***This version of the Health Care Programs Manual has been replaced and is no longer in effect.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 0915 - Changes in Circumstances
All chapters are numbered beginning with 09. The first chapter is 0901 (Table of Contents).
PDF(s): Oct 03
PDF(s): Jul 98
PDF(s): Jul 98
PDF(s): Dec 02
PDF(s): Oct 02
Most changes will be reported by enrollees. Enrollees must report required changes within 10 days after the date of the change. They may report by phone, mail, in person, or on a required scheduled reporting form. Clients must report the following changes for all health care programs:
You may also become aware of changes through other sources, such as:
When you become aware of a change in circumstances, take the following steps:
1. Determine if you need more information. If yes, request the information. See the program specific sections of this chapter for what information to request.
2. Determine if the change affects eligibility for any household member. If eligibility continues, determine if the change affects spenddown or premium amount.
3. Determine what action program rules require as a result of the change. Most changes require you to take action as soon as possible after learning of a change. However, some changes will not affect the case immediately, such as changes in income that result in an increase in the MinnesotaCare premium. See the program specific sections of this chapter.
4. Apply the change according to program rules. If no action is taken, document the circumstances in the case record. Track the change if it will require action in the future.
Some types of changes are covered in detail in other chapters of this manual.
For changes in county of residence for MA and GAMC, see §0906.07 (County Residence).
For changes in certification periods and spenddowns, see §0913.19 (Shortened Spenddown).
For changes when people enter long term care or begin receiving Elderly Waiver (EW) services, see §0913.17 (Begin/End Use of LTC Spenddown - Part 1), §0913.17.01 (Begin/End Use of LTC Spenddown - Part 2), and §0913.17.03 (Begin/End Use of LTC Spenddown - Part 3).
In addition to the changes listed in the general provisions, MinnesotaCare enrollees must report the following changes no later than the next scheduled renewal:
See §0915.07 (Change in Income) for information on income changes reported between renewals.
If you determine that eligibility was determined erroneously on an active case, correct the error for the first available month with 10-day notice, regardless of the type of error. This includes changes that result in increased premiums. Do not wait until the next renewal. Do not allow an additional 12 months of coverage for children under 21 that should have been denied for excess income. See §0912.03.03 (MinnesotaCare Excess Income).
If the correction results in increased eligibility, such as a lower premium, eligibility on a denied case, or eligibility for additional household member(s), correct the error back to the month of the last renewal or application or the time the error occurred, whichever is most recent.
In addition to the changes listed in the general provisions, MA/GAMC enrollees must report the following changes within 10 days or by the due date of the next scheduled income report or renewal, whichever is earlier:
When a new person moves into the household, the new person MUST be added to the MinnesotaCare household at the next renewal. The household may choose to add the new member prior to the next renewal. If the household chooses not to add the new person until the next renewal, document in case notes. Do not add the person to the household size and do not include their income until the next renewal.
Julie, age 16 lives with her parents. She reports that she got married and her new husband, Brad, moved in with her and her parents. Julie is now an emancipated minor and should be closed on her parents’ case and opened on a new MinnesotaCare case with Brad. Julie may choose to either:
Marge reports that her boyfriend, Fred, moved in with her and her daughter Crystal. Fred is Crystal's father. He must be included in the household because of his parental bond with Crystal. He does not want coverage for himself. Marge may choose to add him to her MinnesotaCare case now or wait until her next renewal. At the point that he is added to the case, he must enroll in MinnesotaCare if he is eligible and does not have other heath care coverage. If he is otherwise eligible and refuses coverage, cancel Marge's coverage.
Take the following steps at the time you add the new household member. If the household chooses to wait until the next renewal to add the new member, DO NOT take any of these steps until you process the renewal.
1. Determine if the new household member must be counted in the MinnesotaCare household. See §0908 (Household Composition). Contact the household if you need more information on the person’s relationship to other household members.
2. If the new person will be counted in the MinnesotaCare household, determine if the new member is requesting coverage. If not, determine if the new member must accept coverage, if eligible, in order for other household members to remain covered. See §0908.11 (All or Nothing Rule).
3. Request all information needed to add the new person to the MinnesotaCare household and determine the new household member’s eligibility, including:
The household must provide all required information before the new member can be added.
If a new household member is not being added for coverage but is part of the household size, determine if the new household size results in a decreased premium. If yes, the new premium amount is effective the month the person is added to the household size. If there is no change in income, request an adjustment for any future months for which the higher premium has already been billed. If there is a change in income, MMIS will automatically adjust the premiums.
4. Determine the new household member's group status based on current circumstances. See §0907 (Eligibility Groups and Bases of Eligibility) and §0915.15 (Change in MinnesotaCare Eligibility Group). Determine if the person is eligible for coverage.
5. Enter all information on MMIS to add the person and the person's income to the household size and to add the person to coverage, if applicable. Enroll the person being added in the same health plan as the rest of the household. See §0912.03.03 (MinnesotaCare Excess Income) if the new member's income causes the household's total income to exceed the MinnesotaCare standard.
6. Infants born to a woman enrolled in MinnesotaCare for the month of delivery are automatically eligible beginning the 1st day of the month of birth. See §0907.09.03 (MinnesotaCare Auto Newborns). Infants born to a woman who is not enrolled in MinnesotaCare for the month of delivery are not automatically eligible. If other family members are enrolled and the newborn is eligible, eligibility begins the first day of the month of birth.
