Covered Services
you can receive this service up to 20 units per calendar year without authorization
Acute and chronic pain • Depression • Anxiety • Schizophrenia • Post-traumatic stress syndrome • Insomnia • Smoking cessation • Restless legs syndrome • Menstrual disorders • Xerostomia (dry mouth) associated with the following: – Sjogren’s syndrome – Radiation therapy • Nausea and vomiting associated with the following: – Postoperative procedures – Pregnancy – Cancer care
Acupuncture
services are covered when provided by a licensed acupuncturist or by another Minnesota licensed practitioner with acupuncture training and credentialing
Dental cleaning up to four times per year if medically necessary with Prior Authorization • Fluoride varnish (once per calendar year) (cannot be performed on same date as emergency treatment of dental pain service) • Cavity treatment (once per tooth per six months) (cannot be performed on same date as fluoride varnish service or emergency treatment of dental pain service)
Preventive services
Prescription drug maximum out of pocket (MOOP) — includes both generic and brand name drugs
$70.00 combined maximum per month
name a service that do not have a copay
any one of these will work:
• Preventative and diagnostic dental care • Family planning services and supplies • Home care • Immunizations • Interpreter services • Medical equipment and supplies • Mental health services • Preventive care visits, such as physicals • Rehabilitation therapies • Repair of eyeglasses • Some preventive screenings and counseling, such as cervical cancer screenings and nutritional counseling • Some mental health drugs (antipsychotics) • Substance use disorder treatment • Tests such as blood work • Tobacco use counseling and interventions • 100% federally funded services at Indian Health Services clinics
Eligibility
Applicants must:
with this service you can get up to 24 visits per calendar year, limited to six per month. Visits exceeding 24 per calendar year or six per month require a prior authorization.
Chiropractic Care
Fillings (limited to once per 90 days per tooth) • Sedative fillings for relief of pain (cannot be performed on same date as fluoride varnish service or emergency treatment of dental pain service)
Restorative services
Non-preventive visits
$25.00 per visit
What is a Coinsurance?
A coinsurance is an amount that you will be responsible to pay to your provider. Coinsurance is usually a percentage. This means, you pay a percent of the total cost of the medical equipment.
Languages
Primary Languages spoken by members include:
English
Spanish
Somali
Hmong
Member materials are printed in both English, Somali, Hmong, and Spanish. Additional languages are available upon member request.
these are examples of what type of covered services:
Skilled nurse visit
• Rehabilitation therapies to restore function (for example, speech, physical, occupational, respiratory)
• Home health aide visit
Home Care Services
Who do members contact for dental service information? and what is that number?
Us (member services) 1-888-269-5410
Emergency room visits
$75.00 per visit
Name a few Durable Medical Equipment
any of these would work:
Wheelchairs, canes, crutches, walkers, commodes, decubitus ulcer care equipment, heat/cold application, bath and toilet aids, urinals, beds, oximeters, patient lifts/standers, compression devices and appliances, ultraviolet light equipment, nerve stimulators, traction equipment, orthopedic devices, wound therapy devices, and wound suction pump
Competitors
What would these covered services be under?
• Lab tests and X-rays
• Other medical tests ordered by your doctor
Diagnostic Services
Removable appliances (dentures and partials) (one appliance every six years per dental arch) • Adjustments, modifications, relines, repairs, and rebases of removable appliances (dentures and partials) (repairs to missing or broken teeth are limited to five teeth per 180 days) • Replacement of appliances that are lost, stolen, or damaged beyond repair under certain circumstances • Replacement of partial appliances if the existing partial cannot be altered to meet dental needs • Tissue conditioning liners (once per appliance) • Precision attachments and repairs
Prosthodontics
Inpatient Hospital
$250.00 per admission
What is the Coinsurance amount for medical equipment
10%
how many health plans can enrollees choose from?
This service is covered under what benefits?
Doula services by a certified doula supervised by either a physician, nurse practitioner, or certified nurse midwife and registered with the Minnesota Department of Health (MDH)
• Hospital services for newborns
• Treatment for newborns of HIV-positive mothers
• Testing and treatment of sexually transmitted diseases (STDs) — Open access service
Obstetrics and gynecology (OB/GYN) services
Gross removal of plaque and tartar (full mouth debridement) (once every five years) (cannot be performed on same date as dental cleaning service, comprehensive exam, oral evaluation or periodontal evaluation service) • Scaling and root planing (cannot be performed on same day as dental cleaning or full mouth debridement) (once every two years for each quadrant) (can only be provided in an outpatient hospital or freestanding Ambulatory Surgery Center (ASC) as part of an outpatient dental surgery)
Periodontics
2 parts:
Prescription drugs, generic There are no copays for anti-psychotic drugs
Prescription drugs, brand name There are no copays for anti-psychotic drugs.
2 parts:
$7.00 per prescription
$25.00 per prescription
When to call MN Care
• Name changes
• Address changes including moving out of Minnesota
• Pregnancy begin and end dates
• Addition or loss of a household member
• Lost or stolen Minnesota Health Care Program ID card
• New insurance or Medicare — begin and end dates • Change in income including employment changes
What are the Minnesota BIN/PCN/Group numbers for this benefit?
BIN (Bank Identification Number)610494
PCN (Processor Control Number)4846
Group Number ACUMN