Posted inCardiagtech

Understanding Medicaid Coverage: A Guide to Minnesota Health Care Programs

No Comments

The Minnesota Department of Human Services (DHS) is dedicated to providing essential health care coverage for Minnesotans with limited income through Minnesota Health Care Programs (MHCP). This guide offers a detailed overview of MHCP, including eligibility criteria and the scope of coverage.

Navigating MHCP Eligibility

To effectively utilize MHCP, it’s crucial to understand the various program codes within the MN–ITS system. These codes are vital for eligibility verification and billing. MHCP eligibility is typically assessed and approved on a monthly basis. Healthcare providers are advised to verify a patient’s MHCP eligibility through MN–ITS before rendering services, ideally monthly or per calendar month for recurring services. For details regarding patient financial responsibilities, refer to Billing the Member (Recipient).

### Minnesota Health Care Programs (MHCP) Overview
Understanding MinnesotaCare: This program is designed for Minnesota residents who lack access to affordable health coverage.
### Key Program Codes and Descriptions
Program Code
AC
BB
EH
FP
FF
HH
IM
KK
LL
MA
NM
OO
QM
RM
SL
UN
XX

In cases where individuals qualify for multiple programs, MHCP prioritizes the highest coverage level. For instance, someone with both QM and MA coverage will have Medicare cost-sharing covered by QM, and additional services covered by MA. Program SL only covers Medicare premiums and not direct health care services. Individuals awaiting long-term care assessments are listed as ‘unknown’ until the assessment is complete.

Minnesota Restricted Recipient Program (MRRP)

The Minnesota Restricted Recipient Program (MRRP) is designed to monitor and manage MHCP members who may be overutilizing services or using them in a manner that is not medically necessary, leading to increased costs. Identified members are assigned to a primary care physician or designated providers for a 24-month period to coordinate their health care.

For specialist referrals, the primary care provider must submit a Medical Referral for MRRP Enrollee (DHS-2978) (PDF) to the MRRP office via fax at 651-431-7475 within 90 days of the service date. Failure to do so may result in claim denial. Emergency services do not require prior authorization, but the MRRP office may request documentation to validate the emergency for claim processing.

For questions regarding referrals or the MRRP program, contact MRRP at 651-431-2648 or 800-657-3674. For members in managed care organizations (MCOs), referrals should be faxed to the respective MCO.

Hospital Presumptive Eligibility (HPE) Program

Introduced by the Affordable Care Act, the Hospital Presumptive Eligibility (HPE) program enables participating hospitals and clinics to make preliminary Medical Assistance (MA) eligibility determinations. This initiative aims to expedite health care coverage for individuals in need and facilitate hospital reimbursement while a full MA application is processed.

Hospitals can become qualified HPE providers by enrolling with DHS and adhering to program policies and performance metrics. These hospitals are responsible for assisting individuals approved for HPE in completing and submitting their full MA applications, either directly or by connecting them with navigator organizations. DHS-certified hospital personnel who have completed specific training can determine HPE eligibility without requiring immediate verification. Detailed information is available at HPE: Policies, forms and notices.

Upon HPE approval, the hospital provides the member with a DHS-issued approval notice on security paper, serving as temporary proof of coverage until the official MHCP ID card arrives. This notice allows access to any MHCP provider. DHS will subsequently mail an MHCP ID card containing the member’s unique ID number for future coverage verifications.

Applying for HPE is not contingent on being a hospital patient; qualified hospitals must process applications for anyone, regardless of their immediate need for medical treatment. HPE coverage is effective from the approval date and continues until DHS determines MA eligibility or until the end of the month following the approval month if a full MA application is not submitted. HPE provides full MA benefits, identical to regular MA coverage. Any MHCP provider can bill for services provided during the HPE period using standard MA billing procedures.

Most individuals are eligible for HPE once per year, while pregnant women can receive it once per pregnancy. Hospitals seeking to offer HPE must be enrolled MHCP providers, comply with DHS policies, and submit the Hospital Presumptive Eligibility Provider Assurance Statement (DHS-3887) (PDF), along with the names of trained staff who have completed the DHS HPE training. Further details can be found on the Hospital Presumptive Eligibility program webpage.

