Preface
The Prepaid Minnesota Health Care Program (PMHCP) is comprised of:
Terminology
Action: the denial or limited authorization of a requested service, including the type or level of service; the reduction, suspension, or termination of a previously authorized service; the denial, in whole or in part of payment of service; the failure to provide services in a timely manner; the failure of the MCO to act within the grievance process timeframes; or, for a resident of a rural area with only one MCO, the denial of an enrollee’s request to exercise his or her right to obtain services outside the network.
Adoption Assistance: a legal adoption administered by DHS that provides MA and sometimes certain other financial reimbursement to an adoptive family for certain expenses incurred which relate to the adopted child’s special needs.
Aged: individuals age 65 and over, who meet the MA eligibility criteria.
Appeal: an oral or written request from the enrollee, or the provider acting on behalf of the enrollee with the enrollee’s written consent, to the MCO for review of an Action.
Applicant: a person who has made application for MFIP, MA, or MinnesotaCare and whose application has neither been acted upon nor voluntarily withdrawn.
Authorization: a participating provider’s written referral for health services provided by a nonparticipating provider. Authorization includes an admission request by a participating provider, on behalf of a PMHCP enrollee, following the established health services.
Authorized Representative: a person authorized in writing by a PMHCP enrollee to act on the enrollee’s behalf in matters of the PMHCP. For MA, the authorized representative is the person indicated on the CAF and/or the MAXIS AREP panel.
Autoclose: a process which medical eligibility ends for not complying with time lines established for reporting HRF's and ER's.
Auto Newborn: a child born to a woman participating in a MHCP at the time of birth.
Capitation Payment: a payment the STATE makes periodically to the MCO for each Enrollee covered under the Contract for the provision of services.
Care Management: the overall method of providing on-going health care in which the MCO manages the provision of primary health services with additional appropriate services provided to an Enrollee.
Centers for Medicare and Medicaid Services (CMS): the federal agency which administers both Medicare and Medicaid (MA).
Chemical Dependency (CD): a pattern of pathological use, accompanied by the physical manifestations of increased tolerance to the chemical or chemicals being used or withdrawal syndrome following cessation of chemical use.
Child and Teen Checkups: Minnesota Early Periodic Screening, Diagnosis and Treatment (EPSDT) Program. Every Minnesota recipient between 0-21 who qualifies for MA or MCRE is entitled to this program. It is a service to identify a potentially handicapping condition and to provide diagnosis and treatment for a condition identified according to the requirements of CFR, title 42, section 441.55.
Client: a term used to refer to both an applicant or a recipient of MA or a MinnesotaCare enrollee.
Commissioner: the Commissioner of the Minnesota Department of Human Services or the Commissioner’s designee.
Common Carrier Transportation: the transport of an Enrollee by bus, taxicab, or other commercial carrier or by private automobile.
Consolidated Chemical Dependency Treatment Fund (CCDTF): a combination of funds used for chemical dependency treatment. Combines existing State appropriations for CD treatment from the following sources: MA, RTC’s and State and federal grants. Services covered under the CCDTF include primary rehabilitative services, rehabilitative transitional services, and extended rehabilitative services.
Consumer: a person who is being educated to participate in the PMHCP.
Conversion Recipient: a person who has an open case and is eligible for participation in PMHCP, but has not yet been enrolled in a MCO.
Cost Avoidance Procedure: the process by which a provider obtains payment from the identified third party resource before billing the MCO.
County Advocate: an individual designated by the local agency to assist PMHCP consumers and enrollees through grievance, appeal, and State fair hearing procedures.
County Based Purchasing (CBP): an option that allows counties to choose to assume the responsibility for purchasing health services for recipients eligible for PMAP.
Department: Department of Human Services (DHS)
Early Periodic Screening Diagnosis and Treatment (EPSDT): see Child and Teen Checkups
Elderly Waiver (EW): MA funded home care services for a person over age 65 who would otherwise need care in a nursing facility.
Eligible/Eligibility: a person determined qualified for MA or MinnesotaCare.
Eligibility Verification: a system that links a provider with the MMIS eligibility System through the telephone or internet.
Emergency Care: the provision of covered services required to treat an immediate medical emergency. Also see Medical Emergency.
Enrollee: a person who has been determined by the local agency or MCRE staff to be eligible for the MA, NMED, or MCRE program.
Evidence of Coverage (EOC): also referred to as member contract or evidence of coverage, provided by the managed care organization (MCO) which includes a description of the MCO’s medical information on benefits, limitations, etc., and a description of how enrollee complaints are resolved, including the telephone number of the person/department handling complaints.
