*** The Health Care Programs Manual (HCPM) has been replaced by the Minnesota Health Care Programs Eligibility Policy Manual (EPM) as of June 1, 2016.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. ***
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Effective: November 1, 2012 |
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25.05.20 - Four-Month Penalty |
Archived: June 1, 2016 (Previous Versions) |
Most MinnesotaCare enrollees must pay a premium to establish and maintain coverage. See Initial, Ongoing and Changes to MinnesotaCare Premiums for more information on when the premium is due.
People who fail to pay the premium or who voluntarily request their MinnesotaCare coverage be closed may be ineligible for MinnesotaCare for four months unless they request and are approved for good cause.
Exceptions:
n A household requesting voluntary cancellation due to active military duty does not have a four-month penalty. See Special Provisions - Active Military Duty.
n A household that included any American Indian household members who have verified their American Indian status and that was cancelled solely due to nonpayment of premiums for coverage months July 2009, or later, is not subject to a four-month penalty. See Premium Exemption for Households With an American Indian Member for more information.
n Children with individual or family gross income equal to or less than 200% FPG will not be subject to the four-month penalty due to non-payment of a parent's premiums.
n Children enrolled in MinnesotaCare for Certain Children Exiting Foster Care or a Juvenile Residential Correctional Facility who request voluntary cancellation are not subject to a four-month penalty.
Coverage Request During Four-Month Penalty.
Special Provisions - Active Military Duty.
A person closed for failure to pay the premium or for voluntarily requesting cancellation of coverage cannot re-enroll in MinnesotaCare coverage for four calendar months, unless good cause is requested and approved.
Continue benefits at the level the enrollee received before the action that caused the appeal if the agency or DHS receives the appeal request by the later of these dates:
l Before the effective date of the action.
l Within 10 days after the notice mailing date.
Enrollees must pay all due premiums for coverage to continue during the appeal. See Appeals for more information.
Reminder: Pregnant women during the pregnancy or postpartum period, and infants under age two are not closed for failure to pay premiums and do not have a four-month penalty established.
l The four-month penalty begins with the first month of disenrollment.
Example:
Dante’s March premium payment was due February 15. His coverage was closed February 28. He did not send in the premium payment as of March 21.
Action:
Dante has a four-month penalty and cannot be covered by MinnesotaCare for March (the first month of disenrollment), April, May and June unless good cause is requested and approved.
l Instruct enrollees to call to request re-enrollment at the beginning of the fourth month of the penalty period if both of the following are met:
n Coverage was closed for non-payment.
n Enrollee requests coverage less than 11 months from the last completed application or renewal.
Coverage Request During Four-Month Penalty
People may apply for coverage during a household’s four-month penalty. Eligibility may or may not be approved based on the following instructions:
l Household members who were not enrolled in MinnesotaCare when the penalty period began are not subject to the four-month penalty period. However, before coverage can begin for the new enrollee, all past due premiums must be paid, as well as the premium for current coverage.
Example:
Joan and Louie are enrolled in MinnesotaCare. Their daughter, Jasmine, receives MA. MinnesotaCare is canceled for failure to pay the premium effective June 30. Jasmine’s MA ends August 1. Jasmine applies for MinnesotaCare and meets all eligibility requirements.
Action:
Jasmine is eligible for MinnesotaCare effective August 1. If the household income is greater than 200% FPG, the household must pay the current premium for Jasmine before her coverage can begin. If the household income is equal to or less than 200% FPG, Jasmine will not have a monthly premium.
l Process new applications and requests for coverage received in the fourth month of the penalty period.
Approve applicants who meet all eligibility requirements as pending awaiting payment for coverage to begin effective the first day of the fifth month.
Note: Do not require a new application if the client requests coverage less than 11 months from the last completed application or renewal form.
l If a client submits a new application in the first three months of a four-month penalty, deny the application.
l Use the MMIS code 42 (Penalty Period).
l Send the Review Delay Letter (DHS-3399) advising the household to contact the agency at the beginning of the fourth month to reactivate the application.
l If during the first three months of the four-month penalty period a client returns a renewal form or requests coverage 11 months or more from the last completed application or renewal, send the household the Review Delay Letter (DHS-3399) or a memo and a HCAPP (DHS-3417) to complete and return before processing eligibility.
People may request a good cause determination when they want to re-enroll in MinnesotaCare but are currently in a four-month penalty period for failure to pay the premium or voluntarily canceling coverage.
