***This version of the Health Care Programs Manual has been replaced and is no longer in effect.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.***

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

Chapter 0916 - Notices

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

Chapter 0916

0916

NOTICES

PDF(s): Feb 00

0916.03

CONTENT OF NOTICES

PDF(s): Jul 98

0916.05

NOTICE OF APPROVAL

PDF(s): Jan 01

0916.07

NOTICE OF PROCESSING DELAYS

PDF(s): Jul 98

0916.09

NOTICE OF DENIAL

PDF(s): Jul 98

0916.11

TIMING OF NOTICES OF ADVERSE ACTION

PDF(s): Aug 01

0916.13

NOTICE OF TERMINATION OR CANCELLATION

PDF(s): Jul 98

0916.15

PREMIUM NOTICES

PDF(s): Dec 02

0916.17

NOTICE OF LATE OR INCOMPLETE HRF

PDF(s): Jul 98

0916.19

HOMESTEAD EXCLUSION NOTICE - LTCF RESIDENTS

PDF(s): Jul 98

0916.21

IEVS NOTICES

PDF(s): Jun 02

0916.21.03

MA OVERPAYMENT FROM IEVS MATCHES

PDF(s): Apr 06

0916.23

CERTIFICATES OF CREDITABLE COVERAGE

PDF(s): May 05 | May 01

NOTICES 0916

MinnesotaCare:

MMIS sends written notice in the following circumstances:

• Initial premium (cases approved as pending awaiting payment). • Monthly premium notice. • Overdue premium notice. • Replacement premium notice (change in premium amount). • Pending notice (applications pended for more information). • Denial of coverage. • Cancellation. • Notice of health plan enrollment.

MMIS does not send written notice in the following circumstances. Send a manual notice.

• Clients who claim good cause for non-cooperation with medical support must receive written notice of the decision on their claim. See §0906.13.07 (Good Cause Determinations). • Clients whose income increases beyond the MinnesotaCare standard must receive an 18-month notice of cancellation if 10% of gross annual household income exceeds the MCHA premium for the household size. See §0912.03.03 (MinnesotaCare Excess Income). • Adult applicants without children who receive disability benefits and are potentially eligible for MA without a spenddown must receive notice of the requirement to apply for MA and, if applicable, follow up notices explaining that MinnesotaCare will terminate if people fail to cooperate with MA. See §0907.15 (MinnesotaCare Adults Without Children). • People who are approved for MinnesotaCare under presumed eligibility must receive a Presumed Eligibility letter explaining what they must do to continue coverage. See §0904.07.05 (Application Follow Up), §0904.07.07 (Pending the Application). • Incarcerated people who are removed from an existing household before the next renewal must receive a Notice to MinnesotaCare Enrollees who are Residing in a Correctional Facility. See §0915.05 (Removing a Person from the Household). MMIS will provide the required notice for people who are canceled at renewal or denied at application due to incarceration.

42 CFR 431 Subp. E

MA/GAMC:

MAXIS sends written notice in the following circumstances:

• Approval or denial of applications. • A delay in acting on applications (pending notice). • Termination of eligibility. • Reinstatement of eligibility. • Changes affecting eligibility, such as adding or removing people from MA or GAMC. • A change that did not affect eligibility, if the household reported the change on a Change Report Form (DHS 2402).

Send clients manual notice of the following actions:

• Decisions on claims on good cause for non-cooperation with medical support. See §0916.03 (Content of Notices). • Disqualification of an authorized representative. See §0904.11 (Authorized Representatives). • Approval, denial or termination of payment of cost effective health insurance premiums. See §0910.05.01 (Current Health Insurance--MA/GAMC) and TEMP manual TE02.13.48 (Cost Effective SPEC/LETR).

For special notice requirements in spenddown cases, see §0913.23 (Spenddown Notice Requirements).

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CONTENT OF NOTICES 0916.03

All of the health care programs require the following information in notices of proposed action:

• What the action is. • Which household members the action affects. • The effective date of the action. • The reason for the action. • The legal authority for the action. • The right to appeal and instructions on how to file an appeal. • The conditions under which enrollees may continue to get assistance pending the outcome of the appeal. • The requirement to repay assistance received while an appeal is pending if the agency is upheld in the appeal.

