HealthPartners Care Coordination

MSHO/MSC+ Benefit Exception Instructions

Title:	Exception to Benefit for Delegated MSHO/MSC+ Entities
Program(s):	MSHO/MSC+	Effective Date:	10/1/2017
Frequency:	As needed	System(s):	N/A
Revised by:	Sue Oestreich	Last Revision:	9/7/2017
Work Aid Location:	MSHO/MSC+ portal web page; MSHO/MSC+ SharePoint
Preparation/Materials:	Annual MSHO Supplemental Benefits, Health Risk Assessment results, Individualized Care Plan

Purpose:

To provide information to HealthPartners when requesting an item or service that is outside of the member’s regular benefit set or case mix budget.

When to use:

Prior to requesting an exception, Care Coordinators should consider all other appropriate benefits including annual MSHO supplemental benefits, informal and quasi formal supports.

The need for an item outside of the regular benefit sets must be based on an assessed need and be related to a goal(s) on the member’s individualized care plan (ICP) that demonstrates the necessity of the item or service in order to support the member’s overall health and well-being.

When service plan exceeds case mix cap:

All elderly waiver services authorized by the Care Coordinator must be based on assessed need, included in the individual’s individualized care plan, and must be provided within the patient’s monthly case mix cap. At any point in time within the patient’s waiver span when the service plan exceeds the patient’s case mix cap, the care coordinator will need to complete an Exception to Benefit form and submit to HealthPartners for approval to exceed case mix cap.

Upon approval, complete and submit a Service Authorizaiton form.

When a RCA patient needs an EW equipment item or service on a short term basis:

In addition to Medical Assistance (MA) covered equipment, certain Elderly Waiver (EW) covered products may be purchased by the Care Coordinator for a rate cell A member. This can be approved on a one time basis (with the exception of the ongoing supplies/equipment listed below), for a total of $150.00 or less. Any combination of items that total over $150.00 must be approved by your supervisor and HealthPartners.

The following EW items are available to order for a rate cell A member without approval from a supervisor as long as the following criteria are met:

There is a need for the product reflected in the assessment

This need is documented in the care plan

The combined total or the order does not exceed $150.00

Pill Boxes

Hand Held Showers

Cruiser Walkers

Medical Alert Identification Bracelets

Bathroom Scale

Magnifying Glass

Additional Elderly Waiver covered products may be ordered for a rate cell A member subject to HealthPartners approval. Care Coordinators will need to complete an Exception to Benefit form and discuss with their supervisor. These items must meet the general criteria listed above in addition to product specific criteria. This includes the following products:

Grab Bars/Safety Equipment: There must be a documented fall risk and/or medical need. The total cost cannot exceed $500.00.

Home Delivered Meals: This will be considered for a rate cell A patient on a temporary basis only. Supervisors should be consulted for any available community resources prior to considering coverage under MSHO.

Upon approval, complete and submit a Service Authorizaiton form.

The following items are not available for rate cell A members as an exception to EW and must be submitted to HealthPartners QUI for consideration of coverage under the members Medical Assistance benefits.

Nutritional Supplements

Wheelchairs (manual and electric)

Hospital Beds