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Understanding MN Health Care Programs: A Comprehensive Guide

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Overview of Minnesota Health Care Programs (MHCP)

The Minnesota Department of Human Services (DHS) is dedicated to ensuring that all Minnesota residents, especially those with low income, have access to essential health care coverage. This commitment is realized through the Minnesota Health Care Programs (MHCP), a suite of programs designed to provide a safety net of medical services. This guide offers a detailed look into MHCP, covering eligibility criteria, the range of services offered, and other vital information for both recipients and healthcare providers.

This section will navigate you through the key aspects of MHCP, including:

MHCP Member Eligibility

Eligibility for Minnesota Health Care Programs is typically determined on a monthly basis. To ensure accurate billing and avoid claim denials, it is crucial for healthcare providers to verify a patient’s MHCP eligibility before providing services, or at least once a month for ongoing care. This verification can be done through the secure, online MN–ITS (Minnesota Information Transfer System) portal.

Before providing services, always confirm MHCP eligibility via MN-ITS to guarantee proper reimbursement and to understand any potential cost-sharing responsibilities for the member. Details about member responsibilities can be found in the Billing the Member (Recipient) guide.

Minnesota Health Care Programs (MHCP) Program Codes

Minnesota Health Care Programs encompass various specific programs, each identified by a unique two-letter program code. These codes are essential for eligibility verification and billing processes within the MN–ITS system. Below is a breakdown of the major program codes and their descriptions:

### Major Program Code ### Brief Program Description
AC Alternative Care Program: Designed for Minnesotans aged 65 and over, this state and federally funded program offers home and community-based services. It aims to prevent or delay the need for nursing facility care by providing cost-shared services in a less restrictive setting.
BB MinnesotaCare: This program offers state and federally funded health coverage for adults aged 19 and older who do not have access to affordable health insurance. MinnesotaCare is designed to be an accessible option for those who are uninsured.
EH Emergency Medical Assistance (EMA): EMA provides state and federally funded emergency medical assistance for individuals facing medical emergencies. Coverage is limited to services provided in emergency departments or during inpatient hospital stays resulting from emergency admissions, along with certain services under a certified care plan.
FP Minnesota Family Planning Program (MFPP): MFPP is a state and federally funded program offering pre-pregnancy family planning and related health care services to individuals of all ages. It focuses on reproductive health and family planning services.
FF MinnesotaCare: Similar to program BB, this is another category of MinnesotaCare, providing state and federally funded coverage for adults aged 19 and older who lack affordable health coverage options.
HH HIV/AIDS Program: This federally funded program is specifically for individuals living with HIV or AIDS who meet certain eligibility criteria. It provides comprehensive support services, including case management, dental care, insurance benefits assistance, medication access, mental health services, and nutritional support. Further details on covered services can be found at Program HH Covered Services.
IM Institution for Mental Disease (IMD) Medical Assistance (MA): This state-funded program is for individuals residing in an Institution for Mental Disease (IMD). It provides Medical Assistance to cover healthcare costs for those receiving care in these specialized facilities.
KK MinnesotaCare: This category of MinnesotaCare provides state-funded health coverage for children aged 19 and under, ensuring healthcare access for younger residents.
LL MinnesotaCare: Similar to KK, this MinnesotaCare program offers state and federally funded coverage for children aged 19 and under, expanding healthcare access for minors.
MA Medical Assistance (MA): Minnesota’s Medicaid program, MA, serves over a million Minnesotans, making it the largest of the Mn Health Care Programs. Most MA recipients are enrolled in Managed Care Organizations (MCOs), which coordinate their healthcare services.
NM Children’s Health Insurance Program (CHIP) – Funded MA: Primarily federally funded under CHIP, this MA program covers pregnant women and infants under age 2. NM also extends coverage to a small number of adults aged 19 and over who are not CHIP-eligible. Eligibility and covered services generally mirror those of standard Medical Assistance.
OO Behavioral Health Fund: This state-funded program is specifically for Substance Use Disorder (SUD) services only, providing targeted support for individuals seeking treatment for substance use disorders.
QM Qualified Medicare Beneficiary (QMB) Medicare Savings Program: QM helps cover Medicare Part A and B costs for eligible individuals, including copays, coinsurance, premiums, and deductibles. More information is available in the Qualified Medicare Beneficiary (QMB) (DHS-2087E) (PDF) document.
RM Refugee Medical Assistance: Federally funded MA program available to refugees during their first 12 months in the United States. Covered services are identical to those under standard Medical Assistance, aiding refugees in accessing necessary healthcare upon arrival.
SL Service Limited Medicare Beneficiary Medicare Savings Program: SL assists with Medicare Part B premiums but does not cover other healthcare services or Medicare copays and deductibles. Details can be found in the Service Limited Medicare Beneficiaries (DHS-2087G) (PDF) document.
UN Limited Benefit Programs: This program provides specified benefits that do not require traditional MA eligibility. It includes Essential Community Supports (ECS) and Housing Support Supplemental Services, offering targeted assistance for specific needs.
XX MinnesotaCare: This category of MinnesotaCare offers state-funded health coverage for adults aged 19 or older, further expanding access to healthcare for adult Minnesotans.