Notices of processing delay must include:

• Whether the delay is caused by the agency or the applicant. • What steps, if any, the applicant must take to complete the process.

Caretakers who are required to cooperate with medical support enforcement must receive notice of the right to claim good cause for non-cooperation. The Client Statement of Good Cause (DHS 2338 and 2338C) contain all required information.

Notices of approval of good cause claims must include:

• The action taken. • The length of time for which the claim is approved. • Whether the agency has determined that medical support enforcement can proceed without the caretaker's cooperation.

Notices of denial of good cause claims and notices of approval when the agency has determined that enforcement can proceed without the caretaker's cooperation must include the following client options:

• To cooperate with medical support. • To withdraw the application for the household, including the children for whom good cause was claimed. • To appeal the decision. • To withdraw the caretaker's application.

See §0906.13.05 (Good Cause Exemptions--Medical Support).

MinnesotaCare:

In addition to the information listed in the general provisions, premium notices must include:

• The amount of the required premium and the due date when appropriate. • The right to claim good cause for non-payment of premiums. • The responsibility to continue to pay premiums if MinnesotaCare coverage continues pending the outcome of an appeal.

Except for good cause, MMIS generates standard notices including the required language.

MA/GAMC:

All MAXIS notices contain the required language. Follow general provisions for content of notices pertaining to good cause for failure to cooperate with medical support.

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NOTICE OF APPROVAL 0916.05

MinnesotaCare:

When a case is approved as pending awaiting payment, MMIS generates an initial premium notice. The notice explains that coverage will begin the 1st of the month after the initial premium payment is received. This is the only notice of approval the household receives. If the household fails to pay the initial premium within 4 months, coverage is denied. See §0904 (Applications).

42 CFR 431 Subp. E

MA/GAMC:

MAXIS will notify clients of approval of their application or request for recertification when you approve eligibility. MAXIS generates an individual notice for each household member who is approved for initial or continued eligibility.

MAXIS will use the appropriate reason codes and authority when informing clients of eligibility.

In addition to the requirements in §0916.03 (Content of Notices), approval notices must contain:

• When eligibility begins. • Any spenddown requirements. • Spenddown eligibility calculations. See §0913.23 (Spenddown Notice Requirements).

County workers may add worker comments as needed. See TEMP Manual TE02.07.155 (MA Changes: Spenddown Problems & Workarounds).

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NOTICE OF PROCESSING DELAYS 0916.07

MinnesotaCare:

Send a notice of delay whenever an application will not be completed within 30 days.

Beginning July 1998, MMIS will generate a notice when a case is entered as pending/incomplete. The notice will list all information the applicant needs to supply to complete the application. If the case is still pending/incomplete on the billing date of the month after the effective month of the pending span, MMIS will generate another notice informing the applicant that the case will be denied unless the applicant supplies the information within 30 days. See §0904.07.07 (Pending the Application).

MA/GAMC:

MAXIS will send a pending notice when it will take longer than the time permitted in §0904.07.03 (Date of Application) to process an application.

If the delay is caused by the agency, MAXIS will send the notice by the end of the processing period. If the delay is the result of the household's failure to provide information, MAXIS will send the notice 10 days before the end of the processing period. MA and GAMC applicants must receive 10-day advance notice of intent to deny the application for failure to complete the application process. See §0904.07.07 (Pending the Application).

The pending notice must include:

• Whether the delay was caused by the agency or the client. • A statement that applicants must report any changes in circumstances since the date of application. • The information listed in §0916.03 (Content of Notices).

If necessary to fully explain the delay, initiate an additional notice to the client using the SPEC/MEMO function in MAXIS or add worker comments to the pending notice. Include the exact cause of the processing delay and what steps, if any, the client must take to complete the process.

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NOTICE OF DENIAL 0916.09

MinnesotaCare:

MMIS will generate a denial notice when a representative enters a code indicating that an applicant is ineligible for coverage.

MMIS will also generate a denial notice when a household fails to pay the initial premium within 4 months of receiving the initial premium notice or fails to submit required information within 30 days of the date of the 2nd notice requesting the information. See §0904.07.07 (Pending the Application) and §0916.07 (Notice of Processing Delays).

