for referral to outside providers. Clients should ask about this policy when they schedule appointments to ensure payment for the services.

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MANAGED CARE EXCLUSIONS 0914.03.03

MinnesotaCare:

There are no exclusions. All MinnesotaCare enrollees must receive services through managed care. People may be enrolled in fee-for-service for a limited period in certain circumstances. See §0914.05 (Fee-for-Service).

M.S. 256L.12 subd. 3

MA/GAMC:

Exclude the following groups from managed care enrollment in MA and GAMC:

• People who receive Refugee Cash Assistance or Refugee Medical Assistance. See §0907.21.13 (MA Basis: Refugee Medical Assistance-RMA). • Residents of state institutions, including Regional Treatment Centers (RTC), Institutions for Mental Disease (IMD), and state-operated long term care facilities who reside in the institution at the time of initial enrollment. People already enrolled in managed care who enter state institutions will remain enrolled their health plans if the placement has been approved by the health plan. This includes court-ordered placements for which the health plan is responsible. See §0906.09.01 (Institutional Residence--MA/GAMC) and §0907.27 (MA/GAMC Basis: IMD Residents).

NOTE: Do not exclude residents of Ah Gwah Ching Nursing Facility and Woodhaven Senior Community under this basis.

• People who have private health insurance through the following HMOs certified by the Department of Health. These people may voluntarily enroll in managed care IF THE PRIVATE HMO IS THE SAME AS THE HEALTH PLAN THE CONSUMER WILL SELECT UNDER PMAP. See §0914.03.03.03 (Managed Care Voluntary Enrollment).

Avera Health Plan of Minnesota

Blue Plus

First Plan of Minnesota

Group Health, Inc.

HealthPartners, Inc.

Itasca Medical Care

Medica Health Plans

Metropolitan Health Plan

PreferredOne Community Health Plan

Sioux Valley Health System

UCare Minnesota

PrimeWest Health Systems

South Country Health Alliance

• People eligible with all spenddown types except institutional spenddowns. Note: People that are on Long Term Care (LTC) spenddowns are not excluded from managed care. For enrollees with a waiver obligation, refer to the SIS EW criteria below. Applicants who have a medical spenddown or a combination LTC/medical spenddown while enrolled in MSHO may not enroll in MSHO. See §0914.03.27 (Minnesota Disability Health Options – MnDHO) for information on people with spenddowns who may voluntarily enroll. • Undocumented and non-immigrant non-citizen recipients who only receive emergency MA (EMA). §0907.29 (Medical Emergency Programs). • People under age 65 who are eligible for MA due to blindness or disability as determined by SSA or the State Medical Review Team (SMRT). See §0907.21.05 (MA/Medicare Supplement Basis: Blindness) and §0907.21.07 (MA/Medicare Supplement Basis: Disability). This includes people with blindness or disabilities who receive services under the CAC, CADI, MR/RC and TBI waivers who meet the above criteria. See §0907.23 (MA Waiver Programs). Blind or disabled individuals under 65 who have a Method A basis of eligibility may choose to voluntarily enroll in managed care. • People who are terminally ill with a medical prognosis of 6 MONTHS OR LESS to live and who, at the time of notification of mandatory health plan enrollment, have a permanent relationship with a primary physician who is not part of any available managed care health plan. • People who are enrolled in the SIS EW program with gross incomes greater than the maintenance needs allowance but less than or equal to the Special Income Standard. These people may enroll in managed care voluntarily. SIS EW enrollees with incomes less than the maintenance needs allowance must enroll in managed care. • People eligible for QMB, SLMB, QWD, or QI only (eligibility types BQ, BS, BW, DS, DQ, DW, EQ, ES, 1B, 1D, 1E, 2B, 2D, and 2E). See §0907.21.09 (MA Basis: Medicare Supplement Programs). • People who, at the time of notification of mandatory enrollment in managed care, meet ALL the following:
Have a communicable disease. Have a prognosis of a terminal illness (may exceed 6 months) because of the communicable disease.
The disease and prognosis are verified by a written statement from a licensed physician based on a current medical examination.
Currently have a primary physician who is not a participating provider in an available managed care health plan.
The physician certifies that disruption of the existing physician-patient relationship is likely to result in the patient stopping recommended medication or other health services. • Children who are identified to DHS as having severe emotional disturbance (SED) and who are eligible to receive MA-covered mental health case management services.

Children receiving IV-E or state adoption assistance.

SED and adoption assistance children may enroll voluntarily. See §0914.03.03.03 (Managed Care Voluntary Enrollment).

• Adults who are identified to DHS as having serious and persistent mental illness (SPMI) and who are eligible to receive MA-covered mental health case management services.

These adults may enroll voluntarily if they have a Method A basis of eligibility. See §0914.03.03.03 (Managed Care Voluntary Enrollment).

• American Indians living on an Indian reservation, if the tribal government of that reservation chooses to exclude these people. • Women receiving MA under the MA-BC basis. See §0907.19.13 (MA for Breast/Cervical Cancer MA-BC).

• Enrollees receiving care and rehabilitation services from the Center for Victims of Torture (CVT). See §0907.25.07 State-Funded MA Basis: Victims of Torture).

• People with cost-effective employer-sponsored health insurance or people enrolled in an individual non-Medicare health plan determined to be cost-effective.

Also exclude the following groups from enrollment in GAMC managed care:

• GAMC recipients eligible for Medicare benefits. • GAMC recipients living in nursing facilities. • GAMC recipients in the GAMC Hospital Only (GHO) Program.

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MANAGED CARE VOLUNTARY ENROLLMENT 0914.03.03.03

MinnesotaCare:

No provisions.

MA/GAMC:

The following excluded people may volunteer to enroll in MA or GAMC managed care:

• People who currently have private health insurance through an HMO licensed by the Department of Health. The private HMO must be the same as the health plan the person will select under managed care. See §0914.03.03 (Managed Care Exclusions). • Children with severe emotional disturbance (SED). • Adults with serious and persistent mental illness (SPMI) if they have a Method A basis of eligibility. • People with an LTC spenddown may enroll in MSHO. People with a medical spenddown are not eligible to enroll in MSHO. See §0914.03.25 (Minnesota Senior Health Option - MSHO). • People enrolled in SIS EW with a waiver obligation (those with gross incomes over the maintenance needs allowance but less than or equal to the Special Income Standard). • People under age 65 who are certified as disabled but who choose a non-disabled basis of eligibility. See §0907.17.03 (MA Basis: Multiple Bases of Eligibility). • People ages 18 through 64 who are certified disabled with a primary diagnosis of physical disability and who reside in Anoka, Carver, Dakota, Hennepin, Ramsey, Scot, or Washington counties. These people may voluntarily enroll in Minnesota Disability Health Options for people with physical disabilities (MnDHO-PD). See §0914.03.27 (Minnesota Disability Health Options (MnDHO). • People age 18 through 64 who are determined by the county to have mental retardation or a related condition, who reside in Carver, Hennepin, or Scott counties and are currently receiving residential habilatative services in a Mount Olivet Rolling acres (MORA) owned ICF/MR or a MORA-managed foster home, or receiving residential habilatative services from MORA in their own homes are eligible to enroll. These people may voluntarily enroll in Minnesota Disability Health Options – Developmental Disabilities (MnDHO-DD).

• Children receiving IV-E or state adoption assistance.

Volunteers may choose to disenroll at any time for the next available month on MMIS. Request a written statement from the enrollee or authorized representative that the enrollee wishes to disenroll from the health plan. See §0914.03.11 (Managed Care Disenrollment).

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MANAGED CARE ENROLLMENT PROCESS 0914.03.05

MinnesotaCare:

The managed care enrollment process is done through the mail and is completely automated on MMIS. When MinnesotaCare coverage is approved as pending awaiting payment, MMIS automatically chooses a default health plan and generates a health plan enrollment form. The default plan is the plan the household will be enrolled in if they fail to choose a health plan. The default plan is determined by the following criteria:

• If anyone in the household is enrolled in managed care through MA or GAMC, the default plan is the plan the MA or GAMC person is enrolled in unless that plan is not available through MinnesotaCare. • If more than one household member is enrolled on MA or GAMC in different health plans, the system will select the first plan that is available to MinnesotaCare as the default plan. • If no one in the household is enrolled in managed care through MA or GAMC but anyone in the household has previously been enrolled in managed care through MinnesotaCare, the default plan is the plan in which they were previously enrolled if that plan is still available. • If neither of the above circumstances apply, MMIS assigns a default plan based on the plans available in the household's county of residence.

