|
Effective: December 1, 2006 |
|
|
28.05.10ar1 - Managed Care Covered Services (Archive) |
Archived: June 1, 2009 |
Managed Care Organizations (MCOs) that have contracted with the DHS to provide services to Minnesota Health Care Program (MHCP) enrollees must provide most medical and dental services covered by those programs. MCOs may provide services in addition to those available under MinnesotaCare, MA, or GAMC.
MCOs are not responsible for case management services for people with serious and persistent mental illnesses or severe emotional disturbances. See the Prepaid Minnesota Health Care Programs Manual, section 9.03 for a list of other non-covered services.
Services Outside of MCO Network.
Services Outside of MCO Network
A managed care enrollee must obtain all health care services through the MCO's network of providers unless:
l The enrollee receives services from a provider who is not an MCO provider because of a medical emergency.
l The enrollee is outside the MCO service area and requires urgent or emergency medical care.
l An MCO physician or provider has prescribed or recommended non-emergency services outside of the MCO network.
l The enrollee moves out of the MCO service area, and the system has not been updated to disenroll the client from the MCO.
n Except for emergency services, the MCO may require prior authorization for out-of-plan services.
n Providers must contact the MCO to receive payment.
n Inform enrollees who report a move out of county that they may be responsible for bills incurred without MCO authorization.
l An enrollee enrolls in an MCO while in her third trimester of a high-risk pregnancy. The enrollee must contact the MCO to approve out-of-network services.
l An MA enrollee resides in a long-term care facility, and an MCO physician or dentist orders covered services from a non-MCO provider. There are no special provisions for MinnesotaCare or GAMC enrollees in long-term care facilities.
l A GAMC enrollee who is certified disabled must be disenrolled for the next available month. The MCO will remain responsible for all GAMC-covered services until the date of disenrollment. If the enrollee receives MA services not covered under GAMC, the provider rendering the MA service should bill DHS directly as fee-for-service.
l The enrollee requires post-stabilization care services to maintain, improve, or resolve the enrollee’s condition. The MCO covers the enrollee until one of the following occurs:
n An MCO provider assumes responsibility for the enrollee’s care.
n The MCO reaches an agreement about the enrollee’s care with the treating provider.
n The MCO has contacted the treating provider to arrange for a transfer.
n The enrollee is discharged.
When an enrollee obtains services outside the MCO provider network and does not meet one of the exceptions above, the provider may bill the enrollee directly. In such cases, the provider must notify the enrollee in writing before the service is delivered that payment may be required.
When required by contract, managed care organizations provide common carrier transportation to their enrollees for the purpose of obtaining health care services. See access services for further information.
Advise people who are enrolled in managed care through Minnesota Health Care Programs (MHCP) who also have private coverage or Medicare that they must get medical services through the managed care organization. See Enrollees with Other Health Care Coverage for further information.
The provisions for MA and GAMC enrollees described in cost-effective health care coverage apply to managed care clients. Enrollment in an MCO is not a criterion used in determining cost effectiveness. Enrollees for whom the county pays cost-effective health insurance premiums are excluded from managed care.