Exclusions

Revised: February 23, 2026

This page contains general information regarding exclusions. Processing entities must use current procedural guidance in ONEsource when it is available for a specific exclusion or case scenario.

Processing entities exclude enrollees from health plan enrollment for various reasons. MMIS also excludes enrollees systematically in some situations. These enrollees receive health care through fee for service (FFS) which means the provider submits claims directly to the Minnesota Department of Human Services (DHS) for payment for health care services. Not all exclusions are mandatory. Use the Exclusion Codes chart to determine if an exclusion is voluntary or mandatory.

Exceptions:

· Emergency Medical Assistance (EMA) does not require an exclusion. MMIS does not enroll EMA enrollees into a health plan.

· MinnesotaCare does not allow exclusions.

If an enrollee meets the program requirements for an exclusion, the county or tribal health care worker enters an exclusion code on the MMIS RPPH screen, effective the first day of the next available month. If the exclusion reason changes or ends, the worker enters an end date for the current exclusion span, effective the last day of the current month. If a worker is unable to enter an exclusion code or has other health plan enrollment questions, they should submit a Health Plan Enrollment (HPEN) ticket in SIR for DHS to resolve.

Refer to the following MMIS User Manual pages for further information about exclusion codes.

· Managed Care – Recipient is Excluded from Managed Care – contains details regarding entering exclusions in MMIS.

· RPPH – Lists descriptions of codes used on the RPPH screen in MMIS.

· Edits – Lists possible edits or error messages in MMIS and how to resolve them.

Exclusion Hierarchy

If an enrollee meets more than one of the exclusions on the following hierarchy guide, use the highest-ranking exclusion.

Example: if an enrollee has an HH exclusion code in the system and then becomes incarcerated, DHS will end the HH exclusion and enter a JJ exclusion code for the following month.

If an enrollee meets two or more exclusions that are not on the hierarchy guide, use the exclusion that is expected to last the longest. There may be some situations that fall outside of the scope of the guide and will need to be evaluated on a case-by-case basis using guidance available in ONEsource.

Hierarchy Guide:

· TA – Temporarily absent

· JJ – Incarceration

· DO – Disability opt out

· AB – Medicare Part A or Part B only

· II – Breast and cervical cancer

· SS - Medical spenddown

· ZZ – Regional treatment center (RTC) or institution for mental diseases (IMD) resident

· HH - Private HMO coverage that is determined to be cost effective health insurance (CEHI)