MA/GAMC:

MAXIS will generate a denial notice for each applicant household member who is found ineligible for MA and GAMC. Applicants must receive a notice of denial by the end of the application processing period unless they receive notice that the application will pend beyond the processing period.

If an applicant receives a pending notice and is then found ineligible for any reason, including failure to provide information after receiving 10-day advance notice of denial, send a denial notice.

See §0904.07.07 (Pending the Application) and §0916.07 (Notice of Processing Delays).

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TIMING OF NOTICES OF ADVERSE ACTION 0916.11

MinnesotaCare:

Most cancellations require 10-day advance notice. MMIS generates notices on the monthly cutoff date which is approximately 10 working days before the end of the month. Notices can be issued up to 10 calendar days before the effective date.

A 10-calendar day advance notice is required to reduce benefits. See §0906.03.13 (MinnesotaCare Major Programs) for information on benefit packages.

Do not require 10-day advance notice in the following situations.

• Send notice no later than the effective date of the action when you have factual information confirming the death of an enrollee. • Send notice no later than the date the managed care capitation is made when
• You receive a clear written statement signed by the enrollee indicating that s/he no longer wants coverage. Do not terminate coverage with less than 10-day notice if the enrollee requests cancellation orally but does not submit a written statement. • The enrollee has been found eligible for MA or GAMC or has been found eligible for Medicaid (MA) in another state.

42 CFR 431.211

MA/GAMC:

Adverse actions include denial, termination of benefits for 1 or more household members, or a decrease in benefits (increased spenddown). Most adverse actions require advance notice. Count the day of mailing a notice as the 1st day of the notice period. Count the day before the effective date of action as the last day of the notice period.

The effective date of action is 12:01 AM on the date listed on the notice. When an adverse action ends ongoing monthly benefits, MAXIS will use the 1st of the month as the effective date of action.

For timing of proposed denials, see §0916.07 (Notice of Processing Delays) and §0916.09 (Notice of Denial).

Most terminations and benefit reductions require a 10-day advance notice. MAXIS will issue a 10-day notice unless the worker overrides the notice.

Send 5-day advance notice if the agency verifies it should reduce or terminate benefits because of probable fraud by the household.

Send adequate notice (notice issued no later than the effective date of the action) when:

• A household submits a signed HRF (or a signed Recertification Form at recertification) with information requiring a change that you can determine solely from the HRF or the Recertification Form.

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EXAMPLE:

Boris's 6-month income review is due for October. He submits his HRF on September 25, with all pay stubs attached. The HRF and pay stubs show that Boris will not be able to meet a spenddown for the next certification period. Send notice of termination effective October 1, for failure to meet spenddown. The notice must be mailed no later than October 1.

Do not use adequate notice to reduce benefits or terminate a program when the client completes a CAF as an application for a new program and the ongoing program is not due for recertification.

EXAMPLE:

Alex receives GAMC. His next recertification is due for May. On February 23, he submits a CAF to apply for Food Stamps. The information on the CAF indicates he can no longer meet a spenddown for GAMC. Because the GAMC recertification is not due, Alex must receive 10 day notice of termination. Send notice of termination effective April 1.

• A household provides information in writing other than on a HRF or recertification and acknowledges in writing that the result will be reduction or termination of assistance. • Another state has approved the household for MA or GAMC for assistance for the same period. • People are admitted to institutions where they are no longer eligible for MA. See §0906.09.01 (Institutional Residence--MA/GAMC). • A household makes a WRITTEN request to terminate MA or GAMC. • Clients are approved for MinnesotaCare and pay the required premium. MMIS shows active status once clients have paid the premium.

You may send a notice of denial, termination, or an increase in spenddown AFTER the effective date of the action in the following situations:

• When a case opening is delayed until after the end of an eligibility period, such as after a 6-month spenddown period.

EXAMPLE:

Rhoda applies for MA using a disabled basis on October 31. She requests retroactive coverage to July 1. She submits all required information on December 27. The worker processes the application on January 3 and determines that Rhoda met a 6-month spenddown on July 17. Her 6-month eligibility period ended December 31. Open and close the case on MAXIS and MMIS. Rhoda will receive both approval and termination notices.

• When a court or DHS Appeals Office orders retroactive eligibility for a past period. • When you must adjust a past LTC continuing spenddown to reflect actual income. • When you have verified the client's death.

