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Understanding Minnesota Health Care Programs: What Coverage Options Are Available?

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The Minnesota Department of Human Services (DHS) is dedicated to ensuring that all Minnesotans, especially those with limited incomes, have access to essential health care coverage. Through Minnesota Health Care Programs (MHCP), the state provides a crucial safety net, offering a range of programs designed to meet diverse health needs. This guide will delve into what Minnesota health care programs cover, exploring eligibility requirements, covered services, and how these programs can help individuals and families access the care they need. Understanding the intricacies of MHCP is vital for both beneficiaries and healthcare providers to navigate the system effectively and ensure seamless access to care.

Who is Eligible for Minnesota Health Care Programs?

Minnesota Health Care Programs (MHCP) encompass a variety of programs, each with specific eligibility criteria. Generally, these programs are designed to support Minnesota residents who meet certain income requirements and other conditions. Eligibility is typically assessed on a monthly basis, and it’s crucial to verify a member’s current eligibility through the secure, online MN–ITS system before providing services. This verification should be done at least once a month, particularly for ongoing or multiple services provided within the same month. Understanding member cost-sharing responsibilities is also important; details can be found in the Billing the Member (Recipient) guide.

To provide clarity on the different types of coverage available, here’s a breakdown of major MHCP program codes and their descriptions:

Program Code Program Description and Coverage Details
AC Alternative Care Program: This program is a state and federally funded initiative that helps Minnesotans aged 65 and over receive home and community-based services. It’s designed to prevent or delay the need for nursing facility care by providing cost-shared services in a more comfortable and familiar setting. Learn more about the Alternative Care Program.
BB & FF MinnesotaCare (Adults): MinnesotaCare offers state and federally funded health coverage for adults aged 19 and older. It is specifically designed for Minnesota residents who do not have access to affordable health insurance. MinnesotaCare aims to bridge the gap in coverage and ensure access to essential health services. Find out more about MinnesotaCare.
EH Emergency Medical Assistance (EMA): EMA is a state and federally funded program providing emergency health care assistance to eligible individuals facing medical emergencies. Coverage under EMA is limited to services received in a hospital emergency department or during an inpatient hospital stay directly resulting from an emergency admission. Some limited services under a certified care plan may also be covered. Explore Emergency Medical Assistance details.
FP Minnesota Family Planning Program (MFPP): MFPP is a state and federally funded program dedicated to providing pre-pregnancy family planning services and related health care. This program is available to individuals of all ages and focuses solely on family planning and preventative reproductive health care. Discover the benefits of the Family Planning Program.
HH HIV/AIDS Program: This federally funded program supports Minnesotans living with HIV or AIDS who meet specific eligibility requirements. It provides access to a comprehensive range of support services, including case management, dental care, insurance benefit assistance, medication access, mental health services, and nutritional support. Learn more about HIV/AIDS program support and Program HH Covered Services.
IM Institution for Mental Disease (IMD): IMD is a state-funded Medical Assistance (MA) program specifically for individuals residing in an Institution for Mental Disease. This program ensures that those receiving care in these specialized facilities have access to necessary medical coverage.
KK & LL MinnesotaCare (Children): Similar to adult MinnesotaCare, these programs offer state and federally funded coverage for children aged 19 and under. MinnesotaCare for children ensures that young Minnesotans have access to health care during their developmental years.
MA Medical Assistance (Medicaid): Medical Assistance is Minnesota’s Medicaid program, serving over a million Minnesotans. It is a comprehensive health coverage option for eligible individuals and families. The majority of MA recipients are enrolled in managed care organizations (MCOs) to better coordinate their care. Explore the benefits of Medical Assistance.
NM CHIP-Funded MA: Primarily funded through the Children’s Health Insurance Program (CHIP), this MA program covers pregnant women and infants under age 2. It also extends to a limited number of adults aged 19 and over who are not eligible for CHIP. The eligibility criteria and covered services are largely consistent with standard Medical Assistance.
OO Behavioral Health Fund: This state-funded program is specifically for Substance Use Disorder (SUD) services. It provides a dedicated funding stream to ensure access to treatment and support for individuals struggling with SUD.
QM Qualified Medicare Beneficiary (QMB): QMB is a Medicare Savings Program that assists individuals with Medicare costs. It covers Medicare Part A and B copays, coinsurance, premiums, and deductibles, reducing the out-of-pocket expenses for eligible Medicare beneficiaries. Learn more about the Qualified Medicare Beneficiary program (PDF).
RM Refugee Medical Assistance: This federally funded MA program is available to refugees during their first 12 months in the United States. It helps refugees access essential health care services as they resettle and adjust to a new country. The covered services are the same as those under standard Medical Assistance. Discover Refugee Medical Assistance.
SL Service Limited Medicare Beneficiary: Another Medicare Savings Program, SL helps with Medicare Part B premiums. It does not cover health care services or Medicare copays and deductibles, focusing solely on premium assistance. Understand Service Limited Medicare Beneficiaries (PDF).
UN Limited Benefit Programs: This program provides specified benefits that do not require meeting the standard MA eligibility criteria. It includes Essential Community Supports (ECS) and Housing Support Supplemental Services, targeting specific needs within the community.
XX MinnesotaCare (Adults): Similar to BB and FF, this is another MinnesotaCare program providing state-funded coverage for adults aged 19 or older, further expanding access to care for uninsured adults in Minnesota.

