DHS-6451B-ENG 1-26 (4.4.1)

Non-Integrated Special Needs BasicCare Choice Form

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

The SNBC program has a non-integrated and integrated option, depending on which county you live in.

Non-Integrated SNBC only covers your MA. If you also have Medicare, your Medicare coverage will be directly handled by Medicare, and you will need a separate Medicare Part D Plan.
Integrated SNBC means that MA and Medicare services are combined into one health plan. Contact the health plan directly to enroll in or disenroll from Integrated SNBC.

Do not use this form for Integrated SNBC enrollment or health plan changes.

Use this form only for:

Enrollment in a Non-Integrated SNBC health plan
Disenrollment from a Non-Integrated SNBC health plan
To opt out of Non-Integrated SNBC (If you opt out of Non-Integrated SNBC, you will not be enrolled in a health plan and will receive your MA fee for service. This is also known as "straight MA".)

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

Non-Integrated SNBC Plan Enrollment Qualifications

This Non-Integrated 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 and want to switch health plans, you cannot have any unpaid medical spenddowns

Required field

Complete the following information and select the action you are requesting.

MINNESOTA HEALTH CARE PROGRAM ID or 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.

Type of request for non-integrated SNBC

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 Minnesota 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 TRS: 711

ATTENTION: If you speak English, free language assistance services are available to you free of charge and without unnecessary delay. Additionally, appropriate auxiliary aids and services to provide information in accessible formats are available free of charge and in a timely manner. Please call the number above or speak to your provider. _English

Image of Cantonese (Traditional Chinese) language

Á, DÉ YAWÁ PO! Dakhód'iyaye héčiŋhaŋ, iyápi-wóokiye išíčhona yaŋké. Ka nakúŋ wanáȟ'uŋpi-wóokiye išíčhona yaŋké. Héčhed wónaȟ'uŋ kiŋ iyóhiphiča dó. Wóokiye kiŋ dená išíčhona ičúphiča naháŋ yuthéhaŋšniyaŋ ičúphiča dó. Wičhóiye kiŋ dená iwáŋkab, wóiyawa waŋ yaŋké kiŋ mas'ákiphapi na wóokiye-wičháša kičhí wóhdaka po. _Dakota

PAUNAWA: Kung nagsasalita ka ng Filipino, ang mga libreng serbisyo ng tulong sa wika ay magagamit sa iyo nang walang bayad at walang hindi kinakailangang pagkaantala. may mga angkop na pantulong na kagamitan at serbisyo upang maibigay ang impormasyon sa naaangkop na anyo, nang libre at sa tamang oras. Mangyaring tawagan ang numero sa itaas o makipag-usap sa iyong provider. _{Filipino (Tagalog)}

ATTENTION: Si vous parlez français, des services d'assistance linguistique gratuits sont à votre disposition, sans frais et sans délai. En outre, des aides et services auxiliaires appropriés pouvant fournir des informations dans des formats accessibles sont disponibles gratuitement et rapidement. Veuillez appeler le numéro ci-dessus ou contacter votre fournisseur. _French

CEEB TOOM: Yog koj hais lus Hmoob, muaj kev pab txhais lus dawb rau koj siv. Koj tsis tas them nqi thiab yuav tsis qeeb. Kuj muaj cuab yeej thiab kev pab los pab koj nyeem cov ntaub ntawv kom yooj yim nkag siab. Koj hu tau rau tus xov tooj saum toj no lossis nrog koj tus kws kho mob tham. _Hmong

BALDARÎ: Heke hûn bi Kurdîya Kurmancî diaxivin, xizmetên alîkarîya ziman bêpere û bêyî derengmayîneke nehewce ji we re peyda dibin. Her wiha, hevkariyên guncaw û karûbarên alîkar bêpere û di heman demê de ji bo dabînkirina agahdariya guncaw hene. Ji kerema xwe bi jimareya jorîn re telefon bikin an jî bi dabînkerê xwe re biaxivin. _{Kurdish Kurmanji}

Á, LÉ YAWÁ PO! Lakȟól'iyaye héči, iyápi-wóokiye išíčhola yaŋké. Naháŋ nakúŋ wanáȟ'uŋpi-wóokiye išíčhola yaŋké. Héčhel wónaȟ'uŋ kiŋ iyóhiphiča yeló. Wóokiye kiŋ lená išíčhola ičúphiča naháŋ yutȟéhaŋšniyaŋ ičúphiča yeló. Wičhóiye kiŋ lená iwáŋkab, wóiyawa waŋ yaŋké kiŋ mas'ákipȟapi na wóokiye-wičháša kičhí wóglaka po. _Lakota

Image of Mandarin (Simplified Chinese) language

PALɛ Rɔ PINY: Mi ruaci kɛ thok Nuärä, luäk mi lɔr kɛ kuic thuok kɛnɛ lät tin jiëkɛ tëë thin baaŋ a thiɛl mi yuɔr kɛ piny kä thiɛlɛ mi gaal jɛ. Min dëë nyɔk kɛ mat thin, ɛ luäk mi dɔdiɛn kɛnɛ lät tin kɔkiɛn tin nööŋ kɛ läri kɛ duɔp min jiëkɛ kɛɛ tëë kɛ thin baaŋ thilɛ mi yuɔrkɛ piny kɛ kuicdiɛn kɛ guath mi gɔa. Mi nhɔk i jɛ yɔtni nämbär ɛmɔ tëë nhial ɔ ikä kiɛ ruacni kɛ ram min luäkdu. _Nuer