DHS sends the household a health plan enrollment packet and a premium notice packet. The health plan enrollment packet includes:

• DM-0107: MinnesotaCare Enrollment Form and Letter (printed at IOC) DHS 4106A used for phone-ins (e-Docs only) • DHS 3253: Return Envelope

• DHS 3320A: Window Envelope for MinnesotaCare mailing • DHS 3303: MinnesotaCare Guide to Managed Care Enrollment

The household must choose the same health plan for all household members. However, the household may choose different primary care clinics within the health plan for different household members.

If the household returns the enrollment form before the date that capitation payments are made to the health plans for the next month, MMIS is updated to show the household’s health plan choice. The capitation date is usually 6 business days before the end of the month. However, if the household returns the form after the 15th of the month, there may not be time to enter the enrollment information before capitation. Refer the household to their MinnesotaCare enrollment representative or financial worker to complete a manual enrollment form to ensure enrollment in the plan of their choice for the next month. If the household has been found eligible but there is no enrollment information entered as of the capitation date, either because the household has not returned the form or returned it after the 15th and did not use the manual enrollment process, MMIS will enroll the household in the default plan. If new enrollment information is entered before the next capitation date, MMIS will enroll the household in the plan of their choice beginning the following month. See §0914.03.07 (Health Plan Changes).

EXAMPLE:

John is approved for coverage awaiting payment on October 3. MMIS mails John a premium notice packet and a health plan enrollment packet on October 5. MMIS also selects UCare as John’s default plan. John returns his premium payment and enrollment form on October 22 indicating HealthPartners as his choice of plan. There is not time to process his enrollment form before capitation on October 23, and John does not use the manual enrollment process. He will be enrolled in UCare for November and will be switched to HealthPartners beginning December 1.

If MinnesotaCare is approved after the capitation date but before reinstatement (usually the last business day of the month), the household must choose a health plan by the reinstatement date. Otherwise MMIS will enroll the household in the default plan.

M.S. 256L.12 subd 3

Minnesota Rule 9506.0200 subp 3, 4, 5, 6

MA/GAMC:

See §0914.03.05.01 (Managed Care Enrollment Process--MA/GAMC).

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MANAGED CARE ENROLLMENT PROCESS -- MA/GAMC 0914.03.05.01

MinnesotaCare:

See §0914.03.05 (Managed Care Enrollment Process).

MA/GAMC:

Follow your county's procedures for informing clients about managed care. Refer people to a managed care presentation or give them a managed care education packet in the following situations:

• During an initial intake interview for MA or GAMC. • During an intake interview for an MA or GAMC reapplication when the period of MA or GAMC ineligibility is two full calendar months or more. See §0914.03.09 (Managed Care Re-Enrollments & Reinstatements). • People who are applying for MA or GAMC in conjunction with cash or Food Stamps are required to have a face-to-face interview. People who are requesting only MA or GAMC are not required to have a face-to-face interview but may request one. See §0904 (Applications). When people who apply or reapply for MA or GAMC do not have an interview, you may refer them to a managed care presentation or mail them an education packet. Do not require people to attend a managed care presentation. • When adding a person to a case which has no other people in managed care, if the person being added is required to enroll or volunteers to enroll in managed care. • When adding a managed care eligible person to a case which has at least one other person in managed care, add the recipient to the same health plan as the rest of the case. Effective 6/1/04, all household members will need to choose the same health plan. Current households with multiple health plans will be grandfathered in and will not be required to change. • When an MA or GAMC enrollee from a non-managed care county moves to a managed care county. • When an enrollee moves from a managed care county to another managed care county and the enrollee's health plan is not available in the new county. • When a managed care enrollee requests a change in health plan when moving between managed care counties. See §0914.03.17 (Managed Care County Transfers) for more information on enrollees who move between counties. • When an MA or GAMC enrollee is no longer in an excluded group. If there are other family members enrolled in managed care, add them to the same health plan. • When an enrollee changes from one health care program to another program and the health plan is not available for the new program.

Allow applicants and enrollees 30 days after attending presentations or receiving education packets to return the enrollment forms.

All managed care counties must enter tracking information directly on the MMIS Recipient Tracking (RTRK) screen. Be sure to update tracking information for all case members at the same time to reduce enrollee confusion. The RTRK screen generates a case-based notice for each enrollee which lists the health plan options available in the enrollee’s county of residence and the health plan the client will be enrolled in if a choice is not made. The system also generates a 10-day reminder letter. If the client does not choose a health plan within 30 working days, the tracking system automatically creates an enrollment span on the RPPH panel for the assigned health plan.

Also see §0914.03.05.03 (Managed Care Enrollment Presentations).

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MANAGED CARE ENROLLMENT PRESENTATIONS 0914.03.05.03

MinnesotaCare:

All managed care education is done by mail. See §0914.03.05 (Managed Care Enrollment Process).

Minnesota Rule 9506.0200 subp. 3a, c, 4a, c

Minnesota Rule 9506.0400 subp. 2

MA/GAMC:

Managed care county agencies may conduct in-person presentations as part of the eligibility interview for people who are required to have a face-to-face interview or who request one. See §0904 (Applications).

Include the following information in managed care presentations:

• How a health plan works. • The exclusion groups. • The enrollment form. • The requirement to choose a health plan and to return the enrollment form within 30 days of the presentation date. • Random assignment. • Each health plan and network available in the county. • Covered and non-covered services. • Enrollment effective dates. • A description and instructions on use of the health plan ID card and the Minnesota Health Care Programs card. • How to receive emergency care outside of the health plan service area. • Benefit coordination with primary insurance, Medicare, or private HMO coverage. • Transportation cost reimbursement procedures. • Inform the recipient they may change for cause at any time including:
• Lack of access to services and providers • Amount of travel to get primary care • Poor quality of care.
• Or without cause at the following times:
• Within 90 days from the date they were initially enrolled in the health plan • At least once every 12 months during open enrollment • If they were not eligible at the time of open enrollment • If the health plan no longer provides services in their county. To change health plans, call their worker.
• Enrollee rights to services provided by health plan patient representatives, county advocates, and state ombudsmen. • Enrollee right to file an appeal with the state agency. • Multi-language notification.

Clients may choose health plans and complete the enrollment forms at the time of the presentation. They may also take the forms with them and return them within 30 days.

If a client who is scheduled for a managed care presentation fails to attend, mail an enrollment packet as soon as possible after the missed presentation.

Include the following information in managed care education packets:

Your Guide to Health Plan Enrollment (DHS 3354) Pre-Enrollment Questionnaire (DHS 3354C) available through eDocs only • Automated MA/GAMC Enrollment Form (DM-0084A eDocs version is DHS-4106A • Health plan primary care network listing (PCNL) for each available health plan in the county. • The following county-specific information. Materials other than the return envelope must be approved by DHS:
• A county contact sheet listing where to call with questions. • A prepaid return envelope.

For MSHO Enrollees:

• DM-0084B: Automated MA Enrollment Form for MSHO (eDocs version is DHS-4106B) DHS-3214A: Rights & Responsibilities brochure DHS-3540: MSHO Information Sheet (eDocs only) DHS-4098: Health Plan Option Sheet (eDocs only)
Note: DM-0084B: This version of the enrollment form will print automatically if anyone in the household is potentially eligible for MSHO (eDocs version is DHS-4106B).
County-Based Purchasing (CBP) Packet:
• DM-0084A: Automated MA/GAMC Enrollment Form (eDocs version is DHS-4106A) • DHS-3320: Window Envelope for County Mailing • DHS-3354: Guide to Health Plan Enrollment DHS-3354C: Pre-Enrollment Questionnaire (eDocs only) • Postage paid return envelope

MAXIS interfaces the following information with MMIS for managed care purposes:

• Address. • Date of birth. • Sex. • Medicare Part A and Part B coverage. • Servicing and financially responsible counties.

Enter the following information on MMIS. MMIS uses this information and the MAXIS information above to determine the health plan capitation rate.

