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Who Funds Minnesota Health Care Programs? A Detailed Overview

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The Minnesota Department of Human Services (DHS) plays a crucial role in providing access to essential health care coverage for Minnesotans with limited income through the Minnesota Health Care Programs (MHCP). Understanding Who Funds The Assistance And Health Care Programs is key to appreciating the structure and scope of these vital services. This article delves into the funding and eligibility aspects of MHCP, offering a comprehensive guide for individuals and providers alike.

Understanding MHCP Member Eligibility and Funding

The MN–ITS eligibility verification system utilizes major program codes to identify different MHCP programs. Eligibility for these programs is typically determined monthly. Healthcare providers are advised to verify MHCP eligibility through MN–ITS before providing services, ideally monthly or per calendar month for recurring services. It’s important to be aware of member cost-sharing responsibilities, as detailed in Billing the Member (Recipient).

### Minnesota Health Care Programs (MHCP) Funding and Descriptions
### Major Program Code
### AC
### BB
### EH
### FP
### FF
### HH
### IM
### KK
### LL
### MA
### NM
### OO
### QM
### RM
### SL
### UN
### XX

It is important to note that individuals may qualify for multiple programs simultaneously. In such cases, MHCP ensures payment at 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. Eligibility for long-term care assessment pending individuals is listed as unknown until assessment completion.

Minnesota Restricted Recipient Program (MRRP)

The Minnesota Restricted Recipient Program (MRRP) targets MHCP members who overuse services or incur unnecessary costs. Identified individuals are assigned a primary care physician or designated providers to coordinate their care for 24 months.

Referrals are required for MRRP enrollees. Primary care providers must fax a Medical Referral for MRRP Enrollee (DHS-2978) (PDF) to 651-431-7475 within 90 days of service. Claims without timely referrals may be denied. Emergency services are exempt from referral requirements, but documentation may be requested for claim payment.

For referral inquiries, contact MRRP at 651-431-2648 or 800-657-3674. Managed Care Organization (MCO) enrollees require primary care providers to fax MRRP referrals directly to the MCO.

Hospital Presumptive Eligibility: Immediate Access to Care

Hospital Presumptive Eligibility (HPE), established under the Affordable Care Act, enables participating hospitals and clinics to make preliminary Medical Assistance (MA) eligibility determinations. This facilitates immediate health care coverage and ensures hospitals receive payment for services provided before full MA approval.

Hospitals can enroll as HPE providers and must assist approved individuals in completing the full MA application, either directly or through navigator organizations or certified application counselors. Compliance with DHS policies and HPE performance metrics is mandatory. HPE: Policies, forms and notices offers further details. DHS-certified hospital personnel conduct HPE eligibility determinations, requiring no initial verification.

Upon HPE approval, hospitals issue a DHS-provided security paper approval notice, serving as temporary proof of coverage until the MHCP ID card arrives. This notice allows access to any MHCP provider. DHS subsequently mails an MHCP ID card containing the member’s ID number for provider and pharmacy verification.

HPE application processing is a service offered by qualified hospitals regardless of the applicant’s patient status.

HPE coverage is effective from the approval date, noted on the HPE approval notice as the “coverage begin date.”

HPE coverage termination occurs:

  • Upon DHS’s MA eligibility determination if a full MA application is submitted during the HPE period.
  • On the last day of the month following HPE approval if no MA application is submitted.

HPE provides full MA benefits (adult or children) with no service coverage differences compared to regular MA.

Billing for HPE services follows standard MA procedures and is not limited to HPE-qualified hospitals.

HPE is generally limited to once per person per 12-month period, except for pregnant women, who are eligible once per pregnancy.

Hospitals seeking HPE qualification must be enrolled MHCP providers, comply with DHS HPE policy, and submit the Hospital Presumptive Eligibility Provider Assurance Statement (DHS-3887) (PDF) and staff training certifications to DHS.

Further information is available on the Hospital Presumptive Eligibility program webpage.

Disability Considerations for Applicants

Applicants for MA who indicate a potential disability are evaluated by the State Medical Review Team (SMRT) to determine disability status. Refer to FAQs about the State Medical Review Team for more information on this process.