Extended Medical Coverage: effective 7/1/02 replaces by transitional medical assistance and transition year medical assistance.
Federal Financial Participation (FFP): Reimbursement to DHS for some of the cost of an enrollee’s medical services from the federal government. People must meet certain criteria to be eligible for FFP.
Federal Poverty Guidelines (FPG): The amount of income below which a family is considered to be impoverished. The federal government updates the FPG annually.
Fee-for-Service (FFS): the provider bills the State for MHCP covered services rendered to a MHCP recipient.
Financial Worker (FW): the county financial worker who determines eligibility for public assistance programs in the State of Minnesota.
First Year Change Option: the option available to PMHCP enrollees which allows them to change their MCO once within the first year of their initial enrollment into managed care.
Foster child: a child under age 18 who does not live with his/her natural parents but who has been placed in a foster home or facility by a social services agency.
Grievance: means an expression of dissatisfaction about any matter other than an Action; including but not limited to, the quality of care or services provided or failure to respect the Enrollee’s right.
Health Maintenance Organization (HMO): an organization certified by the Minnesota Department of Health which agrees to provide all defined health care benefits to individuals in return for a premium payment.
Health Plan: The term health plan was changed to Managed Care Organization (MCO) in the DHS Model contract effective 01/01/03.
Health Services: the services and supplies given to a recipient by a provider for a health related purpose under Minnesota Statutes, section 256B.0625.
Household Report Form (HRF): a form used by recipients to report income and circumstance changes.
Initial Enrollment: Enrollment in an MCO for the first time. Indicated by an IN change reason on the RPPH pane in MMIS for MA and RCHP for MinnesotaCare.
Inpatient Hospitalization: includes inpatient medical, mental health and chemical dependency services.
Insolvency: the condition in which the MCO is financially unable to meet financial and health care services delivery obligations in the contract between the Department and the MCO.
Institution for Mental Disease (IMD): a hospital, nursing facility, or other institution of more than 16 beds, that is primarily engaged in providing diagnosis, treatment, or care of persons with mental diseases, including medical attention, nursing care and related services. This definition includes chemical dependency treatment facilities with more than 16 beds.
Intermediate Care Facility/Developmental Disability (ICF/DD): a facility licensed by the Minnesota Department of Health, providing 24-hour a day nursing and medical care for persons with developmental disabilities or related conditions.
Local Agency: a county or multi county agency that is authorized under Minnesota statutes, sections 393.01, Subdivision 7, and 393.07, subdivision 2, as the agency responsible for determining recipient eligibility for the MA Program.
Long-Term Care Facility (LTC): a residential facility certified for the Medicaid program by the MN Department of Health as a nursing facility, or an intermediate care facility for the developmentally disabled.
Managed Care: an organized and coordinated health care delivery system. It includes pre-established provider networks and reimbursement arrangements, administrative and clinical system for utilization review, quality assurance, recipient and provider servicing and comprehensive or targeted management of health services.
Managed Care Enrollment Cut-off Date: the date enrollment information must be entered into MMIS for MCO coverage to be effective the following month. This date is eight working days prior to the end of the month.
Managed Care Organization (MCO): an organization certified by the Minnesota Department of Health which agrees to provide all defined health care benefits to individuals in return for a capitated payment.
Managed Care Reinstatement: the date reenrollment information must be entered into Cut-off Date MMIS for MCO coverage to be effective the following month. This is the last business day of the month.
MAXIS: Minnesota’s statewide automated eligibility system for public assistance programs.
Medicaid: a federal/state/county program of health care for low income, elderly and disabled people, based on Title XIX of the Social Security Act. This program is called Medical Assistance in Minnesota.
Material Modification of Provider Network:
Medical Assistance (MA): the program established under title XIX of the Social Security Act (called Medicaid) and Minnesota Statutes, chapter 256B intended to furnish necessary medical care for low-income persons.
Medical Emergency: a medical condition displaying acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect that if not immediately treated could place a person’s physical or mental health in serious jeopardy, continuation of severe pain, serious impairment to bodily functions, serious dysfunction of any bodily organ or part, or death. Labor and delivery is a medical emergency if it meets this definition. The condition of needing a preventive health service is not a Medical Emergency.
Medicare: a federal health insurance program available to most people over age 65 and certain disabled people, as authorized by Title XVIII of the Social Security Act.