• Living arrangement. • Spenddown type. • Eligibility type and major program.

Managed care counties must complete the appropriate MMIS screens with either an exclusion span or an enrollment span. Contract numbers are the provider numbers of the health plans which serve the managed care counties. Each county will have a list of the health plan provider numbers for that county. See the MMIS User Manual, MMIS Screens, RPPH, and the Managed Care Manual section 4.02.01, both listed under manuals in CountyLink on the DHS web site.

If a client has not chosen a health plan when MA or GAMC is approved, code RENR with exclusion reason YY (Delayed Decision). In mandatory tracking counties, complete the RTRK panel. Follow your county's procedures for entering enrollment information on MMIS when people choose a health plan.

If you receive the enrollment form and can enter the information on MMIS on or before the managed care enrollment cutoff date, the enrollment will be effective the first day of the next month. If you cannot enter the information on MMIS until after the managed care enrollment cutoff date, the enrollment will become effective the first day of the next available (or 2nd) month.

If a client has not chosen a health plan before the counter on the RTRK panel reaches 30 days, MMIS will assign a default plan.

Delay initial enrollment of a hospitalized recipient into managed care until the first of the next available month after discharge.

See MAXIS/MMIS CALENDAR in the TEMP Manual index for the monthly calendar of managed care cutoff dates.

People who are found eligible for MA or GAMC will receive medical care through fee-for-service for any months before health plan enrollment. See §0914.05 (Fee-for-Service).

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HEALTH PLAN CHANGES 0914.03.07

MinnesotaCare:

Once enrolled in a health plan, households may change to a new plan:

• Once during the first year of enrollment. This is known as the first year change option. This option is available for 12 months beginning with the initial date of enrollment. The 12 months continues to run regardless of whether the household remains continuously enrolled in MinnesotaCare during that time. Apply the first year change option to households, not individuals. • Annually during open enrollment. MinnesotaCare enrollees receive open enrollment materials approximately 90 days before the due date for returning enrollment forms. If enrollees choose a different plan, enrollment in the new plan will begin on January 1 of the following year. • If they move to another county and the plan they are enrolled in is not available in the new county. MMIS will generate a new enrollment form and assign a new default plan.

If a household moves to another county and the plan they are enrolled in is available, they may choose a new plan within 60 days of the move date. However, MMIS will not automatically generate an enrollment form.

• A health plan terminates its contract with DHS. • The primary care provider is inaccessible. The DHS Managed Care Ombudsman decides inaccessibility on a case-by-case basis.

• Within the first 90 days of health plan enrollment. This change option will be available to households each time they are enrolled in a new health plan for 90 days or less. This change option is not available to enrollees of MinnesotaCare Limited Benefit Set.

• After a break in eligibility of more than two full calendar months. The household must request the change within 90 days of being re-enrolled.

When a household changes plans, the change is effective the first day of the next available month. For changes completed before capitation, the next available month after receipt of the new enrollment form is the month after capitation. For changes completed after capitation, the next available month is the second month after capitation.

EXAMPLE:

The Browns exercise their first year change option. They return their enrollment form for the plan they wish to select on August 10. All information is entered before capitation in August. The Browns will be enrolled in the new plan effective September 1.

EXAMPLE:

The Greens move to a new county where their health plan is not available. They return their enrollment form on August 26 after capitation. They will be enrolled in the new plan effective October 1. If MinnesotaCare has paid a capitation to their previous health plan for September, they must receive medical services through the previous health plan or make arrangements with their old health plan to receive services elsewhere.

M.S. 256L.12 subd. 3

Minnesota Rule 9506.0200 subp. 5

MA/GAMC:

At the time of the annual recertification, review each person's circumstances to determine whether or not the person should be excluded from managed care. See §0914.03.03 (Managed Care Exclusions). Track known future changes and process changes in exclusion status when you become aware of changes in circumstances.

If an excluded person is now a mandatory managed care enrollee, refer the person to a managed care presentation or assist the person in choosing a health plan. See §0914.03.05 (Managed Care Enrollment Process) and §0914.03.13 (Adding/Removing People From Managed Care). If a managed care enrollee is now in an excluded group, disenroll the person for the next available month on MMIS. See §0914.03.11 (Managed Care Disenrollment).

People enrolled in managed care may voluntarily change health plans at the following times:

• Once during the first year after of initial enrollment in managed care. The first day of enrollment is the initial effective date of health plan enrollment. The 12 months runs continuously from that date regardless of whether the enrollee remains eligible during that time. • During the annual open enrollment period. • When the client's health plan ends its contract with DHS. • Within 60 days of enrollment into a new health plan when the enrollment is a result of the contract termination of the previous health plan. • The enrollee is permitted to change health plans because of problems with access, service delivery, or other good cause. The following changes can be made without a hearing:
- An enrollee may change a primary care provider if travel time to the primary care provider is over 30 minutes from the enrollee's residence. - If the local agency incorrectly designated a health plan or primary physician or dentist.
• When transferring between counties, if the client requests a change within 60 days of the move date. See §0914.03.17 (Managed Care County Transfers). • After a break of more than two full calendar months in MA or GAMC eligibility. The enrollee must request the change within 90 days of being re-enrolled. See §0914.03.09 (Managed Care Re-Enrollments & Reinstatements). • When changing programs between MA, GAMC and MinnesotaCare. Follow these procedures for enrollment when there is a change in health care program:
- If the same health plan is available with the new program, MMIS will re-assign the enrollee to the same plan with the new product ID. - If the same health plan is not available for the new program, code RPPH with exclusion code YY (Delayed Decision) and an exclusion begin date. Code a closing date for the previous enrollment span. Begin tracking on the MMIS RTRK screen. Refer the client to a managed care presentation or mail the information. Medical services may be covered by fee-for-service until the client is enrolled in a new health plan.

If there is a change in basis of eligibility with no change in medical program, do not allow a change in health plan.

• Within the first 90 days of initial health plan enrollment. This change option will be available to enrollees each time they are enrolled in a new health plan for 90 days or less. For counties where the health plan is the only choice, the enrollee cannot disenroll but may change their primary care provider. This section does not apply to enrollees who are under a health plan administrative sanction.

Do not change the enrollment status or health plan of a recipient who is hospitalized in an acute care facility on the effective date of the change. Follow these procedures:

• Delay initial enrollment of a hospitalized enrollee into managed care until the 1st of the next available month after discharge.

EXCEPTION:

Enroll hospitalized MSHO enrollees for the 1st available month. The health plan is not responsible for hospital charges before the effective date of enrollment.

• Delay changing health plans for a hospitalized MA or GAMC managed care enrollee who is eligible to change until the first of the next available month after discharge. • Disenroll a hospitalized GAMC managed care enrollee who becomes excluded from managed care for the next available month.

If you discover after an enrollment change that a household member was in the hospital on the effective date, refer the case to your managed care unit or DHS for an adjustment. See §0914.03.15 (Managed Care Adjustments).

Document dates the person went into and out of the hospital and how you verified the dates in MMIS case notes. Explain the delay in changing the health plan or enrollment status in MMIS case notes.

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MANAGED CARE RE-ENROLLMENTS & REINSTATEMENTS 0914.03.09

MinnesotaCare:

Reinstatements are enrollments or re-enrollments completed between capitation and the last business day of the month. Reinstatements occur when:

• A renewal is completed after capitation. • A household is canceled from MinnesotaCare or disenrolled from a managed care plan and reinstated before the effective date of disenrollment.

EXAMPLE:

Bob calls on October 9 to request to have his MinnesotaCare canceled. He expects to have other insurance in November. On October 23 he calls to report that the other insurance is no longer available. He requests reinstatement. He mails his premium the same day and it is received on October 26. Bob is reinstated into his health plan for November.

When an initial enrollment is completed after capitation, it will be processed the same way as initial enrollments completed before capitation but will appear on the health plan's reinstatement record. See §0914.03.05 (Managed Care Enrollment Process).

Re-enrollments occur when a household is reopened on MinnesotaCare and re-enrolled in managed care after the effective date of cancellation. If the household has been terminated for 12 months or less, MMIS will re-enroll them in the same health plan unless they have moved to a county where the old plan is unavailable. If the case has been canceled for more than 12 months, MMIS will send a new health plan enrollment packet when the case is pended awaiting payment.