Eric is born on January 5. His mother is not enrolled in MinnesotaCare but two siblings are active. Eric is not eligible as an auto newborn. If he meets eligibility requirements, he is eligible beginning January 1, the first day of the month of birth. He will receive fee for service coverage for January.
Children placed in the home of an enrolled family for adoption are eligible to be added the first day of the adoption placement month.
For all other people being added to the household size, the effective date of coverage is the first day of the month following the determination of eligibility for the new household member.
M.S. 256L.04 subd. 1b
See §0915.03.01 (Adding a Person to the Household--MA/GAMC).
See §0915.03 (Adding a Person to the Household).
See §0907.19.05.03 (MA Basis: Auto Newborn) for instructions on adding children born to women receiving or eligible for MA.
Take the following steps when you become aware of new household members other than auto newborns:
1. If the new household member is requesting MA or GAMC, request all information needed to determine the new household member’s eligibility, such as SSN, assets if applicable, income, and information on other health coverage. Do not require an application or addendum.
Require an application if the only active household member is an auto newborn and there is no application or renewal on file in the previous 12 months. See §0904.05.03 (When to Require an Application).
If the new household member is not requesting MA or GAMC, determine if the new member's income and/or assets must
be deemed to members of the existing household. If so, request a Household Report Form (DHS 2120) and verification of
the new member's income, assets if applicable, and any other health coverage the new member has that covers any
members of the existing household.
2. Determine the new member's effect on the household size and basis of eligibility. See §0908.05 (Determining MA/GAMC Household Size), §0908.07 (Household Composition: Deeming), and §0907.17 (MA/GAMC Bases of Eligibility).
3. Determine the new member's eligibility and the effect of adding the new member on eligibility, certification period, and spenddown for the existing household members. People who move into an existing household are eligible to be added effective the first full month that they live with the existing household. If the new member is not requesting MA or GAMC, begin deeming the new member's income effective the first full month they live with the existing household.
If the new member requests coverage for the month of entry into the household or any retroactive months, determine eligibility for those months separately.
If the new member was included in the household size but did not request MA or GAMC when the rest of the household was approved, the new member may be added for the first full month or up to 3 months retroactive for MA or the date that he/she requests GAMC. The new member is subject to the same spenddown type as the rest of the household. See §0913.05 (Which Spenddown Type to Use) and §0913.19 (Shortened Spenddown).
See §0913.19 (Shortened Spenddown) for instructions and examples covering when to interrupt the certification period and recompute the spenddown when adding a household member.
4. Determine if the new member must be enrolled or disenrolled from a health plan. See §0914.03.13 (Adding/Removing People From Managed Care).
There are several circumstances when one or more household members must be removed from an existing case, including:
When a household reports a change that requires one or more members to be removed from the household, take the following steps:
1. Ask whether the household member being removed wishes to be considered for eligibility on a separate case. Send a HCAPP for the household member being removed to complete and request any information needed to determine eligibility for the new case.
When people move out of a MinnesotaCare household, attempt to contact them to find out if they want continued coverage. Remove them from the existing case effective the end of the month following the month in which the change is reported regardless of whether they respond to attempts to contact them. Do not open a separate case unless the person who left completes a HCAPP and is determined eligible for coverage as a separate household.
Julie, age 16, is enrolled in MinnesotaCare with her parents. She reports that she got married and her husband Brad moved in with her and her parents. She would like to continue MinnesotaCare coverage. Because Julie is an emancipated minor, she must have her own case. She may choose to add Brad and apply on her own case now or wait until the next scheduled renewal for her parents' case. Brad is required to be a member of her household no later than the next renewal and to be covered if he is eligible. If Julie chooses to add Brad before her parents' next renewal, send a HCAPP for Brad and Julie to complete and sign. Determine Brad's eligibility. Set up a separate case for Julie and include Brad if he is eligible for coverage. Remove Julie from her parents' case effective the end of the month following the month in which the change is reported, or the month of renewal if Julie chooses not to add Brad until renewal.
Marianne reports that her husband, Jerome, has moved out of the household. She would like continued coverage for herself and her children. If Marianne is able to supply a new address and/or phone number for Jerome, contact him to ask if he would like continued MinnesotaCare coverage for himself. Also ask him to send a written request to be removed from Marianne's case. If he responds and requests coverage, send him a HCAPP to complete and request all information needed to determine eligibility for Jerome as a separate case. Remove him from Marianne's household effective the end of the month after the month in which the change is reported.
2. If people being removed from an existing case are eligible as a separate case, establish a new case. The effective date of coverage for the new case is the first day after the month in which the initial premium payment is received. Deny coverage for people being removed who submit a HCAPP but are not eligible.
3. Remove people who are no longer eligible to be included on an existing case effective the end of the month after the month in which the change is reported. Review income, major program and group status for the remaining members of the original case. Enter the new income and household size information on MMIS. If the removal of a person results I the loss of parental status for anyone in the existing case, change them to the appropriate non-parent major program (BB) and group status of 3 for the next available month with 10-day notice. If removing a person results in a decreased premium, MMIS will rebill. Do not request manual adjustments.