Medically Necessary or Medical Necessity: pursuant to MN Rules, Part 9505.0175, Subpart 25, a health service that is consistent with the enrollee’s diagnosis or condition and:
Minnesota Family Investment Program (MFIP): The program authorized to provide financial assistance and social services to needy families with a minor child. A Federal Grant which replaces AFDC in the Personal Responsibility and Work Opportunity and Reconciliation Act.
Minnesota Health Care Programs (MHCP): the name used to refer to Medical Assistance, General Assistance Medical Care and MinnesotaCare health care programs.
Minnesota Health Care Programs (MHCP) Card: an identification card mailed by DHS to each medical assistance recipient or MinnesotaCare member.
Minnesota Senior Health Options (MSHO): a project which demonstrates the effectiveness and efficiency of integrated service delivery models and payment methods which combine acute and long term care and capitated Medicare and Medicaid financing with managed care for elderly public assistance recipients.
Minnesota Supplemental Aid (MSA): a state funded program that provides financial assistance to elderly, disabled, and blind recipients of Supplemental Security Income (SSI) who are age 18 and older.
MinnesotaCare: a subsidized premium-based health care program created by the Minnesota legislature as an alternative for low income people who would not otherwise have access to health care insurance.
MinnesotaCare Enrollee: a person who has been determined eligible by the State to receive health services under MinnesotaCare and paid the required premium and that premium has been received by the State.
MinnesotaCare Case Obligation: the record of the premium payment history for a MinnesotaCare case.
MinnesotaCare Enrollment Representative: the DHS or county representative who determines eligibility for the MinnesotaCare Program.
MMIS: the Medicaid Management Information System.
Multiple MCO Model: a health service delivery system that allows PMHCP consumers the choice of two or more MCOs.
Needy Child: a person who is under age 21 and meets all other eligibility criteria for MA (income, assets, etc.).
Next Available Month: for initial enrollment. The current month plus one if prior to managed care enrollment cut-off OR the current month plus two if after managed care enrollment cut-off. For reinstatement: the current month plus one if entered prior to the last business day of the month.
New Eligible: recipients whose MA/NMED cases have been newly opened.
NMED: Qualified non-citizens who do not qualify for Medical Assistance because of their date of entry or length of time in the U.S. may qualify for state-funded Program NMED if they meet an MA basis of eligibility. They must meet all other MA eligibility requirements including income and assets. Program NMED provides the same benefits as Program MA. State Paid Program NM is defined in Minnesota Statutes, § 256B.06, subd. 4.
Non-emergency Services: routine medical services or medical services which are provided for a condition which does not constitute a medical emergency (see definition of medical emergency).
Nonparticipating Provider: a provider who is not employed by or under contract with the MCO to provide health services.
Nursing Facility (NF): a facility certified for participation in the Medicaid Program by the Minnesota Department of Health as a nursing facility providing 24-hour a day nursing and medical care.
Nursing Homes (NH): sometimes referred to as a health care center or long-term care facility, including nursing facility (NF) if certified for the Medicaid Program.
Ombudsman: an individual designated by the commissioner under Minnesota Statutes, § 256B.031, subdivision 6, to advocate for PMHCP consumers and enrollees through grievance, appeal, and State fair hearing procedures.
Open Enrollment: the annual 30-day period during which PMHCP enrollees in a multiple MCO model may change to another MCO.
Out-of-Home Placement: a home licensed to provide 24 hour-a-day care for children unrelated to the family (Rules 1, 5, and 8).
Out-of-Network Care: health care provided to an enrollee by non-participating providers.
Participating Provider: a provider employed by or under contract with a MCO to provide health services to enrollees.
Per Diem Rate: the daily rate for room and board and cost of care in a nursing facility.
Person Master Index (PMI): a unique 8-digit number assigned to an individual who is eligible for MHCP. A medical provider must use this number to submit medical claims to DHS under the fee-for-service program for payment.
Personal Care Assistant (PCA): a provider of personal care services prescribed by a physician and supervised by a registered nurse. A personal care assistant must not be the recipient’s spouse, legal guardian, or parent if the recipient is a minor child.
Petitioner: an enrollee in a MCO who files a State fair hearing request with the State regarding mandatory participation in the PMHCP, a grievance or appeal regarding services denied, reduced, or terminated by their MCO, or to change MCOs.
