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Effective: January 1, 2010 |
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24.10.05.10ar2 - Designated Provider Option (Archive) |
Archived: June 1, 2012 |
Some clients may choose to pay their monthly spenddown amount to one provider each month. This is referred to as the Designated Provider Option.
Assigning and Changing Designated Providers.
Only apply the information in this section to monthly medical spenddowns. For information on using a designated provider for a long-term care (LTC) spenddown or waiver obligation, see Long-Term Care (LTC) Spenddowns and Waiver Obligations.
Note: Clients who receive their services through the Minnesota Senior Health Options (MSHO) cannot use the designated provider option.
Clients may choose the designated provider option if they meet all of the following conditions:
l The client has an monthly spenddown.
l The client receives one of the following types of services:
n Personal Care Attendant (PCA) services.
n Child-welfare targeted case management services.
n One of the following home and community-based waivers:
m Community Alternatives for Disabled Individuals (CADI).
m Brain Injury (BI).
m Community Alternative Care (CAC).
m Developmental Disabilities (DD).
m Elderly Waiver (EW) (Most EW clients are enrolled in MSHO and therefore, are not able to use the designated provider option.).
l The client’s recipient amount after deducting health care premiums, Medicare premiums and the remedial care expense deduction is greater than $0.
l The client is the only member of the MA household with a spenddown.
l The client’s health care expenses from one provider will satisfy the entire recipient amount.
Note: Verify the client has expenses through one provider that equal or exceed the recipient amount. The client must be expected to continue to satisfy the spenddown with the same designated provider in the future.
l The client is willing to pay the recipient amount to the designated provider at the time of service. Remove the client from the designated provider option if the provider indicates that the client has refused or failed to pay the spenddown or the cost of the services through the provider no longer equals or exceeds the monthly recipient amount.
Note: The Agreement to Use Designated Provider (DHS-3161) states that the client must use the provider as agreed or will lose the chance to pay just one provider each month. The client will then have to pay the spenddown to different providers or to the state.
Clients who meet all of the criteria for use and choose to use the designated provider option must:
l Sign and return the Agreement to Use Designated Provider (DHS-3161).
The MMIS User Services Help Desk monitors all designated provider cases to make sure:
n The provider submits bills within three months.
n The client incurs enough expenses to meet the spenddown.
Note: Special Recovery Unit (SRU) may bill the client for any unmet spenddown balance for the given month.
l Report designated provider changes prior to the provider service begin date.
Note: MMIS will not apply the new designated provider bills to the client’s current spenddown amount if the client does not report the change timely. Clients must report changes to the designated provider 30 days prior to the change.
Designated providers are required to bill DHS for services within three months.
l Providers cannot refuse to be designated providers.
l DHS will pay claims according to claims policy.
Each provider is assigned a unique designated provider number by DHS. The designated provider number is used in the claims process. An accurate designated provider number assures that claims are paid properly and applied to the client’s spenddown correctly.
To obtain the correct provider number:
l The worker or the client may contact the designated provider and request the provider number used when billing DHS for services.
l Access information through MMIS Provider subsystem. If the designated provider is part of a consolidated provider group, choose from the list based on the provider’s address. See MMIS User Manual, Designated Provider for more information.
Assigning and Changing a Designated Providers
Enter a designated provider number in MMIS:
l For applicants: for the month of application and any retroactive month in which the client is eligible.
l For enrollees: for the next available month. It cannot be entered for the current or prior months.
Remove the designated provider number for the next available month when the client is no longer using the designated provider option.
Clients can meet their spenddown using a provider other than the designated provider only in emergencies. Clients must report the emergency use within five days of incurring the expense.
Send the following information to the DHS MMIS User Services Help Desk:
l Client’s full name.
l Mailing address.
l PMI number.
l Dates of service.
l Names of the emergency providers used.
Contact MMIS User Services Help Desk by fax at (651) 431-7446 or (800) 662-2703.
MMIS sends designated providers a monthly notice which includes the client's name along with the recipient amount the designated provider must collect from the client.
Note: A separate notice is sent for each client.
When a client's health care eligibility is closed, MMIS sends the designated provider a notice indicating the date the provider should stop collecting the recipient amount from the client.
MMIS also sends a notice to the designated provider when the client's recipient amount changes.