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Effective: December 1, 2006 |
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28.15.25ar1 - Disenrollments (Archive) |
Archived: June 1, 2009 |
Managed care enrollees may be disenrolled from their health plan (or ) if they change health plans, if their health care program eligibility closes, or for other reasons.
MMIS will automatically disenroll people from a health plan when:
l They are from MinnesotaCare.
l They change health plans. MMIS will disenroll the household from the current plan to enroll in the new plan.
Disenroll people effective the first day of the first available month. If disenrollment is completed before , the disenrollment will be effective the next month. If disenrollment is completed after capitation, disenrollment will be effective the second month after the disenrollment is completed. The client will be responsible for any premium payments due for months for which a has been paid.
Example:
John calls to request cancellation for himself and his son on June 26. Capitation for July was made on June 23.
Action:
Inform John that his health plan has already been paid for the month of July and that MinnesotaCare cannot be closed until July 31. He will be responsible for his July premium.
See Adjustments for information on retroactive disenrollment.
Disenroll people from a health plan when:
l You receive information that an enrollee is now in an excluded group. End the health plan enrollment span on the MMIS RPPH screen for the last day of the month using reason code ”r;EX.” Enter the appropriate exclusion code and an exclusion date span.
n Disenroll people who are certified disabled by the Social Security Administration (SSA) or the State Medical Review Team (SMRT) if the person is under age 65 and becomes eligible for MA with a disabled basis of eligibility. When you get confirmation of the disability certification from SSA or SMRT, enter an enrollment end date, disenrollment reason of EX, exclusion reason and exclusion begin date on RPPH. Enter the managed care end date on RPPH for the next available month.
n People under age 65 who are certified disabled but who choose a non-disabled basis of eligibility may enroll in managed care voluntarily. See Multiple Bases of Eligibility and Voluntary Enrollment.
n Disenroll people who are in the hospital when certified disabled effective the next available month. The disenrollment may be delayed for an additional month if you cannot enter the information on MMIS on or before the managed care enrollment cutoff date.
l A person who should have been excluded was enrolled in a health plan in error. End the health plan enrollment span on MMIS for the last day of the month in which the error is discovered. If you discover the error before any capitation payments are made, delete the enrollment span on RPPH.
Note: If capitation payments have been made and the enrollee appears to have issues with continuity of care, refer the case to your agency's managed care unit or DHS for a possible adjustment for any retroactive months. The county managed care unit and DHS determine the need for an adjustment on a case-by-case basis.
l MA or GAMC eligibility ends. If you are closing MA or GAMC after the managed care enrollment cutoff date, close MA or GAMC and disenroll the individual or household from the health plan for the next available month on MMIS. In this case, the health plan will receive a capitation payment for a month in which there is no eligibility.
n The individual or household is ineligible for MA and GAMC even if the health plan has received a capitation payment.
n Do not reinstate MA eligibility on MAXIS for the additional month for which a capitation payment was made unless the individual or household is reinstated effective the first of the month for which the additional payment was made. If the client requested closure and you cannot close MMIS because a capitation payment has already been made, notify the client that health plan coverage exists if all MA or GAMC eligibility factors are met.
See the MMIS User Manual for specific coding information.