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Effective: February 1, 2008 |
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07.20.50ar5 - Program Overlap (Archive) |
Archived: November 1, 2008 |
People cannot receive ongoing coverage from more than one health care program, except in certain situations and only for a limited time.
Although MMIS does not always prevent overlapping coverage, it is essential that workers coordinate coverage to prevent ongoing overlapping eligibility or loss of coverage for the client.
Overlapping eligibility creates problems with claims payments and requires a manual claims payment process.
MinnesotaCare (MCRE) and Medical Assistance (MA) Overlap.
MCRE and General Assistance Medical Care (GAMC) Overlap.
MCRE and GAMC - Hospital Only (GHO) Overlap.
MCRE and Transitional MinnesotaCare Overlap.
Minnesota Family Planning Program (MFPP).
In some situations, people may receive overlapping MinnesotaCare (MCRE) and MA for a limited period. Allow overlapping coverage when:
l MCRE enrollees eligible with benefit limits (programs BB, FF or JJ) are found eligible for ongoing MA (program MA or NM).
n MMIS will prevent overlap with program FF.
n Close programs BB and JJ for the first available month.
l MCRE enrollees eligible with benefit limits who have an MA basis of eligibility apply for MA for hospital bills not covered by MCRE.
n The programs may overlap for the months of hospitalization.
n These clients will have MA fee-for-service coverage during retroactive months.
n See MCRE Inpatient Hospitalization for more information.
l See MA for Employed Persons With Disabilities for information on MCRE enrollees who are found eligible for MA-EPD.
l MCRE enrollees apply for and are found eligible for MA for services not covered under MCRE.
n Pregnant Woman:
Although MA and MCRE each cover some pregnancy termination services, MA may provide coverage for procedures that MCRE does not. Follow these steps:
1. Determine if the woman is eligible for MA as a pregnant woman.
Note: Do not change the eligibility type for children under 21 on program LL or KK from C1 or C2 to P1 or P2 as they already receive full MA benefits.
2. Open and close MA on MAXIS and MMIS in one action. Allow overlapping coverage for the month of the service only.
3. Leave MCRE open unless the enrollee requests ongoing MA.
4. To ensure that these enrollees have expanded benefits during the 60-day postpartum period, open program LL or KK for the two months following the month of pregnancy termination.
n Long-term care or waiver services:
MCRE does not cover these services for adults who are not pregnant women (programs BB, FF or JJ).
Allow coverage to overlap when MCRE enrollees apply for and are found eligible for MA to cover these services.
m Close MCRE for the first available month if the client needs ongoing MA.
m If the client received short term MA services and wishes to remain on ongoing MCRE, open and close MA in one action.
If an enrollee is denied MA to cover their inpatient hospital costs, take the following actions:
l Remind the enrollee of the right to appeal.
l Submit a policy question to HealthQuest or contact the MMIS User Services Help Desk if you have questions or need assistance.
l MCRE workers may suggest that the enrollee contact the county worker to ensure that the worker knows the MA was requested to cover inpatient hospital expenses.
MCRE and GAMC may not overlap.
l MCRE to GAMC:
When a MCRE enrollee applies for and is determined eligible for GAMC, the client cannot receive GAMC for the month of application.
n GAMC can be approved for the first of the month following the application month.
n If MCRE capitation has occurred at the time of GAMC approval, keep both eligibility spans open in MMIS.
Note: The client will continue to use the health plan they are enrolled in through MCRE.
n The MCRE span must be closed for the end of the following month. Non-MCRE enrollment sites must request the MCRE worker to close coverage.
n Do not delete overlapping GAMC and MCRE eligibility spans. These spans provide history information needed to properly process claims.
l GAMC to MCRE:
When a GAMC enrollee applies and is determined eligible for MCRE, and pays the premium after the 10 day notice of closure of GAMC:
n Keep both eligibility spans open on the system.
n Close GAMC for the end of the following month. MCRE Operations workers must request the county worker to close coverage.
n Do not delete overlapping GAMC and MCRE eligibility spans. These spans provide history information needed to properly process claims.
n The client will continue to use the health plan they are enrolled in through GAMC.
MCRE and GHO may not overlap, including people who are changing from:
l GAMC - Hospital Only (GHO) to MinnesotaCare.
If it is not possible to close GAMC Hospital Only (GHO) before the approval month for MCRE, contact the MMIS User Services Help Desk to back date the GHO closing span before approving MCRE.
Example:
Kwame is hospitalized from November 20 through November 23. He is approved for GHO for those dates on November 28. He is then determined to qualify for retroactive MCRE starting December 1. It is not possible to close the GHO span until December 31.
Action:
Contact the MMIS User Services Help Desk before approving MCRE.
l MCRE to GHO.
Exception: In some cases, MMIS may require both programs to remain open for one month if changes occur after capitation or 10-day notice cutoff.
Example:
Eloise receives MCRE. She enters the hospital on March 28 and voluntarily cancels MCRE the same day.
Action:
MCRE will close at the end of April because on March 28 April’s capitation has already been paid.
Eloise is still hospitalized on April 1, and requests GHO.
Action:
MMIS will allow GHO and MCRE to overlap for April only.
MCRE and Transitional MinnesotaCare Overlap
MCRE and Transitional MinnesotaCare may not overlap, unless the MinnesotaCare case cannot be closed with ten-day notice. See Transitional MinnesotaCare – Relationship to Other Groups/Bases for more information.
Minnesota Family Planning Program (MFPP)
The Minnesota Family Planning Program (MFPP) may overlap with other Minnesota Health Care Program (MHCP) coverage only in the following circumstances:
l Presumptive eligibility is active for MFPP and other health care programs are approved during the presumptive eligibility period.
l MFPP enrollees are approved for coverage on other Minnesota Health Care Programs. Do not deny eligibility for more beneficial health care program coverage due to MFPP enrollment. DHS staff will close MFPP with ten-day notice; do not delay opening the other programs.
For more information on program overlap and the MMIS system, see MinnesotaCare - Coordination of Coverage in the MMIS User Manual.