If the existing household requests to have the person removed before the end of the month following the month in which the change is reported, require a written request from the person being removed. To receive a premium refund, people who wish to end their MinnesotaCare at the end of the current month must submit the written request for cancellation prior to capitation. If the request is received after capitation, coverage cannot be closed until the next available month and the enrollee will be responsible for any premiums due for months for which a health plan capitation has been paid.
Marianne calls on December 5 to report her husband, Jerome, left the home on November 30. Advise Marianne that Jerome will be removed from her case at the end of January, the month following the month in which the change is reported. Marianne asks to have Jerome removed at the end of December so her January premium can be reduced. Require a written statement from Jerome. If Jerome submits a written request before the January capitation is paid, remove him and reduce the premium effective January 1. If the household has already paid the January premium, refund Jerome's portion. If he submits the written request after capitation, he cannot be removed until February 1.
George calls on December 28 to report his wife Suzanne left the home on December 26. Advise George that Suzanne will be removed from his case at the end of January, the month following the month in which the change is reported. Because January’s capitation payment has been paid, it is not possible to remove Suzanne for January, even if she submits a written request.
People who become incarcerated while enrolled in MinnesotaCare may remain enrolled until the time of the next scheduled renewal. If the existing household requests to have the incarcerated member removed before the renewal, allow the incarcerated member to request MinnesotaCare on a separate case. Send the incarcerated person the Notice to MinnesotaCare Enrollees who are Residing in a Correctional Facility and a HCAPP. Obtain the address of the penal institution if there is no forwarding address. Allow the person 10 days to return the application. If eligibility exists, send a request to the MMIS Help Desk to set the renewal date for the new case to coincide with the existing household's scheduled renewal. See §0905 (Reviews and Renewals).
M. S. 256L.04 subd. 1
M. S. 256L.01 subd. 3a
See §0915.05.01 (Removing a Person From Household--MA/GAMC).
See §0915.05 (Removing a Person From the Household).
Remove people from an existing household when:
Rob and Laura receive MA for themselves and their son. Rob and Laura separate, and Rob moves out on August 10. Remove Rob from Laura's household and cease deeming his income beginning September 1. Offer Rob an opportunity to apply for MA or GAMC for himself as a separate household.
Nadine, age 20, receives MA as part of her parents' household. Nadine turns 21 on April 3. She continues to live with her parents but is no longer counted in the household size. Remove Nadine from the household effective May 1. Offer her an opportunity to apply for GAMC (or MA if she meets a basis other than child under 21) as a separate household.
Steve receives GAMC with his wife. His children receive MA. On June 12, Steve reports he will be eligible for health insurance through his employer for himself only at no cost beginning July 1. The worker requests information on the coverage to determine cost effectiveness. Steve declines to provide the information and requests to be terminated from GAMC. He would like continued coverage for his wife and children. Terminate GAMC for Steve only effective July 1. Continue to include him in the household size and deem his income for the rest of the family.
Determine the effect of removing a household member on the existing household's certification period and spenddown. See §0913.19 (Shortened Spenddown) for instructions and examples covering when to interrupt a certification period or recompute a spenddown when removing a household member.
See §0914.03.13 (Adding/Removing People From Managed Care) for information on disenrolling household members from a health plan.
See §0913.17 (Begin/End Use of LTC Spenddown - Part 1), §0913.17.01 (Begin/End Use of LTC Spenddown - Part 2), and §0913.17.03 (Begin/End Use of LTC Spenddown - Part 3) when a member of the household enters long term care or begins receiving services through the Elderly Waiver (EW).
MinnesotaCare:Act on all income increases and decreases reported between renewals, including those that increase monthly premiums.
Susan calls in November to report that she began receiving child support payments of $125 per month in June. She did not include this information on her September renewal form. Recalculate household income including the child support payment, record the new amount in MMIS to determine the new premium amount.
Jackson reports changes in his household’s employment. He received a raise, but his wife started a new job at a lower hourly rate. He combined effect of the 2 changes is decreased household income that would result in a lower premium. Enter both changes in MMIS.
MMIS will adjust the premium for the first available month when income decreases on an active case. Do not request manual adjustments.
On May 21, Rita calls to report her husband, Karl, left the household. Karl did not have coverage, but his income was counted to determine the household’s premium. Remove Karl’s income and decrease the household size. MMIS will adjust the premium automatically.
If a household reports 2 income changes at the same time, act on the changes to determine if the combined changes would result in an increased or a decreased premium.
Anthony calls his worker to report that his Unemployment Insurance (UI) stopped and he began a job. The wages he reports from the job are higher than the UI and would result in an increased premium. Recalculate household income. Record the new amount in MMIS to determine the new premium amount.
M.S. 256L.07 subd. 1
Minnesota Rule 9506.0040 subp. 2c
See §0915.03 (Adding a Person to the Household) when adding the income of a person who moves in to an existing household.
Households are required to report changes in income within 10 days of the date the change becomes known. Households who use a monthly manual spenddown must submit monthly income reports. See §0913.11 (Manual Monthly Spenddown Calculation) and §0905.07 (Monthly Reporting). All other households must submit income reports every 6 months. See §0913.07 (6-Month Spenddown Calculation), §0913.09 (Automated Monthly Spenddown Calculation), and §0905.09 (6-Month Reporting).