Good cause is defined as circumstances beyond an enrollee's control or that the enrollee could not reasonably foresee, which resulted in the enrollee being unable or failing to pay the premium or requesting voluntary cancellation.
l Good cause circumstances include but are not limited to:
n Serious physical or mental illness.
n MinnesotaCare coverage was dropped due to belief that other health coverage was available, but the other coverage does not materialize.
n A regular source of income on which the enrollee depended to pay the premium is not received.
n Safe at Home participants may request and be granted good cause for late premium payments. See Data Privacy for more information on the Safe at Home program.
l Good cause does not include choosing to pay other household expenses instead of the premium.
Make good cause determinations on a case-by-case basis based on the evidence the enrollee submits.
l Good Cause Approved.
MMIS automatically closes coverage effective the last day of the month after the premium due date. If the agency determines that good cause exists without an appeal, require payment of all due premiums before reactivating coverage.
Example:
Lorelei’s MinnesotaCare eligibility closed April 30 because she did not pay her May premium. On May 29 Lorelei reapplies for MinnesotaCare but is denied for being in a four-month penalty for non-payment. Good cause is granted on June 1.
Action:
Lorelei must pay the May and June premiums before coverage can begin.
l Good Cause Denied.
Notify enrollees of their right to appeal if the agency does not find good cause.
n Continue benefits pending the outcome of the appeal unless the enrollee requests in writing not to have benefits continued.
Note: For benefits to continue, the appeal must be received within 10 days of the notice mailing date.
n Require payment of all missed premiums to continue benefits.
n If the agency is upheld in the appeal, begin a penalty period in accordance with the appeal decision.
Example:
Roland’s MinnesotaCare eligibility closed March 31 for failure to pay his April premium.
Roland filed for good cause and was denied. He also files an appeal of the closure within 10 days of his closing notice and does not request that benefits stop pending appeal.
Action:
Roland must pay all due premiums (April, May and June) for coverage to be reinstated back to April 1. If the appeal decision finds for Roland, coverage continues as long as Roland continues to pay the premiums.
Special Provisions - Active Military Duty
MinnesotaCare households with enrollees who are members of the military may choose to voluntarily disenroll when one or more enrolled members are called to active duty.
l All household members must be disenrolled under this provision.
l Cancel coverage effective:
n The end of the current month if the household requests cancellation before capitation.
n The end of the next month if the household requests cancellation after capitation.
l Allow the household to reenroll at any time during or following the member’s tour of active duty without a four-month penalty. Do not require verification of the end of a member’s tour of duty.
l Disregard increases in income or assets reported at or after reenrollment until the household’s next renewal. The household must meet all other eligibility criteria to be reenrolled.
Example (Part 1):
Jill, her husband Tony, and their two children are enrolled in MinnesotaCare. Jill calls on the fifth of the month to report that Tony has been called to active military duty. He is earning additional combat-related pay, and the family is now covered by TRICARE. The family remains eligible for MinnesotaCare because total income remains within the income limits, and TRICARE is not considered other coverage. The worker explains that the family may remain enrolled in MinnesotaCare or may choose to cancel MinnesotaCare without penalty and reenroll without a new application before or after the end of Tony’s tour of duty. Jill requests to cancel MinnesotaCare.
Action:
Cancel MinnesotaCare for all household members effective the end of the current month since Jill requested closure before capitation. Instruct Jill to contact the agency when Tony’s tour of duty ends if the household wants to reenroll in MinnesotaCare.
Example (Part 2):
Jill calls 18 months later to report that Tony is returning from active duty overseas. The family would like to reenroll in MinnesotaCare. The worker reviews and updates the information on the family’s last renewal with Jill. Tony no longer receives combat pay, but Jill got a raise since the last renewal so that the family’s current income is higher than what was previously recorded. They also received a fishing boat as a gift from relatives. There have been no other changes.
Action:
Calculate the family’s current income and compare it to the income previously recorded. Enter the lesser of the income figures in MMIS. Do not act on any income increases until renewal.
Update asset information in case notes. Do not act on changes in assets until renewal.
Approve MinnesotaCare as pending awaiting payment without a four-month penalty if the family meets all other MinnesotaCare eligibility criteria. Review MinnesotaCare Premiums to determine if the household meets the criteria to be exempt from premium payment for 12 months.