It’s important to note that some individuals may qualify for multiple programs simultaneously. In such cases, MHCP ensures that services are paid at the highest applicable coverage level. For example, someone with both QM and MA coverage would have their Medicare cost-sharing covered by QM, and any additional services covered under MA but not QM would also be covered. Program SL is unique as it only reimburses Medicare premiums and does not cover direct health care services. Individuals awaiting long-term care assessments may have an ‘unknown’ status until the assessment is complete.

Minnesota Restricted Recipient Program (MRRP)

The Minnesota Restricted Recipient Program (MRRP) is designed to monitor and manage healthcare utilization among MHCP members who may be overusing services or utilizing them in a way that is not medically necessary, or that leads to unnecessary costs for MHCP. Members identified under MRRP (across any major program code) are required to have their care coordinated by a designated primary care physician or other specified providers for a 24-month period.

For services to be covered for MRRP enrollees, the primary care provider must submit a Medical Referral for MRRP Enrollee (DHS-2978) (PDF) form to the MRRP office via fax at 651-431-7475. This referral must be submitted within 90 days of the service date from the referred provider to ensure claim processing. Claims submitted without a timely referral may be denied.

Exceptions are made for emergency health care services. If a condition poses an immediate threat of serious physical or mental disability, severe pain, or death, services can be provided without prior authorization or referral from the primary care physician. However, the MRRP office may request documentation to verify the emergency nature of the situation to process the claim.

For questions regarding referrals or the MRRP program, providers can contact the MRRP office directly at 651-431-2648 or 800-657-3674.

For MHCP members enrolled in Managed Care Organizations (MCOs), primary care providers are required to fax all MRRP referrals directly to the member’s respective MCO. This ensures coordinated care management within the managed care framework.

Hospital Presumptive Eligibility (HPE)

Established under the Affordable Care Act, the Hospital Presumptive Eligibility (HPE) program enables participating hospitals and hospital-affiliated clinics to make immediate, temporary Medical Assistance (MA) eligibility determinations based on preliminary applicant information. HPE is crucial for ensuring individuals receive prompt health care coverage and allows hospitals to receive timely payments for services rendered while a full MA application is being processed.

Hospitals and hospital clinics can enroll as qualified HPE providers at any time. A key requirement for qualified HPE hospitals is to assist individuals approved for HPE in completing and submitting their full MA application. This assistance can be direct, provided by hospital staff, or through connections with navigator organizations or certified application counselors. HPE-qualified hospitals must adhere to all program policies, procedures, and performance metrics set by DHS. Detailed information is available on the HPE: Policies, forms and notices webpage. Eligibility determinations under HPE must be made by certified hospital personnel who have completed DHS-approved training. Notably, no formal verification is required to establish HPE eligibility, streamlining the process for immediate coverage.

