Managed Care Enrollment
What is Managed Care?
Managed care is a service delivery model in which the health plan is paid directly from the Department of Human Services (DHS) to provide health care services to members enrolled in that health plan. This is different than the service delivery model of fee for service (FFS) in which the health care provider receives payment from DHS directly to provide health care services. Not all health care services are covered by managed care. Those that are not covered by managed care are considered to be “carved out” services and may be covered through another source.
Within managed care, there are different programs that are designed for specific populations based on their needs. These are listed here, referred to throughout this manual, and determine the processes involved and the information sent to the enrollee.
Who Enrolls into Managed Care?
Most enrollees who are eligible for Minnesota Health Care Programs (MHCP) must enroll in a health plan to receive their health care services. Once eligibility for MHCP is determined, processing entities (county, tribal, or DHS staff) verify whether an enrollee meets criteria to be excluded from managed care and enters the information into the Medicaid management and information system (MMIS).
Participation in managed care is mandatory for enrollees meeting criteria according to Minnesota Statutes, 256B.69, subdivision 4 and Minnesota Rules, 9500.1450 to 9500.1464. Enrollees who do not meet managed care exclusion criteria must enroll in a health plan.
Exclusions
If the processing entity determines that an enrollee is exempt from enrolling in managed care, the appropriate exclusion code must be entered into the MMIS system. The exclusion code indicates that someone is excluded from managed care enrollment and is then considered to be eligible for FFS. All MinnesotaCare enrollees must receive health care services through a managed care organization. There may be fee-for-service coverage for a limited period in certain circumstances per Minnesota Statutes, 256L.12, subdivision 3.
Refer to the Exclusions page of this manual for more detailed information on managed care exclusions. For additional information regarding managed care exclusion codes, refer to the RPPH screen of the MMIS User Manual. If the processing entity encounters system errors or edits related to managed care enrollment, they should submit a HPEN (Health Plan Enrollment) ticket in SIR. These tickets are routed to DHS managed care staff.
Managed Care Education
Managed care education begins once the enrollee has been determined eligible for MHCP. It is the responsibility of the county or tribal health care worker to educate enrollees about the managed care enrollment process or to exclude them from managed care.
County and tribal health care workers should refer enrollees with questions related to SNBC to the Disability Hub MN™. Refer to the Disability Hub MN™ section to learn more about what questions the Disability Hub MN™ can assist with. County and tribal health care workers should refer enrollees over the age of 65 with questions for counseling on Medicare products to the Senior LinkAge Line at 800-333-2433 (this call is free). People under age 65 with questions about Medicare Part D plans are also referred to Senior LinkAge Line at 800-333-2433.
Enrollees required to enroll in managed care are notified via a managed care education packet about the requirement to enroll in a health plan and the deadline date for enrolling. All enrollees are encouraged to make a health plan choice. If the managed care enrollment forms are not received by the deadline, the enrollee will be systematically enrolled into the default health plan listed on the RTRK screen in MMIS.
Managed care enrollment guides and envelopes listed in this manual can be ordered in bulk from DHS forms supply. All other managed care materials listed in this manual can be printed from eDocs.
Provider Network
Not all providers are considered in-network for the available health plans. The enrollee needs to verify if their preferred providers are covered by their chosen health plan. If they want to go to the same health care providers they currently go to, they should review the online provider directories for each of the available health plans. Enrollees can ask if the health plans contract with their provider or they can call their provider’s office to find out which health plans are accepted. Providers that have contracts with the health plans are considered in-network providers.
Education for Non-English-Speaking Enrollees
The Managed Care Enrollment Guide (DHS-8041) (PDF) includes a language block for non-English-speaking enrollees. The language block explains in 16 languages (English, Amharic, Arabic, Burmese, Cantonese, French, Hmong, Karen, Khmer, Korean, Lao, Oromo, Russian, Somali, Spanish and Vietnamese) that the enrollment packet contains important information and instructs enrollees to get help if they do not understand it. Interpreter services must be available whenever necessary.
The following forms are available on DHS eDocs (our electronic document library) in Spanish, Hmong, Russian, Somali, or Vietnamese:
Managed Care Enrollment Process by Program
The enrollee receives an initial packet containing important information about managed care based on their program eligibility and active coverage in MMIS. Specific details based on the applicable program are outlined in this section. Processing entities should review Managed Care Key Dates to determine health plan enrollment start dates.
Medical Assistance (MA)
Managed care enrollment for those in MA is handled by county and tribal health care workers. The health plans available for enrollees to choose from are based on their county of residence as listed on the RCAD screen in MMIS. MA enrollees in the same household may choose different health plans.
