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Effective: March 1, 2007 |
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28.15.10.05arc2 - Managed Care Exclusions (Archive) |
Archived: June 1, 2009 |
All MinnesotaCare enrollees receive health care services through a managed care delivery system. Even though there are certain circumstances in which an enrollee may receive services through a fee-for-service system for a limited period, there are no managed care exclusions for MinnesotaCare.
For Medical Assistance (MA) and General Assistance Medical Care (GAMC), enrollees in managed care counties receive health care services through a unless they are in one of the excluded groups described in this section. All counties are managed care counties for MA and GAMC except for Beltrami, Clearwater, Hubbard, and Lake of the Woods.
l All of these exclusions pertain to both MA and GAMC unless specifically stated otherwise.
l Some of these excluded groups, as indicated, may voluntarily enroll in managed care.
For information about system coding of managed care exclusions, see the Prepaid Minnesota Health Care Programs (PMHCP) Manual, section 4.03.
Major Program or Basis of Eligibility.
Medical or Psychological Conditions.
Major Program or Basis of Eligibility
The following MA or GAMC enrollees who live in managed care counties are excluded from managed care enrollment due to the major program or basis of eligibility under which they are eligible.
l People who receive or Refugee Medical Assistance (RMA).
l Undocumented people or nonimmigrants who only receive Emergency Medical Assistance (EMA).
l People under age 65 who are eligible for MA due to blindness or disability as determined by the Social Security Administration (SSA) or the State Medical Review Team (SMRT). This includes people with blindness or disabilities who receive services under the CAC, CADI, DD and TBI waiver programs who meet the above criteria.
Note: Blind or disabled people under age 65 who have and are using a parent/caretaker basis of eligibility may choose to voluntarily enroll in managed care.
l People eligible for QMB, SLMB, QWD, or QI only.
l Children receiving IV-E or state adoption assistance.
Note: Adoption assistance children may enroll voluntarily.
l Women receiving MA under the MA for Breast/Cervical Cancer (MA-BC) basis.
l Enrollees receiving care and rehabilitation services from the Center for Victims of Torture (CVT).
l Enrollees in the GAMC Hospital Only (GHO) program.
The following MA or GAMC enrollees who live in managed care counties are excluded from managed care enrollment due to living in certain settings or locations.
l Residents of state institutions, including , Institutions for Mental Diseases (IMDs), and state-operated long-term care facilities (LTCFs) who reside in the institution at the time of initial enrollment. This includes enrollees in the Minnesota Sex Offender Program (MSOP).
People already enrolled in managed care who enter state institutions will remain enrolled in their health plans if the placement has been approved by the health plan. This includes court-ordered placements for which the health plan is responsible.
Exception: Do not exclude residents of Ah Gwah Ching Nursing Facility and Woodhaven Senior Community under this provision.
l American Indians living on an Indian reservation may choose to be excluded from managed care.
l GAMC enrollees living in nursing facilities.
Medical or Psychological Conditions
The following MA or GAMC enrollees who live in managed care counties are excluded from managed care enrollment due to having certain medical or psychological conditions.
l People who are terminally ill with a medical prognosis of six months or less to live and who, at the time of notification of mandatory health plan enrollment, have a permanent relationship with a primary physician who is not part of any available managed care organization.
l People who, at the time of notification of mandatory enrollment in managed care, meet all of the following conditions:
n Have a communicable disease.
n Have a prognosis of a terminal illness (may exceed six months) because of the communicable disease.
n The disease and prognosis are verified by a written statement from a licensed physician based on a current medical examination.
n Currently have a primary physician who is not a participating provider in an available managed care health plan.
n The physician certifies that disruption of the existing physician patient relationship is likely to result in the patient stopping recommended medication or other health services.
l Children who are identified to DHS as having severe emotional disturbance (SED) and who are eligible to receive MA-covered mental health case management services.
Note: These children may enroll voluntarily.
l Adults who are identified to DHS as having serious and persistent mental illness (SPMI) and who are eligible to receive MA-covered mental health case management services.
Note: These adults may enroll voluntarily if they have and are using a parent/caretaker basis of eligibility.
The following MA or GAMC enrollees who live in managed care counties are excluded from managed care enrollment due to certain other factors.
l People who have private health insurance through the following certified by the Minnesota Department of Health.
Note: These people may voluntarily enroll in managed care if the private HMO is the same as the health plan the consumer will select under PMAP.
n Avera Health Plan of Minnesota.
n Blue Plus.
n First Plan of Minnesota.
n Group Health, Inc.
n HealthPartners, Inc.
n Itasca Medical Care.
n Medica Health Plans.
n Metropolitan Health Plan.
n PreferredOne Community Health Plan.
n PrimeWest Health Systems.
n Sioux Valley Health System.
n South Country Health Alliance.
n UCare Minnesota.
l People eligible with a medical .
n People with long-term care spenddowns, also known as institutional spenddowns, are not excluded from managed care.
n For information on people with medical spenddowns who may voluntarily enroll in managed care, see Minnesota Senior Health Options (MSHO) or Minnesota Disability Health Options (MnDHO).
l People with cost-effective employer-sponsored health insurance or people enrolled in an individual non-Medicare health plan determined to be cost-effective. See the MMIS User Manual for instructions on coding the TPCO screen for all cost-effective insurance policies.
Note: TRICARE and CHAMPVA are considered cost-effective health insurance. Enrollees with TRICARE or CHAMPVA coverage are excluded from managed care.
l GAMC enrollees who are eligible for Medicare benefits.
At the time of the annual renewal for MA or GAMC, review each person's circumstances to determine whether or not the person should be excluded from managed care. Track known future changes and process changes in exclusion status when you become aware of changes in circumstances.
If an excluded person is now a mandatory managed care enrollee, refer the person to a managed care presentation or assist the person in choosing a health plan. See Managed Care Enrollment and Adding/Removing People From Managed Care. If a managed care enrollee is now in an excluded group, disenroll the person for the next available month on MMIS. See Managed Care Disenrollment.