Upon HPE approval, the hospital must provide the applicant with an official approval notice, printed on security paper provided by DHS. This notice serves as immediate proof of temporary MA coverage until the individual receives their permanent MHCP ID card. With the HPE approval notice, individuals can access services from any MHCP provider. DHS will subsequently mail an MHCP ID card to the newly approved member, which contains their unique MHCP ID number for future coverage verification by providers and pharmacies.

Applying for HPE is not contingent on being a hospital patient. Qualified HPE hospitals are mandated to process applications for anyone, regardless of whether they are seeking medical treatment at the time of application.

HPE coverage begins on the date the hospital approves the HPE application, noted as the ‘coverage begin date’ on the HPE approval notice.

HPE coverage duration is defined as follows:

  • If a full MA application is submitted during the HPE coverage period, HPE coverage ends on the date DHS determines eligibility for MA.
  • If a full MA application is not submitted, HPE coverage ends on the last day of the month following the month of HPE approval.

Individuals approved for HPE receive full MA benefits, whether for adults or children, meaning the scope of covered services is identical to regular MA during the presumptive eligibility period.

Billing for services provided under HPE is the same as for regular MA, and any MHCP provider, not just HPE-qualified hospitals, can bill for these services.

Generally, an individual can receive HPE once within a twelve-month period. However, pregnant women are eligible for HPE once per pregnancy, recognizing the ongoing healthcare needs during pregnancy.

To become an HPE provider, a hospital must be an enrolled MHCP provider and agree to comply with DHS HPE policies and procedures. Hospitals must sign and submit the Hospital Presumptive Eligibility Provider Assurance Statement (DHS-3887) (PDF) and provide DHS with the names of staff members who have completed the DHS HPE training.

For more comprehensive information, refer to the Hospital Presumptive Eligibility program webpage.

Support for Applicants with Disabilities

For individuals applying for Medical Assistance (MA) who indicate a potential disability, the State Medical Review Team (SMRT) plays a crucial role. SMRT is responsible for evaluating whether these applicants meet the state’s criteria for disability status, which is a key factor in MA eligibility for certain programs and services.

For more detailed information about the evaluation process and criteria used by SMRT, please refer to the FAQs about the State Medical Review Team webpage. This resource provides valuable insights into how disability status is determined within the context of Minnesota Health Care Programs.

Waiver Services Programs

Waiver services represent an expansion of coverage within Minnesota Health Care Programs, authorized at the federal level to include services not typically covered under standard Medical Assistance (MA). These waivers are designed to support MHCP members with specific needs, offering home and community-based services as alternatives to institutional care. The Waiver Services Programs include:

Providers seeking more information about waiver and Alternative Care (AC) programs can refer to the HCBS Waiver Services section within the MHCP Provider Manual. This section offers detailed guidance for providers on delivering and billing for waiver services.

Minnesota Children with Special Health Needs (MCSHN) Program

The Minnesota Children with Special Health Needs (MCSHN) Program, while no longer a direct funding resource, continues to serve a vital role for families of children with chronic illnesses or disabilities throughout Minnesota. MCSHN staff provide invaluable assistance in navigating the complex landscape of services and supports, including identifying potential financial aid options. They also act as problem-solvers, collaborating with healthcare providers and county workers to locate necessary resources for families.

For assistance in identifying services and supports for children with special health needs, please contact MCSHN at 800-728-5420. Their expertise can help families access the resources needed to support their children’s health and well-being.

Coverage for Incarcerated Members

Generally, adults who are incarcerated in detention or correctional facilities are not eligible for Minnesota Health Care Programs (MHCP). However, an exception is made for individuals eligible under major program RM (Refugee Medical Assistance), who retain their eligibility regardless of their living situation, provided they meet all other eligibility criteria.

Incarcerated individuals may be eligible for payment through the Behavioral Health Fund if they meet clinical and financial eligibility guidelines and are receiving services in 245G or tribally licensed programs, which are typically substance use disorder treatment programs.

