Services Guide

Health-Care Coverage for Services

Minnesota Health Care Programs (MHCP)

The vast majority (95%+) of our clients receive services from us via MCHP programs. Private/commercial insurance programs rarely pay for services other than Psychotherapy.

Individuals with low income and disabilities qualify for MHCP coverage in a variety of ways. There are income and asset limits that vary depending on how they qualify.

MHCP includes Medical Assistance, quite often managed by a Managed Care Organization, especially for the elderly and persons with disabilities, and MinnesotaCare, an income-based program that includes premiums on a sliding fee scale for individuals with lower incomes regardless of disability.

Types of MA

• Income-based MA covers people with and without disabilities who have low income.
• Disability-based MA covers people with disabilities who have low income.
• MA-EPD (MA for Employed Persons with Disabilities) lets people with disabilities who work pay a monthly premium to get MA coverage, no matter how much they make.

MinnesotaCare

MinnesotaCare is a premium-based program available to citizens of Minnesota with low incomes who do not have access to Medicare, Medical Assistance, or employer-sponsored coverage. Members pay a monthly premium for MinnesotaCare based on family income. It is funded by premiums on a sliding fee scale with state assistance.

Private/Commercial Insurance

We accept private or commercial insurance when the policy covers services. Referrals or requests from individuals for services from us are rare, but not unheard of. At this time, no private/commercial insurance programs of which we are aware pay for any of the services we provide other than Psychotherapy and Diagnostic Assessments.

Medicare

Medicare is a federal program that covers healthcare services to individuals typically over 65. Coverage for the services we provide is limited - typically Medicare covers only Psychotherapy and Diagnostic Assessment. It never pays for: ARMHS, Mental HealthTargeted Case Management, Behavioral Health Home Services, or Housing Stablization. Clients who need these services must have Medical Assitance - which they can have in addition to Medicare.

Check Insurance Before Initiating Services

Contact the billing department to confirm  insurance coverage before initiating new services, even for existing clients. Not all of the services we provide, for example, are covered by MinnesotaCare (e.g. MinnesotaCare does not cover Behavioral Health Home Services and Housing Stabilization Services).

Client Responsibility for Payment

In a variety of circumstances, clients are responsible for payments for services. These might include:

• For Medical Assistance coverage, some clients over certain income limits might have spendowns.
• For private/commercial insurance coverage, clients may have copays and deductibles.
• There are no co-pays for individuals on Medical assistance, including PMAPS. 
• There are no copays for mental health services for individuals on MinnesotaCare.

Spenddowns

A spenddown is a monthly amount a recipient of Medical Assistance must pay for healthcare services when the client's household income exceeds 100% of the federal poverty guideline. MA recipients may choose two options for spenddowns:

1. Recipients may pay their spenddown directly to DHS the month prior to the spenddown month. Arrange this using DHS 3081.
2. Recipients with PCA or Waiver services may choose this provider as the designated provider to whom they will pay their spenddown using the form DHS 3161.

For clients who choose one of the above options, it is essential to provide the help they need to arrange this.

For recipients who do not choose or are not eligible for either option bove, the spenddown will be deducted from the first service provider who bills for services in a given month. If this spenddown is deducted from services we provide, we will bill the client for the spenddown.

Spenddowns Required

Recipients of MA on the basis of disabillity with a spenddown are required to pay it to maintain MA Eligibility. Except in certain conditions, providers cannot routinely waive member cost sharing without violating the federal Anti-Kickback* law and the federal False Claims Act. No matter how we feel about the fairness of spenddowns, we are required to bill individuals who incur them for services we provide and have policies for non-payment.

*A kickback is any financial incentive a healthcare provider offers to entice an individual to get services from them.

Notifying Clients of New or Changed Spenddowns

When we learn of a new or changed spenddown, we will notify the client using the form Notification of New, Past, or Changed Spenddown found in Notifications and Prior Authorizations. The billing department, while checking MA, will learn of this first and start the form, identifying the new or changed spenddown. This form should then be sent to the Integrated Case Manager (ICM) to review with the client, or other provider if the client does not receive CMGT or BHH services. This form also promotes options to spenddowns, like MA-EPD, explained below.

This notification by Accend is not required by law. Clients are notified of potential spenddowns by MA each month with an Explanation of Benefits (EOB) notification. We provide this as an essential service to our clients who often do not open or understand their mail.

