DHS-6451B-ENG 8-25 (4.2.0)

Special Needs BasicCare (SNBC) Choice Form

Special Needs Basic Care (SNBC) is a voluntary managed care program for people on Medical Assistance with disabilities ages 18-64 who live in Minnesota.

This form is only for enrollment and disenrollment from a SNBC Non-Integrated (NI) health plan or to opt out of SNBC-NI.

SNBC-NI: An SNBC-NI health plan only covers your Medical Assistance (MA). If you also have Medicare, then your Medicare coverage will be directly handled by Medicare, and you will need a separate Medicare Part D Plan.
Opt out of SNBC-NI: You will not be enrolled in a health plan and will receive your MA fee for service. If you have Medicare also, then your Medicare coverage will be directly handled by Medicare, and you will need a separate Medicare Part D Plan.

Do not use this form for SNBC Integrated (I) enrollment or health plan changes. SNBC-I means that MA and Medicare services are combined into one health plan. Contact the health plan directly to enroll in SNBC.

If you have questions about any of these SNBC plan options, or need help understanding how to use this form, contact Disability Hub MN™ at 866-333-2466 or online at disabilityhubmn.org.

SNBC Plan Enrollment Qualifications

This DHS-6451B SNBC Choice Form can only be completed for people who have MA and meet the following criteria:

You are certified disabled by the Social Security Administration or by the State Medical Review Team
You are between the ages of 18-64
You have Medicare Parts A and B or no Medicare
If you are not currently on SNBC, you do not have to pay a medical spenddown
If you are currently on SNBC, you have no unpaid spenddown

Directions to Complete This Form

Fill out this form if you meet the bulleted list of qualifications listed in the "SNBC Plan Enrollment Qualifications" section and want to:

Enroll in a SNBC-NI health plan.
Change your SNBC-NI health plan.
Note: Enrolling in a new SNBC-NI health plan will automatically disenroll you from your current SNBC-NI health plan for the next available month.
Opt out or disenroll from SNBC and receive MA fee-for-service.

Required field

MINNESOTA HEALTH CARE PROGRAM ID/PMI

CASE NUMBER

TODAY'S DATE

FIRST NAME

MIDDLE NAME

LAST NAME

DATE OF BIRTH

STREET ADDRESS

CITY

STATE

ZIP CODE

COUNTY OF RESIDENCE

SELECT ONE OF THE FOLLOWING OPTIONS TO MAKE A CHANGE

Special Needs BasicCare (SNBC) not available in this county.

I understand that my signature (or the signature of the person authorized to act on my behalf) on this form means that I have read and understand the contents of this form.

SIGNATURE

PHONE NUMBER

Next Steps

When you submit this form, it is sent to the Department of Human Services (DHS) for processing. DHS determines if you can enroll or change plans based on your circumstances and eligibility.

If DHS determines you can enroll into a plan, or change to a different plan, you will receive a confirmation letter in the mail. You will also receive a new insurance card and information in the mail from the plan you chose.
If DHS determines you cannot enroll into the option you submitted on the form, you will receive a denial letter in the mail.
If you request to disenroll from your current plan, DHS will send you a confirmation letter in the mail confirming that you have been disenrolled.
If you chose to opt out of SNBC by submitting the form, you will not receive a confirmation letter.

NO ENGLISH

651-297-3862 or 800-657-3672

Attention. If you need free help interpreting this document, call the number in the box above.

wáŋ. héčiŋhaŋ niyé wačhíŋyAŋ wayúiyeska ki de wówapi sutá, ečíyA kiŋ wóiyawa ed ophíye waŋ. _Dakota

Paunawa. Kung kailangan mo ng libreng tulong sa pag-unawa sa kahulugan ng dokumentong ito, tawagan ang numero sa kahon sa itaas. _{Filipino (Tagalog)}

Attention. Si vous avez besoin d’aide gratuite pour interpréter ce document, appelez le numéro indiqué dans la case ci-dessus. _French

Lus Ceeb Toom. Yog tias koj xav tau kev pab txhais lus dawb ntawm cov ntaub ntawv no, ces hu rau tus nab npawb xov tooj nyob hauv lub npov plaub fab saum toj no. _Hmong

Baldarî. Ger ji bo wergerandina vê belgeyê hewcedariya we bi alîkariya belaş hebe, ji kerema xwe bi hejmara li qutiya jorîn re telefon bikin. _{Kurdish Kurmanji}

Hoȟpíŋ. Tóháŋ waŋží thí wíyukčaŋpi kiŋ yuhá níyuŋspe héčha čhéya, lé tkíčhuŋ kiŋ k'é náŋpa opáwiŋyaŋ. _Lakota

Pa̱lɛ rɔ piny: Mi gööri luäk lɔrä kɛ luɔ̱c kä mɛmɛ, yɔtni nämbär ɛmɔ tëë nhial guäth ɛmɛ. _Nuer

Mah Biz'sin'dan. Keesh'pin nan'deh'dam'mun chi'wee'chi'goo'yan chi'nis'too'ta'man oo'weh ooshii'be'kan. Ishi'kidoon ah'kin'das'soon ka'ooshi'bee'kadehk ish'peh'mik ka'shi ka'ka'kak. _Ojibwe

Hubachiisa: Yoo barreeffama kana hiikuuf gargaarsa bilisaa barbaaddan, lakkoofsa saanduqa armaan olii keessa jirun bilbilaa. _Oromo

