Health Plan Enrollment Management in MMIS

This section describes the MMIS screens used to record and manage health plan enrollment information and how to update health plan enrollment in MMIS for certain situations.

Page contents

· ONEsource Procedures

· Managed Care Organization ID

· MMIS Managed Care Screens

· MMIS Coding for Certain Situations

· Adding enrollees to open cases

· Newborn enrollment

· Case transfers

· Emergency Medical Assistance (EMA) eligibility

· Long Term Care – North Dakota interstate agreement

· Major Program NM (NMED)

· Transitional Medical Assistance and Transition Year Medical Assistance

· MMIS Case Notes

· MMIS Managed Care Edits

ONEsource Procedures

· Health Plan Enrollment Process

· Add Health Plan Enrollment

· Edit Health Plan Enrollment

· Edit a Future Health Plan Enrollment Span

· Adding and Ending Exclusions

Managed Care Organization (Health Plan) ID

Each health plan is assigned a ten-character Unique Minnesota Provider Identifier (UMPI) number. UMPI or health plan contract numbers can be found in the RPPH page of the MMIS user manual.

MMIS will only accept health plans with a contract for service in the county of residence.

MMIS Managed Care Screens

The following are brief descriptions of the MMIS screens processing entities use to manage and review health plan enrollment information. Refer to the MMIS User Manual for more detailed information.

· RCHP

DHS staff record health plan enrollment information in the RCHP screen. Use the RCHP screen to view case-based enrollment information including the current case default health plan and previous health plans.

· REFM

Processing entities complete the REFM screen after they enter a health plan in the RPPH screen. They enter the enrollee’s clinic choice and responses to the health plan enrollment form questions on this screen and MMIS sends the information to the health plans electronically. The “Date Sent” field indicates when MMIS sent the information to the health plan. Note: If the enrollee wants to change their clinic choice, refer them to the health plan.

· RENR

Processing entities use the RENR screen to build an enrollment or exclusion span on the RPPH screen when the enrollee is not already enrolled or excluded. Processing entities can only access RENR through direct navigation when they first enter a case into MMIS. Enter the health plan’s UMPI number or an exclusion reason code and transmit. MMIS will build a health plan enrollment span for the next available month, based on cut-off, or it will add an exclusion code for the current month. Once the processor transmits from the RENR screen, they are unable to return as the RENR screen does not store any information. MMIS then opens the RPPH screen to view and verify the information coded on the RENR screen. Processing entities make changes to enrollment or exclusion information on the RPPH screen.

· RLVA

Processing entities use the RLVA screen to update an enrollee’s living arrangement. Common living arrangements are community, a nursing facility, a group home, and a correctional facility. Record and update long-term care (LTC) eligibility information on this screen using P-and-U spans. DHS enters a P span to notate when a health plan is liable for covering LTC services. The U spans indicate an enrollee has yet to be determined eligible for long term care services. The county or tribe is responsible for ending or deleting U spans based on the information they receive from the enrollee or Authorized Representative on the Request for Payment of Long-Term Care Services (DHS-3543) form.

· RPPH

Processing entities use the RPPH screen to record health plan enrollment and exclusions. Enrollment spans must conform to Managed Care Key Dates. Most exclusions are effective the first day of the next available month. If an exclusion is needed for a past date, send an HPEN ticket.

· RTRK

The RTRK screen manages the enrollment process in MMIS. Processing entities must update the RTRK screen for all enrollees on the same case at the same time. If the enrollee’s eligibility is not open, the processing entity uses this screen to record the type of health plan education the enrollee received and enrollment form information. This screen also shows the number of processing days the enrollee has been in the tracking process listed by the counter number. Find detailed information about the RTRK screen on the Tracking System within MMIS section on the Education and Enrollment page of the Minnesota Health Care Programs (MHCP) Managed Care manual.

MMIS Coding for Certain Situations

This section describes when to update health plan enrollment for certain situations.

Adding Enrollees to Open Cases

When adding an enrollee to an active Medical Assistance (MA) health care case, determine if the enrollee meets an exclusion reason. If the enrollee meets an exclusion reason, enter the appropriate exclusion code on RPPH for the next available month.

If the enrollee does not meet an exclusion reason and:

1. They have not been enrolled in a health plan in the past 12 months or their previous health plan is not available in their county of residence:

· Add a YY exclusion on RPPH for the next available month.

· Review Education and Enrollment page for more details.

· See Newborn Enrollment for instructions specific to newborns.

2. They have been enrolled in a health plan in the past 12 months and the same health plan is still available:

· Reinstate or reenroll them on their previous plan.

· Review Reinstatement and Reenrollment page for more details.

When adding an enrollee to an active MinnesotaCare (MCRE) case, the enrollee will be systematically enrolled in the same health plan as other MCRE household members.

Newborn Enrollment

All children born to a woman on MA are eligible to be added to the mother's case as an auto newborn for the month of birth, including children who are placed for adoption immediately.

Review the Add Health Plan Enrollment page in OneSource for instructions on updating the RPPH screen.

Newborns must be enrolled in a health plan unless they meet an exclusion reason. If they meet an exclusion reason, update RPPH with the appropriate exclusion code.

If the newborn does not meet an exclusion reason:

· And the mother was not enrolled in a health plan at the time of the child’s birth:

The processing entity will enroll the newborn in the case default health plan for the next available month or track for enrollment if no other household members are enrolled.

· And the mother was enrolled in a health plan during the birth month, but that plan is not available to MA enrollees in the county of residence:

The processing entity will enroll the newborn in the default health plan for the next available month or add a YY exclusion and track for enrollment if no other household members are enrolled.

