*** The Health Care Programs Manual (HCPM) has been replaced by the Minnesota Health Care Programs Eligibility Policy Manual (EPM) as of June 1, 2016.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: June 1, 2009 |
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Archived: June 1, 2016 (Previous Version) |
Minnesota health care program enrollees must follow guidelines for receiving medically necessary services. There are guidelines for benefit sets, managed care plans, cost-sharing, and out-of-state services.
Detailed information on all of these topics is found in the Prepaid Minnesota Health Care Programs (PMHCP) Manual.
Minnesota Restricted Recipient Program (MRRP).
Minnesota Health Care Program (MHCP) has different benefit sets with varying covered services. The benefit set may be determined by the major program, or by the specific eligibility group or basis of eligibility. All new enrollees receive the MHCP Benefit Summary (DHS-3860) which explains the covered services for each benefit set.
Enrollees may be responsible for some of the costs of their health care program coverage. Some enrollees are required to pay a portion of the cost of a service, such as a co-payment on a prescription drug. Other types of cost-sharing include premiums, spenddowns, parental fees or waiver obligations.
DHS contracts with managed care organizations (MCOs) to provide services to most people enrolled in a MHCP.
l Enrollees choose a health plan based on what plans are available in their county of residence.
l Enrollees may receive services via fee-for-service providers before they are enrolled in a health plan.
l Some enrollees are not allowed to enroll in managed care.
l Enrollees must get services from the health plan's network of providers except in special circumstances.
Detailed information on all of these topics is found in the Prepaid Minnesota Health Care Programs (PMHCP) Manual.
New enrollees receive information and enrollment forms from presentations at the county agency or in the mail.
Enrollees with other health care coverage or third party liability (TPL) must ensure DHS is the payer of last resort. Enrollees must provide information about other health coverage, including coverage designated as cost effective, to their managed care organization (MCO) to coordinate coverage.
Enrollees receive two cards:
l MHCP membership card. DHS issues a membership card to each eligible enrollee. These cards are generated by MMIS. See the MMIS User Manual for information on how to issue replacement cards.
l Managed care organization membership card. These cards are sent out by the managed care organization. Enrollees should contact the MCO for replacement cards.
Minnesota Restricted Recipient Program (MRRP)
The Minnesota Restricted Recipient Program (MRRP) identifies enrollees who have used services at a frequency or amount that is not medically necessary or have used health services that resulted in unnecessary costs to the program. Once identified, these restricted enrollees are placed under the care of a primary care physician or other designated providers who will coordinate their care for a 24-month period. More information can be found in the MHCP Provider Manual.
Because managed care enrollees' choice of providers is limited to providers enrolled in the , DHS does not identify restricted status for people enrolled in managed care. The MCO is responsible for prior authorization, monitoring use of medical services, and ensuring continuity of care.
Enrollees may be able to receive certain services, such as transportation and meals, at no cost if needed to obtain medically necessary services not provided by a managed care organization. See Access Services for more information.