The following outlines the process for enrollment into a health plan after eligibility has been approved:
MA Enrollment Packet Contents
The enrollment packet for MA is mailed by the county or tribe and contains the following documents.
If an enrollee reports they have lost their enrollment form, the processing entity should take the enrollee’s information and health plan choice(s) over the phone and enter their choice into MMIS. If the enrollee would like the enrollment form re-sent, processing entities can generate a new enrollment form from the RKE2 screen in MMIS.
MinnesotaCare
MinnesotaCare health plan enrollment is handled by DHS. All MinnesotaCare Enrollment Packets are assembled and mailed from the Issuance Operation Center (IOC) at DHS. The health plans available for the enrollee to choose from are based on their county of residence as listed in MMIS. With limited exceptions, MinnesotaCare does not allow enrollees to be excluded. All MinnesotaCare household members are enrolled in the same health plan by MMIS or DHS.
The following outlines the process for enrollment into a health plan after eligibility has been approved:
Reminder: If a premium payment is required, MinnesotaCare coverage begins the first of the following month after the first payment is made. It is important for the household to make a health plan choice at the same time as their premium payment. Otherwise, the household will be enrolled into the default plan.
MinnesotaCare Enrollment Packet Contents
The enrollment packet for MinnesotaCare is mailed by the IOC and contains the following documents:
If an enrollee reports they have lost their enrollment form, the enrollee must contact Health Care Consumer Support (HCCS) at 651-297-3862 or 1-800-657-3622. HCCS should either take the enrollees information and health plan choice over the phone using the Health Plan Enrollment form (DHS-4106A) (PDF) or, if the enrollee would like the enrollment form resent, processing entities can generate a new enrollment form from the RKE2 screen in MMIS.
Managed Care for Certain Populations
Enrollees who are 65 or older and those with disabilities who are ages 18 through 64 have specialized managed care options. Refer to the next two sections for more detailed enrollment information on these populations.
MSC+ and MSHO
Within managed care there are two programs available for those over 65 years of age. They are Minnesota Senior Care Plus (MSC+) and Minnesota Senior Health Options (MSHO). In order to be eligible to enroll in the health plan for these programs, the enrollee must:
The descriptions for MSC+ and MSHO are as follows:
The health plans available for enrollees to choose from are based on their county of residence as listed in MMIS.
The process for new enrollment into MSC+ and MSHO is as follows.
Once the enrollment form is completed, the enrollee sends it to DHS in the return envelope or faxes it to:
Fax Number: 651-431-7548
Mail to:
Managed Care – Department of Human Services
PO Box 64984
St. Paul, MN 55164-0838
Senior Enrollment (MSC+ and MSHO) Packet Contents
The enrollment packet for enrollees who are 65 years of age or older includes the following documents:
If an enrollee reports they have lost their enrollment form, processing entities create and mail the Health Plan Enrollment Form for People 65 and Older (DHS-4106C) (PDF). When printing the DHS-4106C form from eDocs, workers must indicate the default plan following the instructions on the form. Processing entities can also submit an HPEN ticket in SIR requesting a new form.
Enrollees using a DHS-4106C form to enroll in MSHO must check the box as illustrated in the following image and return it to DHS.
MSHO Denial and Rejection Information
An enrollee’s enrollment into MSHO may be delayed if the enrollment form or DHS-4106C is incomplete. Examples of missing information include a missing signature, not having Medicare eligibility, or a missing plan selection. The enrollee will be given a due date to provide the missing information on the enrollment form.
MSHO requires a complete enrollment form and final approval depends on the Centers for Medicare & Medicaid Services (CMS) guidelines. If CMS rejects the enrollment, the enrollee will receive a letter with further information and instructions. If CMS rejects an enrollee’s MSHO enrollment, the enrollee will be enrolled into MSC+ with the selected health plan.
Regardless of how many MSHO health plans are available in the enrollee’s county of residence, they must select a health plan by completing an enrollment form. If they do not, they will remain in MSC+.
Senior LinkAge Line
Processing entities should refer enrollees with questions to the Senior LinkAge Line at 800-333-2433 (this call is free) for counseling on Medicare products.
Enrollees may call the Senior LinkAge Line to:
Special Needs BasicCare (SNBC)
SNBC is a voluntary managed care program.
In order to enroll, the enrollee must:
Depending on the county, there may or may not be more than one health plan that offers SNBC. Some health plans offer incentives for this population, such as fitness programs or discounts. Enrollees should contact each health plan directly if they want more information on incentives or discounts provided.