M.S. 256L.12

MA/GAMC:

Reinstatements for MA and GAMC occur when:

• An individual or household is reinstated between capitation and the last working day of the month. If you enter the GAMC or MA reinstatement on the MMIS RELG screen on or before the last working day of the month in which the case closed, the managed care enrollment will be active the 1st day of the next month. There will be no break in health plan coverage.

EXAMPLE:

Marcia’s annual recertification is due for October. She has not returned her recertification forms by the September cutoff date. MA is canceled. She submits a new application and all required verification on October 27. She remains eligible for MA and is reopened effective October 1. Reinstate MA with the same health plan effective November 1.

• An individual or household is reinstated after the effective date of closing with no break in MA or GAMC eligibility. If you enter the MA or GAMC reinstatement on the MMIS RELG screen after the last working day of the month in which the case was closed, reopen managed care the 1st day of the next available month. Create a new enrollment span on the MMIS RPPH screen with the new enrollment begin date and an exclusion span for the current month. Fee-for-service may cover medical needs during the interim month(s). See "MAXIS/MMIS CutOff Calendar" in the TEMP Manual index for managed care enrollment cutoff dates.

Follow MinnesotaCare for re-enrollments. Re-enroll MA and GAMC applicants who have been terminated from MA or GAMC with less than a 12 full calendar month break in eligibility in the same health plans they had before the termination. The effective date of the re-enrollment will be the next available month on MMIS. See "MAXIS/MMIS Calendar" in the TEMP Manual for enrollment cutoff dates. Also see §0914.03.07 (Health Plan Changes). Fee-for-service may cover the interim month(s).

EXAMPLE:

Louis is canceled from GAMC effective March 1 because he has excess income and is unable to meet a spenddown. He reapplies on April 10 because his income has dropped. He is found eligible without a spenddown effective April 1. Re-enroll Louis in his previous health plan. If the required information is entered on MMIS before the cutoff date in April, his managed care enrollment will be effective May 1. If the information is entered after April cutoff but before May cutoff, managed care enrollment will be effective June 1. He will be eligible on a fee-for-service basis for the month(s) before managed care enrollment.

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MANAGED CARE DISENROLLMENT 0914.03.11

MinnesotaCare:

MMIS will automatically disenroll people from a health plan when:

• They are canceled from MinnesotaCare. • They change health plans. MMIS will disenroll the household from the current plan to enroll in the new plan.

Disenroll people effective the first day of the first available month. If disenrollment is completed before capitation, the disenrollment will be effective the next month. If disenrollment is completed after capitation, disenrollment will be effective the 2nd month after the disenrollment is completed and the client will be responsible for any premium payments due for months for which a health plan capitation has been paid.

EXAMPLE:

John calls to request cancellation for himself and his son on June 26. Capitation for July was made on June 23. Inform John that his health plan has already been paid for the month of July and that MinnesotaCare cannot be closed until July 31. He will be responsible for his July premium.

See §0914.03.15 (Managed Care Adjustments) for information on retroactive disenrollment.

M.S. 256L.12

MA/GAMC:

Disenroll people from a health plan when:

• You receive information that an enrollee is now in an excluded group. See §0914.03.03 (Managed Care Exclusions). End the health plan enrollment span on MMIS for the last day of the month using reason code EX. Enter the appropriate exclusion code and an exclusion date span on the MMIS RPPH screen.

Disenroll people who are certified disabled by the Social Security Administration (SSA) or the State Medical Review Team (SMRT) if the person is under age 65 AND becomes eligible for MA with a disability basis. When you get confirmation of the disability certification from SSA or SMRT, enter an enrollment end date, disenrollment reason of EX, exclusion reason and exclusion begin date on RPPH. Enter the managed care end date on RPPH for the next available month.

People under age 65 who are certified disabled but who choose a non-disabled basis of eligibility may enroll in managed care voluntarily. See §0907.17.03 (MA Basis: Multiple Bases of Eligibility) and §0914.03.03.03 (Managed Care Voluntary Enrollment).

Disenroll people who are in the hospital when certified disabled effective for the next available month. The disenrollment may be delayed for an additional month if you cannot enter the information on MMIS on or before the managed care enrollment cutoff date.

• A person who should have been excluded was enrolled in a health plan in error. End the health plan enrollment span on MMIS for the last day of the month in which the error is discovered. If you discover the error before any capitation payments are made, delete the enrollment span on RPPH.

If capitation payments have been made and the enrollee appears to have issues with continuity of care, refer the case to your managed care unit or DHS for a possible adjustment for any retroactive months. The county managed care unit and DHS determine the need for an adjustment on a case-by-case basis.

• MA or GAMC eligibility ends. If you are closing MA or GAMC after the managed care enrollment cutoff date, close MA or GAMC and disenroll the individual or household from the health plan for the next available month on MMIS. In this case, the health plan will receive a capitation payment for a month in which there is no eligibility. The individual or household is ineligible for MA and GAMC even if the health plan has received a capitation payment.

Do not reinstate MA eligibility on MAXIS for the additional month for which a capitation payment was made unless the individual or household is reinstated effective the 1st of the month for which the additional payment was made. If the client requested closure and you cannot close MMIS because a capitation payment has already been made, notify the client that health plan coverage exists if all MA or GAMC eligibility factors are met.

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ADDING/REMOVING PEOPLE FROM MANAGED CARE 0914.03.13

MinnesotaCare:

Newborns born on or after 10/1/04, to a mother who was enrolled in a health plan at the time of birth will be retroactively enrolled in the same health plan back to the birth month, unless the newborn meets an exclusion (see §0914.03.03 Managed Care Exclusions).

If eligibility for the newborn is added within 90 days from the birth, the newborn should be retroactively enrolled in the health plan for the birth month and all succeeding months unless a health plan change is requested.

If the newborn is added to the case more than 90 days from the birth, an adjustment to pay the health plan for birth month ONLY must be requested. Add the newborn to the same health plan for the next available month based on managed care cut-off, unless a health plan change is requested. There will be a break in health plan enrollment, covered by fee-for-service, between the birth month and the next available month.

Disenroll people who are removed from coverage in an active household effective the first day of the next available month. If a capitation has already been made, coverage cannot be canceled until the next available month and the enrollee will be responsible for the premium payment. See §0914.03.11 (Managed Care Disenrollment).

Terminate coverage when an enrollee dies effective the date of death. See §0914.03.15 (Managed Care Adjustments). DHS identifies and recovers any capitation claims after the date of death.

Minnesota Rule 9506.0030 subp. 4

MA/GAMC:

Newborns born on or after 10/1/04, to a mother who was enrolled in a health plan at the time of birth will be retroactively enrolled in the same health plan back to the birth month, unless the newborn meets an exclusion (see §0914.03.03 Managed Care Exclusions).

If eligibility for the newborn is added within 90 days from the birth, the newborn should be retroactively enrolled in the health plan for the birth month and all succeeding months unless a health plan change is requested.

If the newborn is added to the case more than 90 days from the birth, an adjustment to pay the health plan for birth month ONLY must be requested. Add the newborn to the same health plan for the next available month based on managed care cut-off, unless a health plan change is requested. There will be a break in health plan enrollment, covered by fee-for-service, between the birth month and the next available month.

When adding a non-excluded person, enroll the person in the same health plan as the rest of the household. See §0914.03.05 (Managed Care Enrollment Process).

When adding a person to a household in which no other members are receiving MA or GAMC or are excluded from managed care, refer the applicant for a managed care presentation or provide a managed care education packet. When you approve eligibility, code the RENR screen with either an exclusion reason or a health plan contract number. If the person fails to choose a health plan within 30 days, MMIS will assign a default plan. Review RPPH to verify that the exclusion or enrollment is correct.

See MAXIS/MMIS Calendar in the TEMP Manual index for managed care enrollment cutoff dates. MA fee-for-service may cover medical services the client receives in the initial months before the enrollment effective date.

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MANAGED CARE ADJUSTMENTS 0914.03.15

MinnesotaCare:

An adjustment is either:

• Making a capitation payment to a health plan for a current or past month.

OR

• Recovering a capitation payment from a health plan.