Example: A baby is born to a mother who is enrolled in a Special Needs BasicCare health plan. This health plan is not available to MA enrollees in the county of residence. Enroll the newborn in the same plan as other MA members in the household or add a YY exclusion. The newborn’s coverage will be fee for service (FFS) for the birth month.

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

The processing entity will enroll the newborn in the same health plan effective the first day of the month of birth using the following guidance:

If eligibility for the newborn is added within 90 days from the birth:

· Retroactively enroll the newborn in the same health plan the mother was enrolled in for the birth month and all succeeding months unless a health plan change is requested.

· If a health plan change is requested for the newborn, enroll them in the same plan as the mother for the birth month and the new plan for the next available month. This may result in some months being FFS coverage.

· Example 1: A baby is born on June 7 and is reported to the processing entity on Aug. 30, after capitation. The mother was enrolled in HealthPartners in June but changed enrollment to Blue Plus on July 1. Enroll the newborn in HealthPartners for June, to match mom’s enrollment, and then enroll them in Blue Plus for the next available month which is Sept. 1, with no end date. The newborn’s July and August coverage will be FFS.

· Example 2: A baby is born on June 7 and is reported to the processing entity on July 30, after capitation. The mother was enrolled in HealthPartners in June but is requesting the newborn be enrolled in Blue Plus for the next available month. The mother also requested the plan change on July 30. Enroll the newborn in HealthPartners for June 1 through Aug. 31 and Blue Plus for the next available month which is Sept. 1, with no end date.

If eligibility for the newborn is added after 90 days from the birth:

· Add the newborn to the same health plan the mother was enrolled in for the next available month based on managed care cut-off unless a health plan change is requested.

· If a health plan change is requested for the child, allow the change for the next available month based on managed care cut-off.

· Send an HPEN ticket to request an adjustment to enroll the newborn for the birth month.

· There will be a break in health plan enrollment, covered by fee-for-service, between the birth month and the next available month.

MCRE newborns will be enrolled in the same health plan as all other MCRE household members.

Case Transfers

Do not update RPPH before transferring a case to another processing entity.

Enrollees who have moved to a new county where their current health plan is not available are identified on the Potential Enrollee Report (report number MW0506) and on the Capitation Error Report (report number MW0510) with the error message, “(product) (date), 001- health plan/product not available in county of residence”.

Processing entities must make every effort to avoid a gap in health plan enrollment. If this is not possible, fee-for-service will cover intervening months if there is medical eligibility.

Emergency Medical Assistance (EMA) eligibility

Emergency Medical Assistance enrollees are excluded from managed care. They are identified on the RELG screen in MMIS by the Major Program type EH, RM, or EC. Processing entities do not need to add an exclusion code for these Major Program types.

Helpful links:

· Process Applications for Emergency Medical Assistance Application (EMA) - OneSource processing instructions

· Emergency Medical in MMIS user manual

Long-Term Care – North Dakota interstate agreement coding instructions

When a Minnesota resident moves to a North Dakota nursing facility from Minnesota they are still a Minnesota resident.

Keep the enrollee’s MA enrollment open and update the residential county code to 89.

· These are considered excluded time cases, so processing entities must enter the correct county of financial responsibility on the RELG screen.

· For detailed instructions, refer to POLI/TEMP in MAXIS.

· Find details on policy and timelines in the MHCP Eligibility Policy Manual (EPM) section 1.4.1 MHCP Interstate Residency Agreements

Major Program NM (NMED)

Major Program type NM (NMED) on the RELG screen in MMIS is an MA program that is mostly federally funded under the Children’s Health Insurance Program (CHIP), which covers pregnant women and infants under age 2 who are undocumented or are noncitizens otherwise eligible for MA.

NMED also covers a small number of adults age 21 and over who are not covered by CHIP. Eligibility and covered services mirror MA.

People who may be eligible for NMED are defined in Minnesota Statutes, 256B.06, subd. 4.

Enrollees eligible for medical benefits through NMED must be enrolled in a health plan.

Transitional Medical Assistance (TMA) and Transition Year Medical Assistance (TYMA)

Enrollees who become eligible for TMA or TYMA must continue to be enrolled in a health plan.

· When an enrollee is changing eligibility status due to TMA or TYMA and health plan coverage exists, do not change the coding until the case closes.

· When the case closes, the system will enter the health plan end date on the RPPH screen and MMIS will send a disenrollment notice. These cases will be listed on the county Capitation Error Report.

MMIS Case Notes

It is important for processing entities to enter case notes in the FCSN screen in MMIS to track various health plan changes and the reasons for those changes. For more detailed instruction on how to enter a case note in MMIS refer to the MMIS User Manual.

Examples of when to enter a case note in MMIS:

· Initial health plan enrollment

· Multiple exclusion reasons

· Adjustment requests

· Change of health plans

· Denial of a health plan change

· Newborn enrollment requests

· State Appeal information related to health plan enrollment

· County adjustment request has been modified or denied

· Unable to complete adjustment request due to system problem

MMIS Managed Care Edits

If a processing entity enters incorrect health plan information into MMIS, an edit message may appear. An edit is an informational message in MMIS that details the reason a change is not allowed. Review the list of MMIS edits on the Edits page of the MMIS User Manual for more information.

If you cannot find the edit in the MMIS User Manual, submit an HPEN ticket via SIR to DHS for resolution. Be sure to include the full text of the edit and a description of the change or update you were trying to make.