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

  • City, county, state, and federal correctional and detention facilities for adults, including inmates in work-release programs or those temporarily admitted to hospitals for medical treatment or childbirth but required to return to the facility afterward.
  • Individuals sent by court order to chemical dependency residential treatment programs while serving a sentence, with a requirement to return to correctional facilities post-treatment.
  • Secure juvenile facilities licensed by the Department of Corrections (DOC) used 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 the DOC with more than 25 non-secure beds.

Eligibility for children in juvenile programs placed by a juvenile court depends on the specific type of facility.

It is possible for MHCP to be notified of a member’s incarceration after eligibility has been determined. In such cases, MHCP will retroactively terminate the member’s eligibility and recover any reimbursements made to providers for services delivered during the period of incarceration.

Incarcerated Member’s Living Arrangement (LA):

When verifying eligibility, if the member’s Living Arrangement (LA) does not indicate incarceration, it is recommended to contact the member’s local tribal or county office before billing for services. Similarly, if a member has been released from incarceration but their LA still shows ‘incarcerated,’ contact the local tribal or county office to update their status before billing.

Billing for Incarcerated Members:

While generally ineligible, individuals incarcerated in state or local correctional facilities may qualify for MA payment specifically for hospital services. Refer to the Incarceration section of the Inpatient Hospital Services provider manual for detailed billing guidelines.

For billing inquiries related to services provided to incarcerated individuals, contact the relevant county jail or correctional facility for specific procedures.

How to Apply for MHCP Coverage

Individuals interested in applying for Minnesota Health Care Programs (MHCP) coverage have several convenient options:

  • Online via MNsure.org: The most direct method is through the state’s health insurance marketplace, MNsure.org. This website allows individuals to apply for various health coverage options, including MHCP.
  • Local Tribal or County Agency: Applications can also be made in person at local tribal or county human services agencies. These agencies can provide direct assistance with the application process.
  • MinnesotaCare Office at DHS: Applications can be submitted directly to the MinnesotaCare office at the Department of Human Services.

MinnesotaCare legislation mandates that application forms and informational materials be readily available at provider offices, local human services agencies, and community health offices. You can access and print online applications or request to have applications mailed to your office. Each application form includes guidance on which form to use based on the applicant’s circumstances.

For further assistance or to request applications by mail, contact MinnesotaCare directly:

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

Postpartum Care Coverage Extension

Minnesota’s Medical Assistance (MA) and CHIP-funded MA programs ensure comprehensive healthcare access for pregnant individuals throughout the entire 12-month postpartum period. This includes the full range of MA benefits without any premiums, copays, or deductibles.

Effective July 1, 2022, Minnesota law extended postpartum coverage from the previous 3 months to a full 12 months for individuals enrolled in MA or CHIP-funded MA during pregnancy. This expansion aims to support maternal health and well-being in the critical year following childbirth.

Automatic Newborn Coverage

Children born to mothers who are covered by Medical Assistance (MA) during the month of the child’s birth are automatically enrolled in MA newborn coverage. There is no need to apply separately for MHCP coverage for these newborns. This automatic eligibility continues as long as the child remains a resident of Minnesota, regardless of their living situation, until the last day of the month in which they turn one year old. This ensures continuous health coverage during the crucial first year of life.

Understanding Spenddowns

In certain Minnesota Health Care Programs like MA, IM (Institutions for Mental Disease), or EH (Emergency Medical Assistance), eligibility may be contingent on a “spenddown” or waiver obligation. Spenddowns are designed for individuals whose income exceeds the standard MA income limit but still require healthcare assistance. A spenddown functions similarly to an insurance deductible, representing the amount a member must pay out-of-pocket for medical expenses before MHCP coverage begins.