It’s important to note that some individuals may qualify for multiple programs simultaneously. In such cases, MHCP will ensure services are paid at the highest applicable coverage level. For example, someone with both QM and MA coverage would have their Medicare cost-sharing covered under QM, and any services not covered by QM but covered by MA would also be included. Conversely, the SL program only covers Medicare premiums and does not extend to health care services. For individuals awaiting long-term care assessments, their program status may initially appear as unknown until the assessment is complete.

The Minnesota Restricted Recipient Program (MRRP)

To ensure responsible utilization of health care services, the Minnesota Restricted Recipient Program (MRRP) identifies MHCP members who may be overusing services or utilizing them in a way that is not medically necessary, leading to unnecessary costs. Members identified by MRRP are enrolled in a program where their care is coordinated by a designated primary care physician or other specified providers for a 24-month period.

For providers treating MRRP enrollees, it’s crucial to obtain a referral from the designated primary care physician. A Medical Referral for MRRP Enrollee (DHS-2978) (PDF) must be faxed to the MRRP office at 651-431-7475 within 90 days of the service date. Failure to submit the referral within this timeframe may result in claim denial. However, in emergency situations where immediate care is needed to prevent serious disability, severe pain, or death, services can be provided without prior authorization or referral. The MRRP office may request documentation to verify the emergency nature of the services for claim processing.

For questions regarding referrals or the referral form, providers can contact MRRP directly at 651-431-2648 or 800-657-3674. For members enrolled in managed care organizations (MCOs), all MRRP referrals should be faxed to the appropriate MCO, not directly to the state MRRP office.

Hospital Presumptive Eligibility (HPE) Program

The Hospital Presumptive Eligibility (HPE) program, established under the Affordable Care Act, streamlines access to temporary Medical Assistance (MA). Participating hospitals and hospital clinics can make preliminary eligibility determinations for MA based on applicant-provided information. This program is designed to provide immediate health care coverage to individuals in need while their full MA application is being processed and also helps hospitals receive timely reimbursement for provided services.

Hospitals and hospital clinics interested in participating in HPE can enroll at any time. A key requirement for qualified HPE hospitals is to assist individuals approved for HPE in completing and submitting their full MA application. This assistance can be provided directly or by connecting applicants with navigator organizations or certified application counselors. HPE-qualified hospitals must adhere to all program policies and performance metrics outlined by DHS. Further details are available on the HPE: Policies, forms and notices page. Eligibility determinations under HPE must be made by certified hospital personnel who have completed DHS-approved training. No formal verification is required to establish HPE eligibility, simplifying the process for immediate coverage.

When a hospital approves HPE, they must provide the applicant with an official approval notice printed on security paper provided by DHS. This notice serves as temporary proof of coverage until the individual receives their permanent MHCP ID card in the mail from DHS. With the HPE approval notice, individuals can access services from any MHCP provider. The MHCP ID card, once received, contains the member’s unique MHCP ID number, which is used for coverage verification by providers and pharmacies.

Importantly, individuals do not need to be hospital patients to apply for HPE at a qualified hospital. Hospitals are obligated to process HPE applications for anyone seeking coverage, regardless of whether they are currently seeking medical treatment at that facility.