Do not send additional notice when a client appeals an action and the agency is upheld. The original notice and appeal decision are the client's notice.

Send notice of increased benefits (spenddown reduction) before the effective date of the action whenever possible. Clients are eligible for the increased benefits regardless of whether they receive advance notice.

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NOTICE OF TERMINATION OR CANCELLATION 0916.13

MinnesotaCare:

MMIS will generate a cancellation notice when:

• A premium has not been received by the cutoff date of the coverage month. • A renewal application has not been received by the cutoff date for the month in which it is due. • A representative enters information indicating the household is no longer eligible.

MA/GAMC:

MAXIS will generate a notice of termination or benefit reduction for each affected household member when you terminate eligibility or increase the spenddown. Notices must contain all information in §0916.03 (Content of Notices). MAXIS will include the appropriate reason code and authority based on the information you enter.

See §0916.11 (Timing of Notices of Adverse Action) for information on when notices must be sent.

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PREMIUM NOTICES 0916.15

MinnesotaCare:

See §0916.05 (Notice of Approval) for information on initial premium notices. MMIS generates monthly premium notices for all households on the cutoff date. The premium amount is based on the information MMIS has on income, household size, and number covered as of the date the notice is issued. Any changes entered after cutoff are reflected in the next month's billing.

MMIS generates replacement premium notices to change the premium amount when there is a change between the time an initial premium notice is generated and the initial premium payment is received. This occurs when:

• There has been a change in income which results in a change in premium since the initial premium notice was generated. • Someone is added to the household before the initial premium payment is received. • Someone is removed from the household before the initial premium payment is received.

MMIS generates overdue premium notices when no payment has been received by the premium due date.

EXAMPLE:

August premium notice is mailed on June 15. No payment has been received as of July 15. MMIS generates the premium notice for September with PAST DUE text included for the August premium and a Cancellation Notice for Non-Payment of Premiums effective July 31.

See §0913 (Premiums and Spenddowns).

MA/GAMC:

No provisions.

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NOTICE OF LATE OR INCOMPLETE HRF 0916.17

MinnesotaCare:

No provisions.

MA/GAMC:

MAXIS will send a notice of termination to clients who fail to submit a required Household Report Form (HRF). For missing report forms, MAXIS will send a notice at least 10 days before the effective date. For incomplete report forms, send the Notice of Late or Incomplete Household Report (DHS 2414). Include this information:

• When the HRF was received. • Which items were missing. • The requirement to complete the missing items and return the form. • The date by which the household must return the HRF. • What items of verification the household must provide.

If a client submits an incomplete HRF after receiving a notice of termination for late HRF, send a DHS 2414 with the information listed above. The client must submit all of the missing information before the effective date of termination for late HRF.

If clients who are required to report monthly sign or send in the HRF before the end of the month for which they were reporting, tell them on the termination notice to sign and date the form again. See §0905.07 (Monthly Reporting).

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HOMESTEAD EXCLUSION NOTICE - LTCF RESIDENTS 0916.19

MinnesotaCare:

No provisions.

MA:

Some clients in long term care facilities (LTCFs) are eligible for a homestead exclusion for 6 months. See §0909.13 (Real Property: Homestead).

If the LTCF Physician Certification Form (DHS 1503) says a client will be in the LTCF more than 6 months and the client does not meet 1 of the conditions for indefinite exclusion in §0909.13 (Real Property: Homestead), give written notification that the county agency will consider the value of the homestead against the asset limit when the 6-month exclusion ends. Give this notice when the client enters the facility or with the eligibility decision, whichever is later. However, give notice no later than the last day of the 5th month of residence in the LTCF.

Notify the client of asset reduction procedures. See §0909.29 (Excess Assets - Applicants) and §0909.29.03 (Excess Assets -Enrollees).

The notice must also contain the information listed in §0916.03 (Content of Notices).

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IEVS NOTICES 0916.21

MinnesotaCare:

No provisions.

MA:

At application and recertification, tell clients about the Income and Eligibility Verification System (IEVS). Use the Notice About IEVS (DHS 2759). MAXIS includes this notice with recertification packets.