For individuals who have authorized us to receive a copy of their mail, including EOB, it is absolutely essential we use this process since they have asked us to receive mail as a part of the supports we provide.

Lack of a client signature on this notification does not mean we will not bill the individual for the spenddown amount.

Failure to Pay Spenddown

It is our policy that failure to pay a spenddown for three months might result in suspension of services without a payment plan. That payment plan must include the current spenddown and additional amount. It should be developed with the client based on what they can afford. This is another reason why use of the Notification of New, Past, or Changed Spenddown is so vital. This form informs the individual of the risks of failure to pay a spenddown.

One Possible Option to a Spenddown: MA-EPD

Medical Assistance has a program called MA-EPD (Medical Assitance for Employed Persons with Disabilities. If individuals with high spenddowns are able to find employment that pays at least $65.00/month, they may qualify for this benefit.

Recipients pay a monthly premium for MA-EPD. Premiums are based on income and household size. The amount is set by a sliding-fee scale or a minimum of $35, whichever is greater. To get an estimate of premiums, use the MA-EPD calculator found here at DB101.

Unearned Income Obligation for MA-EPD

If recipients have unearned income like Social Security Disability, they must pay one-half of one percent of unearned income each month. To calculate the unearned income obligation, multiply your total unearned income by .005. This cost is in addition to the monthly premium.

Copays for MA-EPD

Recipients may also have copays for non-preventative healthcare services. There are no copays for mental health services in any Medical Assistance program in Minnesota.

Renewing MHCP Coverage

All recipients of MHCP insurance must renew their coverage annually. Typically, they will receive notice of renewal about two months before the month they originally applied for health insurance.

For some individuals, DHS can automatically renew MA or MinnesotaCare for everyone in the household. They will send a notice and an information summary. Recipients must review the information summary to make sure all the information about them and their family is correct. They don't have to do anything else, unless they have a change or correction to report.

When DHS cannot automatically renew MA or MinnesotaCare for one or more people in a household, DHS will send a renewal form to complete, sign and return. Recipients must return the form by the due date. When DHS gets the completed renewal form, they will decide whether the people in the household remain eligible for health care coverage.

Important Actions for Providers

Essential for all providers is monitoring renewal dates and helping clients with renewals. the View Insurance Status Alerts report, available on the home page of Tabs^TM tells you when renewals are coming due. Monitor this report and understand the following:

*The Insurance Alerts report is current being reworked to match color protocols in Due Items. Check back soon for more details.

Do not assume that clients will respond in a timely manner and correctly. Offer assistance with this task as it can be complicated.

Document your assistance with renewing healthcare coverage using the note type Insurance Advocacy or the add-on Insurance Advocacy During/After Service.

When Individuals Decline Assistance With Renewals

While not common, there are times when clients decline assistance with renewals, and in some of these cases, insurance is more likely to lapse. Respect this choice, but remind them that maintaining insurance is essential for continuing services. Check in with them on their progress and document this in notes, using the Insurance Advocacy note type.

If such an individual's insurance does lapse, reach out with another offer of assistance.

Let them know that services like ARMHS, CTSS, Psychotherapy, HSS, etc. may need to be suspended until the insurance is re-instated, and that ICM help will be limited. Do not decline to help them, but cancel regularly-scheduled services. Offer that for urgent needs (food, shelter, safety) they may call or (in Duluth) walk in for outreach help. Document this support as BHH or AMH-TCM in case insurance is back-dated, but the service will be held for billing.

Retroactive Coverage

For all recipients of MA where insurance has lapsed, they may apply for retroactive coverage up to 3 months prior to renewal if they have received health care services, including services from Accend, that were not paid due to a lapse in insurance.

Procedures for Non-Payment

This section describes how clients will be notified and billed for services provided when they have responsibility for payment. These include:

• Private/commercial insurance
• MA Spendowns
• Insurance Lapses

Intake Treatment Consent

The initial Treatment Consent (included in the Treatment Plan) identifies charges that may be billable to the client. During the intake process, you will receive information from billing on potential charges to the client and must inform them during the intake process.

Changes in Client Responsibility

Changes in client responsiblity for payment may be identified upon renewal. In this case, you (the provider) and they (client) will be notified of new client responsibility for payment by the billing department. In this case, a new Notification of New, Changed or Past-Due Spenddown is required, notifying the client of new charges for services they will receive. Use the stand-alone Notification of New, Changed or Past-Due Spenddown form to inform the client of new charges to them.

