*** The Health Care Programs Manual (HCPM) has been replaced by the Minnesota Health Care Programs Eligibility Policy Manual (EPM) as of June 1, 2016. Please refer to the EPM for current health care program policy information. ***
Effective: November 1, 2012 |
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24.15.35 - MinnesotaCare Expenses |
Archived: June 1, 2016 (Previous Versions) |
Some MinnesotaCare expenses can be used to meet an MA spenddown if they are not eligible for federal financial participation (FFP). Specific criteria is applied to MinnesotaCare expenses based on the client’s major program and whether or not the bill was incurred in a month in which the client was enrolled in managed care.
For information on MinnesotaCare clients applying for MA to cover the costs of inpatient hospitalization, see Inpatient Hospitalization - MinnesotaCare Enrollee.
When to Use MinnesotaCare Expenses.
Determining the MinnesotaCare Expense Amount.
Follow these steps when considering whether a person’s MinnesotaCare expenses can be use to meet a spenddown:
1. Note the major program for each eligible MinnesotaCare household member.
2. Note whether the eligible household member is enrolled in managed care.
3. Determine what MinnesotaCare expenses can be used based on each person’s major program.
4. Determine the amount of the MinnesotaCare expense.
When to Use MinnesotaCare Expenses
MinnesotaCare expenses may be applied to a spenddown in certain situations. These situations include:
l MinnesotaCare enrollees who are subject to the $10,000 inpatient hospitalization limits and who meet a basis of eligibility for MA may be eligible for MA with a spenddown. The enrollee can choose to apply for MA for coverage of any amount not covered by MinnesotaCare. Any of the unpaid MinnesotaCare expenses that MA cannot cover can then be applied to the spenddown.
l Clients with an MA spenddown whose household has members receiving state-funded MinnesotaCare and have health care expenses that are not paid by MinnesotaCare.
Expenses paid by MinnesotaCare for clients receiving FFP cannot be used to meet a spenddown.
l DHS receives FFP for MinnesotaCare clients who are U.S citizens, or noncitizens meeting qualification requirements, and are one of the following:
n Parent or relative caretaker on major program FF.
n Pregnant woman or child under 21 on major program LL.
l DHS receives State funding (non-FFP) for the following MinnesotaCare clients:
n All legal guardians and foster parents.
n Non-pregnant adults without children with household income equal to or less than 75% FPG.
n Noncitizen parent or relative caretakers who have an immigration status that qualifies them for state funding only.
n Pregnant women and children who are incarcerated while enrolled in MinnesotaCare.
Apply the following MinnesotaCare expenses to the MA household member’s spenddown based on the MinnesotaCare major program.
Note: Children living in households with income equal to or less than 200% FPG do not have a monthly MinnesotaCare premium.
l Major Program LL. Allow the following expenses to meet a spenddown:
n MinnesotaCare premiums.
n Non-reimbursable expenses not covered by MinnesotaCare for which the household is responsible.
Do not allow the MinnesotaCare capitation payment or any other expenses paid by MinnesotaCare.
Example:
Brett, age 16, receives MA with a monthly spenddown of $100. His mother, Peggy, is enrolled in MinnesotaCare and pays a monthly premium of $45. Peggy is enrolled in Health Partners through MinnesotaCare.
On July 12, Peggy is injured and is hospitalized. She incurs hospital charges of $15,000. She has a $10,000 inpatient hospital cap. Peggy is on major program FF (FFP).
Action:
Allow the following MinnesotaCare expenses to meet Brett’s spenddown:
m Peggy's MinnesotaCare monthly premium.
m Peggy's inpatient charges in excess of the inpatient hospitalization cap.
l Major Program KK. Allow the following expenses to meet a spenddown:
n Enrolled in managed care:
m The greater of either the MinnesotaCare premium or the monthly capitation payment.
m Health care expenses incurred outside the health plan for which the household is responsible.
n Not enrolled in managed care:
m MinnesotaCare premium.
m Fee-for-service claims paid through MinnesotaCare.
Example:
Mark has a six-month spenddown. Mark’s wife, Angela, is six months pregnant and enrolled in MinnesotaCare on major program KK. Angela has a monthly premium of $58 and a capitation payment of $350.
Action:
Angela’s MinnesotaCare capitation payment can be used to meet Mark’s spenddown because she is on major program KK and the capitation payment is greater than the premium.
l Major Program FF. Allow the following expenses to meet a spenddown:
n Enrolled in managed care:
m The MinnesotaCare premium.
m MinnesotaCare copayments.
m Bills incurred outside the health plan for which the household is responsible.
n Not enrolled in managed care:
m The MinnesotaCare premium.
m MinnesotaCare co-payments.
Note: Do not apply any claims paid fee-for-service by MinnesotaCare.
l Major Program JJ and Major Program BB. Allow the following expenses to meet a spenddown:
n Enrolled in managed care:
m MinnesotaCare co-payments.
m The greater of either the MinnesotaCare premium or the monthly capitation payment.
m Bills incurred outside the health plan for which the household is responsible.
n Not enrolled in managed care:
m The MinnesotaCare premium.
m MinnesotaCare co-payments.
m Fee-for service claims paid by MinnesotaCare.
Example:
Elaine and her four children are on MinnesotaCare with a monthly premium of $150. Elaine's monthly capitation payment is $185. Elaine is on major program JJ because of her immigration status. The children are U.S. citizens on major program LL.
Elaine's husband, Randy, has health insurance through work and is not eligible for MinnesotaCare. Randy applied for MA to cover $2,000 in dental expenses not covered by his health insurance. Randy has a $1,300 spenddown.
Action:
Apply Elaine’s $185 capitation payment and any MinnesotaCare co-payments to Randy’s spenddown because she is on major program JJ and the capitation payment is greater than the household premium.
Do not apply further MinnesotaCare expenses because the children are on major program LL. Major program LL allows only premiums to apply toward the spenddown so it was to Randy’s benefit to use Elaine’s capitation payment rather than the premium.
Example:
Gloria, age 63, is in enrolled in MinnesotaCare major program BB. Her premium is $75 and her capitation payment is $50. Her husband, Bud, age 67 is eligible for MA with a spenddown.
Action:
Apply Gloria’s premium of $75 to Bud’s spenddown because it is greater than the capitation payment. Also apply any co-payments Gloria incurs.
Determining the MinnesotaCare Expense Amount
Verify each expense in the manner listed:
l MinnesotaCare premium amount. Verify in one of the following ways:
n Check the Financial Control subsystem of MMIS.
n Contact the MinnesotaCare worker.
n Obtain a copy of the client’s premium statement.
l Capitation payment. Verify the amount by checking the MMIS Claims subsystem.
Note: Not all workers have access to this subsystem. Request the information from the county staff person who has the appropriate access.
l Paid fee-for-service claims. Verify in one of the following ways:
n Check the Claims subsystem of MMIS.
n Submit a Claims History Request to the Benefit Recovery Section.
n Obtain a copy of the client’s Explanation of Medical Benefits (EOMB).
n Obtain a copy of the provider statement.