Non-Integrated and Integrated SNBC
Within SNBC there are two programs available for enrollees with a certified disability. They are the non-integrated and integrated SNBC programs.
Non-Integrated: When enrolled in a non-integrated SNBC program, the enrollee receives their Medical Assistance benefits through a health plan. If the member is enrolled in Medicare, they will receive their Medical Assistance and Medicare benefits separately. Eligible enrollees will be auto-enrolled in a non-integrated health plan unless they opt out. Enrollment information is entered into MMIS by DHS staff. Counties do not enter SNBC enrollments for the non-integrated is basically the message we are trying to get across.
Integrated: When enrolled in an Integrated SNBC program, the enrollee’s Medical Assistance and Medicare benefits are both administered by the same health plan. To be eligible to enroll in the integrated SNBC program, the member must be enrolled in both Medicare Parts A and B. Enrollment information is entered into MMIS by DHS staff.
Non-Integrated SNBC Enrollment Process
Fax Number: 651-431-7464
Mail to:
Managed Care – Department of Human Services
PO Box 64838
St. Paul, MN 55164-0838
If the enrollee does not respond with a health plan choice or a request to opt out, they will be defaulted into a plan. The section, Default Health Plan Enrollment Process, has more information on this process.
Integrated SNBC Enrollment Process
There are no DHS forms for enrolling into an integrated SNBC plan. The health plans have their own forms. Enrollees will not be defaulted into a plan.
SNBC Enrollment Packet Contents
The enrollment packet for SNBC contains the following documents:
If an enrollee reports they have lost their enrollment form, they can be referred to Disability Hub MN™ at 866-333-2466 for assistance. If the enrollee would like the form resent processing entities create and mail the Special Needs BasicCare SNBC Choice Form (DHS‑6451) (PDF) being sure to select the enrollee’s county of residence from the drop down box.
Integrated SNBC Denial and Rejection Information
An applicant’s enrollment into integrated SNBC may be delayed if the enrollment form is incomplete. Missing information includes a missing signature, not having Medicare eligibility, a missing plan selection, and so forth. The enrollee will be given a due date to provide the missing information on the enrollment form.
Integrated SNBC requires a complete enrollment form to enroll and final approval depends on CMS guidelines. If CMS rejects the enrollment, the person will receive a letter with further information and instructions. If CMS rejects an enrollee’s integrated SNBC enrollment, the enrollee will be enrolled into non-integrated SNBC.
Enrollees who are interested in integrated SNBC must complete the enrollment process with their chosen health plan; otherwise, they will remain in non-integrated SNBC.
Disability Hub MN ™
Enrollees may call Disability Hub MN™ at 866-333-2466 (this call is free) or use their preferred relay service to:
Default Health Plan Enrollment Process
Health plan choices vary depending on county of residence. The default health plan for a household may vary depending on several factors:
For more information on a county’s default health plans, refer to the Default Enrollment Technical Specifications document on the managed care contracts website.
Newly eligible PMAP, MinnesotaCare, and MSC+ enrollees who have not been enrolled in a health plan within the past 12 months who do not make a health plan selection will be enrolled into a plan based on their county of residence.
Non-integrated SNBC is a voluntary managed care program. The health plan default assignment process will be used when the enrollee has not opted out of managed care. Non-integrated SNBC enrollees may choose to dis-enroll at any time. They will be FFS for the next available month.
MSHO and integrated SNBC plans are voluntary and members must complete an enrollment form. There are no default plans for these programs.
The default health plan can be viewed on the RCHP screen in MMIS.
After the enrollee is enrolled in the health plan, they will receive a system generated enrollment notice. This notice informs them which health plan they are enrolled in and the effective begin date of their coverage with that health plan. DHS will mail the enrollee a Minnesota Health Care Program (MHCP) member ID card. The enrollee gets a Notice of Health Plan Enrollment indicating what health plan they are enrolled in and the effective date. The health plan will mail additional information and a health plan ID card to the enrollee.
Tracking System within MMIS
MMIS manages the enrollment process on the Recipient Tracking (RTRK) screen.
The RTRK screen does the following:
RTRK Screen
Processing entities (county, tribal, or DHS staff) update information on the RTRK screen in MMIS using the “case path” from the RKEY screen. This begins the process of enrollment into managed care.
Note: It is important to update the tracking information for all enrollees on the same case at the same time to reduce confusion. Each tracking span triggers MMIS to generate a case-based notice.
