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Effective: December 1, 2006 |
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28.15.40ar1 - Managed Care County Transfers (Archive) |
Archived: June 1, 2009 |
When managed care enrollees move between counties, they may need to change to a new managed care organization (MCO), depending on what MCOs are available in their new county of residence. They may also have the option of choosing a new MCO.
Note: For maps showing the MCOs available in each county for each health care program, see Managed health care programs – maps.
Remind enrollees that if they seek non-emergency services outside the MCO service area, the MCO may require providers to request authorization from the plan. Enrollees who do not follow MCO provisions may be responsible to pay for any health care services they receive.
MCO Not Available in New County.
Move To or From a Non-Managed Care County (MA/GAMC only).
When a managed care enrollee moves to a county in which the same MCO is available, enrollment will continue in the same MCO at the time of the transfer. The enrollment span remains open on MMIS, and there will be one continuous span for both counties. No worker action is required unless the enrollee requests a change in MCO (see below).
If an enrollee requests a change in MCO when moving to another county, allow the change if the enrollee makes the request within 60 days of the move date. The enrollee must complete and return a new Health Plan Enrollment Form (DHS-4106A).
MCO Not Available in New County
When a managed care enrollee moves to a county in which the enrollee's MCO, or health plan, is not available:
l The transferring agency does not need to make any manual updates to the enrollment information before transferring the case. MMIS will close the enrollment span on RPPH automatically at the next capitation.
Note: For MA and GAMC, these clients will be reported on the county's Potential Enrollee Report.
l The managed care education and enrollment process should be initiated as soon as possible.
n MinnesotaCare enrollees: the change to the new MCO will be initiated by the system. MMIS will send an education and enrollment packet. Enrollees who do not select a new plan before the next capitation will be enrolled in the default health plan.
n MA and GAMC enrollees: the worker at the receiving agency must initiate the process. Every effort should be made to avoid a gap in managed care coverage. If this is not possible, MA or GAMC coverage will be fee-for-service for the interim months.
When an MA/GAMC enrollee moves to a non-managed care county, the transferring agency does not need to make any manual updates to the enrollment information before transferring the case. The system will be updated automatically at the next capitation, and the enrollee's coverage will be through fee-for-service effective the next available month.
Note: A worker in the non-managed care county may receive an edit on MMIS which prevents updates. If this occurs, the worker in the managed care county should enter an enrollment span end date on RPPH for the next available month.
When an MA/GAMC enrollee moves from a non-managed care county to a managed care county, the receiving agency should initiate the education and enrollment process as soon as possible. Follow the same procedures as for other new enrollees.