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Managed care and MMIS

Page posted: 8/3/26

Medical Assistance (MA) is Minnesota's largest health care program. It serves children and families, pregnant women, adults without children, older adults and people who are blind or have a disability. There are three general health care purchase and delivery models in Minnesota:

· Fee for service (FFS).

· Managed care (also called prepaid MA).

· Mixed model, in which some services are through managed care and others through FFS.

People who access home and community-based services (HCBS) waiver services may receive services through managed care, FFS or the mixed model.

Overview of models

FFS

People who are not enrolled in managed care for MA services get care on an FFS basis. Providers bill the state directly for services they provide. Some services require prior authorization or a service agreement for provider payment.

Managed care

Most people who have MA get their health care through managed care organizations (MCOs), which are also called “health plans.” Enrollment in managed care is mandatory for some MA-eligible populations.

Managed care products differ in the benefits they provide and the MA populations they serve. For example, families and children are served through a different managed care product than people age 65 and older. For more information about these products, refer to MMIS LTSS Manual – Managed care products.

MCOs must have an approved contract with DHS to enroll people and provide services. Choice of MCO and products vary based on the person’s location.

MCOs use the long-term care (LTC) screening document. However, MCOs do not use the DHS service agreement system to authorize and pay for services included in the MCO’s benefit set. Instead, the MCO authorizes services and pays providers using its own provider authorization and payment system for services.

Mixed model

Through the mixed model, people are served under a combination of FFS and MCO-provided benefits. For example, people enrolled in an MCO under the Families and Children product receive personal care assistance (PCA) services on an FFS basis. Some FFS services require prior authorization or a service agreement for provider payment.

Enrollment and disenrollment

For information about finding enrollment information and reasons for disenrolling, refer to MMIS LTSS Manual – Managed care enrollment and disenrollment.

LTC screening document

For MCO-specific instructions to use the LTC screening document, refer to MMIS LTSS Manual – Managed care use of the LTC screening document.

Relocation and transition assistance

For instructions related to relocation and transition assistance, refer to MMIS LTSS Manual – Relocation and transition assistance.

Disability waivers

People age 65 and older who enroll in Minnesota Senior Health Options (MSHO, product ID MA02) or Minnesota Senior Care Plus (MSC+, product ID MA30) may continue on their Brain Injury (BI), Community Alternative Care (CAC), Community Access for Disability Inclusion (CADI) or Developmental Disabilities (DD) waiver programs. The county/Tribal Nation case manager will continue to manage the waiver support plan and FFS waiver service agreements.

The waiver case manager and the MCO care coordinator use Managed Care Organization, County Agency and Tribal Nation Communication Form – Recommendation for State Plan Home Care Services, DHS‑5841 to facilitate communication about home care services that may be part of the person’s support plan.