When you become aware of a change in household income, determine the effect of the change on the household's eligibility. If the change is reported during a certification period, recalculate eligibility for the current certification period. Do not require verification of the change if it is reported at a time other than a scheduled 6-month or annual review.
For income increases:
When you become aware of an increase in income during a certification period, determine the affect on eligibility and take action immediately.
Request verification of new or increased earned income that affects eligibility. Require verification be submitted within 10 days of notification. New or increased earned income affects eligibility if it results in a change in eligibility basis, creates the need for a spenddown, or changes a spenddown amount.
Do not require verification if:
Do not require verification of an increase in unearned income if it is reported at a time other than a scheduled 6-month or annual renewal.
Bridget receives MA for herself and her two children. Their current certification period is June-November. The household's only income is child support for the children. All household members are eligible without a spenddown. On September 5, Bridget reports that she began a job on September 1.
Redetermine eligibility for each household member for the current certification period. Count zero income for Bridget for June-August, since the children’s child support is not deemed to her. Project anticipated earnings for September-November. Count child support for the children for the entire 6-month certification period. Add Bridget’s projected net earnings for September-November. Determine whether any household members are eligible for Transition Year MA. See §0907.19.11 (Transitional/Transition Year MA). If any household member has a spenddown as a result of the new calculation, determine whether the spenddown can be met with bills incurred before the current certification period or with bills incurred during the certification period that were not covered by MA.
If a household member with a spenddown cannot meet a 6-month spenddown with existing bills, determine if the person could meet a monthly spenddown based on anticipated income and bills for the remaining months in the certification period. Terminate MA effective the first month for which you can give 10-day notice for any household member who cannot meet a 6-month or monthly spenddown.
If any household members move to Transition Year MA or MA with a spenddown due to the new earned income, request verification of the new earned income to be submitted within 10 days. Cancel MA coverage with 10-day notice for household members whose eligibility was affected by the increased earned income if verification is not submitted.
For income decreases:
When you become aware of a decrease in income during a certification period, determine the effect on eligibility and take action immediately. If no one in the household has a spenddown, no action is required. Do not require verification of decreases in either earned or unearned income reported between 6-month or annual reviews.
If the household has an automated or monthly manual spenddown, re-compute the spenddown beginning with the month the change occurred. See §0913.09 (Automated Monthly Spenddown Calculation) and §0913.11 (Manual Monthly Spenddown Calculation).
If any household member has a 6-month spenddown, recompute eligibility for the existing certification period. If the decreased income results in an earlier satisfaction date, change the spenddown amount and satisfaction date on MAXIS and MMIS. Send a notice to the household to notify appropriate providers to bill MA or GAMC. See §0913.07 (6-Month Spenddown Calculation) and §0913.19 (Shortened Spenddown).
Delbert receives GAMC with a 6-month spenddown. His current certification period is January-June. He was hospitalized from January 13-16 and met his spenddown on January 14. On April 9, he reports his hours have been cut from 30 to 20 per week. The worker determines that Delbert would meet his spenddown on January 13 based on the reduction in income. Change the spenddown satisfaction date and recipient amount on MAXIS and MMIS. Notify Delbert of the change and advise him to have the hospital rebill the January 13-14 charges to GAMC. When the hospital receives payment, they will refund the difference between the old and new spenddown amounts to Delbert.
Premiums for people enrolled in Medical Assistance for Employed Persons with Disabilities (MA-EPD) are established for the full 6-month certification period. If a MA-EPD enrollee reports a change in income during the certification period, change the premium only if the income change results in a decreased premium or no premium. If the change results in an increased premium, do not take action to increase the premium until the next 6-month income review or annual recertification.
If an IEVS match results in an increase in the MA-EPD premium, apply the increased premium amount for the next available month. See §0916.21.03 (MA Overpayments fro IEVS Matches).
When you become aware of a change in a household's other health coverage, evaluate the effect of the change on eligibility for each household member. If a household remains eligible for MinnesotaCare with the other health coverage, send a HIIF (DHS 1922) to the Benefit Recovery Section with information on new or changed health care coverage. See §0910 (Other Health Coverage).
You may learn of changes in a household's coverage in several ways, including:
Changes in other health coverage may include:
Evaluate the effect of the change in other health coverage using the rules that apply to each household member's group status. See §0907 (Eligibility Groups and Bases of Eligibility) and §0910 (Other Health Coverage).
Billy is enrolled in MinnesotaCare with his mother, stepfather, and his half-brother, who is a child of his mother's current marriage. The family has Group 2 status. The local IV-D agency reports that Billy's father has obtained dependent care coverage for him in accordance with a medical support order. Terminate coverage for Billy effective the first month for which you can give 10-day notice. The rest of the household remains eligible.
Lea and her son David had a private health insurance policy. They both have Group 1 status and were determined eligible for MinnesotaCare with the other coverage. Lea reports she dropped the coverage because she couldn't afford the premiums.
Both Lea and David remain eligible. Notify Benefit Recovery that the household no longer has other coverage.
M. S. 256.9357
Availability of other health coverage does not affect eligibility for MA or GAMC. However, adult household members who fail to cooperate in providing information about other coverage or to assign rights to other coverage for themselves and their dependents may lose eligibility.
