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Effective: December 1, 2006 |
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28.05.05arc1 - Benefit Sets by Major Program (Archive) |
Archived: March 1, 2007 |
There are many factors in determining the correct Minnesota Health Care Program benefit set for each enrollee. Key factors include the enrollee’s major program and eligibility group or basis of eligibility. However, other factors such as income, citizenship, and household composition may also play a role.
MinnesotaCare has five different benefit sets. The benefit sets vary depending on the major program and other factors. They are:
l Expanded benefit set – This is the benefit set for pregnant women and children under 21 (major programs KK and LL).
n This benefit set has the greatest number of covered services for MinnesotaCare (similar to the covered services in the MA benefit set).
n Enrollees in this benefit set are exempt from .
n There is no annual inpatient hospital coverage limit for this benefit set.
l Basic Plus Two – This is the benefit set for non-pregnant adults with children (major programs FF and JJ) who have income < 175% FPG.
n This benefit set includes many, but not all, of the same services as those in the expanded benefit set.
n Enrollees in this benefit set have co-payments on a number of services, such as prescription drugs, eyeglasses, and non-preventive visits. They also have a 50% co-payment for restorative dental services (such as fillings or root canals).
n There is no annual inpatient hospital coverage limit for this benefit set (and no co-payments for inpatient services).
l Basic Plus – This is the benefit set for non-pregnant adults with children (major programs FF and JJ) who have income > 175% FPG and < 275% FPG (or $50,000, whichever is less).
n This benefit set has covered services and co-payments that are similar to the Basic Plus Two benefit set. However, there is no co-payment for restorative dental services.
n There is a $10,000 annual inpatient hospital coverage limit for this benefit set (but no co-payments for inpatient services).
l Basic Plus One – This is the benefit set for non-pregnant adults without children (major program BB) who have income < 75% FPG.
n This benefit set has covered services and co-payments that are similar to the Basic Plus Two and Basic Plus benefit sets. There is a 50% co-payment for restorative dental services.
n There is a $10,000 annual inpatient hospital coverage limit for this benefit set (and a 10% co-payment for inpatient services, up to $1000 per year).
l Limited benefit set – This is the benefit set for non-pregnant adults without children (major program BB) who have income > 75% FPG and < 175% FPG.
n This benefit set offers the most limited number of covered services for MinnesotaCare. It does not include services such as dental, eyeglasses, hearing aids, or hospice care.
n Enrollees in this benefit set have co-payments on many services, such as prescription drugs, mental health services, emergency room, and non-preventive visits. These co-payments may be slightly higher than those for other benefit sets.
n There is a $10,000 annual inpatient hospital coverage limit for this benefit set (and a 10% co-payment for inpatient services, up to $1000 per year).
MinnesotaCare enrollees in all five benefits sets have a common cost-sharing requirement: they must pay a premium before eligibility may begin.
For Medical Assistance (MA), there are several different benefit sets:
l Medical Assistance (MA), Refugee Medical Assistance (RMA), and Noncitizens Medical Assistance (NMED) all provide the most comprehensive set of covered health care services.
l Program IM is a state-funded MA program for some people who live in an Institution for Mental Diseases (IMD). Program IM has the same covered services as MA, RMA, and NMED except for coverage of nursing homes that are IMDs.
l Emergency Medical Assistance (EMA) does not cover all of the services that are otherwise covered by MA. Examples of the services it does not cover include preventive care, organ transplants, and waiver services.
Many MA enrollees have co-payments on services such as prescription drugs, eyeglasses, and non-preventive visits. However, some MA enrollees are exempt from co-payments, including pregnant women, children under 21, RMA enrollees, and some residents of certain facilities (such as nursing homes). See the MHCP Provider Manual, Chapter 2 for further information about co-payments, including a complete list of enrollees who are exempt.
Note: Some people with disabilities or who are age 65 or older are eligible for MA through a waiver program. The waiver programs provide certain home- and community-based covered services in addition to the standard MA services. Some people who are Medicare-eligible for the Medicare Savings Programs instead of or in addition to MA. These programs provide help with some Medicare-related expenses.
There are two benefit sets for GAMC:
l General Assistance Medical Care (GAMC) GAMC with full benefits, which is the primary GAMC program.
n The full GAMC benefit set provides fewer covered services than MA. Examples of the services it does not cover include case management, hospice care, and nursing home care.
n Enrollees in this benefit set have co-payments for services such as prescription drugs, eyeglasses, and non-emergency visits to an emergency room. They also have a 50% co-payment for restorative dental services.
l GAMC Hospital Only (GHO) is a very limited benefit set.
n The only GHO-covered services are inpatient hospital services and physician services provided during the inpatient hospital stay.
n GHO enrollees have a $1000 co-payment for each hospital admission.
The information in this manual about covered services and benefit sets is provided as a general overview.
l For detailed information about covered services and benefit sets, see the MHCP Provider Manual (Chapter 2).
l For a client-oriented overview of services and benefit sets, see the MHCP benefit summary (DHS-3860). This form is sent to new health care program enrollees with a variety of notices.