Adjustments (Archive)

A managed care adjustment is a capitation payment made outside of the usual capitation schedule. An adjustment may be payment to a health plan (or managed care organization) for a current or past month, or, recovery of a capitation payment that was previously made.

An adjustment request does not guarantee an adjustment will be made. The DHS Managed Care unit reviews each request on a case-by-case basis based on federal and state law and health plan contract terms.

Note:  For information about possible adjustments when adding newborns to an MA or MinnesotaCare case, see Adding/Removing People From Managed Care.

MinnesotaCare.

MA/GAMC.

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MinnesotaCare

For MinnesotaCare, request adjustments in the following situations:

l  When an enrollee is hospitalized on the effective date of a change in health plans. In this case DHS will recover the capitation payment made to the new plan and will make a retroactive capitation payment to the previous plan.

l  When necessary to maintain continuous coverage, continuity of care, or to resolve a service issue. Refer these requests to appropriate staff. Decisions are made on case-by-case basis.

Do not make an adjustment when there has been a systems, coding, or enrollment form error. The household’s enrollment will be changed for the next available month.

MA/GAMC

Follow your agency's procedures to request adjustments from the DHS managed care unit when:

l  People are enrolled into health plans incorrectly and retroactive disenrollment would result in continuity of care issues. If there are no service issues, disenroll the person for the next available month.

l  People are disenrolled from health plans incorrectly.

l  People are hospitalized on the effective date of an enrollment change.

If the change is for a future month and no erroneous capitation payment has been made, delete the incorrect span or change the incorrect information on the RPPH panel.

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