To begin tracking, processing entities record the type of managed care education provided to the enrollee using the appropriate contact type:
M (Mail out) | An enrollment form will print at the county, tribe, or DHS the next working day. This form must be mailed to the enrollee with an education packet informing them about their choice of MCO’s health plan’s and how to choose and use health plan services. |
P (Presentation) | Rarely used: no enrollment form will print; however, the system clock will be activated. Once the counter reaches 30, MMIS will create an enrollment span using the default plan for the next available month. Only use this code if you have discussed the managed care process with the enrollee in office and have provided the education materials. |
C (Phone Call) | Rarely used: use this code if the enrollee has obtained education materials and you have discussed enrollment options by phone. |
O (System Entered) | MMIS will enter this code when a YY or BB exclusion entered on RPPH or when DHS runs a monthly program to begin tracking for enrollees who do not have an active tracking span but should. An enrollment form will be printed at the county, tribe, or DHS and must be mailed to the enrollee with the education packet. |
If a processing entity enters the wrong contact type, do not overwrite it. Instead, submit a HPEN ticket to request that the tracking span be deleted, and a new span added.
The tracking program begins the evening that the enrollee meets all criteria listed in the Tracking Criteria section. The counter number on the RTRK screen records the number of days an enrollee has to select a health plan. When the counter number reaches the 30-day mark and there is no open enrollment span on RPPH, MMIS will automatically generate an enrollment span and enroll the enrollee in the default health plan for the next available month.
Tracking Criteria
For the tracking program to begin in MMIS and the counter number to progress forward, all of the following factors must be true:
For each day the above factors are met, the tracking counter number increases by one. This process occurs automatically in a nightly batch job. If at any time one of the factors above is not true, the counter will stop and will not increase that evening. If all factors become true again, the counter will automatically continue to increase from where it left off, unless the tracking span on the RTRK screen is over 90 days old.
Note: If the enrollee meets the criteria to enter tracking and a tracking span was not created, MMIS will add a tracking span to the case on the first of the month.
To reset the 30-day counter on the MMIS RTRK screen, submit an HPEN ticket.
Counter Number Timeline
When the contact type on the RTRK screen is “M”, “C”, or “O” and the counter number reaches:
001: The tracking system generates a one-day cover letter, (MW0412-RTRK 1-Day Letter Report) also referred to as an enrollment form in an overnight batch job. The enrollment form lists the health plan options available in the county of residence. The county or tribe will print the notice from InfoPac and mail it with all other enrollment packet contents to the enrollee. For MCRE and SNBC enrollees this will be done by DHS.
010: A reminder notice will be generated when the counter reaches 010 if an enrollee has not selected a health plan. This notice will be mailed to the enrollee on the next working day.
030: If an enrollee does not respond and the counter reaches 030, the tracking system automatically creates an enrollment span on the RPPH screen for the default health plan and sends the enrollee an enrollment notice.
When the contact type is “P” and the counter reaches:
001: Nothing happens. No one-day cover letter is sent.
010: A reminder notice will be generated when the counter reaches 010.
030: If the enrollee has not made a health plan selection and the counter reaches 030, the tracking system automatically creates an enrollment span on the RPPH screen for the default health plan and sends the enrollee an enrollment notice.
Changing System Generated Enrollment Spans
A processing entity can change the system-created enrollment span on the RPPH screen. If all the following apply:
Instructions for how to Edit a Future Health Plan Enrollment Span can be found in OneSource.
Managed Care Key Dates
According to Minnesota Rules, 9500.1453, enrollees must be given at least 30 days following written notification of health plan choices to select a health plan. Key dates for METS, MAXIS, and MMIS can be found in three locations:
Capitation
First capitation is six working days from the last working day of each month. This is the date on which enrollees are enrolled in managed care for the upcoming month. DHS sends enrollment reports and capitation payments to the health plans.
The managed care reinstatement cut-off date is the last working day of each month and is sometimes known as second capitation.
Managed Care Enrollment Cut-Off Date
The cut-off date for entering health plan enrollment information onto the MMIS system for Medical Assistance, MSC+, or Major Program NM (NMED) is two days prior to capitation to allow for the necessary interface jobs between the MMIS, MAXIS and METS systems.
MinnesotaCare health plan enrollment has two cut-off dates based on when eligibility is opened on MMIS.
These cut-off dates do not apply for integrated SNBC and MSHO programs. In most cases, as long as DHS receives an integrated enrollment form by the end of the month, the coverage will begin the following month.
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