MAH BIZ'SIN'DAN: Keesh'pin, keen Ojibwe'mo, kaa'ween ina'gin'de wiiji'kaa'kii'ki'do miina'waa ke'nebe-naa'ta'maw chi'nis'too'ta'man noon'goom. Da'kon'an, wee'chi'ma'zinaa'beke'webene'kan'an ozhe'che'kan miina'waa kinah ozhee'bee'geh ma'zenah'egan'an kaa'ween ina'gin'de miina'waa da'daa'ta'be'bee'an. Da'gah'na'sa ka'noozh aseh'ge'beh'egan ish'peh'meng ge'maa kee'kidoon wii'doo'kaa'geh. _Ojibwe

HUBADHAA: Yoo Afaan Oromoo dubbattu ta'e, tajaajila gargaarsa turjumaana afaanii biliisaan akkasumas turtii barbaachisaa hin taane hambisu danda'u isiniif dhihaatee jira. Dabalataanis, odeeffannoo haala salphaan argamuu danda'an dhiyeessuuf gargaarsa fi tajaajiloota deeggarsaa qama midhamtootaaf mijatoo ta'an, kaffaltii tokko malee fi yeroo isaa eeggatee kennamu dhihaatee jira. Odeeffanno dabalataaf lakkoofsa armaan oliitti fayyadamuun namoota gargaarsa kana isiniif kennan qunnamaa. _Oromo

ATENÇÃO: Se fala português, tem à sua disposição serviços de assistência linguística gratuitos e sem demoras desnecessárias. Além disso, estão disponíveis, gratuitamente e numa forma atempada, ajudas e serviços auxiliares adequados para fornecer informações em formatos acessíveis. Por favor, contacte o número acima ou fale com o seu prestador de serviços. _Portuguese

ВНИМАНИЕ: Если вы разговариваете на русском языке, воспользуйтесь услугами языковой поддержки бесплатно и без лишних проволочек. Также бесплатно и незамедлительно предоставляются соответствующие вспомогательные средства и услуги по обеспечению информацией в доступных форматах. Позвоните по указанному выше номеру или обратитесь к своему поставщику услуг. _Russian

PAŽNJA: Ako govorite srpski, besplatne usluge jezičke pomoći su vam dostupne besplatno i bez nepotrebnog odlaganja. Pored toga, odgovarajuća pomoćna sredstva i usluge za pružanje informacija u pristupačnim formatima dostupne su besplatno i blagovremeno. Molimo vas da pozovete gore navedeni broj ili razgovarate sa vašim pružateljem usluga. _Serbian

FIIRO GAAR AH: Haddii aad ku hadasho Soomaali, waxaa si bilaash ah kuugu diyaar ah adeegyada caawinada luuqadeed oo aan lahayn daahitaan aan munaasib ahayn. Intaas waxaa dheer, waxaa la heli karaa adeegyada iyo kaabitaanka naafada ee haboon si macluumaadka loogu bixiyo qaabab la adeegsan karo oo bilaash ah laguna bixinayo waqqigeeda. Fadlan wac lambarka kore ama la hadal adeegbixiyahaaga. _Somali

ATENCIÓN: si habla español, tiene a su disposición los servicios gratuitos de traducción sin costo alguno y sin demoras innecesarias. Además, se encuentran disponibles de forma gratuita y oportuna ayuda y servicios auxiliares adecuados con el fin de brindarle información en formatos accesibles. Llame al número indicado anteriormente o hable con su proveedor. _Spanish

ZINGATIO: Ikiwa unazungumza Kiswahili, huduma za msaada wa lugha zinapatikana kwa ajili yako bila malipo na bila ucheleweshaji usio wa lazima. Aidha, vifaa saidizi vya mawasiliano na huduma kwa walemavu ili kutoa habari katika miundo inayofikika zinapatikana bila malipo na kwa wakati. Tafadhali piga simu kwa namba ya hapo juu au zungumza na mtoa huduma wako. _Swahili

УВАГА: Якщо ви розмовляєте українською мовою, ви можете скористатися послугами мовної підтримки безкоштовно та без зайвих зволікань. Ви також можете безкоштовно та оперативно отримати відповідні допоміжні засоби та послуги з надання інформації у доступному форматі. Зателефонуйте за вказаним вище номером або поговоріть зі своїм постачальником послуг. _Ukrainian

LƯU Ý: Nếu bạn nói tiếng Việt, bạn có thể được hỗ trợ ngôn ngữ miễn phí mà không phải chờ đợi lâu. Ngoài ra, các thiết bị hỗ trợ và dịch vụ phù hợp để cung cấp thông tin ở định dạng dễ tiếp cận cũng có sẵn miễn phí và kịp thời. Vui lòng gọi số điện thoại phía trên hoặc trao đổi với nhân viên y tế của bạn. _Vietnamese

ÌKÉDE PÀTÀKÌ: Tí o bá leè sọ èdè Yorùbá, àwọn ètò ìrànlówọ́ èdè wà fún ọ ní ọ̀fẹ́ tí kò sì ní ìdènà nínú. Ní àfikún, àwọn ìlànà isẹ́ àti ohun èlò ìrànlówọ́ tó pé ye wá ní ẹ̀kúnrẹ́rẹ́ láti pèsè àlàyé èyíkéyìí tí o bá nílò ní ọ̀fẹ́ àti ní òrèkóòrè. Jọ̀wọ́, pe ẹ̀rọ Ìbánisọ̀rọ̀ tó wà lókè tàbí kí o bá aṣojú rẹ sọ̀rọ̀. _Yoruba

LB (7-25)

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