Post-Stabilization Care Services: medically necessary covered services, related to an emergency medical condition, that are provided after an enrollee is stabilized, in order to maintain the stabilized condition, and for which the MCO is responsible when: (i) the services are service authorized; (ii) the services are provided to maintain the enrollee’s stabilized condition within 1 hour of a request to the MCO for service authorization of further post-stabilization care services; (iii) the MCO could not be contacted; (iv) the MCO did not respond to a service authorization within an hour; or (v) the MCO and treating provider are unable to reach agreement regarding the enrollee’s care.
Pregnant Women (PW): women whose basis of eligibility is due to pregnancy regardless of age.
Premium: a monthly payment made by a MinnesotaCare applicant or enrollee for health care coverage.
Prepaid Medical Assistance Program (PMAP): the prepaid, capitated managed care program authorized under MN Statutes §256B.69 and MN Rules, parts 9500.1450 through 9500.1464.
Prepaid Minnesota Health Care: the Prepaid Managed Health Care Programs (PMHCP) comprised of PMAP, PMCRE, MSHO, SNBC, and PIN.
Prepaid MinnesotaCare Program (PMCRE): the prepaid managed care program authorized under Minnesota Statute, § 256.9351 - 256.9369.
Primary Care Network Listing (PCNL): a standardized document that provides information about the MCO’s provider network and includes a description of the essential components of the MCO to be used by local agencies to educate consumers.
Primary Care Provider MCO Model: a health services delivery system that allows PMHCP consumers to select a primary care physician and primary care dentist from a list of providers under contract with a MCO to provide health services to PMHCP enrollees.
Provider: a person or entity providing health care services.
Qualified Medicare Beneficiary (QMB): an individual who is eligible for Department payment of Medicare premium, co-insurance and deductible and is eligible to receive Medicare covered services as mandated by the Medicare Catastrophic Coverage Act of 1988, which requires states to pay certain Medicare cost sharing expenses.
Recertification: the process used by the county agency to determine a recipient’s continued eligibility for benefits.
Recipient: a person who has been determined by the local agency to be eligible for MA, NMED or by the State and/or county for the MinnesotaCare Program.
Refugee Assistance Program (RAP): a program for refugees who have resided in the US for 12 months or less from their initial entry into the country. Individuals who are part of the RAP receive MA under the Refugee Act and are ineligible for MA under Title XIX. This population is excluded from participation in PMHCP.
Regional Treatment Center (RTC): State institution as defined in Minnesota Statutes, § 245.0312.
Reinstatement: the reenrollment into a MCO for an enrollee before the effective date of disenrollment.
Remittance Advice (RA): a report generated by DHS which explains to providers the reimbursement amount for medical services provided to MHCP recipients.
Residential Treatment: a 24 hour-a-day program under the clinical supervision of a mental health professional, in a community residential setting other than an acute care hospital or RTC inpatient unit that must be licensed as a residential treatment program for children with emotional disturbance under MN Rules 9544.0900 to 9545.1090 or other rules adopted by the commissioner.
Renewal: the annual process used by MinnesotaCare to determine eligibility.
Rule 1: Minnesota Rule 9545.0010 to 9545.0260 sets standards governing licensure of foster homes for children.
Rule 5: Minnesota Rule 9545.0900 to 9545.1090 establishes minimum standards for licensure of residential treatment programs for children with severe emotional disturbance.
Rule 8: Minnesota Rule 9545.1400 50 9545.1500 sets licensing standards for group homes that provide staffed foster care on a 24-hour a day basis for no more than ten children.
Service Area: the area where a MCO is licensed in Minnesota.
Service Authorization: a managed care Enrollee’s request, or a Provider’s request on behalf of an Enrollee, for the provision of a medical service, and the MCO’s determination of the Medical Necessity for the medical service prior to the delivery or payment of the service.
Service Limited Medicare Beneficiary (SLMB): a person eligible for payment of the Medicare Part B premium by the MA program. The person does not have to be eligible for MA.
Special Needs BasicCare (SNBC): the Minnesota prepaid managed care program, pursuant to Minnesota Statues 256B.69, subd. 28, that provides Medicaid services and/or integrated Medicare and Medicaid services to Medicaid eligible people with disabilities who are ages eighteen (18) through sixty-four (64).
Spenddown: the process by which a person who has income in excess of the MA standard becomes eligible for MA by incurring medical expenses that are not covered by a liable third party and that reduce the excess income to zero.
State Fair Hearing: a hearing filed according to an enrollee’s written request with the State pursuant to Minnesota Statutes, Section 256.045, related to: the delivery of health services or participation in the MCO, denial (full or partial) of a claim or service, failure to make an initial determination in 30 days, or any other Action or Grievance.