· All other exclusions

Exclusion Codes

Code	Exclusion Description	Updated By	Voluntary or Mandatory Enrollment	When to Use
AA	Adoption Assistance	County, tribe or DHS	Voluntary	Children in subsidized adoption · Must have eligibility type 09 or 10 · If a foster care child enrolled in a health plan moves to Adoption Assistance, to avoid continuity of care issues, leave the child enrolled in the health plan, unless the parents specifically request to have the child excluded.
AB	Medicare Part A Only or Medicare Part B Only	DHS	Mandatory	Enrollees under 65 years of age who are eligible for Medical Assistance due to blindness or certified disability. · Used for Special Needs BasicCare (SNBC) · Do not use this exclusion if the enrollee has both Medicare Part A and B
BB	Blind or Disabled Under 65	County, tribe or DHS	Mandatory	Use this exclusion for children under the age of 18 with a disability eligibility basis. Or To ensure that enrollees between the ages of 18 and 64 with a disabled eligibility type receive an SNBC enrollment packet and enter the tracking process. For more information on this, refer to the Education and Enrollment page of this manual. · Enrollees under the age of 65 who are certified disabled by SSA or SMRT. Note: A pending SMRT does not qualify for exclusion from a health plan. · If an enrollee does not have a disabled eligibility type, the person may be excluded from a health plan if they have a certified disability (refer to the first bullet). · Enrollees between the ages of 18 and 64 with a disabled eligibility type and a BB exclusion will be enrolled in SNBC unless an opt-out form is received, or the enrollee meets another exclusion. · Children under the age of 18 will not receive SNBC enrollment or opt-out information. Note: This exclusion should not be used for enrollees age 65 years and older. Review for other exclusion or enter a YY to begin tracking.
CV	Center for Victims of Torture (CVT)	County, tribe or DHS	Mandatory	MA or NM enrollees receiving services at a center for victims of torture. · Will have NM/GS eligibility type. · Program participants must be fee for service.
DD	Terminal Communicable Disease	County, tribe or DHS	Voluntary	Enrollees who at the time of initial enrollment: · Have a communicable disease, and · Prognosis is terminal; the prognosis may exceed 6 months, and · The enrollee’s primary physician is not a participating provider in Prepaid Medical Assistance Program (PMAP) and · The physician certifies that disruption of the existing physician patient relationship is likely to result in the enrollee becoming noncompliant with medication or health services.
DO	Disabled Opt Out	DHS	Voluntary	Use for disabled enrollees between the ages of 18-64 who have requested to disenroll or be excluded from SNBC. An enrollee with a disabled eligibility type who has previously been excluded with a DO code will remain DO excluded unless they have chosen an SNBC plan. Do not add or change to a BB exclusion.
EE	Serious Mental Illness (SMI) and Serious and Persistent Mental Illness (SPMI)	County, tribe or DHS	Voluntary	· The county social worker will verify a child is eligible to receive children’s mental health targeted case management to use the serious mental illness (SMI) exclusion. · The county social worker will verify an adult is eligible to receive adult mental health targeted case management to use the serious persistent mental illness (SPMI) exclusion. · An eligibility worker must add a case note in MMIS stating a social worker has verified eligibility for this exclusion.
HH	Private HMO Coverage or Cost-Effective Insurance	County, tribe or DHS	Review the “When to Use” column.	· Mandatory exclusion for enrollees with private health insurance or a non-Medicare individual health plan that has been determined cost effective (CEHI). · Note: ChampVA and TriCare are considered CEHI for purposes of assessing the HH exclusion. · TriCare for Life is not reimbursable under the CEHI program and does not require an HH exclusion. · The enrollee’s private insurance information must be listed on the RPOL screen in MMIS. · Voluntary enrollment, into the same HMO, for enrollees with private health insurance through a state-certified HMO. · Refer to Minnesota Department of Health website for a list of state-certified HMOs. · Refer to Third Party Liability and Cost Effective Health Insurance in ONEsource for specific procedural instructions
II	Breast and Cervical Cancer Control Program	County, tribe or DHS	Mandatory	Women receiving Medical Assistance through the Breast and Cervical Cancer Control Program. Eligibility type is MA/BC.
IP	Pending Cost Effective Health Insurance (CEHI)	County, tribe or DHS	Mandatory	Use when a CEHI determination is pending. · Prior to health plan enrollment, an enrollee may be excluded for up to 90 days while a CEHI determination is being processed. · Do not disenroll from a health plan while a CEHI determination is pending. · If a CEHI determination is not made, tracking will begin when the 90-day exclusion period is over. · Do not add another IP code exclusion after the 90-day period has lapsed.
JJ	Incarceration	DHS	Mandatory	Used when an enrollee is involuntarily confined in a correctional facility. · If an enrollee is incarcerated, send an HPEN ticket to DHS to exclude the member. Include the start and end dates, of the incarceration and the correctional facility code (RLVA 68 or 69). If the end date is unknown enter 12/15/40 in the ticket. · Do not add this exclusion if an enrollee is incarcerated for less than one month with a known release date in the same month.
KK	Combination Spenddown	DHS	Mandatory	Use when an enrollee has an Elderly Waiver (EW) or Long-Term Care with periodic combination spenddown. · An enrollee receives periodic income which puts them over the income or asset limit for MA in a month within the budget period. The other months within the budget period do not have a spenddown. · Entered by DHS. Processing workers should send an HPEN ticket to request this exclusion. · If case notes indicate that the enrollee is no longer periodically ineligible, they must be enrolled. · Enter a YY exclusion code to begin tracking.
MM	American Indian and living on a reservation	County, tribe or DHS	Voluntary	· MMIS must show race code = N on RCIP · METS: Demographics tab must indicate American Indian living on reservation · MAXIS must show Indian Reservation = Y on STAT/ADDR
NN	Presumptive Eligibility	DHS		· Hospital Presumptive Eligibility (HPE) · Workers processing HPE applications will enter an NN span to cover the HPE months.
SS	Medical Spenddown	County, tribe or DHS	Mandatory	· Used when an enrollee is eligible for MA on a medical spenddown basis. · Not used for long term care continuous (institutional) spenddowns. · Not used for waiver obligations. · Existing MSHO or SNBC enrollees who acquire an automated monthly medical spenddown or a combination long term care and medical spenddown while enrolled in a health plan may remain enrolled in that health plan. · Enrollees with medical spenddowns will be required to pay their medical spenddowns monthly. This exclusion can’t be used if the enrollee has an elderly waiver or institutional spenddown. · Enrollees who are residing in a nursing facility and coded with a medical spenddown and have elected hospice may enroll into MSHO. · MMIS must have spenddown method = M on the RSPD screen.
TA	Temporarily Absent	County, tribe or DHS	Mandatory	MA enrollees who are absent from Minnesota for more than 30 consecutive days but are still considered a resident of Minnesota. · There is no limit to how long an enrollee may be temporarily absent from the state. · No exceptions, including college students in cities bordering Minnesota. · Covered services for these enrollees are paid by FFS. · When the temporary absence return date is unknown, the end date on the TA exclusion span is 3 months into the future, or the end of the current certification period (whichever is longer). · On the RPPH screen, use disenrollment reason code TA instead of EX. Both the exclusion and the DIS RSN will be coded TA. This is necessary for the correct text to print on the disenrollment notice. · Use Temporary Absence MMIS Exclusion and Disenrollment instructions in ONEsource
TT	Terminal Illness	County, tribe or DHS	Mandatory	Persons terminally ill as defined in Minnesota Rules, 9505.0297, subp. 2, (N) and who at the time of enrollment in PMAP, have an established relationship with a primary care physician who is not part of a PMAP health plan. · Enrollee must have a terminal illness at initial enrollment only. · Enrollee’s primary physician is not part of a PMAP provider network. · Do not disenroll if diagnosis comes after enrollment.
US	Unpaid Spenddown	DHS	Mandatory	Used when an enrollee has not paid their spenddown in full for 3 months. · An enrollee may not enroll in SNBC or MSHO with an unpaid spenddown. · If the enrollee does not have Medicare, the disenrollment reason needs to be EX instead of SP. · Prior to enrolling, verify that the spenddown has been paid. · The DHS MADE Request Form found in SIR is used to verify spenddown information.
YY	Pending Enrollee Decision	County, tribe or DHS	Mandatory	Waiting return of enrollment information. · Starts the enrollment tracking process. For more information and exceptions refer to the tracking section of the Education and Enrollment page. · Entered by both the system and processing workers. · When a form is received, end the exclusion, and enroll into a health plan for the next available month.
ZZ	Regional treatment center (RTC) or institution for mental disease (IMD) Resident	County, tribe or DHS	Mandatory	Used for enrollees who are residents of state regional treatment centers or a state-owned long term care facility. · Refer to the RPPH page in the MMIS user manual for list of NPIs associated with the ZZ exclusion. · Do not end the exclusion if an enrollment form is received unless there is verification the enrollee has left the facility.