HPE coverage begins on the date of application approval by the hospital, as indicated on the HPE approval notice. HPE coverage duration is as follows:

  • If a full MA application is submitted during the HPE coverage period, HPE coverage ends on the date DHS makes a final MA eligibility determination.
  • If a full MA application is not submitted, HPE coverage ends on the last day of the month following the month of HPE approval.

Individuals approved for HPE receive the full scope of benefits available under regular MA (for adults or children). There is no difference in covered services between HPE and standard MA. Any MHCP provider can bill for services provided during an HPE coverage period, using the same billing procedures as for standard MA.

Generally, an individual can receive HPE only once within a twelve-month period. However, pregnant women are eligible for HPE once per pregnancy, recognizing the ongoing health care needs during pregnancy.

To become a HPE provider, hospitals must be enrolled MHCP providers and agree to comply with all DHS HPE policies and procedures. This includes signing and submitting the Hospital Presumptive Eligibility Provider Assurance Statement (DHS-3887) (PDF) and providing DHS with the names of staff members who have completed the DHS HPE training. For further information, refer to the Hospital Presumptive Eligibility program webpage.

Disability Considerations for MHCP Applicants

For MA applicants who indicate a potential disability, the State Medical Review Team (SMRT) plays a crucial role. SMRT evaluates these applications to determine if the applicant meets the state’s criteria for disability status, which can impact eligibility and program options. More information about this process can be found on the FAQs about the State Medical Review Team webpage.

Waiver Services Programs: Expanding Coverage

Minnesota offers several waiver services programs that provide expanded health care coverage beyond standard MA. These programs have received federal approval to cover services not typically included in MA, addressing specific needs of certain populations. These waivers include:

Providers seeking more information about waiver and Alternative Care (AC) programs can refer to the HCBS Waiver Services section of the MHCP Provider Manual.

Minnesota Children with Special Health Needs (MCSHN) Program

While the Minnesota Children with Special Health Needs (MCSHN) Program no longer provides direct funding for children with chronic illnesses or disabilities, it remains a valuable resource. MCSHN staff offer crucial assistance to families across Minnesota in identifying and accessing various services and supports, including potential financial aid, for children with special health care needs. They also serve as a problem-solving resource for providers and county workers navigating the complex landscape of resources for these families. For assistance, contact MCSHN at 800-728-5420.

Coverage for Incarcerated Individuals

Generally, adults incarcerated in detention or correctional facilities are not eligible for MHCP coverage. However, an exception exists for individuals eligible under the Refugee Medical Assistance (RM) program; they remain eligible for RM regardless of their living situation, provided they meet all other eligibility criteria.

Furthermore, incarcerated individuals receiving services in 245G or tribally licensed programs may be eligible for payment through the Behavioral Health Fund if they meet current clinical and financial eligibility guidelines.

MHCP coverage ineligibility applies to members of all ages residing in the following types of correctional facilities:

  • City, county, state, and federal correctional and detention facilities for adults, including inmates in work release programs, those temporarily hospitalized for acute care or childbirth who must return to the facility, and those in court-ordered chemical dependency residential treatment programs requiring return to custody post-treatment.
  • Secure juvenile facilities licensed by the Department of Corrections (DOC) for holding, evaluation, and detention.
  • State-owned and operated juvenile correctional facilities.
  • Publicly owned and operated juvenile residential treatment and group foster care facilities licensed by the DOC with more than 25 non-secure beds.

Eligibility for children placed by a juvenile court depends on the specific type of facility.

In cases where MHCP is not notified of a member’s incarceration until after eligibility determination, MHCP will retroactively terminate eligibility and recover any reimbursements made to providers for services rendered during the period of incarceration.

When verifying eligibility for incarcerated individuals, it is essential to check the member’s Living Arrangement (LA) in MN–ITS.

  • If the LA does not indicate incarceration, contact the member’s local tribal or county agency before billing to confirm their current status.
  • If a member is no longer incarcerated but their LA still shows as incarcerated, contact the local tribal or county agency to update their status before billing.

For billing for hospital services provided to individuals incarcerated in state or local correctional facilities who qualify for MA, refer to the Incarceration section of the Inpatient Hospital Services provider manual and contact the relevant county jail or correctional facility for specific billing procedures.