Atenção. Se você precisar de ajuda gratuita para interpretar este documento, ligue para o número na caixa acima. _Portuguese

Внимание! Если Вам нужна бесплатная помощь в переводе этого документа, позвоните по телефону, указанному в рамке выше. _Russian

Pažnja. Ukoliko vam je potrebna besplatna pomoć u tumačenju ovog dokumenta, pozovite broj naveden u kvadratu iznad. _Serbian

Fiiro gaar ah. Haddii aad u baahan tahay caawimo bilaash si laguugu turjumo dukumiintigan, wac lambarka ku jira sanduuqa sare. _Somali

Atención. Si necesita ayuda gratuita para interpretar este documento, llame al número que aparece en el recuadro superior. _Spanish

Zingatia. Iwapo unahitaji msaada usio na malipo wa kutafsiri hati hii, piga simu kwa namba iliyo kwenye kisanduku hapo juu. _Swahili

Увага! Якщо Вам потрібна безкоштовна допомога в перекладі цього документа, зателефонуйте за номером, вказаним у рамці вище. _Ukrainian

Xin lưu ý: Hãy liên hệ theo số điện thoại trong ô trên nếu bạn cần bất kỳ sự hỗ trợ miễn phí nào để hiểu rõ về tài liệu này. _Vietnamese

Àkíyèsí. Tí o bá nílò ìrànlówọ́ pẹ̀lú tí tú mọ̀ àkọ̀ọ́lẹ̀ yìí, pe nọ́mbà tó wà nínú àpótí tí wà ló kè. _Yoruba

LB (7-24)

CB5 (MCOs) 10-21

Civil Rights Notice

Discrimination is against the law. The Minnesota Department of Human Services (DHS) does not discriminate on the basis of any of the following:

race
color
national origin
creed
religion
sexual orientation
public assistance status
age
disability (including physical or mental impairment)
sex (including sex stereotypes and gender identity)
marital status
political beliefs
medical condition
health status
receipt of health care services
claims experience
medical history
genetic information

Auxiliary Aids and Services

DHS provides auxiliary aids and services, like qualified interpreters or information in accessible formats, free of charge and in a timely manner to ensure an equal opportunity to participate in our health care programs. Contact Minnesota Health Care Programs (MHCP) Member Help Desk – DHS.info@state.mn.us or 800-657-3739.

Language Assistance Services

DHS provides translated documents and spoken language interpreting, free of charge and in a timely manner, when language assistance services are necessary to ensure limited English speakers have meaningful access to our information and services. Contact 651-431-2670 or 800-657-3739.

Civil Rights Complaints

You have the right to file a discrimination complaint if you believe you were treated in a discriminatory way by a human services agency. You may contact any of the following three agencies directly to file a discrimination complaint.

U.S. Department of Health and Human Services’ Office for Civil Rights (OCR)

You have the right to file a complaint with the OCR, a federal agency, if you believe you have been discriminated against because of any of the following:

race
color
national origin
disability
age
sex
religion (in some cases)

Contact the OCR directly to file a complaint:

U.S. Department of Health and Human Services
Office for Civil Rights
200 Independence Avenue SW, Room 509F, Room 515F
Washington, DC 20201

Customer Response Center: Toll-free 1-800-368-1019
TDD 1-800-537-7697
Email: ocrmail@hhs.gov

Minnesota Department of Human Rights (MDHR)

In Minnesota, you have the right to file a complaint with the MDHR if you believe you have been discriminated against because of any of the following:

race
color
national origin
religion
creed
sex
sexual orientation
marital status
public assistance status
disability

Contact the MDHR directly to file a complaint:

Minnesota Department of Human Rights
540 Fairview Avenue North, Suite 201
St. Paul, MN 55104
651-539-1100 (voice)
1-800-657-3704 (toll free)
711 or 1-800-627-3529 (MN Relay)
651-296-9042 (fax)
Info.MDHR@state.mn.us (email)

Minnesota Department of Human Services (DHS)

You have the right to file a complaint with DHS if you believe you have been discriminated against in our health care programs because of any of the following:

race
color
national origin
creed
religion
sexual orientation
public assistance status
marital status
age
disability (including physical or mental impairment)
sex (including sex stereotypes and gender identity)
political beliefs
medical condition
health status
receipt of health care services
claims experience
medical history
genetic information

Complaints must be in writing and filed within 180 days of the date you discovered the alleged discrimination. The complaint must contain your name and address and describe the discrimination you are complaining about. After we get your complaint, we will review it and notify you in writing about whether we have authority to investigate. If we do, we will investigate the complaint.

DHS will notify you in writing of the investigation's outcome. You have the right to appeal the outcome if you disagree with the decision. To appeal, you must send a written request to have DHS review the investigation outcome. Be brief and state why you disagree with the decision. Include additional information you think is important.

If you file a complaint in this way, the people who work for the agency named in the complaint cannot retaliate against you. This means they cannot punish you in any way for filing a complaint. Filing a complaint in this way does not stop you from seeking out other legal or administrative actions.

Contact DHS directly to file a discrimination complaint:

Civil Rights Coordinator
Minnesota Department of Human Services
Equal Opportunity and Access Division
P.O. Box 64997
St. Paul, MN 55164-0997
651-431-3040 (voice) or use your preferred relay service