Request adjustments in the following situations:

• When an enrollee is hospitalized on the effective date of a change in health plans. In this case DHS will recover the capitation payment made to the new plan and will make a retroactive capitation payment to the previous plan. • When necessary to maintain continuous coverage, continuity of care, or to resolve a service issue. Refer these requests to appropriate staff. Decisions are made on case-by-case basis.

Do not make an adjustment when there has been a systems, coding, or enrollment form error. The household's enrollment will be changed for the next available month.

M.S. 256L.12

MA/GAMC:

Request adjustments from the DHS managed care unit when:

• People are enrolled into health plans incorrectly and retroactive disenrollment would result in continuity of care issues. If there are no service issues, disenroll the person for the next available month. • People are disenrolled from health plans incorrectly. • People are hospitalized on the effective date of an enrollment change. • MA enrollees are incarcerated at the time of initial managed care enrollment.

NOTE: Incarcerated GAMC enrollees remain in the health plan.

If the change is for a future month and no erroneous capitation payment has been made, delete the incorrect span or change the incorrect information on the RPPH panel. See instructions for adding newborns under §0914.03.13 (Adding/Removing People From Managed Care).

A request does not guarantee an adjustment will be made. The DHS Managed Care unit reviews each request on a case-by-case basis based on federal and state law and health plan contract terms.

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MANAGED CARE ADJUSTMENTS 0914.03.17

MinnesotaCare:

Follow §0914.03.07 (Health Plan Changes) when MinnesotaCare enrollees move to another county.

MA/GAMC:

When managed care enrollees move between counties, the new county of residence determines whether health plan enrollment is mandatory. See §0906.07 (County Residence).

Remind enrollees that if they seek non-emergency services outside the health plan service area, the health plans may require providers to request authorization from the plan. Enrollees who do not follow health plan provisions may be responsible to pay for medical services received.

See TEMP Manual TE02.07.413 and TE02.07.414 (Managed Care Health Plans) for a list of plans available in each managed care county.

When an enrollee moves from a managed care to a non-managed care county, it is not necessary for the transferring county to update the RPPH screen. The MMIS system will close the enrollment span on RPPH at the next capitation. A worker in a non-managed care county may receive an edit on MMIS which prevents updates. If this occurs, update RPPH by entering an end date in the PPHP Managed Health Care Enrollment span for the next available month.

When an enrollee moves from a managed care county to another managed care county in which the enrollee's health plan is not available, it is not necessary to update RPPH before transferring the case on SPEC/XFER in MAXIS. MMIS will close the enrollment span on RPPH at the next capitation run. These clients will be reported on the county's Potential Enrollee Report. Refer the client to a managed care presentation or mail a managed care education packet as soon as possible. (In managed care counties, after receiving a transferred case, refer the recipient for a managed care presentation as soon as possible. Every effort should be made to avoid a gap in managed care coverage. If this is not possible, MA or GAMC fee-for-service will cover intervening months).

When an enrollee moves from a managed care county to another managed care county and the same health plan is available, continue enrollment in the same health plan at the time of the transfer. The enrollment span on RPPH remains open, and there will be one continuous span for both counties. The receiving (servicing) county does not have to make a referral for a managed care presentation.

If an enrollee requests a change in health plan when moving to another county, allow the change if the enrollee makes the request within 60 days of the move date. Refer clients requesting changes to a managed care presentation or mail a managed care education packet. The enrollee must complete and return a new enrollment form. See §0914.03.07 (Health Plan Changes).

When an MA or GAMC enrollee moves from a non-managed care county to a managed care county, refer the person for a managed care presentation as soon as possible. Follow the same procedures as for other new enrollees. See §0914.03.05.01 (Managed Care Enrollment Process--MA/GAMC) and §0914.03.05.03 (Managed Care Enrollment Presentations.

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MANAGED CARE COVERED SERVICES 0914.03.21

Health plans that have contracted with the DHS to provide services to MinnesotaCare, MA, or GAMC enrollees must provide most medical and dental services covered by those programs. Health plans are not responsible for case management services for people with serious and persistent mental illnesses or severe emotional disturbances.

See the Prepaid Minnesota Health Care Programs Manual, section 9.03.01 for a list of other non-covered services.

Health plans may provide services in addition to those available under MinnesotaCare, MA, or GAMC.

If an MA enrollee resides in a nursing facility on the effective date of enrollment in Minnesota Senior Health Options (MSHO), the nursing facility per diem is not a health plan covered service. If a person covered by MA enrolls in MSHO while living in the community and later enters a nursing facility, the health plan is responsible for payment of the nursing facility services for 180 days.

A person enrolled in a health plan must obtain all health care services through the health plan's network of providers unless:

• The enrollee receives services from a provider who is not a health plan provider because of a medical emergency. • The enrollee is outside the health plan service area and requires urgent or emergency medical care. • A health plan physician or provider has prescribed or recommended non-emergency services outside of the health plan network. • The enrollee moves out of the health plan service area, and MMIS has not been updated to disenroll the client from the health plan. Except for emergency services, the health plan may require prior authorization for out-of-plan services. Providers must contact the health plan to receive payment from the plan. Inform enrollees who report a move out of county that they may be responsible for bills incurred without health plan authorization. • An MA enrollee enrolls in a health plan while in her 3rd trimester of a high-risk pregnancy. The enrollee must contact the health plan to approve out-of-network services. There are no special provisions for pregnant PGAMC recipients. • A person enrolled in a health plan through MA resides in a long term care facility, and a health plan physician or dentist orders covered services from a non-plan provider. There are no special provisions for MinnesotaCare or GAMC recipients in long term care facilities. • A person who is enrolled in a health plan through GAMC who is certified disabled must be disenrolled for the next available month. The health plan will remain responsible for all GAMC covered services until the date of disenrollment. If the enrollee receives MA services not covered under GAMC, the provider rendering the MA service should bill DHS directly as fee-for-service.

When an enrollee obtains services outside the health plan provider network and does not meet 1 of the exceptions above, the provider may bill the enrollee directly. In such cases, the provider must notify the enrollee in writing before the service is delivered that payment may be required.

When required by contract, health plans provide common carrier transportation to their enrollees for the purpose of obtaining health care services.

The county is responsible for reimbursing the MA/GAMC enrollee for private automobile transportation to a non-emergency covered service, and meals and lodging as necessary, in accordance with the county's health care access plan.

Advise people who are enrolled in health plans through MinnesotaCare, MA, or GAMC who also have private coverage or Medicare that they must get medical services through the managed care health plans. The health plans are responsible for coordination of benefits for managed care enrollees. The enrollee must inform the MinnesotaCare representative or MA/GAMC financial worker of changes in coverage.

The cost effective coverage provisions for MA and GAMC enrollees described in §0910.05.03 (Health Insurance Premium Payment) apply to managed care clients. Enrollment in a managed care health plan is not a criterion used in determining cost effectiveness. Enrollees for whom the county pays cost effective health insurance premiums are excluded from managed care. See §0914.03.03 (Managed Care Exclusions).

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MANAGED CARE COMPLAINTS AND APPEALS 0914.03.23

MinnesotaCare:

MinnesotaCare enrollees may direct complaints to the health plan or to the DHS Managed Care Ombudsman at 651-296-1256 or 1-800-657-3729. They may file appeals directly with the DHS Appeals Office. See §0917 (Appeals).

Minnesota Rule 9506.0400 subp. 13

MA/GAMC:

Each managed care county has staff designated as advocates to help enrollees resolve problems with health plans. County advocates may be able to resolve problems with the plans or help enrollees file appeals. Health plans must give each enrollee a Certificate of Coverage. This certificate includes the health plan complaint and appeal procedures.

Managed care enrollees may appeal the following issues to the State Appeals Office. See §0917 (Appeals).

• Mandatory participation in MA managed care. Pending the appeal decision, the person must either select or be assigned a plan. There is no provision for appealing mandatory participation in MinnesotaCare or GAMC managed care. • Denial, reduction, or termination of services by the health plan. • Payment of bills for services already provided. • The health plan's resolution of a complaint. • Whether travel time to the primary care provider is considered excessive. In the Twin Cities metropolitan area, travel time over 30 minutes from the enrollee's residence is considered excessive. In the rest of the state, travel time is considered excessive by community standards. • Request to change health plans when travel time is less than 30 minutes, but the enrollee considers the travel time excessive. • The county entered the wrong health plan or primary care provider.