When an IEVS report shows different information from the case record, contact the client for verification by generating an IEVS Difference Notice on MAXIS. Send the notice from the Verification Log Update (IULA and IULB) panels from REPT/IEVW, REPT/IEVC, or INFC/IEVP on MAXIS. The notice includes a release of information form.

• The client has 10 days to respond to and cooperate with verifying match information. Clients may provide proof of income received from the source listed in the notice or sign and return the release of information attached to the notice. • Do not send the IEVS Difference Notice if your county has written procedures allowing fraud investigators to resolve IEVS matches. The investigator will verify the information. • When the client cooperates, enter the code on MAXIS showing the client's response. • If you do not enter a code showing cooperation and 10 days have passed, MAXIS produces a message on the worker's DAIL/DAIL. The message tells you to close or deny the case and create a disqualification (DISQ) panel. The DISQ panel inhibits eligibility.

When ending, reducing, or denying eligibility based on an IEVS match, send the client a notice of denial or termination. See §0916.09 (Notice of Denial) and §0916.13 (Notice of Termination or Cancellation).

GAMC:

No provisions.

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MA OVERPAYMENT FROM IEVS MATCHES 0916.21.03

MinnesotaCare:

No provisions.

MA:

Review IEVS Matches for prior periods of eligibility for Medical Assistance cases. Follow current policy for all IEVS Matches. See §0916.21 (IEVS Notices) & TE02.12.10. (IEVS Wage Match: Wage Earner Discrepancy).

When an IEVS match resolution shows that an enrollee received unreported income or assets, redetermine eligibility for the affected eligibility.

Redetermine MA eligibility. Using the information from the IEVS Match, redetermine eligibility for all affected household members for the same budget period for which the IEVS Match showed the receipt of the unreported income and/or asset.

• If the information from the match does not affect past or future eligibility, enter a detailed case note. No further action is required. • If the redetermination results in future ineligibility, terminate eligibility providing a 10-day notice. See §0916.11 (Timing of Notices of Adverse Action). • If the information results in excess assets for past months, determine the months of ineligibility based on the excess assets. If the excess assets result in future ineligibility, allow the reduction of assets according to policy. If the enrollee reduces excess assets before the effective date of termination, eligibility may continue. See §0909.29.03 (Excess Assets—Enrollees). If the assets are not reduced, terminate eligibility providing 10-day notice. • If the information from the IEVS Match results in ineligibility or adverse changes in past months, determine the amount of the MA overpayment. • If the redetermination results in a manual monthly, automated monthly, or six month spenddown; determine if the spenddown could have been met based on income and medical bills. • Document detailed information in case notes.

Determine the amount of MA overpayment. Request a Claims History Profile. See MMIS User Manual, County Administered Program, Claims History Profiles, for more information.

• If there is ineligibility for past periods, request a Claims History Profile for that timeframe using DHS-2133 or through the Program Integrity Network (PIN). • When Claims history information is received, determine the amount of the overpayment for the ineligibility period. • The claims history will list the amounts the state has paid for medical services. It will indicate payments to medical providers or payments to managed health care plans depending upon whether the enrollee was fee-for-service or enrolled in a managed care health plan. • If the enrollee is enrolled in a managed health care plan, the overpayment is the amount of the capitation payment regardless of whether any services have been received.

Example:

Jim is disabled and enrolled in MA-Fee-For-Service (FFS) for the periods of 1/1/05 to 6/30/05 and 7/1/05 to 12/31/05. He receives Social Security income and reports assets totaling $2,500.

IEVS Match information: In 9/05 an IEVS match is received indicating Jim has an asset valued at $25,000 which the worker finds was never reported. The worker sends an IEVS Difference Notice. Jim contacts the worker and provides proof that he does have an available asset valued at $25,000 that he has owned since 1995 and forgot to report. His total countable assets going back to the first date his MA was opened total $27,500.

Required action: The worker determines that Jim is not eligible for MA currently, in the future nor was he eligible for MA at anytime he was receiving it in the past because his assets are more than the $3,000 limit. The worker sends a letter informing Jim he has to reduce his assets by 10/31 or his MA will close. Jim contacts the worker and states that he does not want to reduce the assets. On 10/10/05 the worker terminates eligibility due to excess assets because the assets were not reduced. MAXIS issues a 10-day notice to terminate MA effective 10/31/05 due to excess assets.