Disability Considerations for Applicants

For MA applicants who indicate a disability, the State Medical Review Team (SMRT) assesses whether they meet disability criteria. More information can be found on the FAQs about the State Medical Review Team webpage.

Waiver Service Programs

Waiver services represent an expansion of MHCP coverage, approved federally, to include services typically not covered under standard MA. These programs are designed to support specific populations with unique needs:

Additional provider information on waiver and AC programs is available in the HCBS Waiver Services section of the MHCP Provider Manual.

Minnesota Children with Special Health Needs (MCSHN) Program

The Minnesota Children with Special Health Needs (MCSHN) Program no longer provides direct funding for children with chronic conditions or disabilities. However, MCSHN staff offer crucial support to families across Minnesota by helping them navigate and identify available services and resources, including financial assistance. They also collaborate with providers and county workers to resolve resource-related challenges. For assistance, contact MCSHN at 800-728-5420.

Coverage for Incarcerated Individuals

Generally, adults in detention or correctional facilities are not eligible for MHCP. However, individuals under major program RM may retain eligibility if they meet all other requirements, regardless of their living situation. Incarcerated individuals in 245G or tribally licensed programs who meet clinical and financial criteria can receive services paid through the Behavioral Health Fund.

MHCP coverage is not available for members, irrespective of age, residing in the following correctional facilities:

  • City, county, state, and federal adult correctional and detention facilities, including inmates in work release programs or those temporarily hospitalized but required to return to custody.
  • Individuals in chemical dependency residential treatment programs mandated by court or penal institutions as part of their sentence.
  • Secure juvenile facilities licensed by the Department of Corrections (DOC) for holding, evaluation, and detention.
  • State-owned and operated juvenile correctional facilities.
  • Publicly owned and operated juvenile residential treatment and group foster care facilities licensed by DOC with over 25 non-secure beds.

Eligibility for children in juvenile programs depends on the facility type. In cases where MHCP is not promptly notified of a member’s incarceration, retroactive eligibility termination and recoupment of payments for services during incarceration may occur.

Example of a Minnesota Health Care Programs (MHCP) member ID card issued between April 2020 and the present, displaying essential identification information.

Incarcerated Member’s Living Arrangement (LA) & Billing:

If a member’s living arrangement (LA) does not indicate incarceration, contact the local tribal or county of residence before billing. Similarly, if a member is no longer incarcerated but their LA still reflects incarceration, contact the local tribal or county office. For MA payment for hospital services for incarcerated individuals in state or local facilities, refer to the Incarceration section of the Inpatient Hospital Services provider manual and contact the relevant correctional facility for billing procedures.

Applying for MHCP Coverage

Applications for MHCP coverage can be submitted online through MNsure.org, at local tribal or county agencies, or the MinnesotaCare office at DHS. Application and informational materials are available at provider offices, human services agencies, and community health offices. Online applications can be accessed and printed, or requested by mail. For application guidance, refer to each application form. Contact MinnesotaCare at:

MinnesotaCare P.O. Box 64838 St. Paul, MN, 55164-0838 651-297-3862 or 800-657-3672

Extended Postpartum and Newborn Coverage

Medical Assistance (MA) and CHIP-funded MA offer comprehensive benefits throughout the 12-month postpartum period for pregnant individuals, without premiums, copays, or deductibles. Minnesota has extended postpartum coverage from 3 months to 12 months, effective July 1, 2022.

Children born to mothers with MA coverage during their birth month automatically receive MA newborn coverage, without needing a separate application. This automatic coverage continues as long as the child resides in Minnesota, until the last day of the month they turn one year old.

Understanding Spenddowns

Members in MA, IM, or EH programs may encounter spenddowns or waiver obligations. A spenddown functions similarly to an insurance deductible, where members with income exceeding MA limits can become eligible by ‘spending down’ their income on medical expenses.