This must be done immediately upon discovery of new charge: clients must be informed of new charges and offered the opportunity to decline services if they do not wish to receive the services and pay the associated fees.

Co-Pays and Deductibles

There is no cost-sharing (copays or deductibles) for individuals on Medical Assistance, including PMAP/MCO coverage.

Theres is no cost-sharing (copays or deductibles)for Mental Health services for individuals with MinnesotaCare. Non-mental health services we provide (BHH, HSS) are not covered by MinnesotaCare.

Clients with commercial insurance will in almost all cases have co-pays, deductibles, or both.

Clients with MA=EPD may have copays for some non-mental health healthcare services.

Spenddowns

When we receive notice that a client has a new spenddown or when a client a past-due balance, provider staff will be notified using the form Notification of New, Changed or Past-Due Spenddown. Please review Spendowns and options above and be prepared to compassionately work with the client and educate them about their options.

Procedures

Non-payments of charges to clients shall be handled as follows:

• Clients with charges (new or existing) will be billed for these monthly.
• Clients with new spenddowns will receive notice from DHS about their spenddown, but may not read or understand their mail. When we learn of the spenddown, provider staff will be notified to help clients understand.
• If a client fails to pay charges, they will be notified in each invoice of the date of potential suspension of services.
• Integrated Care Managers, if they have this service, are responsible for discussing this notice with the client.
• Other providers not accustomed to or familiar with these processes may ask for help from outreach staff or MnSure Navigator who are.

Payment Plans

We may develop payment plans for clients with overdue payments. These can be as little as $5.00 per month over and above current charges for which they are responsible.

Returning Clients with Bad Debt

Clients who have terminated services and return requesting more may have bad debt from a previous episode of care. For these individuals, a payment plan must be started upon re-initiation of services using the form Notification of New, Changed or Past-Due Spenddown.

Service Rates

Rates paid for services provided vary based on the payer. The rates in the table below reflect the rates we bill for each service we provide and the amounts we are paid. Tap and scroll in the table to view entries.

Rates reimbursed vary based on payer, some payers pay less for some services. Rarely do they pay more. While we appeal denials, on average, we collect 80% of what we bill. 

Often payers reject claims resulting in no revenue for the service provided (zero pay). Denials often appear arbitrary, or may be associated with mistakes on our part or the part of the payer. We appeal these denials but may or may not ever receive payment.

Rates Tables

Please be aware that this table may contain errors where rates have changed - a common occurence - but we will try to keep this up-to-date when we learn of rate changes.

Rates Billed Vs Costs

Please keep in mind that rates billed are one thing, while costs include not just staff time, but all expenses related to service delivery, inclduding administrative staff supports, leases for properties, program costs and supplies, staff training costs, etc. These are broken down in a broad sensen in the Money Follows Mission guide.

Rates Tables

Some of the tables below are scrollable. Tap in the table and scroll up or down to see details.

ARMHS Medication Education	Code	Type	Rate Billed
Medication Education	H0034	15-minute unit	$18.02
Med Education Community Intervention	90882	Occurrence	$51.11

Behavioral Health Home Services	Code	Type	Rate Billed
x-Services		Monthly Contact	252.35 - $360.50

AMH-TCM	Code	Type	Rate Billed
x-Services		Monthly Contact	$446 - $500

Mental Health Travel	Code	Type	Rate Billed
Mental Health Travel*	H0046	Minute	$0.52

*Please notice that travel reimbursement is not comprehensive. Paid by the minute, it typically pays for staff time, but not the mileage costs we reimburse.

Feedback or Questions about this Guide

This guide is a living document. We want to improve it with your help. Do you have questions? Found a typo? Find yourself wanting more information? Please send us your thoughts about anything in this chapter by tapping on the link below.

Updates to This guide

---

September 27, 2024:

Major update with procedures for spenddowns, client responsiblity for payment of copays, deductibles and spenddowns. Service rates posted.

---

October 4, 2024:

Additional and clarified information about Spenddowns. Navigation menu enhanced. Procedures for non-payment clarified.

---

October 16, 2024

Additional and clarified information about Spenddowns and MA-EPD. Links to resources and forms for both added.

---

October 22, 2024

Missing Psychotherapy service (30 minutes) added and broken link to assets and income fixed.

---

Decmeber 6, 2024

Guidance added for when clients decline assistance with insurance renewal.

---