MA overpayment calculation: The worker requests a Claims History Profile. The profile shows that MA paid $5,200 in medical bills from 1/1/05 – 10/31/05.

The MA Overpayment is $5,200.

The worker fills out and mails DHS 4600 to Jim requesting repayment of $5,200.00. The worker puts a copy of the completed DHS 4600 in the case file and sends a copy to DHS. The worker enters a detailed case note in MAXIS.

Follow up information: Six days later Jim sends a check to the worker with payment of $5,200 to repay his MA overpayment. The worker sends the check to the accounting unit with a copy of the overpayment letter that instructs them to code the repayment as a Type IV recovery. The worker enters a detailed case note in MAXIS.

Example:

John is disabled and has been enrolled in MA since 1/1/05. He has also been enrolled in a managed care health plan since he went on MA. He receives Social Security income and reports assets totaling $2,000.

IEVS Match information: In 9/05 an IEVS match is received indicating John had stocks that were valued at $15,000 which the worker finds he never reported. The worker sends an IEVS Difference Notice. John contacts the worker and provides proof that he did have the stocks from 1/1/05 to 6/30/05 valued at $15,000 that he forgot to report. He provides proof that he lost the stocks when the company went bankrupt on 6/25/05. His countable assets going back to the first date his MA was opened through 6/25/05 totaled $17,000.

Required action: The worker determines that John was not eligible for MA from 1/1/05 through 6/30/05 due to excess assets. He continues to remain eligible for MA since he no longer has this asset and his current assets total $2,000.

MA overpayment calculation: The worker requests a Claims History Profile. The profile shows that capitation payments were made for John from 1/1/05 through 6/30/05 totaling $2,400.

The MA Overpayment is $2,400.

The worker fills out and mails DHS 4600 to John requesting repayment of $2,400. The worker puts a copy of the completed DHS 4600 in the case file and sends a copy to DHS. The worker enters a detailed case note in MAXIS.

Follow up information: Two years later John sends a check to the county with payment of $500 to repay part of his MA overpayment. The worker sends the check to the accounting unit with a copy of the overpayment letter that instructs them to code the repayment as a Type IV recovery. The worker enters a detailed case note in MAXIS.

When the redetermination results in a spenddown, or a higher spenddown, the amount of the overpayment is whichever is the lesser of:

• The spenddown amount minus any co-payments, out of pocket medical expenses or medical expenses not used in a prior spenddown.

OR

• The amount of the capitation payment.

Example:

Mae is over age 65 and has been enrolled in MA since 06/01/05. She is enrolled in a managed care health plan. Her counted assets total $1,300. She receives Social Security of $620.00 a month.

IEVS Match information: In 7/05 an IEVS match was received indicating Mae received a lump sum payment of $1,200. The worker sends an IEVS Difference Notice. Mae contacts the worker and provides proof that she did receive the income on 7/12/05 and forgot to report it. Mae told the worker that

she used the $1,200 to buy a car on 7/18/05 and gave the worker a copy of the title.

Required action: The worker determines that Mae was not eligible for MA during the month of July due to excess income. The lump sum payment did not result in excess assets in the month after receipt.

MA overpayment calculation: The worker requests a Claims History Profile for the month of 07/05. The profile shows that a capitation payment of $240.00 was made.

The MA Overpayment is $240.

The worker fills out and mails DHS 4600 to Mae requesting repayment of $240. The worker puts a copy of the completed DHS 4600 in the case file and sends a copy to DHS. The worker enters a detailed case note in MAXIS.

Follow up information: Two weeks later Mae sends a check to the county with payment of $240 to repay the MA overpayment. The worker sends the check to the accounting unit with a copy of the overpayment letter that instructs them to code the repayment as a Type IV recovery. The worker enters a detailed case note in MAXIS.

If redetermination results in a higher spenddown, request a claims history to determine if claims were paid during the month(s) of overpayment. If no claims were paid, there is no overpayment.

When the redetermination results in a higher spenddown, the amount of the overpayment is the increased spenddown amount minus the original spenddown amount. Deduct any co-payments, out of pocket medical expenses or medical expenses not used in a prior spenddown.

