Adjustments

Revised: August 3, 2026

An adjustment occurs when a managed care capitation payment is added, changed, or removed. Changes made to a health care case can impact health plan enrollment. Many of these changes are completed automatically by MMIS. In some cases, a processing entity needs to report the change by sending an HPEN (Health Plan Enrollment) ticket in SIR to request an adjustment. This section will outline when an adjustment request is necessary.

System Problems

Report MAXIS systems problems to:

· Transition Support Systems (TSS) Help Desk 651-431-4100

· Toll Free 1-800-383-7987

· TSS Help Desk Request Web Form in SIR

Report MMIS or METS systems problems to:

· Health Care Eligibility System Support (HCESS) 651-431-3930

· Toll Free 1-800-366-7894

· HCESS Request Form in SIR

Requesting an Adjustment

County and tribal staff, the state ombudsperson, health plans, or MinnesotaCare staff can file adjustment requests. A request is not a guarantee of adjustment. The Minnesota Department of Human Services (DHS) will review all adjustment requests before a decision is made.

Health plans should request adjustments using already established communication methods. All other processing entities should request adjustments via HPEN ticket in SIR.

Please include the following when requesting an adjustment:

· Case name and case number

· Enrollee name

· Person master index (PMI) number

· Dates for which adjustment is being requested (month/year)

· Pay or recover from health plan

· Name of the health plan to or from which payment or recovery should be made. Include the 10-digit health plan contract number if possible

· Briefly, but concisely, explain the reason for the request

· For inpatient stays include:

· the date of admission into the hospital

· the date of discharge from the hospital (if applicable)

· Facility national provider identifier (NPI) number

· For incarcerations include:

· the date of incarceration and

· the actual or expected release date. If an expected release date is not known, enter 12/15/40 in the request

· Correctional Facility Code (refer to RLVA for codes)

In certain instances, DHS will notify the requestor to correct the coding in MMIS before an adjustment can be made. If coding is not corrected, the adjustment will be denied, possibly resulting in reduced or no service to the enrollee and billing problems.

If an adjustment is approved and processed as requested, the payment or recovery claim listed on the remittance advice will be the only notice that DHS sends to the health plan.

If an adjustment request has been modified or denied, DHS will respond to the person submitting the request in the same format the request was received.

An adjustment will be denied or delayed if:

· Coding is incorrect (counties and tribes will be notified to correct coding if appropriate).

· The request is for an unreasonable length of time or not timely.

· Not enough information was given.

· The adjustment was not requested within one year after payment was received or should have been received by the health plan.

Adjustment Types

There may be situations that do not fit any of the policy examples in the following list. If you have a case that does not fit the policy example or you think is different, please send an HPEN ticket and DHS will review the case.

Continuity of Care

DHS will determine if the enrollee qualifies for a continuity of care change option and then approve adjustments on a case-by-case basis. Refer to the Continuity of Care section of the Changing Health Plans page for details on when to request a continuity of care change.

Coding Error

The processing entity reviews each situation on an individual basis to determine if there is need for an adjustment. If it is determined that an adjustment is necessary, the processing entity will follow the guidance in the Agency Error section of the Changing Health Plans page.

Good Cause

DHS approves good cause adjustments on a case-by-case basis. Refer to the Good Cause Changes section of the Changing Health plans page for details on when to request a good cause change.

Incarceration

When an enrollee is involuntarily confined in a correctional facility an adjustment may be needed. Refer to the JJ exclusion in the Exclusion Codes section of the Exclusions page to determine when to send an HPEN ticket.

Prepaid Medical Assistance Program (PMAP), Minnesota Senior Care Plus (MSC+), Minnesota Senior Health Options (MSHO), and Special Needs BasicCare (SNBC)

· DHS will update the RPPH screen in MMIS by:

· ending the enrollment span for the end of the month in which the enrollee was incarcerated.

· adding a JJ exclusion for the first full month of incarceration

· and requesting an adjustment to recover capitations paid to the health plan.

Example: A PMAP enrollee is incarcerated on 6/5 with an expected release date of 12/3. On 8/15 the county reports the incarceration to DHS via HPEN ticket.

· DHS will enter a JJ exclusion with a start date of 7/1 and will request an adjustment from the health plan to recover July and August capitation.

· The JJ exclusion will remain in place for the duration of the incarceration.

· The processing entity must send a new HPEN ticket after confirming the enrollee has been released from incarceration. DHS will then end the JJ exclusion.

· MinnesotaCare

· MinnesotaCare enrollees who are awaiting the court’s determination of charges, also known as pending disposition of charges, remain eligible for MinnesotaCare.

· Once the enrollee has been sentenced to jail, enrollment will end on the last day of the month their incarceration begins. An applicant residing in a correctional or detention facility is not eligible for MinnesotaCare.