Enrollees may contact the DHS Managed Care Ombudsman at 651-431-2660 or 1-800-657-3729. Enrollees are not required to resolve complaints through the county advocates or health plan complaint processes before filing an appeal with DHS.

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MINNESOTA SENIOR HEALTH OPTION - MSHO 0914.03.25

MinnesotaCare:

No provisions.

MA:

Minnesota Senior Health Options (MSHO) is an integrated project to serve people who are age 65 and over and who are either eligible for both parts Medicare Part A and B or who do not have Medicare. MSHO integrates primary, acute, long term care, and prescription services for people who enroll in the option. Federal waivers allow DHS to purchase both Medicare and Medicaid (MA) services in the same contract and to serve people with both community and long term care spenddowns in the demonstration. MSHO enrollment is voluntary.

People who are eligible for MA may enroll in MSHO if they:

• Are age 65 or over.

AND

• Are eligible for Medicare Part A and Part B or who do not have Medicare.

AND

• Live in a participating MSHO county. Effective 01/01/06, those counties not participating in MSHO are Beltrami, Clearwater, Hubbard, and Lake of the Woods.

AND

• Are eligible for MA without a medical spenddown. Effective 06/01/05, applicants with a medical spenddown are not eligible to enroll in MSHO.
Note:
Current enrollees in MSHO that gain a medical spenddown or combined LTC/medical spenddown following MSHO enrollment are allowed to remain enrolled in MSHO. Their medical spenddown will be paid to DHS.

OR

• Are eligible for SIS EW with a waiver obligation (those with incomes over the maintenance needs allowance). SIS EW enrollees with waiver obligations must pay their monthly waiver obligation OR the amount of the waiver services received, whichever is less, to the health plan. If the enrollee is moving from a medical spenddown to a waiver obligation, be sure to update MMIS to reflect the waiver obligation prior to submitting the MSHO enrollment form. Do not add designated providers for waiver and medical spenddown types I MMIS for people enrolled in MSHO. See MMIS User Manual, County-Administered Programs, Spenddowns for more information.
Exception: People in hospice should be coded with the hospice provider as the designated provider.

For further information, refer to DHS Bulletin 03-21-02 Minnesota Senior Health Options Serves Seniors.

GAMC:

No provisions

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MINNESOTA DISABILITY HEALTH OPTIONS (MNDHO) 0914.03.27

MinnesotaCare:

No provisions.

MA:

Minnesota Disability Health Options (MnDHO) is a health care program available to some people with physical disabilities. MnDHO provides the same benefit set (acute care, nursing home, home and community-based services, etc.) as regular MA as well as flexible alternative services beyond the scope of MA and waiver services. DHS contracts with UCare Minnesota to provide these services through their UCare Complete product. AXIS Healthcare coordinates these services for MnDHO enrollees. MA enrollees who are also enrolled in Medicare will receive both MA and Medicare services through MnDHO.

To be eligible for MnDHO, people must:

• Have a physical disability

AND

• Be at least age 18 and under age 65

AND

• Live in a county participating in MnDHO. These counties are Anoka, Dakota, Hennepin and Ramsey.

AND

• Be enrolled in MA (including MA-EPD). People with spenddowns may enroll but must pay their monthly spenddowns to MnDHO.

People who receive home and community-based services through Community Alternatives for Disabled Individuals (CADI) waiver or the Traumatic Brain Injury (TBI) waivers are eligible to enroll in MnDHO . CADI and TBI participants who choose to enroll in MnDHO will still get the waiver services but will receive case management services from a health coordinator at AXIS Healthcare instead of a county case manager.

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MINNESOTA SENIORCARE and SENIORCARE PLUS 0914.03.29

MinnesotaCare:

No provisions.

MA:

People age 65 and older who are currently enrolled in the Prepaid Medical Assistance Program (PMAP) will remain enrolled in their same health plan with the same basic care services. Minnesota SeniorCare will replace PMAP for people age 65 and older.

Minnesota SeniorCare Plus is in the 20 County Based Purchasing (CBP) counties. The counties are: Big Stone, Brown, Dodge, Douglas, Freeborn, Goodhue, Grant, Itasca, Kanabec, McLeod, Meeker, Pipestone, Pope, Renville, Sibley, Steele, Stevens, Traverse, Wabasha and Waseca.

People age 65 and older in these counties will continue to receive the same basic care services. However, home and community based services delivered through the Elderly Waiver (EW) and longer nursing home stays (180 days) will be covered by the health plan. Minnesota SeniorCare Plus also incorporates new requirements of providers including health screenings, care management and quality assurance activities. Enrollees should contact their health plan with questions about the changes or to request services.

GAMC:

No provisions.

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FEE-FOR-SERVICE 0914.05

People obtain medical care through fee-for-service by presenting their Minnesota Health Care Programs Card to the provider. See §0914.07 (Minnesota Health Care Programs Card). DHS pays claims directly to the provider. Enrollees receive an Explanation of Medical Benefits (EOMB) each month showing what claims DHS has paid on their behalf.

To receive payment through fee-for-service, providers must be enrolled to receive payment from the Minnesota health care programs. Refer providers who request information about enrollment to the DHS Provider Help Desk at 651-431-2670 or 1-800-366-5411. The service must be covered by the program in which the person is enrolled. Providers receive detailed information about covered services in the Minnesota Health Care Programs Provider Manual. Information is also available through the Eligibility Verification System (EVS) or the Provider Help Desk.

MinnesotaCare:

DHS provides medical care to MinnesotaCare enrollees on a fee-for-service basis in the following instances:

• When adding a newborn or newly adopted child whose mother is not enrolled in a health plan. The child is covered on fee-for-service for the month of birth or adoption and any subsequent months pending health plan enrollment.

EXAMPLE:

Julie has 2 children enrolled in MinnesotaCare. She is not enrolled in MinnesotaCare. On October 2, she reports she had a baby on September 25. Enroll the baby in MinnesotaCare fee-for-service for September and October. Enroll the baby in the same health plan as the other children beginning in November.

• When an enrollee requests continued benefits pending the outcome of an appeal after cancellation. Re-enroll the person in the health plan for the next available month.

EXAMPLE:

Joan' s MinnesotaCare is canceled effective March 1. On March 3 she appeals the action and requests continued benefits. No payment was made to the health plan for March because her coverage had been terminated before capitation. If Joan pays her premium, reinstate coverage on fee-for-service for March. Re-enroll Joan in the health plan for April if the appeal is still pending.

• When a case is reopened after the reinstatement date if the enrollee took all required action before the effective date of termination. Reopen the case on fee-for-service for the first month. Re-enroll the household in the health plan beginning the second month.

EXAMPLE:

Andrew received a termination notice for October for failing to provide information. MinnesotaCare received the necessary information at the end of the month and determined that Andrew remains eligible. However, MinnesotaCare was not able to process the change before reinstatement ran on the last working day of September. Reopen the case on fee-for-service for October. Re-enroll Andrew in his health plan beginning in November.

• When enrollees canceled for nonpayment pay all billed premiums by the due date in the month following disenrollment and are reinstated back to the date of closing. These enrollees receive coverage through fee-for-service for the reinstatement month. They are reenrolled in their former health plans for the following month. See §0915.11.05 (Fail to Pay Premium/Reinstatement).

M.S. 256L.12

MA/GAMC:

DHS provides medical care to MA and GAMC enrollees on a fee-for-service basis for:

• People who do not live in managed care counties. See §0914 (Service Delivery) for a list of managed care counties as of September 2003. • People who live in managed care counties but are in excluded groups, and: • Are not in a group that may voluntarily enroll in managed care.

OR

• Are in a group that may voluntarily enroll in managed care but choose not to enroll. See §0914.03.03 (Managed Care Exclusions) and §0914.03.03.03 (Managed Care Voluntary Enrollment). • People who live in managed care counties and are required to enroll in managed care but who are not enrolled for a particular month because enrollment could not be completed in time for a capitation payment to be made for that month. Examples include: • People who are approved for MA or GAMC for any months before the first month they can be enrolled in managed care. See §0914.03.05 (Managed Care Enrollment Process) and §0914.03.05.03 (Managed Care Enrollment Presentations).