How to Apply for MHCP Coverage

Applying for MHCP coverage is a straightforward process. Individuals can apply through several convenient methods:

MinnesotaCare legislation mandates the accessibility of application and informational materials at provider offices, local human services agencies, and community health offices. Applications can be accessed and printed online, or you can request to have applications mailed to your office. Each application provides guidance on which form to use. For direct assistance, contact MinnesotaCare at:

MinnesotaCare P.O. Box 64838 St. Paul, MN, 55164-0838 Phone: 651-297-3862 or 800-657-3672

Extended Postpartum Coverage

Minnesota Medical Assistance (MA) and CHIP-funded MA offer comprehensive benefits for pregnant individuals, extending throughout the 12-month postpartum period. This extended coverage includes the full range of MA benefits with no premiums, copays, or deductibles. Effective July 1, 2022, Minnesota expanded postpartum coverage from the previous 3 months to a full 12 months for those enrolled in MA or CHIP-funded MA, ensuring continued health care access after childbirth.

Automatic Newborn Coverage

To ensure immediate health coverage for newborns, children born to mothers covered by MA during their birth month are automatically enrolled in MA newborn coverage. These newborns do not need a separate MHCP application. If the child continues to reside in Minnesota, this automatic MA eligibility extends through the last day of the month in which they turn one year old, regardless of their living situation.

Understanding Spenddowns

For certain MHCP programs like MA, IM (Institutions for Mental Disease), and EH (Emergency Medical Assistance), individuals may be eligible even with income exceeding the standard limits through a “spenddown” provision. A spenddown is similar to an insurance deductible. It represents the amount a member is responsible for paying towards their medical expenses before MHCP coverage begins.

There are different types of spenddowns:

  • Medical Spenddown: Members are responsible for paying for medical services, including prescriptions, typically on a monthly basis, until their spenddown amount is met.
  • Institutional or Long-Term Care (LTC) Spenddown: Members pay a portion or all of their daily institutional charges to meet their spenddown.
  • Elderly Waiver (EW) Obligation: Members are responsible for a portion or all of their Elderly Waiver service costs. For those in senior managed care programs, MCOs pay providers, deduct the waiver obligation, and the provider then bills the member for this obligation. Designated providers cannot be used for waiver obligations.

Spenddowns and Managed Care Plan Enrollment

The interaction between spenddowns and managed care enrollment is important to understand:

  • Individuals eligible for MA who are enrolled in managed care plans for Families and Children (F&C) and Minnesota Senior Care Plus (MSC+) cannot have a medical spenddown. If a member becomes eligible with a medical spenddown while enrolled in these plans, they will be disenrolled and transitioned to fee-for-service (FFS) for the following month.
  • Enrollment in Minnesota Senior Health Options (MSHO) or Special Needs BasicCare (SNBC) is not possible with an existing medical spenddown. However, members already enrolled in MSHO or SNBC without a medical spenddown who later become eligible with one can remain enrolled if they consistently pay their medical spenddown to DHS.
  • Failure to pay medical spenddowns to DHS for three months will result in disenrollment from MSHO or SNBC.
  • Following disenrollment from SNBC or MSHO due to unpaid spenddowns, members have a 90-day period to pay the outstanding balance to DHS and be reinstated in their health plan.
  • After 90 days from disenrollment, reinstatement into SNBC or MSHO is not possible until the member no longer has an ongoing medical spenddown and has paid any previous outstanding spenddown balances.
  • An exception exists for individuals in institutions receiving hospice care; they can enroll in MSHO even with a medical spenddown related to hospice services.

Spenddown Payment Options

MHCP offers several payment options for spenddowns, varying by program:

  • Potluck Spenddown (FFS): In fee-for-service (FFS), the first provider to bill will have the spenddown amount deducted from their claim. This provider is then responsible for billing the member for the deducted spenddown amount.
  • DHS Spenddown (MSHO/SNBC): For members in MSHO and SNBC, spenddowns are paid directly to DHS in advance.
  • Designated Provider Spenddown (FFS): FFS members can choose a specific provider to apply their spenddown to using the Request for Designated Provider Agreement (DHS-3161) (PDF). The designated provider agrees to apply the member’s spenddown to their claims each month services are rendered. MSHO members cannot use designated providers for medical spenddowns (except for hospice in nursing facilities). SNBC members can use designated providers for services not covered by their health plan, such as Home and Community-Based Services waivers, PCA, or home care nursing. Institutional spenddowns can utilize designated providers.

