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Effective: December 1, 2011 |
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06.05ar6 - Cooperation (Archive) |
Archived: June 1, 2012 |
Clients must comply with various requirements for health care program eligibility. This includes general requirements, such as providing information about and required verifications for eligibility factors such as income and assets. However, there are certain eligibility factors for which the term "cooperation" is used. A few of these specific cooperation requirements are highlighted in this manual section.
For more detailed information on these topics, please see the links to each chapter under Related Topics below.
Medicaid Eligibility Quality Control (MEQC) and Payment Error Rate Measurement (PERM) Cooperation.
MinnesotaCare Eligibility Reviews for Adults Without Children.
Other Health Care Coverage Cooperation.
Medicaid Eligibility Quality Control (MEQC) and Payment Error Rate Measurement (PERM) Cooperation
DHS conducts MEQC and PERM eligibility reviews for MA and for MinnesotaCare for families with children. Enrollees are encouraged to cooperate with these eligibility reviews; however, enrollees are not required to cooperate as a condition of their eligibility for MA and for MinnesotaCare for families with children.
l Redetermine eligibility for enrollees when an MEQC or PERM review results in new information that impacts eligibility.
l Request verification from enrollees when MEQC or PERM eligibility reviews provide information that is inconsistent with information or documentation on file. See Inconsistent Information.
DHS conducts eligibility reviews annually for MinnesotaCare adults without children. Enrollees who are adults without children must cooperate with MinnesotaCare eligibility reviews.
l Enrollees who fail to cooperate without good cause will lose eligibility for MinnesotaCare for adults without children.
n Indicate in case notes that coverage is closed for failure to cooperate with a MinnesotaCare eligibility review.
n Use closing reason 18 - Quality Control to cancel MinnesotaCare on MMIS. The MinnesotaCare closing notice states the reason for closing is due to not assisting Quality control with a review. No further notice is needed.
l Clients whose MinnesotaCare for adults without children coverage is closed for failure to cooperate with a MinnesotaCare eligibility review may qualify for another health care program, such as MA, if they apply for and meet the eligibility criteria of the other program.
l Good cause may be granted if a diagnosis of mental illness, or physical disability or illness is severe enough and lasting long enough to prevent an enrollee from participating in the completion of the review process.
n Enrollees must provide a doctor’s statement that verifies their illness or disability.
n The agency responsible for determining the client’s MinnesotaCare eligibility determines if good cause may be granted. Notify the client if good cause is granted. Redetermine eligibility if there has been a break in coverage. Explain on a memo the reason for reopening coverage.
l Do not process or approve eligibility for MinnesotaCare for adults without children if clients reapply at a later date until they cooperate with the MinnesotaCare eligibility review.
n Deny the MinnesotaCare reapplication if clients fail to cooperate by the end of the application processing period.
n Consult with the DHS Program Compliance and Audits section if there are questions about whether or not to reopen MinnesotaCare coverage.
l Approve health care coverage with retroactive MA eligibility for up to three months before the month of application if clients cooperate and all other eligibility criteria are met.
Some parents and legal guardians who are requesting or receiving MCRE or MA must cooperate with medical support requirements on behalf of children in their family. They must work with the county child support enforcement office, also known as the IV-D Agency , to:
l Obtain medical support.
l Enforce an existing order.
l Establish paternity.
Examples of cooperation include:
l Providing information about non-custodial parents.
l Establishing paternity of eligible dependent children.
l Forwarding any medical support payments received directly from the non-custodial parent to DHS.
Parents and legal guardians assign their (and their legal dependents') rights to medical support by signing the application or renewal.
Parents and legal guardians required to assign rights who do not cooperate with obtaining medical support or establishing paternity are not eligible for Minnesota Health Care Program coverage. Non-cooperation is determined by the county child support enforcement office.
The parent’s or legal guardian’s actions do not affect eligibility for his or her children or spouse.
Exception: A parent or guardian applying only on behalf of children is not subject to this requirement.
Some Minnesota Health Care Program (MHCP) clients must cooperate with payment requirements to establish and maintain eligibility. The two programs that require a premium payment are:
l MinnesotaCare.
l Medical Assistance for Employed Persons with Disabilities (MA-EPD).
Other Health Care Coverage Cooperation
Most MHCP clients must cooperate by providing information about other health care coverage and any other third party liability (TPL) that they have or that may be available to them. They may also be required to maintain or enroll in coverage that is cost effective.
l For MinnesotaCare, availability of other health care coverage may be a barrier to program eligibility.
l Most MA clients must cooperate with cost effective health care coverage requirements. Availability of other health care coverage does not affect eligibility for these programs.
Some other general cooperation requirements include:
l People who have other health care coverage must assign their rights to coverage to DHS as a condition of eligibility by signing the Health Care Application (HCAPP) or Combined Application Form (CAF).
l Adults who refuse to assign their rights or the rights of other household members for whom they are legally able to assign rights are not eligible for MA.
Note: Children whose parents refuse to assign their rights to other health care coverage or third party liability remain eligible.
l Most applicants and enrollees must provide information on other health care coverage or TPL which is or may be available to them or their dependents, regardless of whether the applicant or enrollee is the policyholder.
l People must cooperate with the MCRE or county agency and the state Benefit Recovery Section (BRS) in identifying potential sources of other health care coverage.
For further information about specific cooperation requirements, see the following chapters: