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Effective: February 1, 2011 |
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07.20.50ar7 - Program Overlap (Archive) |
Archived: June 1, 2011 |
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 to 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.
Minnesota Family Planning Program (MFPP).
In some situations, people may receive overlapping MinnesotaCare (MCRE) and MA for a limited period.
Note: See MinnesotaCare Major Program Eligibility Type (MPET) for more information.
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.
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 Open and close MA in one action if the client received short-term MA services and wishes to remain on ongoing MCRE.
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 for questions or assistance.
l MCRE workers may suggest that the enrollee contact the county worker to ensure that the worker knows the enrollee requested MA to cover inpatient hospital expenses.
MCRE and GAMC may not overlap.
l MCRE to GAMC:
A MCRE enrollee who applies for and is determined eligible for GAMC cannot receive GAMC for the month of application.
n Approve GAMC for the first of the month following the application month.
n Keep both eligibility spans open in MMIS if MCRE capitation has occurred at the time of GAMC approval.
Note: The client will continue to use the health plan they are enrolled in through MCRE.
n Close the MCRE span 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 cutoff for closing GAMC:
n Keep both eligibility spans open in MMIS.
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.
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.