Minnesota Administrative Rules

9500.1452 ELIGIBILITY TO ENROLL IN A HEALTH PLAN.

Subpart 1.

Medical assistance eligibility required for PMAP participation.

Only persons who have been determined eligible for medical assistance under parts 9505.0010 to 9505.0140 shall be eligible to participate in the prepaid medical assistance program.

Subp. 2.

Medical assistance categories ineligible for PMAP.

A person who belongs to a category listed in items A to N is ineligible to enroll in a health plan under the prepaid medical assistance program:

A.

a person who is eligible for medical assistance on a spenddown basis as defined in part 9500.1451, subpart 17a;

B.

[Repealed, L 1995 c 207 art 6 s 124]

C.

a person who is a resident of a state institution;

D.

a person who is receiving benefits under the Refugee Assistance Program, established at United States Code, title 8, section 1522(e);

E.

a person who is eligible for medical assistance through an adoption subsidy;

F.

a person who is determined eligible for medical assistance due to blindness or disability as certified by the Social Security Administration or the state medical review team, unless the recipient is 65 years of age or older;

G.

a person who is eligible for medical assistance but currently has private health insurance coverage through a health maintenance organization licensed under Minnesota Statutes, chapter 62D;

H.

a person who resides in Itasca County but who lives near the county border and who chooses to use a primary care provider located in a neighboring county;

I.

a person who is a qualified medicare beneficiary, as defined in United States Code, title 42, section 1396(d), who is not otherwise eligible for medical assistance;

J.

a person who is terminally ill as defined under part 9505.0297, subpart 2, item N, and who, at the time of notification of mandatory enrollment in PMAP, has a permanent relationship with a primary physician who is not part of any PMAP health plan;

K.

a person who is in foster placement;

L.

a child who prior to enrollment in a health plan is determined to be in need of protection under Minnesota Statutes, sections 626.556 to 626.5561, is identified to the state by the county social service agency, and is receiving medical assistance covered services through a provider who is not a participating provider in PMAP;

M.

a child who prior to enrollment in a health plan is determined to be severely emotionally disturbed under Minnesota Statutes, sections 245.487 to 245.4889, and is:

(1)

coded as severely emotionally disturbed on the Minnesota welfare information system;

(2)

receiving county mental health case management services; and

(3)

under the primary care of a mental health professional as defined in Minnesota Statutes, section 245.4871, subdivision 27, who is not a participating provider in PMAP; or

N.

a person who, at the time of notification of mandatory enrollment in PMAP:

(1)

has a communicable disease;

(2)

the prognosis of the communicable disease is terminal illness, however, for the purpose of this subitem, "terminal illness" may exceed six months;

(3)

the person's primary physician is not a participating provider in any PMAP health plan; and

(4)

the physician certifies that disruption of the existing physician-patient relationship is likely to result in the patient becoming noncompliant with medication or other health services.

Subp. 3.

Exclusions during phase-in period.

The 65 percent of medical assistance eligible persons in Hennepin County who were not randomly selected to participate in the former medical assistance prepaid demonstration project because they served as a control group must participate in PMAP. Hennepin County may temporarily exclude individuals' participation in PMAP in order to provide an orderly phase-in period for new enrollees. The phase-in period must be completed within one year from the start of the enrollment period for each category of eligible PMAP consumers.

Counties participating in the prepaid medical assistance program for the first time after June 30, 1991, may temporarily exclude PMAP consumers from participation in PMAP in order to provide an orderly phase-in period for new enrollees. The phase-in period must be completed within one year from the start of the enrollment period for each category of eligible PMAP consumers.

Subp. 4.

Elective enrollment.

An individual categorically excluded from PMAP under subpart 2, item G, may enroll in PMAP on an elective basis if the private health insurance health plan is the same as the health plan the consumer will select under PMAP.

Individuals categorically excluded from PMAP under subpart 2, items K, L, and M, may enroll in the prepaid medical assistance program on an elective basis.

Program requirements are the same for elective and mandatory PMAP enrollees under Minnesota Statutes, section 256B.69.

Statutory Authority:

MS s 256.045; 256B.031; 256B.69

History:

11 SR 1107; 16 SR 1086; L 1995 c 207 art 6 s 124; L 2007 c 147 art 8 s 38

Published Electronically:

October 16, 2013