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Effective: December 1, 2006 |
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28.15.10ar1 - Managed Care Enrollment - MA/GAMC (Archive) |
Archived: June 1, 2009 |
People who are found eligible for Medical Assistance (MA) and General Assistance Medical Care (GAMC) and are not excluded from managed care enrollment should be referred to a managed care presentation or given a managed care education packet in the situations described below. Follow your agency’s procedures for educating clients about managed care.
l Allow applicants and enrollees 30 days after attending presentations or receiving education packets to return the Health Plan Enrollment Form (DHS-4106A).
l Clients will receive their health care coverage through fee-for-service for any months before health plan enrollment.
When people who apply or reapply for MA or GAMC do not have an interview, you may refer them to a managed care presentation or mail them an education packet. Do not require people to attend a managed care presentation.
Note: People who are applying for MA or GAMC in conjunction with cash assistance programs or Food Support are required to have a face-to-face interview for those programs. People who are requesting only MA or GAMC are not required to have a face-to-face interview but may request one. See Applications.
Enrollment Presentations and Packets.
Refer MA and GAMC clients to a managed care presentation or given them an education packet in the following situations:
l During an initial intake interview for MA or GAMC.
l During an intake interview for an MA or GAMC reapplication when the period of MA or GAMC ineligibility is two full calendar months or more. See Reenrollments and Reinstatements.
l When adding a person to a household with no one else enrolled in managed care, if the person being added is required to enroll or volunteers to enroll in managed care.
l When adding a managed care-eligible person to a household which has at least one other person in managed care. Add the enrollee to the same health plan (or managed care organization) as the rest of the household.
l When an enrollee from a non managed care county moves to a managed care county.
l When an enrollee moves from a managed care county to another managed care county and the enrollee's health plan is not available in the new county.
l When a managed care enrollee requests a change in health plan when moving between managed care counties. See Managed Care County Transfers for more information on enrollees who move between counties.
l When an enrollee is no longer in an excluded group. If there are other family members enrolled in managed care, add them to the same health plan.
l When an enrollee changes from one health care program to another program and the health plan is not available for the new program.
Enrollment Presentations and Packets
Managed care presentations must include a variety of educational information, including how a health plan (or managed care organization) works, who is excluded from managed care, and the rights of the enrollee.
l Clients may choose a health plan and complete the enrollment form at the time of the presentation. They may also take the form with them and return it within 30 days.
l If a client who is scheduled for a managed care presentation fails to attend, mail an enrollment packet as soon as possible after the missed presentation.
Managed care education packets must include the appropriate enrollment form, educational information, return envelope, and other materials as described in the Prepaid Minnesota Health Care Programs (PMHCP) Manual, section 2.01. The required forms and materials vary for PMAP, county-based purchasing (CBP), and Minnesota Senior Health Options (MSHO).
All managed care counties must track the education and enrollment process by updating the RTRK screen in MMIS. Be sure to update tracking information for all household members at the same time to reduce enrollee confusion. See the MMIS User Manual for specific coding information.
l The RTRK screen generates a case-based notice for each enrollee. The notice lists the health plan options available in the enrollee’s county of residence and the health plan the client will be enrolled in if a choice is not made.
l The system also generates a ten-day reminder letter.
l If the client does not choose a health plan within 30 working days, the tracking system automatically creates an enrollment span on the RPPH panel for the assigned health plan.
Managed care counties must complete the appropriate MMIS screens with either an exclusion or an enrollment span. Follow your agency's procedures for entering enrollment information on MMIS when people choose a health plan. A general overview of system coding is provided in this section. See the MMIS User Manual and the PMHCP Manual, section 4 for specific details.
l If a client has not chosen a health plan when MA or GAMC is approved, code RENR with exclusion reason YY (Delayed Decision).
l When a client chooses a health plan, enter the corresponding contract number on RPPH. Contract numbers are the provider numbers of the health plans which serve the managed care counties. Each county will have a list of the health plan provider numbers for that county.
l If you enter the enrollment information on MMIS on or before the managed care enrollment cutoff date, the enrollment will be effective the first day of the next month. If you cannot enter the information on MMIS until after the managed care enrollment cutoff date, the enrollment will become effective the first day of the next available (or second) month.
n Delay initial enrollment of a hospitalized client into managed care until the first of the next available month after discharge.
n See MAXIS & MMIS Cutoff Calendar on CountyLink for the monthly calendar of managed care cutoff dates.
Enrollee information coded in MMIS will be used for managed care enrollment purposes and to determine the health plan capitation payment rate, including:
l Information entered in MAXIS that is interfaced to MMIS, such as address, date of birth, sex, Medicare coverage, and counties of residence/financial responsibility.
l Information entered directly in MMIS, such as living arrangement, spenddown type, major program, and eligibility type.