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Effective: December 1, 2006 |
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28.15.30arc1 - Adding/Removing People from Managed Care (Archive) |
Archived: February 1, 2008 |
Adding someone to or removing someone from a managed care household is completed based on the circumstances and when the action is being taken in relation to key dates on the managed care calendar.
See MAXIS & MMIS Cutoff Calendar on CountyLink for the monthly calendar of managed care cutoff dates.
Adding a Non-Newborn to an Active Managed Care Case.
MinnesotaCare Coverage Closed.
No Other Managed Care Enrollees in MA/GAMC Household.
Adding a Non-Newborn to an Active Managed Care Case
When adding someone to an active MinnesotaCare, MA, or GAMC managed care case, enroll the person in the same health plan (or managed care organization) as the rest of the household.
l The enrollment begin date is effective for the next available month.
l For MA and GAMC clients, fee-for-service may cover health care services the client receives in the initial months before the enrollment effective date.
Exception: MA or GAMC clients who meet an exclusion reason are not enrolled in managed care; their coverage will be on a fee-for-service basis.
Health plans are generally guaranteed payment for the birth month for newborns whose mothers were enrolled in a health plan (and eligible for either MA or MinnesotaCare) at the time of the birth. Newborns who are added to the case are retroactively enrolled in the same health plan as the mother back to the birth month.
Exception: If a newborn is eligible for MA and meets an exclusion, enroll the newborn in the health plan for the birth month only.
Note: There is no requirement that MA or MinnesotaCare coverage be added for the newborn just to pay the health plan. If the mother chooses not to add the child to the case, the health plan is not paid for the birth month.
If eligibility for the newborn is added within 90 days from the birth:
l The newborn should be retroactively enrolled in the health plan for the birth month and all succeeding months unless a health plan change is requested.
If the newborn is added to the case more than 90 days from the birth:
l An adjustment to pay the health plan for the birth month only must be requested.
n Add the newborn to the same health plan for the next available month based on managed care cutoff, unless a health plan change is requested.
n There will be a break in health plan enrollment, covered by fee-for-service, between the birth month and the next available month.
Disenroll people who are removed from coverage in an active MinnesotaCare household effective the first day of the next available month. If a capitation payment has already been made, coverage cannot be closed until the next available month and the enrollee will be responsible for the premium payment.
Close health care coverage when an enrollee dies effective the date of death. DHS identifies and recovers any capitation claims after the date of death.
When adding a person to a household in which no other members are receiving MA or GAMC or are excluded from managed care:
l Refer the applicant for a managed care presentation or provide an education packet.
l Code the RENR screen with either an exclusion reason or a health plan contract number.
l If the person fails to choose a health plan within 30 days, MMIS will assign a default plan.
l Review RPPH to verify that the exclusion or enrollment is correct.
See the MMIS User Manual for further coding information.