Example: A MinnesotaCare enrollee is incarcerated on June 5 but is awaiting sentencing. On June 15, the enrollee is sentenced to incarceration until December 3. Their enrollment in MinnesotaCare will end on June 30.

Newborn Enrollment

Newborns born to a mother enrolled in a health plan for the month of birth will be retroactively enrolled in the same health plan, unless the mother’s health plan is not available to Medical Assistance (MA) enrollees, or the newborn meets an exclusion reason (refer to Exclusions page). Instructions on updating MMIS to add a newborn to a health plan are on the Health Plan Enrollment Management in MMIS page of this manual.

· If the mother was not enrolled in a health plan at the time of the child’s birth, or the mother’s health plan is not available to MA enrollees:

· The newborn must be added to the case default health plan for the next available month or tracked for enrollment if no other household members are enrolled. An adjustment request is not needed.

· If the mother was enrolled in a health plan during the birth month and the health plan is available to MA enrollees:

· And the newborn is enrolled in the health plan on MMIS within 90 days of birth, the processing entity will enter the health plan enrollment span and the health plan will be paid retroactively for the birth month and all succeeding months unless a health plan change is requested.

· If a system error prevents the processing entity from enrolling for the birth month, send an HPEN ticket with the names and PMIs of the newborn and the mother to request an adjustment to pay the health plan and enroll the newborn for the appropriate month(s).

· If the newborn is not enrolled into the health plan in MMIS within 90 days, the health plan will be paid retroactively for the birth month only. The processing entity should enroll the newborn for the next available month and send an HPEN ticket with the names and PMIs of the newborn and the mother to request an adjustment to pay the health plan and enroll the newborn for the birth month only.

· If a health plan change is requested for the newborn, allow the change for the next available month.

For MinnesotaCare newborns, also follow this policy. However, since health plan enrollment is case based for MinnesotaCare, no change option is available to the newborn unless the case has a change option available to all MinnesotaCare enrollees.

Overlapping MinnesotaCare and MA Spans with Elderly Waivers (EW)

Elderly Waivers (EW) can be administered through both the fee for service (FFS) model and managed care. When an enrollee is enrolled in MinnesotaCare and is assessed for MA mid-month, resulting in overlapping MinnesotaCare and MA spans, and if the enrollee is eligible for an EW, workers must take special action.

Submit an HPEN ticket. DHS will consult with the contract manager. The contract manager will follow up with the health plan. One of two things will occur:

· The health plan agrees to allow the enrollee to be converted to an MA product.

· The health plan will be responsible for paying the EW claims.

· DHS will:

· Update RPPH so that the enrollee’s coverage is changed from a MinnesotaCare product to an MA product.

· Contact the county worker to have RSPL updated if it shows the enrollee as having a medical spenddown.

· The county worker must update RSPL to allow changes to be entered on RPPH.

· Recover the capitation payment for the month in question.

· The health plan does not agree to allow the enrollee to be converted to an MA product.

· DHS will pay EW claims through FFS.

· DHS will:

· Update RPPH to remove MinnesotaCare coverage for the month in which the enrollee has overlapping eligibility.

· Recover the capitation payment.

System Error

If the system prevents or inaccurately enrolls an enrollee into a health plan, contact DHS by sending an HPEN ticket.

Changes that do not require an adjustment request

Certain changes to a case can impact health plan enrollment but do not require an adjustment. An HPEN ticket does not need to be sent in these situations.

Address Change

· If a change in address involves a change in county of residence, the processing entity must be sure to complete all eligibility updates and changes in circumstance before changing the case address.

· This is important to avoid potential MMIS edits that would apply to the new county of residence. The transferring county will no longer be able to update MMIS after the case has been transferred.

· It is not necessary to update the RPPH screen. MMIS will redetermine health plan availability for the new county of residence at the next capitation after the move.

Example 1

The enrollee contacts the processing entity on 4/5 stating they are going to move to a new county on 5/1. The processing entity updates the address according to current instructions for the applicable eligibility system.

· If the enrollee’s health plan is available in the new county, the current enrollment span on RPPH remains open and there will be one continuous span for both counties.

· If the enrollee’s health plan is not available in the new county, the system enters a 4/30 end date to the enrollment span on RPPH at the next capitation run. These enrollees will be reported on the new county’s PPHP Potential Enrollee Report (MW0506).

Example 2

· The enrollee contacts the processing entity on 4/29, after managed care cut-off, to report their move out of state. They request their case be closed as soon as possible.

· Since the capitation payment has already been issued to the health plan for next month (May), the earliest the processing entity can end health plan enrollment is 5/31, the last day of the next month.

Basis of Eligibility or Major Program Change

When there is a change in major program or eligibility type which affects health plan enrollment, the worker enters the health plan change on MMIS effective the next available month.