Waiver Services Programs: Expanded Coverage

Waiver services programs have secured federal approvals to broaden MHCP coverage to include services typically not covered by MA. These programs are crucial for providing comprehensive support.

Two examples of MHCP member ID cards showcasing different designs used over time.

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: Resource Navigation

While the Minnesota Children with Special Health Needs (MCSHN) Program no longer provides direct funding, its staff remains a valuable resource. They assist families of children with special health care needs across Minnesota in identifying available services and supports, including potential financial aid. MCSHN staff also collaborate with providers and county workers to locate resources for families. For assistance, call 800-728-5420.

Incarcerated Members: Eligibility Limitations

Generally, incarcerated adults in detention or correctional facilities are ineligible for MHCP. However, individuals eligible under major program RM retain eligibility regardless of living arrangements.

Incarcerated individuals in 245G or tribally licensed programs meeting clinical and financial criteria may be eligible for Behavioral Health Fund payments.

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

  • City, county, state, and federal adult correctional and detention facilities, including work release programs requiring facility return during non-work hours.
  • Acute care medical hospitals for medical treatment or childbirth with required return to the facility post-treatment.
  • Chemical dependency residential treatment programs mandated by court or penal institutions, with required return to correctional facilities after treatment.
  • 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 certain juvenile programs placed by juvenile courts varies by facility type.

MHCP may retroactively terminate eligibility and recoup reimbursements if incarceration notification is received after eligibility determination.

Incarcerated Member’s Living Arrangement (LA) Verification:

  • If the LA does not indicate incarceration, contact the member’s local tribal or county of residence before billing.
  • If the LA still shows incarceration after release, contact the local tribal or county of residence before billing.

Incarcerated Member Billing: MA payment for hospital services may be available for individuals incarcerated in state or local correctional facilities. Refer to the Incarceration section of the Inpatient Hospital Services provider manual. Contact the relevant correctional facility for specific billing procedures.

Applying for MHCP Coverage: Multiple Access Points

Applications for MHCP coverage can be submitted online via MNsure.org, at local tribal or county agencies, or at the MinnesotaCare office at DHS.

MinnesotaCare legislation mandates application and informational materials availability at provider offices, local human services, and community health offices. Online applications can be accessed and printed from online applications, or requested by mail. Application-specific instructions are provided on each form. Contact MinnesotaCare at:

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

Extended Postpartum Coverage

Medical Assistance (MA) and CHIP-funded MA now offer comprehensive benefits for pregnant individuals throughout a 12-month postpartum period, eliminating premiums, copays, and deductibles. Minnesota extended postpartum coverage from 3 months to 12 months, effective July 1, 2022, for MA and CHIP-funded MA enrollees.

Automatic Newborn Coverage

Infants born to mothers with MA coverage during the birth month automatically receive MA newborn coverage, eliminating the need for a separate MHCP application. Continuous MA eligibility extends to the last day of the month in which the child turns one year old, provided they remain in Minnesota.

Spenddowns: Meeting Income Eligibility

Individuals eligible for MA, IM, or EH with income exceeding limits may qualify through a spenddown or waiver obligation. Spenddowns, similar to insurance deductibles, represent the member’s financial responsibility before MHCP coverage activates.

  • Medical spenddown: Members cover medical service costs, including prescriptions, typically monthly.
  • Institutional or long-term care (LTC) spenddown: Members pay a portion or all institutional daily charges.
  • Elderly waiver (EW) obligation: Members cover part or all EW service costs. For senior managed care enrollees, MCOs pay providers net of the waiver obligation, and providers bill members. Designated providers cannot be used for waiver obligations.

Spenddowns and Managed Care Plan Enrollment

  • Medical spenddowns are incompatible with managed care plans for families and children (F&C) and Minnesota Senior Care Plus (MSC+). Enrollees becoming eligible with medical spenddowns will be disenrolled and transitioned to fee-for-service (FFS) the following month.
  • Enrollment in Minnesota Senior Health Options (MSHO) or Special Needs BasicCare (SNBC) is prohibited with existing medical spenddowns. However, existing MSHO/SNBC enrollees who later become spenddown-eligible can remain enrolled if they consistently pay their medical spenddown to DHS.
  • Failure to pay medical spenddowns to DHS for three months results in MSHO or SNBC disenrollment.
  • Disenrolled members have a 90-day reinstatement window to pay outstanding balances to DHS and regain health plan enrollment.
  • After 90 days post-disenrollment, re-enrollment in SNBC or MSHO is contingent on no ongoing medical spenddown and payment of previous outstanding balances.
  • MSHO enrollment is permitted for institutionalized members with medical spenddowns due to hospice care.