DHS will pursue recovery from insurance carriers or others who may be responsible for a client's medical expenses. MA or GAMC will pay premiums for other health insurance that is determined to be cost effective. Follow the provisions in §0910 (Other Health Coverage) when you become aware of potential 3rd party coverage.
People who fail to pay premiums by the last day of the month after the premium is due (the grace month) and people who request voluntary cancellation are ineligible to re-enroll in MinnesotaCare for 4 months unless they show good cause for non-payment or voluntary cancellation. People who pay all billed premiums by the 20th day following cancellation may be reinstated. See §0915.11.05 (Fail to Pay Premium/Reinstatement).
Good cause means circumstances beyond an enrollee's control or that the enrollee could not reasonably foresee which resulted in the enrollee being unable or failing to pay the premium or requesting voluntary cancellation. Good cause circumstances include but are not limited to:
Good cause does not include choosing to pay other household expenses instead of the premium.
Make good cause determinations on a case by case basis based on the evidence the enrollee submits. Notify enrollees of their right to appeal if the agency does not find good cause. Continue benefits pending the outcome of the appeal unless the enrollee requests in writing not to have benefits continued. Require payment of all missed premiums to continue benefits. See §0917 (Appeals).
MMIS will automatically terminate coverage effective the last day of the month after the premium due date. If the agency determines that good cause exists without an appeal, require payment of all due premium(s) before reactivating coverage.
If the agency does not find good cause and the household does not appeal, the household must wait 4 calendar months beginning with the first month of disenrollment before re-enrolling.
Do not require a new application for re-enrollment unless more than 11 months have elapsed since the household last completed an application. Update income and other pertinent information on the most recent application. Re-evaluate group status based on current circumstances.
Jerry’s August premium notice is mailed on June 15. No payment has been received as of cutoff on July 17. MMIS generates a cancellation notice for July 31. No payment has been received as of noon on the last working day of July. Jerry’s coverage ends July 31. He cannot re-enroll until December unless he becomes eligible for reinstatement by paying all billed premiums during the 20-day reinstatement period. August, September, October, and November are his penalty months.
If Jerry does not pay the due premiums during the reinstatement period but shows good cause and then pays the due premiums, reinstate coverage for August. If Jerry files a timely appeal of a finding of no good cause, does not request that benefits stop pending appeal and pays the due premiums, reinstate coverage for August. If the appeal decision finds that Jerry had good cause, coverage continues as long as Jerry pays the premiums. If the agency is upheld in the appeal, begin a penalty period in accordance with the appeal decision.
Do not require a new application for re-enrollment unless more than 11 months have elapsed since the household last completed an application or previous renewal form. Instruct enrollees canceled for non-payment who have completed a HCAPP or renewal form in the 11 months before the end of the penalty period to call to request re-enrollment at the beginning of the 4th month. Update income and other pertinent information on the most recent application. Re-evaluate group status based on current circumstances.
If you receive a HCAPP before the 4th month of the penalty period, deny the application using MMIS code 42 (Penalty Period). Send the Review Delay Letter (DHS 3399) advising the household to contact the agency at the beginning of the 4th month to reactivate the application.
If you receive a renewal form during the penalty period and the household has not completed a HCAPP or renewal form in the past 11 months, send the household the DHS 3399 and a HCAPP to complete and return.
Process applications received in the 4th month of the penalty period. Approve applicants who meet all eligibility requirements as pending awaiting payment for coverage to begin effective the first day of the 5th month.
Forgive any premiums included in an approved bankruptcy order. Request a copy of the final order to verify whether the MinnesotaCare premium is included in the list of debts to be forgiven. Do not forgive premiums not specifically listed.
Do not cancel a pregnant woman for non-payment of premiums during the pregnancy and 60-day postpartum period. See §0907.09 (MinnesotaCare Pregnant Women). Also do not cancel a child under age 2 for non-payment of premiums. Cancel other household members if appropriate. See §0915.11.03 (Fail to Pay Premium/PW’s and Infants).
Household members who were not enrolled in MinnesotaCare when the penalty period began are not subject to the 4-month penalty period.
Joan and Louie are enrolled in MinnesotaCare with their son Paul. Their daughter Jasmine receives MA. MinnesotaCare is canceled for failure to pay premium effective June 30. Jasmine’s MA ends August 1. Jasmine is eligible for MinnesotaCare effective August 1 if she meets all eligibility requirements other than the 4-month penalty. The household must pay the past due premium and the current premium for Jasmine before her coverage begins.
If you are notified that an enrollee’s premium check has been returned for non-sufficient funds (NSF), return the check with a letter requesting payment by money order or cashier’s check. MMIS will terminate coverage and impose a 4-month penalty period if the enrollee fails to replace the NSF check with a guaranteed form of payment. See §0913 (Premiums and Spenddowns).
M. S. 256L.06 subd. 3
Minnesota Rule 9506.0040 subp. 6
All people receiving MA through the Medical Assistance for Employed Persons with Disabilities (MA-EPD) program pay a premium. The county agency bills and collects the initial premium. DHS bills and collects the ongoing MA-EPD premiums and determines if a client has good cause for non-payment based on the guidelines listed in the MinnesotaCare section of this chapter. If DHS determines the client has good cause for non-payment, MA-EPD eligibility continues. A finding of good cause does not relieve the client’s obligation to pay the premium. Deny or terminate MA-EPD for people who fail to pay without good cause. If the client later pays the premium in full, reinstate coverage back to the date of termination. SRU will send MAXIS E-mail to notify the financial worker of the good cause decision and whether the premium payment is made.