For issues related to designated provider spenddowns, such as incorrect form information, improper application of spenddowns, provider service changes, or continued notices after service termination, contact the county or tribal agency. MHCP may recover overpayments if providers do not take appropriate corrective actions. Designated providers should bill promptly after service delivery to ensure timely spenddown application and avoid member ineligibility for other services.

  • Client Option Spenddown: Members can prepay their spenddowns directly to DHS. This option is not available to MSHO members.

Providers who are owed spenddown amounts will see group and reason code PR142 on their remittance advices, indicating the member’s spenddown amount. Refer to the Billing the Member (Recipient) section of the MHCP Provider Manual for further guidance.

Member ID Cards and Eligibility Verification

Each MHCP member receives an 8-digit member number, printed on their individual ID card. Household members each receive their own cards, which may vary in appearance depending on their enrollment date.

Example of MHCP Member ID cards issued April 2020 through present.

Example of MHCP Member ID cards issued March 2006 through April 2020.

Please note: As of October 29, 2024, newly enrolled MHCP members will receive a redesigned ID card. Currently enrolled members will continue to use their existing cards until new cards are issued in 2025. There is no need for current members to request new cards at this time. Updates regarding the distribution of new cards will be provided in the MHCP Provider Manual.

Key points about MHCP ID cards and verification:

  • MHCP ID numbers remain constant, regardless of program changes, eligibility updates, or address changes.
  • MHCP ID cards do not contain eligibility details.
  • It is crucial to verify member eligibility before each service visit through MN–ITS to ensure accurate and up-to-date coverage information.

What Services are Covered Under MHCP?

For a health service to be covered by MHCP, it must meet specific criteria to ensure medical necessity, effectiveness, quality, and appropriate use of program funds. Covered services must be:

  • Medically Necessary: Determined to be essential for the patient’s health needs based on prevailing community standards and customary practice.
  • Appropriate and Effective: Suitable and beneficial for the patient’s medical condition.
  • Quality and Timely: Meeting established standards of quality and provided in a timely manner.
  • Effective Use of Funds: Representing a responsible and appropriate allocation of program resources.
  • Within Program Limits: Adhering to specific limitations outlined in DHS rules and detailed in the service-specific sections of the MHCP Provider Manual.
  • Personally Rendered: Typically provided directly by a qualified provider, unless explicitly authorized otherwise in the MHCP Provider Manual.

For a comprehensive overview of covered services by program, refer to the MHCP benefits at a glance chart.

Services Not Covered by MHCP

MHCP has specific limitations on coverage. The following health services are not covered:

  • Services requiring a physician’s order that has not been obtained.
  • Services not documented in the member’s health or medical record.
  • Services not included in the member’s plan of care, individual treatment plan, IEP, or individual service plan.
  • Services not provided directly to the member, unless specifically designated as a covered service in the MHCP Provider Manual.
  • Services of a quality lower than the prevailing community standard; providers of such services are responsible for the costs.
  • Non-emergency services provided to a member in a long-term care facility that are not in their plan of care and not ordered in writing by a physician (when an order is required).
  • Non-emergency services provided without the member’s or their legal guardian’s full knowledge and consent.
  • Services paid for directly by the member or another source, except for payments made for services incurred during a retroactive eligibility period (refer to Billing Policy and Billing the Member (Recipient)).
  • Services lacking required supervision documentation (if supervision is mandated).
  • Missed appointments (members should not be billed for missed appointments).
  • Non-U.S. (out-of-country) care.
  • Reversal of voluntary sterilizations.
  • Surgery primarily for cosmetic purposes.
  • Vocational or educational services, including functional evaluations or employment physicals, except as provided under IEP-related services.

For detailed information on noncovered services specific to different service types, consult the relevant sections of the MHCP Provider Manual.

Legal References for Minnesota Health Care Programs

The operation and regulations of Minnesota Health Care Programs are grounded in various Minnesota Statutes and Rules, as well as relevant sections of the Code of Federal Regulations. Key legal references include:

Minnesota Statutes:

Minnesota Rules:

Code of Federal Regulations:

This overview provides a comprehensive understanding of Minnesota Health Care Programs and the range of coverage available. For detailed information and the most up-to-date guidelines, please refer to the official Minnesota Department of Human Services resources and the MHCP Provider Manual.

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