Minnesota Senior Care Plus (MSC+)

Jump To...

 

Question mark in a bubbleQuestions? Need help? Call Member Services! All calls during business hours are answered by a person, not a machine. We're here to help you. You can also access the PrimeWest Health Member Web Portal to get more information about your services, to contact us, or to request print copies of your member materials.

Program Description

Minnesota Senior Care Plus (MSC+) is a program for people age 65 and over who have Medical Assistance (Medicaid). People apply for Medical Assistance (Medicaid) through their county Social/Human/Family Services/Tribal office. While you are in PrimeWest Health's MSC+ program, you will work with a county case manager. Your county case manager can help you arrange health care and support services. County case managers and PrimeWest Health care coordinators work together to help you maintain your health whether you live in your own home or in a care facility.

To get the most up-to-date information about the Medical Assistance (Medicaid) program, go to the Minnesota Department of Human Services (DHS) website.

Enrollment/Eligibility

To apply for Medical Assistance (Medicaid) coverage, contact the Social/Human/Family Services department for your county or the Tribal office. If you are found eligible for Medical Assistance (Medicaid), you will be able to enroll in PrimeWest Health MSC+ for your covered services if you live in our service area. PrimeWest Health MSC+ is available to residents of the following counties: Beltrami, Big Stone, Clearwater, Douglas, Grant, Hubbard, McLeod, Meeker, Pipestone, Pope, Renville, Stevens, or Traverse.

Note: People who qualify for MSC+ and have Medicare may also qualify for PrimeWest Senior Health Complete (HMO SNP). To learn more, visit the PrimeWest Senior Health Complete (HMO SNP) section of this website.

Benefits

To learn about the benefits and coverage provided by MSC+, read your Member Handbook/Evidence of Coverage. It gives details about the health care services we will cover. It tells how to get your health care as a PrimeWest Health MSC+ member. It also explains the rights, benefits, and responsibilities of members. Individual chapters below tell more about specific subjects.

You will also need to read the Addendum to the Member Handbook/Evidence of Coverage. This contains important changes and/or additions to the Member Handbook/Evidence of Coverage for the 2017 contract year.

Welcome to PrimeWest Health

Section  1. Telephone Numbers and Contact Information
Section  2. Important Information on Getting the Care You Need
Section  3. Member Bill of Rights
Section  4. Member Responsibilities
Section  5. Your Health Plan Identification Card
Section  6. Cost Sharing
Section  7. Covered Services
Section  8. Services We Do Not Cover
Section  9. Services That Are Not Covered under the Plan but May Be Covered through Another Source
Section 10. When to Call Your County Worker
Section 11. Using the Plan Coverage with Other Insurance
Section 12. Subrogation or Other Claim
Section 13. Grievance, Appeal, and State Fair Hearing Process
Section 14. Definitions
Section 15. Additional Information


Organization Determinations
PrimeWest Health has made an organization determination when it makes a decision about whether items or services are covered or how much you have to pay for covered items or services. Organization determinations are also called “coverage decisions” in the Member Handbook/Evidence of Coverage. Standard organization determinations are made as expeditiously as the member’s health condition requires, not to exceed 14 calendar days (10 business days) from the date the request was received. Expedited organization determinations are made as expeditiously as the member’s health condition requires, not to exceed 72 hours from the date the request was received. Expedited organization determinations are for cases where the provider indicates or PrimeWest Health determines that following the standard time frame could seriously jeopardize the member’s life or health, or ability to attain, maintain, or regain maximum function.

Providers and Pharmacies

  • Read your Provider Directory to see a full list of health care providers (including specialists) in the PrimeWest Health network.
  • Use our online search feature to see if a specific provider is in the PrimeWest Health network.
  • Use our online search feature to see if a specific pharmacy is in the PrimeWest Health network.

Prescription Drug Benefits

Drug Coverage

  • To see if specific prescription drugs are covered by PrimeWest Health MSC+, use our online search feature. Note: If you have other insurance coverage, contact that insurance plan for information about its drug coverage. If you have Medicare, you must enroll in a Medicare Prescription Drug Plan (Part D) to receive most of your prescription drug services. PrimeWest Health will not pay for any Part D eligible drugs when you have Medicare through another plan.
  • To see if any of your over-the-counter drugs are covered by PrimeWest Health MSC+, use our online search feature. The items included there are covered when you have a prescription from your health care provider or pharmacist.
  • If the drug you are taking is not on the list of covered drugs, read your Member Handbook/Evidence of Coverage to find out what you can do. This includes instructions for both new and current members.
  • If you would like help managing your prescription drugs, read about our Medication Therapy Management program and its eligibility requirements.

Restrictions on covered drugs
Some drugs have restrictions on coverage. The restrictions are called Utilization Management (UM) programs. UM programs include Prior Authorization, Quantity Limits, and Step Therapy. Read more about our Utilization Management programs.

You may ask for an exception to the drug coverage and restriction rules by using the Formulary Exception Form. Note: This form must be completed by a health care provider. You can also submit an online Formulary Exception.

Cost Sharing (copays/deductibles/premiums)

Cost sharing refers to your responsibility to pay an amount towards your medical costs. For more information about what cost sharing you may have, see your Member Handbook/Evidence of Coverage or call Member Services.

Appeals and Grievances (complaints)

If you disagree with a decision or have a complaint about your health care, services, or coverage, you may file a Grievance (complaint) or Appeal or request a State Fair Hearing. Read more about the processes for doing any of these things in your Member Handbook/Evidence of Coverage.

Member Outreach

PrimeWest Health hosts stakeholder meetings for members of our MSC+, SNBC, PrimeWest Senior Health Complete (HMO SNP), and Prime Health Complete (HMO SNP) programs. These meetings give members and their advocates and providers a chance to learn about their benefits and how to navigate the health care system. Members, advocates, and providers share their ideas, opinions, concerns, and suggestions about the services offered by PrimeWest Health. This stakeholders’ group has helped PrimeWest Health identify and put in place changes to provide better service to our members. If you want to see a copy of the minutes from the stakeholders’ meetings, call Member Services.

Contact Us

Call: Member Services: 1-866-431-0801
TTY users: 1-800-627-3529 or 711
Hours are Monday – Friday, 8 a.m. – 8 p.m.

Utilization Management: 1-866-431-0803
  Questions about where to get services, getting authorization for services, or restrictions on prescription drugs
Hours are Monday – Friday, 8 a.m. – 4:30 p.m.

Calls to all of these numbers are free.
 
Write:

PrimeWest Health
3905 Dakota St
Alexandria, MN 56308

Email: To contact Member Services through secure email, sign in to the Member Web Portal.

Member Web Portal

Log in to the PrimeWest Health Member Web Portal to view your benefits and member information. Once logged in, you can do the following:

  • Ask for a new member ID card
  • Update your member information
  • Choose or change a primary care provider or clinic
  • Complete a Health Risk Assessment and access online tools to keep you healthy
  • Ask to have disease management or care management services
  • Ask questions
  • Request materials
  • View services requiring authorization
  • View eligibility and claims status 

 

How does our website work for you? If you have comments, questions, or feedback about our website, please call Member Services. We look forward to hearing from you!

 

PW_12-16_543R_08-17
DHS_Approved_10/13/2017
Updated_10/13/2017