Spenddown Payment Options: Flexibility for Members

MHCP offers four spenddown payment options:

  • Potluck spenddown: For FFS members, the initial billing provider has the spenddown amount deducted from their claim and bills the member directly.

  • DHS spenddown: MSHO and SNBC members pay spenddowns directly to DHS in advance.

  • Designated provider spenddown: FFS members designate a provider via the Request for Designated Provider Agreement (DHS-3161) (PDF). The designated provider ensures the member’s spenddown is applied to their claims for each service month. MSHO enrollees cannot use designated providers for medical spenddowns, except for hospice care within nursing facilities with institutional spenddowns. Designated providers are permissible for institutional spenddowns. SNBC enrollees can use designated providers for medical spenddowns for services not covered by their health plan, specifically Home and Community-Based Services waivers, PCA, or home care nursing.
    Contact the county or tribal agency if:

    • Form information is incorrect.
    • Spenddowns are not applied correctly.
    • The provider no longer services the member.
    • The provider no longer provides services equaling or exceeding the spenddown amount.
    • Designated provider notices persist after service cessation.

    MHCP may recover overpayments if providers don’t take corrective actions. Designated providers should bill promptly after service delivery. Member ineligibility for other services persists until the designated provider’s claim processing.

  • Client option spenddown: Members prepay spenddowns to DHS. This option is unavailable to MSHO enrollees.

Providers owed spenddown amounts will see group and reason code PR142 on remittance advices, indicating the spenddown amount. Refer to the Billing the Member (Recipient) section of the MHCP Provider Manual for further details.

Member ID Cards and Eligibility Verification

MHCP assigns an 8-digit member number to each approved member, printed on their ID card. Each household member receives their own ID card, potentially with varied designs depending on eligibility dates.

  • MHCP ID numbers remain constant despite program, eligibility, or address changes.
  • MHCP ID cards lack eligibility details. Card designs may vary.

Eligibility verification via MN–ITS is essential before each visit.

A redesigned MHCP member ID card, set to be issued to newly enrolled members starting October 29, 2024.

Note: As of Oct. 29, 2024, newly enrolled MHCP members receive a redesigned ID card. Currently enrolled members will continue using their existing cards until DHS issues new cards in 2025. Current members do not need to request new cards. Manual updates will be provided regarding the new card distribution timeline.

MHCP Covered Services: Defining Medical Necessity

MHCP coverage requires health services to meet prevailing community standards and be:

  • Medically necessary.
  • Appropriate and effective for the patient’s medical needs.
  • Aligned with quality and timeliness standards.
  • An efficient and appropriate use of program funds.
  • Within specific limits outlined in DHS rules and the MHCP Provider Manual.
  • Personally rendered by a provider, unless explicitly authorized in the MHCP Provider Manual.

Refer to the MHCP benefits at a glance chart for program-specific covered services.

MHCP Noncovered Services: Services Outside Coverage

MHCP generally does not cover health services in the following situations:

  • Physician’s order required but not obtained.
  • Undocumented services in the member’s health record.
  • Services not in the member’s care plan, treatment plan, IEP, or service plan.
  • Services not directly provided to the member, unless explicitly covered in the MHCP Provider Manual.
  • Services below prevailing community quality standards (providers bear the cost of low-quality services).
  • Non-emergency services in long-term care facilities not in the care plan or without written physician orders (when required).
  • Non-emergency services without full member or legal guardian consent.
  • Services paid directly by the member or other sources, except for retroactive eligibility periods. Refer to Billing Policy and Billing the Member (Recipient).
  • Services lacking required supervision documentation.
  • Missed appointments.
  • Non-U.S. care.
  • Reversal of voluntary sterilizations.
  • Primarily cosmetic surgery.
  • Vocational or educational services, including functional evaluations or employment physicals, except IEP-related services.

Consult specific manual sections for more noncovered service details.

Legal References: Statutory and Regulatory Framework

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