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Effective: December 1, 2006 |
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02.05ar1 - Hierarchy of Major Programs (Archive) |
Archived: October 1, 2007 |
The three primary Minnesota Health Care Programs are MinnesotaCare, Medical Assistance (MA), and General Assistance Medical Care (GAMC). When people submit an application for Minnesota health care program coverage, they may meet the eligibility criteria for more than one of these major programs. However, there is a hierarchy to consider in determining which health care program is best for each applicant.
People may be eligible for only one of the three primary health care programs (MA, GAMC, or MinnesotaCare) at a time, with a few exceptions. For further information, see Programs Overlap.
In addition to the three primary health care programs, people may also qualify for the Medicare Savings Programs. See that section of the manual for further information about those programs.
General Assistance Medical Care.
There are five major programs within MinnesotaCare. Each major program has a system code used to identify the correct benefit set for the applicant or enrollee, and whether DHS will receive Federal Financial Participation (FFP) .
l Major program LL is for children under 21 and pregnant women who are either:
n U.S. citizens, or
n Noncitizens who qualify for federally funded health care coverage.
l Major program KK is for children under 21 and pregnant women who are noncitizens who do not qualify for federally funded health care coverage.
l Major program FF is for parents and relative caretakers who are either:
n U.S. citizens, or
n Noncitizens who qualify for federally funded health care coverage.
l Major program JJ is for:
n All legal guardians and foster parents, and
n Parents and relative caretakers who are noncitizens who do not qualify for federally funded health care coverage.
l Major program BB is for all adults without children.
There are several different Medical Assistance (MA) programs. These major programs also use system codes to identify the correct benefit set and whether DHS will receive FFP.
l Medical Assistance (MA) (major program MA) is funded by both federal and state dollars, and is the federally funded Minnesota Health Care Program that provides the most covered services.
l Emergency Medical Assistance (EMA) (major program EH) is funded by both federal and state dollars. However, it is available only for some noncitizens that have a medical emergency, and does not cover all of the services otherwise covered by MA.
l Refugee Medical Assistance (RMA) (major program RM) is funded entirely by federal dollars, and provides up to eight months of MA coverage for some refugees who are otherwise ineligible for MA.
l State-funded Medical Assistance (major program NM) provides all MA-covered services for two groups of people who are not eligible for federally funded MA:
n Some noncitizens who do not meet the immigration status requirements for federally funded MA. They must have an MA basis of eligibility and meet all other MA requirements. This group uses major program NM.
n People who receive services from the Center for Victims of Torture who are not otherwise eligible for MA. This group also uses major program NM.
l Some people who live in an Institution for Mental Diseases (IMD) have an MA basis of eligibility but are ineligible for federally funded MA solely because they live in an IMD . These people may be eligible for major program IM, which is a state-funded MA program that does not include nursing home coverage.
General Assistance Medical Care
General Assistance Medical Care (GAMC) (major program GM) is funded entirely by state dollars, and includes:
l GAMC with full benefits, which is the primary GAMC program. It provides fewer covered services than MA.
l GAMC Hospital Only (GHO), which is for GAMC clients whose income is too high for full benefits, but who are hospitalized. Inpatient hospitalization and some related costs are the only GHO services.
Note: People who have an MA basis of eligibility are not eligible for GAMC.
When determining the best health care program for an applicant or enrollee, there are a number of factors:
l Which program will provide the most covered medical services with the minimal amount of cost-sharing ?
n Spenddowns are a form of cost-sharing for some MA enrollees. People with a spenddown have income that is greater than their income limit, so they must remain responsible for a certain amount of their medical bills.
n All MinnesotaCare enrollees must pay a monthly premium, which is another form of cost-sharing. If clients are potentially eligible for both MinnesotaCare and MA with a spenddown, further examination of the type of medical bills they have in relation to the cost of a MinnesotaCare premium is needed.
l Will the state of Minnesota receive FFP for the applicant or enrollee's health care costs under a given program?
l Where is the client's application for health care coverage received? County agencies will generally determine eligibility for MA first; MinnesotaCare Operations at DHS will generally determine eligibility for MinnesotaCare. See Where to Apply for further information.
l Does the client have a choice between programs or bases of eligibility? Some people may meet the eligibility requirements for both MinnesotaCare and MA, and may choose whichever program is more beneficial. Other people may qualify for more than one MA basis of eligibility (see Multiple Bases of Eligibility for further information).
The usual major program hierarchy for MA and GAMC should be:
1. Medical Assistance (MA).
2. Emergency Medical Assistance (EH).
3. Refugee Medical Assistance (RM).
4. State-funded Medical Assistance (NM, IM).
5. General Assistance Medical Care (GM).
6. GAMC Hospital Only (GHO).
For MinnesotaCare (major programs BB, FF, JJ, KK, LL), no hierarchy is needed. People will fit into only one of the five major programs due to the income and other eligibility criteria.
For more information about the specific eligibility criteria for each program, see Eligibility Groups and Bases of Eligibility.