EXAMPLE:

Sheila applies for MA on November 12. She requests coverage retroactive to August. She attends a managed care presentation on November 15 and selects a health plan on December 7. MA is approved effective August 1. Sheila will be covered through fee-for-service for August through December. Enroll Sheila in the health plan she selects effective January 1.

• People who move from a managed care county to a non-managed care county. These people may continue to receive coverage through fee-for-service for one or more months after the move. See §0914.03.17 (Managed Care County Transfers). • People who were in an excluded group who become mandatory managed care enrollees. These people will continue to receive coverage through fee-for-service until the 1st available month they can be enrolled in managed care.

EXAMPLE:

Doug, age 20, lives in a managed care county. He is eligible for MA with a spenddown and is excluded from managed care. He submits his 6-month income report, due on March 8, on March 20. The worker determines that he no longer has a spenddown and he is required to enroll in managed care. Doug will continue to receive coverage through fee-for-service until he can attend a managed care presentation or receive an education packet and be enrolled in a health plan.

• People who are reinstated or re-enrolled after being terminated from MA or GAMC and disenrolled from their health plans. These people may be eligible under fee-for-service for the any month(s) in which they are eligible for MA or GAMC but have not been reinstated or re-enrolled in a health plan. See §0914.03.09 (Managed Care Re-Enrollments & Reinstatements). • Certain people, including newborns, who are added to a managed care household for one or more months before they can be enrolled in managed care. See §0914.03.13 (Adding/Removing People From Managed Care).

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MINNESOTA HEALTH CARE PROGRAMS CARD 0914.07

DHS issues a Minnesota Health Care Programs Card for each eligible person in the household. The card does not specify the program of coverage and does not verify eligibility. The card gives information the medical service provider needs to call the Eligibility Verification System (EVS) to verify eligibility dates. EVS also provides health plan enrollment information for managed care enrollees. For ID cards issued before January 2003, the front of the ID card has the metro and 1-800 telephone numbers for provider access into EVS. The back of the ID card has the metro and out-state telephone numbers for enrollees to call with questions about medical services they have received. For ID cards issued after January 2003, the front of the ID card has the metro and out-state telephone numbers for enrollees to call with questions about medical services they have received. The back of the ID card has the metro and 1-800 telephone numbers for provider access into EVS.

MMIS generates a Minnesota Health Care Programs Card. See MMIS User Manual (Health Care Identification Cards). If enrollees need medical services before they receive their cards, providers can use the PMI number for each approved person to verify eligibility through EVS. The PMI numbers are shown on initial notices. Also provide PMI numbers to enrollees over the phone on request.

Issue replacement identification cards at no charge to the enrollee for:

• Lost, destroyed, damaged, or stolen cards.

OR

• Corrections to name, gender, or date of birth.

There is no limit on the number of replacements.

Managed care enrollees receive both a Minnesota Health Care Programs Membership Card and an identification card from the health plan. Medical providers use the Minnesota Health Care Programs Cards to access EVS medical eligibility information.

Enrollees must present the Minnesota Health Care Programs Card along with other health care coverage information to all health care providers. Clients must be eligible during the time of services for the provider to be paid. Providers should contact EVS or the provider help desk to verify medical eligibility. You may verify the PMI number and eligibility dates without the client's written consent.

DHS may restrict clients' use of the medical identification card to certain providers of health care services for the following reasons:

• To prevent duplication or abuse of services. • To prevent violation of prior authorization requirements. • To ensure continuity of care.

Because managed care enrollees' choice of providers is limited to providers enrolled in the health plan, DHS does not restrict cards for people enrolled in managed care. The health plan is responsible for prior authorization, monitoring use of medical services, and ensuring continuity of care.

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LIENS AND ESTATE CLAIMS 0914.09

MinnesotaCare:

No provisions.

MA:

The county agency may file an estate claim with a court of appropriate jurisdiction if the estate is opened, regardless of the estate’s value, when a person who received MA, QMB, SLMB, or QI after turning age 55 dies. If there is a surviving spouse, the county agency may file the claim after the surviving spouse dies.

People who received MA, QMB, SLMB or QI after age 55 are always subject to estate recovery. They are NOT automatically subject to a lien on their real property. See §0914.09.03 (Liens).

The maximum amount of an estate claim is:

• The total amount of MA, QMB, SLMB and QI paid, without interest, for a person who received MA after turning age 55, regardless of whether the person received hospital or long term care services. The age for estate recovery was lowered from age 65 to age 55 on July 1, 1995. For people who were between ages 55 and 64 on July 1, 1995, the estate claim recovery is limited to MA/QMB/SLMB/QI services received on or after July 1, 1995. • The total amount of MA, QMB, SLMB and QI paid, without interest, during institutionalization for a person who resided permanently in an LTCF or hospital before age 55, OR who resided in an LTCF or institution for 6 months or less before age 55 without reasonable expectation of discharge to the home. People in this category may be subject to real property liens as well as estate claims. See §0914.09.03 (Liens).

Do not file estate claims against MinnesotaCare or Prescription Drug program expenses, even if the person also received MA, QMB, SLMB or QI.

EXAMPLE:

Myrtle received QMB and Prescription Drug for 2 years until her death. Do not include any expenses paid by the Prescription Drug program in the estate claim.

Do not file a claim against the estate of a person who received MA while there is a surviving spouse, or if there is a surviving child who is under age 21, blind, or totally disabled.

Limit the claim against the estate of a surviving spouse who did not receive MA to the value of the assets of the estate that were marital property or jointly owned property at any time during the marriage.

Limit the claim to the value of non-homestead property if one or more of the following people survives the client. Do not include the value of the homestead.

• A child or grandchild who resided in the home, provided care which permitted the client to live at home for at least 2 years immediately before the client's LTCF admission, and has resided in the homestead continuously since the date of the deceased client's institutionalization.

OR

• A sibling who resided in the homestead at least one year before the client's institutionalization and continuously since the date of the deceased client's institutionalization.

Counties may use an Affidavit of Collection of Personal Property instead of filing an estate claim if all of the following conditions are met:

• The person has been dead for at least 30 days. • The estate has not been opened. • The assets consist entirely of personal property. • The value of the estate, less liens and encumbrances, is $20,000 or less.

Serve the affidavit on the financial institution, person, or other entity holding the client's money or property. This includes the contents of safe deposit boxes. For funds held in a joint or pay on death account, the affidavit must contain the amount of the county's claim and a good faith estimate of the extent to which the deceased enrollee was a contributor or beneficiary of the funds in the account. The institution or other entity receiving the affidavit is only obligated to turn over the deceased person's money or other property still in its possession when the affidavit is served. The institution is not obligated to turn over funds or property that have already been distributed to the joint owner or payable on death beneficiary.

DHS must file a lien against the homestead or other real property of a person who receives MA while residing in a long term care facility, intermediate care facility for the mentally retarded, or as an inpatient in a hospital unless the property is otherwise exempt. DHS cannot file a lien against real property under the following conditions:

• It is the homestead of the person's spouse. • It was the person's homestead at the time the person entered the facility and any of the following people now live in the property:
• The person's child who is under age 21 OR who is blind or disabled. Use the MA definition of disability. See §0906.15 (Disability Determinations). • The person's child of any age who lived in the home for at least 2 years before the person began receiving institutional care and who provided care that allowed the person to remain in the community, and the child has lived in the home continuously since the person entered the institution. • The person's sibling who has an equity interest in the homestead and who resided in the home for at least 1 year before the person began receiving institutional care, and the sibling has lived in the home continuously since the person entered the institution.

If the homestead or other real property does not meet one of the exemptions and the person is expected to remain in institutional care for 180 days or more, send a Medical Assistance Lien Worksheet to DHS immediately.

GAMC:

When a person who received GAMC, or the surviving spouse who also received GAMC dies, the county agency may file an estate claim with a court of appropriate jurisdiction. The amount of the claim is the total amount of GAMC paid without interest. Do not file a claim while there is a surviving spouse, or if there is a surviving child who is under age 21, or blind, or totally disabled.

Limit the claim against the estate of a surviving spouse who did not receive GAMC to the value of the assets of the estate that were marital property or jointly owned property at any time during the marriage.

The county may use an Affidavit of Collection of Personal Property instead of filing an estate claim under the same conditions as for MA.