Refer clients who are unable to pay the premium by the due date or wish to claim good cause to DHS SRU at 1-800-657-3762 or (651) 296-6607. The client or financial worker may submit a written request to:
DHS Special Recovery Unit
444 Lafayette Road
St. Paul, MN 55155-3863
or fax to (651) 282-6744.The written request should include the client’s legal name, PMI number, mailing address and phone number, reason for requesting good cause, and supporting documentation. SRU will provide the client with written notice of the decision within 30 days. Clients may appeal a finding that good cause does not exist.
Do not cancel pregnant women during the pregnancy or postpartum period or infants under age 2 for failure to pay premiums. See §0915.11 (Fail to Pay Premium/Voluntary Cancellation). Cancel other household members who fail to pay their premiums without good cause. Make a request to forgive the portion of the past due payments attributed to the pregnant woman or infant under age 2 for covered months in the past at any of the following times:
Sally is pregnant and is enrolled in MinnesotaCare with her family. Her portion of the family’s $112 monthly premium is $20. The rest of the household is canceled for non-payment of the $112 June premium at the end of May. Sally’s coverage continues. The family does not pay her $20 premium for June, July, August, or September. On September 18, Sally asks to have MinnesotaCare reopened for the rest of the household effective October 1, the end of their 4-month penalty period.
Make a request to forgive Sally’s unpaid premiums ($80, or $20 per month for June through September). The October and November premiums remain at $20 and are not adjusted. Do not make a request to forgive the October premium. The other household members will automatically become active October 1 if they pay the October premium of $20 by the end of September. The next premium cycle, for December, will reflect the household’s ongoing monthly premium of $112.
Krystle is pregnant and enrolled in MinnesotaCare. She fails to pay her June premium. Coverage continues. On July 3, she reports that her son has moved in with her and asks to add him to her coverage effective August 1. Make a request to forgive Krystle’s June and July premiums. The August premium is not adjusted. Do not make a request to forgive the August premium. Pend the son awaiting payment and advise Krystle that she must pay the August premium by the last day of July to get coverage for her son.
If Krystle’s son is added before the July billing date, the September premium billing will reflect the new ongoing premium amount for both household members.
Do not make a request to forgive payments attributed to the pregnant women or infant at any time other than those listed. Do not make a request to forgive the PW’s or infant’s payments for future months.
In the last month of a pregnant woman’s 60-day postpartum period, MMIS will create a worker message to alert the enrollment representative that the postpartum period is ending at the end of the month and the woman will be changed to a new major program effective the first of the next month. Make a request to forgive all unpaid premiums that have accumulated since the enrollee was designated as pregnant on MMIS that were not previously forgiven. This includes unpaid premiums for the months of pregnancy and unpaid premiums for the woman’s 60 day postpartum period.
Wilma is a pregnant woman enrolled in MinnesotaCare with her husband Tom. Their monthly premium is $20. Tom’s MinnesotaCare is canceled for non-payment on July 31. Wilma continued to receive coverage throughout her pregnancy. On September 15, Wilma gave birth to her son Sam. Sam was enrolled in MinnesotaCare effective September 1 as an auto newborn. On November 17, MMIS created a worker message alerting the enrollment representative that Wilma’s 60-day postpartum period is ending. Request an adjustment to forgive Wilma’s premiums for July, August, and September and Wilma’s portion of the premiums for October and November ($50, Wilma’s monthly portion of $10 for 5 months).
Wilma must pay her premium for December and the premium due for Sam. If the December premiums are paid by noon on the last business day of the month, Wilma’s coverage will continue. If the December premiums are not paid by noon on the last business day of the month, Wilma will be canceled for non-payment on December 31 and she will have to serve a 4-month penalty period. Sam remains eligible as an auto newborn.
MMIS will create monthly worker messages to identify infants who are turning 2 in the current month for whom a premium payment has not been made. Before billing in the month of the infant’s 2nd birthday, make a request to forgive the infant’s portion of any unpaid premiums that were not previously forgiven. This includes the infant’s unpaid premiums through the month in which the child turns 2.
At billing cutoff in the month the child turns 2, the household must pay the premium for the next month. Payment must be received by noon on the last business day of the month. If the premium is paid, the infant will continue MinnesotaCare coverage. If the premium is not paid, the infant will be canceled at the end of the month and will be required to serve a 4-month penalty period.
Sam was enrolled in MinnesotaCare on September 1, 1998. His mother Wilma was canceled on November 30 because she did not begin paying premiums when her postpartum period ended. Sam remained enrolled in MinnesotaCare, and the family has not paid premiums for him during his enrollment.
Sam turned 2 on September 15, 2000. Before the September billing, request an adjustment to forgive Sam’s portion of the unpaid premiums ($4 per month) for October 1998 through September 2000.