Example:

Joel is 19 years old and is living on his own and employed. He was enrolled in MA with a $100 six-month spenddown for the period 1/1/05 – 6/30/05. John was not enrolled in a managed care health plan.

IEVS Match information: In 9/05 an IEVS match is received indicating Joel received income that he did not report in 3/05 and 4/05. The worker sends an IEVS Difference Notices to Joel. Joel provides proof to the worker that he did have another temporary job and forgot to report the income.

Required action: The worker redetermines Joel’s eligibility during 1/1/05 – 6/30/05 which results in a higher six-month spenddown of $500. Joel did not have any out-of-pocket medical expenses or co-payments.

MA overpayment calculation: The worker requests a Claims History Profile for the period of 02/01/05 to 6/30/05. The profile shows that MA services totaling $1,700 were paid during this period.

The Amount of the Overpayment is $400 ($500 minus $100 = $400).

The worker fills out and sends DHS 4600 to request repayment for the $400.00 overpayment, puts a copy in the case file, and sends a copy to DHS. The worker enters a detailed case note in MAXIS.

If determination results in a higher MA-EPD premium, redetermine the amount of the premium based upon the information received from the IEVS match.

The overpayment amount is the redetermined premium amount minus the original premium amount. This overpayment does not affect current or future MA-EPD eligibility.

Example:

Bob is disabled and employed. He is enrolled in MA-EPD beginning 8/1/05 with a monthly premium of $50.

IEVS Match information: In 09/05, an IEVS match is received. The report shows income that was received in 8/05

and 9/05 that was not reported.

Action required: The worker sends an IEVS Match Difference Notice. Bob provides proof of the income that he forgot to report.

The worker redetermines Bob’s eligibility for 8/05 and 9/05 which results in a higher MA-EPD premium of $75 for each month.

MA-EPD overpayment calculation: A $25.00 overpayment has resulted for August and a $25.00 overpayment has resultedfor September ($75.00 {new premium amount}-$50.00 {previous premium amount} = $25.00 overpayment).

The worker fills out and sends DHS 4600 to request repayment of the $50.00 overpayment and puts a copy in the case record and sends a copy to DHS. The worker enters a detailed case note in MAXIS.

Document detailed information in case notes.

To request repayment of the overpayment, complete the Notice of Medical Assistance Overpayment, form DHS 4600 and mail the form to the enrollee. Retain a copy of the Notice of Medical Assistance Overpayment for the case record. Mail or fax a copy of this form to:

HCEA –IEVS

PO Box 64989

St. Paul, MN 55164-0989

FAX number: 651-431-7446

Follow your county’s current fraud procedures whenever fraud is suspected.

When repayment is received, forward all voluntary repayments to your county fiscal department for receipt along with the IEVS Notice of Medical Assistance Overpayment letter. The fiscal department should process the repayments in the same manner your county processes other recoveries, such as estate recoveries. The fiscal department should code this recovery as a TYPE IV-INELIGIBLITY- VOLUNTARY REPAYMENT.

GAMC:

No provisions.

CERTIFICATES OF CREDITABLE COVERAGE 0916.23

People who have received coverage under MA (with or without cash assistance), GAMC (with or without cash assistance), EMA, or MinnesotaCare are entitled to a Certificate of Creditable Coverage (COCC) when coverage ends. The COCC verifies receipt of health care coverage through the Minnesota Health Care Programs. It provides evidence of past coverage that may be used for the purpose of reducing the exclusion period that a new health plan imposes because of a pre-existing condition or to permit special enrollment in a health plan outside of an employer’s open enrollment period.

See §0910.11.03 (18-Month Rule) for more information on special enrollment allowed under the Health Insurance Portability and Accountability Act (HIPAA).

COCCs are available any time within 24 months after coverage ends, or before coverage ends if requested. MMIS issues COCCs automatically 2 months after eligibility ends. Enrollees may request COCCs before eligibility ends and up to 24 months after the end date. If you receive a request for a COCC, submit the enrollee’s full name, current mailing address, names of any dependents needing certificates and PMI numbers for each person requesting a certificate to:

SRU-COCC DHS

444 Lafayette Road

St. Paul, Minnesota 55155-3863

Interoffice mail code 3863

MAXIS E-Mail: MADE

Phone: (651) 431-3205 or 1-800-657-3762

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