There are different types of spenddowns:

  • Medical Spenddown: Typically applied monthly, members are responsible for paying for medical services, including prescriptions, up to the spenddown amount each month.
  • Institutional or Long-Term Care (LTC) Spenddown: Members are required to contribute a portion or all of their daily institutional charges towards their care costs.
  • Elderly Waiver (EW) Obligation: Members enrolled in the Elderly Waiver program may have to pay a portion or all of their EW service costs. For those in senior managed care programs, Managed Care Organizations (MCOs) will pay providers, minus the waiver obligation, and the provider then bills the member for this obligation. Designated providers cannot be used for waiver obligations.

Spenddowns and Managed Care Considerations

The interaction between spenddowns and managed care within Minnesota Health Care Programs has specific rules:

  • Members eligible for MA and enrolled in managed care plans for Families and Children (F&C) or Minnesota Senior Care Plus (MSC+) cannot have a medical spenddown. If a member becomes eligible for MA with a medical spenddown while in F&C or MSC+, they will be disenrolled from their managed care plan and transitioned to fee-for-service (FFS) for the following month.
  • Enrollment in Minnesota Senior Health Options (MSHO) or Special Needs BasicCare (SNBC) is not permitted for individuals with an existing medical spenddown. However, if a member is already enrolled in MSHO or SNBC without a spenddown and later becomes eligible with one, they can remain enrolled as long as they consistently pay their medical spenddown to DHS.
  • Failure to pay medical spenddowns to DHS for three consecutive months will result in disenrollment from MSHO or SNBC.
  • Following disenrollment from SNBC or MSHO due to unpaid spenddowns, members have a 90-day period to pay the outstanding balance to DHS and be reinstated in their health plan.
  • If more than 90 days have passed since disenrollment, and the member has not paid the outstanding balance and continues to have a medical spenddown, they cannot re-enroll in SNBC or MSHO until the spenddown obligation is resolved.
  • An exception exists for members residing in institutions who have a medical spenddown due to hospice care, which is considered a medical service. These individuals are permitted to enroll in MSHO.

Spenddown Payment Options

Minnesota Health Care Programs offer several methods for members to manage their spenddown obligations:

  • Potluck Spenddown: For members in fee-for-service (FFS) arrangements, the first provider to bill will have the spenddown amount deducted from their claim. This provider then becomes responsible for billing the member directly for the spenddown portion.
  • DHS Spenddown: Primarily for members in MSHO and SNBC, this method requires members to pay their spenddown amount directly to DHS in advance.
  • Designated Provider Spenddown: FFS members can choose a specific provider to manage their spenddown. By completing a Request for Designated Provider Agreement (DHS-3161) (PDF), members designate a provider who agrees to apply the member’s monthly spenddown to their claims for services rendered.
    • Note: MSHO enrollees cannot use a designated provider for medical spenddowns and must pay DHS directly, except for those in nursing facilities receiving hospice care (where the hospice provider can be designated when an institutional spenddown is converted to a medical spenddown). Designated providers are allowed for institutional spenddowns.
    • SNBC enrollees can use designated providers for medical spenddowns, but only for services not covered by their health plan, such as Home and Community-Based Services waivers for people with disabilities, PCA, or home care nursing under fee-for-service.

For issues related to designated provider spenddowns, such as incorrect form information, improper application of spenddowns, or changes in provider services, contact the county or tribal agency. MHCP may recover overpayments if providers do not manage designated provider agreements correctly. Providers billing under a designated provider agreement should bill promptly after service delivery to ensure the member’s eligibility for other services is updated after the spenddown is met.

  • Client Option Spenddown: Members can prepay their spenddown amounts directly to DHS. This option is not available to MSHO members.

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

Member ID Cards and Eligibility Verification

Upon approval for Minnesota Health Care Programs (MHCP), each member is assigned an 8-digit member number, which is printed on their MHCP ID card. Each eligible household member receives their own ID card, and card designs may vary based on their enrollment date.

Current MHCP member ID card example, demonstrating the layout and information provided to recipients.

Redesigned MHCP member ID card example, illustrating the updated look for newly enrolled members starting October 2024.