If the premiums are forgiven before September billing, the premium due on September 15 will include $4 for Sam’s October coverage and $4 for November coverage. If the October premium is paid by noon on the last business day in September, Sam will remain enrolled. If the premium is not paid by noon on the last business day of September, Sam will disenrolled for non-payment of premiums and must serve a 4-month penalty period.
Reinstate MinnesotaCare back to the date of closing for households who:
MMIS sends a notice on the first day of the reinstatement month to households who are canceled for non-payment. The notice informs the household of the reinstatement option and includes the total amount due and the due date. If all billed premiums are received by the due date, MMIS reinstates coverage back to the date of cancellation and sends each enrollee a letter explaining that MinnesotaCare has been reinstated. Enrollees receive coverage through fee-for-service for the reinstatement month. MMIS will reenroll them in their previous health plan beginning the month after reinstatement.
Enrollees who are canceled for nonpayment and another reason are not eligible for reinstatement. Other household members are eligible for reinstatement if they were canceled only for nonpayment. MMIS will calculate the amount due based on the number of people who had coverage during the cancellation month and the number who could have coverage in the reinstatement month and the following month.
Mike, Judy and their daughter Debbie are enrolled in MinnesotaCare with a monthly premium of $100. MinnesotaCare is canceled effective July 31 due to nonpayment of the August premium. Mike’s coverage also ends because he has access to ESI. Judy and Debbie would be eligible beginning August 1 with a premium of $67 per month. On August 1, MMIS generates a notice informing the household that they must pay $134 ($67 for August and $67 for September) by August 20 to have coverage reinstated for Judy and Debbie. If payment is received by the due date, MMIS will reinstate coverage for Judy and Debbie back to August 1.
Track cases for enrollees who cancel for nonpayment and noncooperation with medical support. The child support indicator on the MMIS RIND screen cannot be changed during the 20-day reinstatement period. See the MMIS User Manual and Bulletin #00-23-1 (DHS Introduces MinnesotaCare Reinstatement for Payment of Past Due Premiums) dated June 7, 2000 for further information.
If a household asks to add new members during the 20-day reinstatement period, the new member must pay all billed premiums during the 20-day period to reinstate household coverage and begin coverage the following month for the new member. After the 20-day period, the new member must pay only the household’s past due amount and the new member’s future premium to begin coverage for the new member.
Sally and John’s MinnesotaCare coverage ends on April 30 due to nonpayment of the May premium. On May 5, John requests to add his daughter Melanie, who has moved into the household. Melanie is determined eligible and is approved as pending awaiting payment. MMIS automatically changes the pending awaiting payment span to denied for nonpayment. The household must pay the May and June premiums during the 20-day reinstatement period for John and Sally to be reinstated effective May 1 and Melanie’s coverage to begin June 1. After the 20-day reinstatement period, the household must pay the future month’s premium for Melanie only to begin Melanie’s coverage beginning the month after payment is received. Enter a new pending awaiting payment span for Melanie. John and Sally will have a 4-month penalty period unless they show good cause for nonpayment.
If an enrollee is approved for MA during the 20-day reinstatement period and pays the MinnesotaCare premiums, MMIS will not automatically reinstate MinnesotaCare. MMIS will generate a worker message for the worker to follow up with the enrollee to confirm that they want continued MA. The MinnesotaCare re-bill procedure will recalculate the premium and create a credit.
If the reinstatement month is the month prior to the renewal month, MMIS will send a closing notice to enrollees who have not paid all billed premiums by the reinstatement month billing date advising them that they must pay all billed premiums and submit a completed renewal by the 20th to be eligible for reinstatement.
Joelle’s MinnesotaCare coverage is canceled for nonpayment on July 31. Her renewal date on MMIS is August 30. If she has not paid the August premium by billing on August 15, MMIS generates a notice advising her that she must pay the premiums and submit her renewal by August 20 to be eligible for reinstatement. The notice also advises her that she will be canceled for failure to renew if she fails to submit the renewal. If she pays the premium but fails to submit the renewal, no further notice is required.
When you are notified of the possible pregnancy of a child under age 21 living with parents through reports from a source other than the enrollee or household, do not contact the enrollee or household. Enter a case note regarding the information received and the source.
When a child under age 21 reports a pregnancy:
Enter case notes for all contact with the household. If another household member inquires about a premium or eligibility change resulting from the reported pregnancy of a child, do not disclose the pregnancy unless you have a signed Consent Form if the child is age 18 or over, or the child is under age 18 and has stated that you may share the information. If you cannot disclose the pregnancy, inform the caller that a change was reported by a member of the household, but that you cannot discuss the change due to data privacy laws.
Take the following steps when an enrollee reports a pregnancy. If you become aware of a pregnancy through a health plan, provider, or another MinnesotaCare enrollment site or county agency, contact the enrollee for date of diagnosis and estimated date of delivery before taking these steps.
1. Enter the necessary information on MMIS to change the woman’s status to pregnant woman effective the 1st of the month the pregnancy was diagnosed or the date the woman last became active, whichever is later. Do not change the status to pregnant woman effective the month of conception unless you verify that the pregnancy was diagnosed by a medical professional during that same month. MMIS will increase the household size by the number of expected fetuses. Do not include the unmarried father of the expected child even if he is living with the mother.
