Title XIX of the Social Security Act (SSA), SSA §1915, SSA §1915(b), SSA §1915(c), SSA Ch. 1115, 42 CFR part 434, 42 CFR part 438, Minn. Stat. Ch. 256L, Minn. Stat. §256B.69, subd. 23 and 28, Minn. Stat. §256B.692

Managed care: A health care delivery system that provides a wide range of health care services by using a preferred provider network, offering preventative incentives and using care coordination to improve health care outcomes for people. It emphasizes preventative care and addresses health care concerns that are important to and for the person. Enrollment may be voluntary or mandatory.

Medical spenddown: Situation in which the person pays for medical services, including prescriptions, generally on a monthly basis. Some people who have more income than the MA income limit allows may become eligible by spending down to the income limit. The spenddown dollar amount (similar to an insurance deductible) becomes the person’s financial responsibility before the Minnesota Health Care Program (MHCP) payment can be made. For more information, refer to MHCP Eligibility Policy Manual – Medical spenddown.

Institutional or long-term care (LTC) spenddown: Situation in which the person pays a portion or all of their institutional daily charges. For more information, refer to MHCP Eligibility Policy Manual – Medical spenddown.

Elderly Waiver (EW) obligation: Situation in which the person pays a portion or all of their EW service costs. For people enrolled in a senior managed care program, managed care organizations (MCOs) pay providers minus the waiver obligation, and the provider bills the person. The person cannot use a designated provider for waiver obligations. For more information, refer to MHCP Eligibility Policy Manual – Medical spenddown.

DHS contracts with MCOs to provide health care to eligible people. Through these contracts, DHS pays the MCO a monthly amount to provide services to the people they serve.

Minnesota offers three main managed health care programs under MA for special populations:

1. Minnesota Senior Care Plus (MSC+): A mandatory managed care program for people age 65 and older. This program does not coordinate Medicare services, but the person may have Medicare plans.

2. Minnesota Senior Health Options (MSHO): A voluntary managed care program for people age 65 and older who are also enrolled in Medicare Parts A and B. This program combines MA and all Medicare A and B benefits, drugs and other services into one coordinated plan.

3. Special Needs BasicCare (SNBC): A voluntary managed care program for people ages 18-64 with a certified disability. There are two programs within SNBC:

MSC+

MSC+ is a mandatory program available to people who:

MSHO

MSHO is a voluntary program available to people who:

SNBC

SNBC is a voluntary program available to people who:

People age 65 and older

If a person has an institutional spenddown or waiver obligation, they may be enrolled in MSC+ or MSHO.

If a person has a medical spenddown, they cannot enroll in MSC+ and must be managed by a fee-for-service entity.

If a person is enrolled in MSHO without a medical spenddown and later gains a spenddown, they can remain enrolled as long as they pay their monthly spenddown to DHS. DHS will bill the person for their monthly spenddown and include information about the payment rules with the first bill.

If a person has a medical spenddown and is on SNBC, they have one opportunity to enroll in MSHO when they turn 65.

People age 18-64

A person cannot enroll in SNBC if they have an existing medical spenddown or institutional spenddown. If a person is enrolled in SNBC without a spenddown and later gains a spenddown, they can remain enrolled as long as they pay their monthly spenddown to DHS. DHS will bill the person for their monthly spenddown.

A person can enroll in SNBC if they are on Medical Assistance for Employed People with Disabilities (MA-EPD). If a person loses their MA-EPD eligibility and gains a spenddown, they may remain enrolled in SNBC as long as they pay their monthly spenddown to DHS.

If the person does not pay their spenddown for three months, they will be disenrolled from SNBC and will receive their health care through fee-for-service MA. The three months do not need to be consecutive.

Once disenrolled from SNBC, the person has 90 days from the date of disenrollment to pay the outstanding spenddown balance to DHS. Paying the entire balance within these 90 days allows the person to reenroll in SNBC.

If the person pays their entire owed spenddown within three months of disenrollment, they must call Health Care Billing at 651-431-3205 or 800-657-3762 to inform DHS that they have paid the entire balance due.

If it has been more than 90 days since a person has been disenrolled from SNBC, they cannot enroll in SNBC until they no longer have an ongoing medical spenddown and have paid the outstanding balance of the previous spenddown.

A person may disenroll from managed care for several reasons:

Note: During any period of time between disenrollment and reenrollment in managed care, the person remains eligible for fee-for-service MA.

DHS – Health plan member services phone numbers
The Office of Ombudsperson for Public Managed Health Care Programs
Disability Hub MN
Senior LinkAge Line

DHS – Managed care model contracts