Key points regarding MHCP ID cards and eligibility:

  • MHCP ID numbers remain constant, regardless of changes in program, eligibility status, or address.
  • MHCP ID cards do not contain eligibility details.
  • Eligibility verification should be conducted before each service visit via MN–ITS to ensure up-to-date coverage information.

Note: As of October 29, 2024, newly enrolled MHCP members will receive a redesigned ID card. Existing members will continue using their current cards until DHS issues the new cards to them sometime in 2025. Current members do not need to request new cards; DHS will automatically send them in due course. Updates regarding the distribution timeline will be provided in the MHCP Provider Manual.

Services Covered Under MHCP

For a health service to be covered by Minnesota Health Care Programs (MHCP), it must meet specific criteria to ensure medical necessity, appropriateness, effectiveness, and efficient use of program funds. Covered services are those that are:

  • Medically Necessary: Determined by prevailing community standards and customary medical practice.
  • Appropriate and Effective: Suitable and effective for the patient’s medical needs.
  • Quality and Timeliness Standards: Able to meet established standards for quality and timely delivery of care.
  • Effective Use of Program Funds: Represent an appropriate and cost-effective use of MHCP resources.
  • Within Program Limits: Compliant with specific limits and guidelines outlined in DHS rules and the MHCP Provider Manual.
  • Personally Rendered: Services must be directly provided by a qualified provider, unless otherwise authorized in the MHCP Provider Manual.

For a program-specific overview of covered services, refer to the MHCP benefits at a glance chart. This chart provides a concise summary of benefits covered under different MHCP programs.

Services Not Covered Under MHCP

Minnesota Health Care Programs (MHCP) have specific exclusions regarding service coverage. MHCP generally does not cover the following:

  • Services Without Proper Authorization: Health services requiring a physician’s order that has not been obtained.
  • Undocumented Services: Services not properly documented in the member’s health or medical record.
  • Services Outside of Care Plans: Services not included in the member’s plan of care, individual treatment plan, IEP, or individual service plan.
  • Indirect Services: Services not provided directly to the member, unless explicitly defined as a covered service in the MHCP Provider Manual.
  • Substandard Quality of Care: Services that fall below the prevailing community standard of quality expected from professional peers. Providers of substandard services are responsible for the costs.
  • Non-Emergency Services in Long-Term Care Facilities without Orders: Non-emergency health services provided to a member in a long-term care facility that are not part of the member’s care plan and lack a written physician’s order (when an order is required).
  • Services Without Informed Consent: Non-emergency health services provided without the full knowledge and consent of the member or their legal guardian.
  • Services Paid by Other Sources: Services already paid for by the member or another source, except for payments made by the member for services during a retroactive eligibility period. Refer to Billing Policy and Billing the Member (Recipient) for details on retroactive eligibility.
  • Unsupervised Services: Services lacking required documentation of supervision, if supervision is a condition of coverage.
  • Missed Appointments: MHCP does not cover charges for missed appointments, and members should not be billed for these.
  • Out-of-Country Care: Health care services received outside of the United States are not covered.
  • Voluntary Sterilization Reversal: Procedures for the reversal of voluntary sterilizations are not covered.
  • Cosmetic Surgery: Surgery primarily for cosmetic purposes is excluded from coverage.
  • Vocational or Educational Services: Vocational or educational services, including functional evaluations or employment physicals, are generally not covered, except as specifically provided under IEP-related services.

For more detailed information on specific noncovered services, please consult the relevant sections of the MHCP Provider Manual.

Legal and Regulatory Framework

The Minnesota Health Care Programs (MHCP) operate under a robust legal and regulatory framework, ensuring compliance and defining the scope and limitations of the programs. Key legal references include:

Minnesota Statutes:

Minnesota Rules:

Code of Federal Regulations:

This comprehensive guide aims to provide a thorough understanding of Minnesota Health Care Programs. For the most current and detailed information, always refer to the official resources from the Minnesota Department of Human Services and the MHCP Provider Manual.

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