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Effective: December 1, 2006 |
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24.20ar1 - Inpatient Hospitalization - MinnesotaCare Enrollees (Archive) |
Archived: October 1, 2009 |
Some MinnesotaCare enrollees have limits on payments and must pay co-payments for inpatient hospitalization. These clients may apply for MA to help cover costs incurred in excess of MinnesotaCare payment limits and costs of co-payment.
Note: Clients are not required to apply for MA to cover these additional costs.
MinnesotaCare enrollees may not receive GAMC or GHO for MinnesotaCare inpatient hospitalization costs. See Programs Overlap for more information on how programs may overlap.
MinnesotaCare Inpatient Hospitalization Limits.
Steps to Determine MA Eligibility.
MinnesotaCare Inpatient Hospitalization Limits
MinnesotaCare has inpatient hospitalization co-payments and limits for the following major programs:
l Major Program FF and Major Program JJ.
Parents and relative caretakers with income between 175% FPG and 275% FPG have a $10,000 payment limit.
l Major Program BB.
This major program has a 10% co-payment and $10,000 payment limit.
Steps to Determine MA Eligibility
Take the following steps to determine MA eligibility for clients applying due to inpatient hospitalization payment limits and co-payments:
1. Determine if the client wants MA for the months of hospitalization only.
l If yes, determine eligibility for those months only and, if eligible, approve for the months of hospitalization only.
l If no, and the clients requests ongoing MA coverage, determine eligibility for the months of hospitalization and the remaining months of the certification period.
2. Complete the appropriate income calculation and determine if there is a spenddown.
l If the client does not have a spenddown, approve MA if all other eligibility factors are met.
l If there is a spenddown continue to Step 3.
3. Determine what MinnesotaCare expenses can be used to meet the spenddown based on major program for each MinnesotaCare enrollee in the household. See MinnesotaCare Expenses for more information.
4. Determine spenddown eligibility using an automated monthly spenddown. Apply expenses, based on the determination in Step 3, to the spenddown in the order listed:
a. MinnesotaCare capitation payment for clients enrolled in a MinnesotaCare managed care plan.
b. MinnesotaCare premium.
c. M Bills and P Bills.
These are health care expenses which will not be reimbursed by MA or MCRE because they were incurred before enrollment in MinnesotaCare or MA, or the expense was a non-covered service.
Note: MA will not reimburse bills incurred outside the health plan network that MinnesotaCare would have otherwise covered.
d. MinnesotaCare fee-for-service payments.
e. The applicant’s MinnesotaCare inpatient hospitalization expenses.
Note: MinnesotaCare enrollees who receive services through a managed care health plan may not be able to provide information regarding the costs incurred because they did not receive health care bills to verify the incurred expenses.
n Do not delay acting on the MA application if client is unable to verify inpatient hospital expenses.
n If the client does not meet the spenddown after applying bills listed before this expense, apply an inpatient hospital bill equal to the amount of the remaining spenddown.
n Do not enter any third party payment amounts, even if the hospitalization is covered by the MinnesotaCare health plan.