MinnesotaCare

3.1.2.2 Premiums and Cost Sharing

Premiums

Many MinnesotaCare enrollees must pay a monthly premium to establish and maintain coverage. The premium amount is based on household income and household size.

The following enrollees have no premium:

Households that include one or more military members, enrolled in MinnesotaCare, who have completed a tour of active duty within 24 months of MinnesotaCare eligibility, are exempt from paying MinnesotaCare premiums for up to 12 months, which do not have to be consecutive
Households with one or more American Indians or Alaska Natives enrolled in MinnesotaCare
Households with projected annual income below 35% of the Federal Poverty Guidelines (FPG)
People younger than 21

American Indian and Alaska Native enrollees are not required to provide proof of status to be exempt from paying MinnesotaCare premiums.

If a person is added to an existing MinnesotaCare household that is required to pay a premium, or is newly determined eligible for MinnesotaCare as an existing household member, the effective date of the resulting premium change is as follows:

If adding the person to the MinnesotaCare household results in a premium decrease, the decrease is effective the first day of the month after the person was determined eligible.
If adding the person to the MinnesotaCare household results in an increase in the household's premium, the increase in the overall premium is effective at the next regular billing for the household.

A household may become newly exempt from premiums when a returning military member, American Indian or Alaska Native is added to the household and is determined eligible for MinnesotaCare. A household may also become newly exempt when a person is added to the household, which causes the household to have income below 35% of the federal poverty guidelines. The effective date of the premium exemption is the first day of the month after eligibility for that person was determined.

The MinnesotaCare Premium Estimator Table (DHS-4139A) lists estimated premiums based on household income and household size. The premium listed on a bill is the official calculation and the amount an enrollee must pay.

People who are required to pay a monthly premium must pay it to keep MinnesotaCare coverage. Ongoing MinnesotaCare premiums are due the 15th of the month, but can be paid through noon on the last working day of the month. Premiums should be paid on time to avoid a gap in coverage. There is no good cause exception for nonpayment of a MinnesotaCare premium.

Households may pay the premiums for coverage months that have not yet been billed. A MinnesotaCare premium is refunded only if, at the time the household requested a refund, the premium was for a future month of coverage for which the agency has not yet paid a health plan.

Grace Month

MinnesotaCare enrollees who do not pay their premium before the coverage month, have a one-month grace period. An enrollee will remain covered during the grace month, regardless of whether the enrollee pays the premium for that month. Coverage stops at the end of the grace month if they fail to pay their past due premium for the grace month.

A person must pay the grace month premium in full by noon on the last working day of the grace month to avoid a gap in coverage for enrollees who are required to pay a premium. People who are disenrolled from coverage because they did not pay a premium may have a gap in coverage of one month or more.

To restart coverage, the person must pay the past-due premium for the grace month, if it has not yet been forgiven, and the future month’s premium. Coverage begins the first day of the month after the month in which the person pays both these premiums in full.

A person may have back-to-back grace months. If the person pays the grace month premium by noon on the last working of the grace month, but does not pay for a future month of coverage, the future month of coverage is a grace month.

A person approved for retroactive Medical Assistance (MA) for a month in which the person had MinnesotaCare eligibility and was in a grace month must still pay the grace month premium, if it has not yet been forgiven, to re-enroll in coverage.

The MinnesotaCare grace month applies only to enrollees who are required to pay a MinnesotaCare premium. Household members who are not required to pay premiums, such as people under the age of 21, remain covered, regardless of whether other household members’ premiums are paid.

Grace Month and Renewals

Whether a person is a MinnesotaCare enrollee who is in a grace month or was disenrolled for failure to pay premiums has no effect on his or her MinnesotaCare renewal process. The agency must process renewals for MinnesotaCare enrollees who have entered a grace month and people who are disenrolled for nonpayment, following the same process for MinnesotaCare enrollees who are not in a grace month. Disenrollment for nonpayment of a MinnesotaCare premium does not prevent or delay a person's renewal of MinnesotaCare eligibility.

People who are subject to a premium must continue paying their premiums timely during the renewal process to maintain coverage.

A person disenrolled for nonpayment whose eligibility is renewed with a different monthly premium must pay the new premium amount for a future month of coverage in addition to the past due premium for a grace month, if it has not yet been forgiven, to re-enroll in MinnesotaCare coverage.

The grace month and premium payment policies apply to enrolles who are required to complete a renewal form. MinnesotaCare enrollees have a January renewal month. January may be a grace month.

Premium Forgiveness

Any full or partial unpaid grace month premium, whether it s unpaid because of lack of payment or insufficient funds, is forgiven before issuing the MinnesotaCare premium bill for the fourth month of coverage after disenrollment. Premiums are forgiven even though capitation was paid for the grace month After the grace month's premium is forgiven, a person is only required to pay a future month's premium to re-enroll in coverage.

When a person is added to an existing MinnesotaCare case during a grace month, and, as a result of the person being added, the household is no longer required to pay a premium for coverage, the household is premium exempt effective the first day of the month after the change was reported. Any unpaid grace month premium for the household that is no longer required to pay a MinnesotaCare premium is forgiven once the person is added to the household and determined eligible for MinnesotaCare.

Cost Sharing

Cost sharing includes those costs a MinnesotaCare enrollee pays towards their health care. MinnesotaCare cost sharing includes deductibles, medical visit and prescription copays.

Adults age 21 or older have a:

Monthly deductible
Copays for non-preventative visits
Copays for nonemergency ER visits
Copays for eyeglasses
Copays for prescription drugs

There is no cost sharing for mental health services.

American Indians and Alaska Natives enrolled in a federally recognized tribe are exempt from cost sharing. Verification of membership in a federally recognized tribe is required to be exempt from cost sharing. Acceptable verifications include a data match from an electronic data source or paper documentation.

Providers must serve MinnesotaCare enrollees who are not able to pay a copay or deductible at the time of the visit, however, that provider does not have to serve an enrollee again if their cost sharing is still not paid.

Legal Citations

Code of Federal Regulations, title 42, section 600.505

Code of Federal Regulations, title 42, section 600.510

Code of Federal Regulations, title 42, section 600.525

Code of Federal Regulations, title 45, section 155.350

Minnesota Statutes, section 256L.03

Minnesota Statutes, section 256L.06

Minnesota Statutes, section 256L.15