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Effective: December 1, 2006 |
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24.10.05.10ar1 - Designated Provider Option (Archive) |
Archived: January 1, 2010 |
Some clients choose one provider to whom they pay their spenddown amount each month. This option is referred to as the Designated Provider.
Assigning and Changing Designated Providers.
For information on using a designated provider for a long-term care (LTC) spenddown or waiver obligation, see Long-Term Care (LTC) Spenddowns and Waiver Obligations.
Clients may choose the designated provider option if they meet all of the following conditions:
l The client has an automated monthly spenddown.
l The client receives one of the following types of services:
n Personal Care Attendant (PCA) services.
n Child-welfare targeted case management services.
n One of the following home and community-based waivers:
m Elderly Waiver (EW).
m Community Alternatives for Disabled Individuals (CADI).
m Traumatic Brain Injury (TBI).
m Community Alternative Care (CAC).
m Developmental Disabilities (DD).
l The client does not receive services through the Minnesota Senior Health Options (MSHO) program.
l The client’s net recipient amount is greater than $0. The net recipient amount is the amount after health care premiums, Medicare premiums, and remedial care expenses have been applied.
l The client is the only member of the MA household with a spenddown.
l The client’s health care expenses from one provider will satisfy the entire recipient amount.
Note: Verify the client has expenses through one provider that equal or exceed the net spenddown amount. The client must be expected to continue to satisfy the spenddown with the same designated provider in the future.
l The client is willing to pay the net recipient amount to the designated provider at the time of service.
n Past payment history or other factors must indicate that the client will cooperate in paying the spenddown.
n If the provider indicates that the client has refused or failed to pay the spenddown, remove the client from the designated provider option.
Clients who meet all of the criteria for use and choose to use a designated provider must:
l Sign and return the Agreement to Use Designated Provider (DHS-3161).
The DHS Special Recovery Unit (SRU) will monitor all designated provider cases to make sure:
n The provider submits bills within three months.
n The client incurs enough expenses to meet the spenddown.
Note: SRU may bill the client for any unmet spenddown balance for the given month.
l Report designated provider changes prior to the provider service begin date.
Note: If the client does not report the change timely, MMIS will not apply the new designated provider bills to the client’s current spenddown amount.
Designated providers are required to bill DHS for services within three months.
l Providers cannot refuse to be designated providers.
l DHS will pay all claims in full upon submission.
Each provider is assigned a unique designated provider number by DHS. The designated provider number is used in the claims process. An accurate designated provider number assures that claims are paid properly and applied to the client’s spenddown correctly.
The correct provider number can be obtained by:
l The worker or the client may contact the designated provider and request the provider number used when billing DHS for services.
l Accessing information through MMIS.
Assigning and Changing a Designated Providers
A designated provider can be entered:
l For applicants for the month of application or any retroactive month.
l For enrollees for the next available month. It cannot be entered for the current or retroactive months.
If the client is no longer using the designated provider, the designated provider number is removed for the next available month.
Clients can meet their spenddown using a provider other than the designated provider only in emergencies. Clients must report the emergency use within five days of incurring the expense.
Send the following information to the DHS Special Recovery Unit (SRU):
l Client’s full name.
l Mailing address.
l PMI number.
l Dates of service.
l Names of the emergency providers used.
SRU can be contacted by either:
l MAXIS e-mail to COSD.
l Fax at 651-282-6744.
MMIS sends designated providers a monthly notice which includes the client's name along with the spenddown amount the designated provider must collect from the client.
Note: A separate notice is sent for each client.
When client health care eligibility ends, the designated provider will receive a notice indicating the date the provider should stop collecting the spenddown amount from the client.
If the client spenddown amount changes, MMIS will generate a notice to the provider, indicating the change in spenddown amount.