State Institution: all regional treatment centers as defined in Minnesota Statutes, § 245.0312, and all state operated facilities as defined in Minnesota Statutes, § 252.50.
State Medical Review Team (SMRT): the person or group of persons designated by the Commissioner of Human services to determine disability under MN Rule, Part 9500.2220.
Supplemental Security Income (SSI): a federal program which provides a minimum income level for people who are aged, blind, or disabled.
Terminally Ill: the recipient has a medical prognosis that life expectancy is six months or less. However, for the purpose of MN Rule, Part 9500.1452 Subpart. 2. Item N, a recipient with a terminal prognosis due to a communicable disease may have a life expectancy that exceeds six months.
Title XIX: the part of the Social Security Act, enacted in 1965 which governs the MA program.
Urgent Care: acute, episodic medical services which are available on a 24 hour basis required in order to prevent a serious deterioration of the health of an enrollee.
Acronyms
ACF | Adult Correction Facility |
ACS | Alternative Community Based Services |
C & TC | Child and Teen Checkups |
CAC | Community Alternative Care |
CADI | Community Alternative for Disabled Individuals |
CCDTF | Consolidated Chemical Dependency Treatment Fund |
CBP | County Based Purchasing |
CD | Chemical Dependency |
CFR | Code of Federal Regulations |
CMS | Centers for Medicare and Medicaid Services |
CISN | Community Integrated Service Network |
DAW | Dispense As Written |
DHS | Department of Human Services |
DT | Disabled Tefra |
EOC | Evidence of Coverage |
EPSDT | Early Periodic Screening, Diagnosis & Treatment Program |
EVS | Eligibility Verification System |
EW | Elderly Waiver |
FFS | Fee-For-Service |
FQHC | Federally Qualified Health Center |
FW | Financial Worker |
HCFA | Health Care Financing Administration (now CMS) |
HP | Health Plan |
HMO | Health Maintenance Organization |
HRF | Household Report Form |
ICF/DD | Intermediate Care Facility for Persons with Developmental Disabilities |
IHS | Indian Health Service facilities |
IMC | Itasca Medical Care |
IMD | Institution for Mental Disease |
IP | Incapacitated Parent |
LTC | Long Term Care Facility |
MA | Medical Assistance |
MCO | Managed Care Organization |
MCRE | MinnesotaCare |
MEQC | Medicaid Eligibility Quality Control |
MFIP | Minnesota Family Investment Program |
MHCP | Minnesota Health Care Programs |
MMIS | Medicaid Management Information System |
MSA | Minnesota Supplemental Aid |
MSHO | Minnesota Senior Health Options |
NF | Nursing Facility |
NH | Nursing Home |
NMED | State Paid Medical Assistance - Program NM |
PCA | Personal Care Assistant |
PCNL | Primary Care Network Listing |
PCUR | Primary Care Utilization Review |
PIN | Preferred Integrated Network |
PMAP | Prepaid Medial Assistance Program |
PMCRE | Prepaid MinnesotaCare |
PMHCP | Prepaid Minnesota Health Care Programs |
PMI | Person Master Index |
PPHP | Prepaid Health Plan (referred to as health plan or HP) |
PPO | Preferred Provider Organization |
PW | Pregnant Woman |
QA | Quality Assurance |
QMB | Qualified Medicare Beneficiary |
RA | Remittance Advice |
RAP | Refugee Assistance Program |
RCHP | Recipient Health Plan (MMIS) |
REFM | Recipient Enrollment Form (MMIS) |
RELG | Recipient Eligibility Information Screen (MMIS) |
RENR | Recipient Enrollment (MMIS) |
RFI | Request for Information |
RFP | Request for Proposal |
RHC | Rural Health Clinic |
RPPH | Recipient Prepaid Health Plan Screen (MMIS) |
RSDI | Retirement, Survivors, and Disability Insurance |
RTC | Regional Treatment Center |
RTRK | Recipient Tracking |
SCHA | South Country Health Alliance |
SED | Severely Emotionally Disturbed |
SIS EW | Special Income Standard Elderly Waiver |
SLMB | Service Limited Medicare Beneficiary |
SMRT | State Medical Review Team |
SNBC | Special Needs BasicCare |
SPMI | Seriously and Persistently Mentally Ill |
SSI | Supplemental Security Income |
TBI | Traumatic Brain Injury |
TPL | Third Party Liability |
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