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Effective: May 1, 2007 |
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28.10.10ar2 - Managed Care Delivery Systems (Archive) |
Archived: June 1, 2009 |
In a managed care delivery system, DHS contracts with a to provide services to people enrolled in MinnesotaCare, Medical Assistance (MA), or General Assistance Medical Care (GAMC). The MCO must provide most services covered by the program the person is enrolled in.
The primary resource for managed care policy and procedures is the Prepaid Minnesota Health Care Programs (PMHCP) Manual. However, a number of topics that most workers may need to be familiar with are included in this manual as well.
Choice of Managed Care Organization (MCO).
All MinnesotaCare enrollees receive their health care coverage through a managed care delivery system.
Exception: Some enrollees may have MinnesotaCare coverage on a fee-for-service basis for a limited period in certain circumstances.
Most MA and GAMC enrollees receive their health care coverage through managed care if they live in a managed care county and are not part of an excluded group.
DHS pays a fixed monthly fee, called a , to the MCO. Enrollees must receive services through the MCO.
Note: Services that are part of the enrollee's benefit set but are not covered in the managed care contract will be billed under .
Choice of Managed Care Organization (MCO)
MinnesotaCare enrollees may select from two or more health plans available in their county of residence. If required, enrollees must also choose specific clinics within the health plan network.
For MA and GAMC enrollees, there are two different managed care models:
l - Like MinnesotaCare, PMAP or PGAMC enrollees choose one of two or more health plans. If required, enrollees must also choose specific clinics within the health plan network.
Note: "PMAP" is often used to refer to both PMAP and PGAMC.
l County-Based Purchasing (CBP) - In some counties, a CBP model is used instead of PMAP/PGAMC. County-based purchasing is an option that allows counties to choose to assume the responsibility for purchasing health care services for enrollees in their county who would otherwise be served by a PMAP/PGAMC model.
For MA-eligible managed care enrollees who are age 65 or older, or disabled, there may be other delivery systems or options within the PMAP or CBP organization.
l People age 65 or older have the option of enrolling in Minnesota Senior Health Options (MSHO).
l People age 65 or older in PMAP counties who do not choose to enroll in MSHO are enrolled in Minnesota Senior Care (MSC). In CBP counties, they are enrolled in Minnesota Senior Care Plus.
l In some counties, people ages 18-64 who are certified as having a physical disability may voluntarily enroll in Minnesota Disability Health Options (MnDHO).