If you first become aware of a pregnancy after the birth, change the woman’s status to pregnant woman for the birth month only, unless you receive verification that the woman’s pregnancy was diagnosed by a medical professional in an earlier month. Do not consider the birth itself to be a "diagnosis" for any previous months.
Pregnant women who meet the MA citizenship and residency requirements will be eligible for federal funding. See §0907.09 (MinnesotaCare Pregnant Women).
2. Review the woman’s group status. A Group 3 woman with no other children will become a Group 2 parent effective the month the pregnancy is diagnosed. Assign the pregnant woman’s husband to Group 2 or Group 4 depending on citizenship/immigration status and income. See §0907 (Eligibility Groups and Bases of Eligibility) and §0915.15 (Change in MinnesotaCare Eligibility Group).
3. Request medical verification of the pregnancy. See §0907.09 (MinnesotaCare Pregnant Women) for a list of verification sources. If the household fails to submit verification within 30 days of the request, send a notice informing the household that the woman, and her husband if applicable, will lose pregnant woman status if verification is not received within 30 days of the second notice.
Cindy and her husband Bruce enrolled in MinnesotaCare as Group 3 adults without children in May with income of 150% FPG. On August 15, Cindy reports that her pregnancy was confirmed at the doctor’s office on August 12. Her estimated date of conception is July 7 with a due date of April 4. Change Cindy’s status to pregnant woman and assign Cindy to Group 2 and Bruce to Group 4 effective August 1. Request verification of the pregnancy. If Cindy fails to submit verification within 30 days of the request, send a notice informing her that she will lose pregnant woman status and she and Bruce will be reassigned to Group 3 unless she submits verification within 30 days. If she fails to submit verification within 30 days of the second notice, change the status back to Group 3 adults effective the first available month.
Any co-payments paid by the pregnant woman after the date the pregnancy is diagnosed may be refunded. If a woman wants to be refunded co-payments, instruct her to request the refund from the provider to whom the co-payment was paid. Co-payments incurred between the month of conception and the month of diagnosis are not eligible to be refunded.
M.S. 256L.03 Subd. 1a and 1b
Women who become pregnant while receiving MA under any basis of eligibility become eligible under the pregnant woman basis from the date of conception through the 60-day postpartum period. Require verification of pregnancy. If you receive a report of a pregnancy-related health services claim through MMIS, follow up with the client.
Women receiving MA using Method B due to blindness or disability who become pregnant may choose to continue using Method B. Explain to the woman that the pregnant woman basis has a higher income standard. Flag the case to ensure that MA remains open if the woman becomes ineligible for MA using Method B.
Women who become pregnant while receiving GAMC become eligible for MA without a new application. See §0904.05.05 (When Not to Require an Application). See §0907.19.05 (MA Basis: Pregnant Women) for more information on eligibility requirements.
All MinnesotaCare enrollees are assigned to an eligibility group. See §0907 (Eligibility Groups and Bases of Eligibility). People maintain their eligibility group status between renewals unless:
Children who were enrolled in the Children’s Health Plan on or before 6-30-93 retain Group 1 status until they reach age 21 as long as they maintain continuous enrollment. See CONTINUOUS ENROLLMENT in §0902.07 (Glossary: Client...) and §0907.03 (MinnesotaCare Eligibility Group 1).
All changes must be made at renewal. Change group status between renewals when:
Reevaluate group status when children turn age 21.
Mary is a single adult enrolled in Group 3. She reports and verifies that she is pregnant. Her income is 225% FPG. She now has Group 2 status and will retain this status as long as she is pregnant or has a child under 21 living with her.
Stuart is enrolled as a Group 2 child with his parents. His mother calls between renewals to report that the household income has decreased. She verifies the new income, which is now below 150% FPG. Change Stuart's status to Group 1.
Monica is enrolled as a Group 3 adult. She reports that her 12-year-old son, who was living with his grandmother, has returned to live with her and she would like to add him to her case. Her income is 175% FPG. Change Monica’s status to Group 4. See §0915.03 (Adding a Person to the Household).
Greta is enrolled as a Group 2 parent with income between 200-275% FPG. She reports an income decrease. Income is now between 100-200% FPG. Greta is a U.S. citizen. Assign her to Group 4 effective the first available month.
Norman is enrolled as a Group 4 parent. He reports an income increase. Income is now over 200% FPG. Reevaluate group status at the time of the next renewal.
Mai is enrolled as a Group 2 child. She turns 21 in June. Mai becomes Group 3 and will be on her own MinnesotaCare case effective in July.
M.S. 256.9354 subd. 1.
See §0915.15.01 (Change in MA/GAMC Basis of Eligibility).
See §0915.15 (Change in MinnesotaCare Eligibility Group).
When you become aware of a change in circumstances, evaluate the effect of the change on the basis of eligibility. Also determine if the person is eligible for a different major program (MA to GAMC or GAMC to MA). Leave MA or GAMC open while the determination is in process as long as the client is cooperating in providing necessary information.
Examples of changes that may affect basis of eligibility or major program include:
NOTE: Parents of TEFRA children may be liable for parental fees through the month of the child’s 18th birthday.
When people receiving GAMC are certified blind or disabled, they are eligible for MA beginning with the month of the blindness or disability certification. Do not require a new application if the person was initially approved for GAMC pending the disability or blindness certification. See §0904.05.05 (When Not to Require an Application).