The health plan is responsible for covering the benefit set they received a capitation payment for. That benefit set is shown in the product ID column on RPPH. Services covered by the increased benefit set should be submitted to DHS on a FFS basis. There will not be adjustments in these situations.

Example
A MinnesotaCare enrollee is active with an Adult Without Children Basis (BB) for January, February, and March.

On March 10, the enrollee provides documentation regarding her pregnancy. The documentation confirms the date of conception was in January.

The processing entity redetermines the enrollee’s eligibility and she is now eligible for major program MA with a Pregnant Woman (PX) basis.

Her MA PX eligibility appears on the RELG screen with an effective date of 1/1.

The system will automatically add a new health plan enrollment span to RPPH with an MA product ID with an effective date of 4/1.

Providers will bill DHS on a FFS basis for any services not covered by the “BB” capitation rate.

Death

When medical eligibility is terminated due to death, capitation payments issued for any months following the month of death must be recovered. Death adjustments do not need to be requested. DHS identifies and recovers any capitation claims after the date of death through a monthly MMIS report.

· The servicing agency should ensure eligibility is closed on RELG with the date of death and Status: C Reason: 20

Enrollment Form Error

When an enrollee makes an error on their enrollment form, the enrollee must complete a new enrollment form. After a new enrollment form is received, the processing entity enters the correction in MMIS effective the next available month. There will not be adjustments in these situations.

Note: For any system-related problems associated with system-maintained enrollment form information, send an HPEN ticket.

Inpatient Hospitalization

· Inpatient at Time of Enrollment Guidelines

· Enrollees receiving Inpatient Hospitalization services on the first effective date of enrollment will be enrolled according to regular procedure.

· All charges related to inpatient hospitalization services for any enrollee on the effective date of enrollment will not be the responsibility of the new health plan or FFS.

Note: The payer that is responsible on the day of the admission to the inpatient hospital facility is the responsible payer for that inpatient stay and remains responsible until the patient is discharged from the admitting facility. The discharge that triggers the change in payer can be to any number of other facilities or settings.

· Inpatient at Time of Health Plan Change or Termination

· All health plan contracts specify when termination takes place due to:

· ineligibility for MA or MinnesotaCare

· or the enrollee becomes ineligible for participation in the health plan and

· the enrollee is receiving Inpatient Hospitalization services on the effective date of ineligibility

Health plan coverage of the inpatient hospital services and associated ancillary services shall cease at midnight, central standard time, on the first day following discharge from the hospital.

DHS will not pay the health plan a capitation payment for any month after the month in which the enrollee’s enrollment was terminated. Providers must include actual dates for admission and discharge in the documentation for DHS to make the capitation payment.

Payment Application Error

If the MinnesotaCare premium payment is applied to the wrong obligation, it may result in either a delay in enrollment or a nonpayment cancellation. If this happens and the enrollee is given retroactive MinnesotaCare eligibility, the enrollee will have FFS coverage for the retroactive month(s).

Placements in State Institutions

Enrollees who are in a state institution, including regional treatment centers (RTC), institutions for mental disease (IMD), and state-operated long-term care facilities are enrolled in a health plan unless they meet one of the following exceptions:

· They have been admitted to a residential facility that is excluded from managed care.

· Refer to OneSource or the MMIS User Manual for a list of excluded facilities.

· The enrollee qualifies for any other exclusion (such as, Disability opt out, Medical Spenddown, etc.)

· Refer to Exclusions page.

· Adjustments will not be made for placement in IMDs or residential treatment facilities.

· Health Plans will report admit and discharge dates to DHS.

Example 1: Applicant applied today. They are not enrolled in a health plan nor have they ever been enrolled in a health plan. They reside in an IMD facility that is not on the residential treatment facility list. Enter a YY exclusion to begin tracking. Send an HCESS Request Form.

Example 2: Enrollee is enrolled in a health plan and enters an IMD. Add a case note in the eligibility system and stop.

Example 3: Enrollee is FFS in May and is scheduled to be enrolled in a health plan on June 1. Enrollee enters an IMD in May. Allow the enrollee to enroll into managed care. Send an HCESS Request Form for the May stay. No actions needed for June forward.

Reinstatement

If the processing entity reestablishes the enrollee’s eligibility before the managed care enrollment cut-off date, the system will reinstate the enrollee for that month with no lapse in coverage. The processing entity must enter eligibility into MMIS on or before the last working day of the month. This is an automatic process and will result in an appropriate retroactive capitation payment. Processing entities will not need to request an adjustment.

Third Party Liability (TPL)

For enrollees who have third party liability, the health plan must coordinate benefits in accordance with Minnesota Rules, 9505.0070 and Minnesota Statutes, 62A.046. There will be no adjustments in these situations.