FAQs about health plans and managed care

Managed care is a system for providing health care benefits through health plans. People enrolled in a health plan must get their medical care through the health plan. The health plan may require you to:

• Choose a primary care clinic, which will coordinate all your care
• Get a referral from your primary care clinic before you see a specialist
• Get all your care from participating providers.

Everyone who has MinnesotaCare and many people who have Medical Assistance (MA) must enroll in a health plan. Contact your worker to see if you have to enroll in a plan.

For general information about health plan enrollment, see:

Managed Care Enrollment Guide for Families and Children Prepaid Medical Assistance Program (PMAP) and MinnesotaCare (DHS-8041) (PDF)

People age 65 and older must enroll in a health plan. You will get information in the mail to help you choose a Minnesota SeniorCare Plus (MSC+) health plan. If you have Medicare and want to get all of your Medicare and Medical Assistance services through one health plan, you can choose to enroll in a Minnesota Senior Health Options (MSHO) health plan.

People who have disabilities and have MA, with or without Medicare, may choose to enroll in a Special Needs BasicCare (SNBC) health plan.

Some counties have more than one health plan for you to choose from. Each plan has different doctors and dentists who you may see. You may want to choose a plan that your current doctor or dentist participates in. If you do not have a doctor, you may want to choose a plan with doctors close to your home or workplace.

The program you are approved for determines the benefits you get. The health plan does not determine your benefits. The health plans have different rules about how you receive your benefits.

If there is more than one health plan available in your county, you may be able to change health plans. You may change health plans with the following limits:

• Once during the first year you are enrolled in a health plan.
• Once each year during the annual health-plan-selection period. Annual health-plan-selection notices are mailed in the fall. If you change health plans during this period, the change will take effect Jan. 1 of the following year. For more information, see our annual health-plan-selection web pages.
• At other times for specific reasons. Contact your worker if you have MinnesotaCare. If you have MA, contact your county's managed care advocate (PDF) or the Ombudsman for Public Managed Health Care Programs.

Call your health plan.

Call your health plan to find out if you need a referral to see the specialist you want. Talk to your primary care doctor about a referral.

Read the Certificate or Evidence of Coverage the health plan sent to you. Call your health plan member services if you have more questions.

Each health plan has a list of medications they cover (called a formulary). If your doctor thinks that a medication not on the list is the best medication for you, ask your doctor to submit a request for authorization to the health plan. The health plan may approve the medication even if it is not on their formulary.

If the health plan denies the request for authorization, you may choose to appeal that decision using the health plan appeal process or the state fair hearing process.

The health plan must send you a notice if it denies, ends or reduces services you or your doctors have requested. The notice will tell you why the plan decided to deny, end or reduce your services. If you disagree with the health plan, you may file an appeal or ask for a state fair hearing.

If you get a bill from a doctor's office, dental office, hospital or other health care provider, call the provider and ask if they have billed your health plan. Give them your insurance information.

The health plan must send you a notice if it is not going to pay a bill. The notice will tell you why the health plan is not going to pay a bill. If you disagree with the decision not to pay a bill, you may file a grievance, file an appeal or ask for a state fair hearing.

Your rights and responsibilities are explained in this Notice about your rights and responsibilities (PDF).

• Health plan member services
• County and tribal offices
• MinnesotaCare office