  • Medical Spenddown: Members cover medical service costs, including prescriptions, typically on a monthly basis.
  • Institutional or Long-Term Care (LTC) Spenddown: Members are responsible for a portion or all of their daily institutional charges.
  • Elderly Waiver (EW) Obligation: Members pay a part or all of their EW service costs. For senior managed care program enrollees, MCOs manage payments to providers, deducting the waiver obligation, which is then billed to the member. Designated providers cannot be used for waiver obligations.

Spenddowns and Managed Care Interactions

  • Members in managed care plans for families and children (F&C) and Minnesota Senior Care Plus (MSC+) are not eligible for medical spenddowns. Enrolling with a medical spenddown in F&C or MSC+ results in disenrollment, with fee-for-service (FFS) eligibility for the following month.
  • Enrollment in Minnesota Senior Health Options (MSHO) or Special Needs BasicCare (SNBC) is not possible with an existing medical spenddown. However, members enrolled without a spenddown who later become eligible with one can remain enrolled if they pay the spenddown to DHS.
  • Failure to pay medical spenddowns to DHS for three months leads to MSHO or SNBC disenrollment.
  • Disenrolled members have 90 days to reinstate their health plan by paying the outstanding balance to DHS.
  • Beyond 90 days post-disenrollment, re-enrollment in SNBC or MSHO is contingent on resolving the ongoing medical spenddown and settling any prior balances.
  • Members in institutions with a medical spenddown due to hospice care (considered medical service) are eligible for MSHO enrollment.

Spenddown Payment Options

MHCP offers several spenddown payment methods:

  • Potluck Spenddown: For FFS members, the initial billing provider has the spenddown amount deducted from their claim and bills the member directly.
  • DHS Spenddown: For MSHO and SNBC members, spenddowns are prepaid directly to DHS.
  • Designated Provider Spenddown: FFS members can designate a provider to apply their spenddown to their claims using the Request for Designated Provider Agreement (DHS-3161) (PDF). This provider must ensure the spenddown is applied monthly. MSHO members cannot use designated providers for medical spenddowns, except for hospice care within nursing facilities. SNBC members can use designated providers for fee-for-service covered services like Home and Community-Based Services waivers, PCA, or home care nursing.

An updated example of a Minnesota Health Care Programs (MHCP) member ID card, redesigned for new enrollees starting October 29, 2024, enhancing visual clarity while maintaining essential information.

Contact the county or tribal agency for issues like incorrect form information, misapplied spenddowns, provider changes, or discrepancies in service amounts. MHCP may recover overpayments if providers do not manage designated spenddowns correctly. Prompt billing by designated providers is essential to maintain member eligibility for other services.

  • Client Option Spenddown: Members prepay spenddowns to DHS, not available for MSHO members.

Providers see spenddown amounts on remittance advices with group and reason code PR142. Refer to Billing the Member (Recipient) for more details.

Member ID Cards and Eligibility Verification

MHCP members receive an 8-digit ID number on their individual ID cards. Household members each receive their own cards, which may vary in design based on their enrollment date. MHCP ID numbers remain constant despite program or address changes. ID cards do not contain eligibility details, so verification via MN–ITS is crucial before each service.

Example MHCP Member ID Cards:
(Issued April 2020 – Present & Redesigned Card from Oct 29, 2024)

MHCP Covered Services

MHCP covers health services deemed medically necessary, appropriate, effective, and meeting community standards, quality, timeliness, and efficient use of program funds. Services must comply with DHS rules and MHCP Provider Manual guidelines. Services must be directly provided by a provider unless otherwise authorized. For program-specific covered services, consult the MHCP benefits at a glance chart.

MHCP Noncovered Services

MHCP does not cover services including:

  • Services lacking required physician orders or proper documentation.
  • Services not in the member’s care plan or of substandard quality.
  • Non-emergency services in long-term care facilities without physician orders or member consent.
  • Services paid directly by members or other sources (except for retroactive eligibility periods).
  • Services lacking required supervision documentation.
  • Missed appointments, non-U.S. care, voluntary sterilization reversals, cosmetic surgeries, and vocational/educational services (unless IEP-related).

Refer to specific sections of the MHCP manual for detailed noncovered services information.

Legal References

Comments

No comments yet. Why don’t you start the discussion?

Leave a Reply

Your email address will not be published. Required fields are marked *