DHS may not file a lien against the homestead of a person who received only GAMC.

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LIENS 0914.09.03

MinnesotaCare:

No provisions.

MA:

DHS must file a lien against the homestead or other real property of a person of any age who receives MA while residing in a long term care facility, intermediate care facility for the mentally retarded, or as an inpatient in a hospital unless the property is otherwise exempt. This process is separate from estate recovery. See §0914.09 (Estate Claims). People who receive MA,QMB, SLMB or QI but did not reside in an LTCF, ICF-MR or inpatient hospital are NOT subject to a lien against their real property.

DHS cannot file a lien against real property under the following conditions:

• It is the homestead of the person’s spouse. • It was the person’s homestead at the time the person entered the facility and any of the following people now live in the property:
• The person’s child who is under age 21 OR who is blind or disabled. Use the MA definition of disability. See §0906.15 (Disability Determinations). • The person’s child of any age who lived in the home for at least 2 years before the person began receiving institutional care and who provided care that allowed the person to remain in the community, and the child has lived in the home continuously since the person entered the institution. • The person’s sibling who has an equity interest in the homestead and who resided in the home for at least 1 year before the person began receiving institutional care, and the sibling has lived in the home continuously since the person entered the institution.

If the homestead or other real property does not meet one of the exemptions and the person is expected to remain in institutional care for 180 days or more, send a Medical Assistance Lien Worksheet to DHS immediately, even if the homestead is excluded for MA eligibility for the first 6 months of LTC residence. This exclusion does not apply to MA liens.

GAMC:

No provisions. DHS may not file a lien against the homestead of a person who received only GAMC.

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ACCESS SERVICES 0914.11

Access services are transportation and other enabling services to help enrollees obtain medically necessary health care. County agencies and MinnesotaCare Operations must provide access services to enrollees who are eligible for access services and who do not receive the service through a health plan.

Access services plans must cover reimbursement for the following items:

• Costs of transportation to receive medical services. Enrollees must use the most cost-effective available means of transportation. Reimbursable costs include:
• Mileage reimbursement for vehicle use of 20 cents per mile to enrollees who transport themselves. • Mileage reimbursement at the current IRS rate to volunteer drivers registered with the county who use their vehicles to transport enrollees. Effective January 1, 2005 the IRS rate is 40.5 cents per mile. The rate for 2004 was 37.5 cents per mile. • Access plans must specify whether people other than registered volunteers who transport enrollees, such as friends or relatives, receive 20 cents or the current IRS rate per mile. • Actual cost of parking. • Actual cost of taxicab, bus or other commercial carrier when this is the most cost-effective means available. • Ambulance transportation from a non-enrolled provider when the ambulance is medically necessary. If the ambulance provider is enrolled in the Minnesota Health Care Programs, the provider will bill DHS directly for the services.

Access plans must specify whether reimbursement is available for no-load transportation. No-load transportation means mileage incurred when the enrollee is not in the vehicle, such as the distance traveled to pick up enrollees.

Do not allow the following transportation costs in access plans:

• Special transportation. Special transportation providers are enrolled in Minnesota Health Care Programs. DHS will reimburse the providers directly unless the cost is included in a per diem payment to an ICF-MR facility. • Transportation to a health care site for detention ordered by a court or law enforcement agency unless an ambulance is medically necessary. • Transportation to an alcohol detoxification facility unless detoxification is medically necessary. • Additional charges for luggage, stair carry of the enrollee, airport surcharge or other airport, bus or railroad terminal services. • Federal or state sales or excise taxes on ambulance service. • Transportation to services that are not covered under Minnesota Health Care Programs. The service does not have to be billed to DHS or obtained from an enrolled provider. However, both the service and the provider must be eligible for enrollment and coverage under Minnesota Health Care Programs. Consult the Provider Manual on the DHS Web Site or the Provider Help Desk at 1-651-431-2700 or 1-800-366-5411 for more information on services allowed and provider enrollment under Minnesota Health Care Programs.

EXAMPLE:

Jordan is enrolled in MA and receives psychotherapy at the VA hospital. The service is not billed to MA because the VA has separate funding. The psychotherapist and the service provided meet the requirements for enrollment and reimbursement in Minnesota Health Care Programs. Jordan’s transportation costs are eligible for reimbursement if they meet the requirements of the local agency’s access plan.

• Lodging if necessary for the enrollee to obtain services outside the local area. The local agency must prior authorize charges over $50 per night. • Meals if necessary to obtain services. Maximum reimbursement amounts are

Breakfast- $5.50

Lunch- $6.50

Dinner- $8.00

• Transportation, meals and lodging for people required to accompany the enrollee to obtain services or whose involvement in a treatment program is part of the enrollee’s written treatment plan. • Interpreter services for hearing impaired people to obtain services at the local agency or from a provider with fewer than 15 employees. Providers with at least 15 employees and prepaid health plans must provide these services. Required services include sign language interpreters, oral or lip-reading interpreters, and interpreters for people who are deaf/blind.

Access plans must require receipts for commercial carrier transportation, meals, parking (other than parking meters) and lodging.

Access plans must require prior authorization for:

• Lodging and meal expenses for people accompanying the enrollee. • Transportation and related expenses outside the local trade area, as defined by the local agency. Access plans may require prior authorization within the local trade area at county option. • Transportation if the local agency determines the enrollee has misused transportation in the past.

Access plans may not require prior authorization for emergency services.

MinnesotaCare:

Pregnant women and children under age 21 are entitled to receive access services. MinnesotaCare enrollees who are eligible for access services and who receive case services at MinnesotaCare county enrollment sites receive access services under the county agency’s access plan. MinnesotaCare enrollees who are eligible for access services and who receive case services at MinnesotaCare Operations receive access services through MinnesotaCare Operations’ access plan.

Follow your agency’s access plan when enrollees request access services. Explain prior authorization requirements, limitations on services and billing procedures. Provide written information on your agency’s access plan to people eligible for access services.

MA and GAMC:

All MA and GAMC enrollees are eligible for access services. People enrolled in managed care plans may receive some services through the health plan and other services through the county agency’s access plan. In general, health plans must provide their members with:

• Sign language and foreign language interpreters if needed to receive medical services. • Reimbursement for transportation and child care if needed for a state appeal hearing related to the health plan’s denial, reduction or termination of a health service. • Common carrier transportation to receive medical services.

Health plans are not required to provide:

• Reimbursement to enrollees for personal mileage or parking unrelated to an appeal. • Lodging, meals or out-of-state airfare related to obtaining medical services.

County agencies are responsible for services in their access plans that are not covered by the health plans.

Follow your agency’s access plan when enrollees request access services. Explain prior authorization requirements, limitations on services and billing procedures. County agencies must provide written information on their access plans to all enrollees.

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OUT OF STATE SERVICES 0914.13

Minnesota Health Care Programs will pay out-of-state medical providers for medical services rendered to Minnesota Health Care Programs enrollees who:

• Are temporarily absent from the state and who receive services due to a medical emergency or receive needed services and their health would be endangered if they traveled to Minnesota to receive services.

See §0908.13 (Temporary Absence--MinnesotaCare-Part 1), §0908.13.01 (Temporary Absence--MinnesotaCare-Part 2) and §0908.13.03 (Temporary Absence--MA/GAMC).

• Remain Minnesota’s responsibility while living in another state. This includes:
• Non-IV-E foster children placed in other states under the Interstate Compact. • Non-IV-E adoption assistance children who move to a state that does not exercise the federal option to accept responsibility for non-IV-E adoption assistance children from other states. • Residents of North Dakota nursing homes covered under the Interstate Agreement. • Other enrollees placed in another state by agents of the state of Minnesota.

See §0906.05 (State Residence).

Instruct managed care enrollees who report temporary absences to contact their health plans for information on receiving out-of-state services. The health plan may require prior authorization for non-emergency services and may have special provisions for payment of emergency services.

Providers who treat fee-for-service Minnesota Health Care Programs enrollees must enroll as Minnesota Health Care Programs providers to receive payment. Providers may enroll retroactive to the date on which they provided services to a Minnesota Health Care Programs enrollee. Provider enrollment forms are available on the internet at www.dhs.state.mn.us. Providers may also call the DHS Provider Enrollment Unit at (651) 431-2700 or 1-800-366-5411.

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