as introduced - 81st Legislature (1999 - 2000) Posted on 12/15/2009 12:00am
1.1 A bill for an act 1.2 relating to human services; making health care 1.3 changes; clarifying prescription drug coverage for the 1.4 senior drug program; allowing reconsideration of 1.5 commissioner's decision that services are not 1.6 medically necessary under medical assistance program; 1.7 changing medical assistance payments for hospital 1.8 providers; establishing performance measurement for 1.9 health care; changing a provision for medical 1.10 assistance eligibility; establishing medical 1.11 assistance income standard for supplemental security 1.12 income recipients; adopting income deductions for 1.13 medical assistance for institutionalized persons; 1.14 changing rehabilitation services review; establishing 1.15 telemedicine consultation; improving pharmacy medicine 1.16 management; refinancing medical assistance school 1.17 reimbursement; providing community-based services for 1.18 severely emotionally disturbed children; increasing 1.19 professional provider payment; improving dental 1.20 access; clarifying MinnesotaCare premium payment 1.21 provisions; clarifying earned income disregard in the 1.22 waiver request to health care financing 1.23 administration; amending Minnesota Statutes 1998, 1.24 sections 256.955, subdivisions 3, 4, 7, 8, and 9; 1.25 256.9685, subdivision 1a; 256.969, subdivision 1; 1.26 256B.04, by adding a subdivision; 256B.055, 1.27 subdivision 3a; 256B.056, subdivision 4; 256B.057, by 1.28 adding a subdivision; 256B.0575; 256B.0625, 1.29 subdivisions 8, 8a, 13, 26, 32, 35, and by adding 1.30 subdivisions; 256B.0635, subdivision 3; 256B.75; 1.31 256B.76; 256L.03, subdivision 5; 256L.04, subdivisions 1.32 2, 8, and 13; 256L.05, subdivision 4; 256L.06, 1.33 subdivision 3; 256L.07; and 256L.15, subdivisions 1, 1.34 1b, and 2; Laws 1995, chapter 178, article 2, section 1.35 46, subdivision 10. 1.36 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MINNESOTA: 1.37 Section 1. Minnesota Statutes 1998, section 256.955, 1.38 subdivision 3, is amended to read: 1.39 Subd. 3. [PRESCRIPTION DRUG COVERAGE.]Coverage under the1.40program is limited to prescription drugs covered under the2.1medical assistance program as described in section 256B.0625,2.2subdivision 13, subject to a maximum deductible of $3002.3annually, except drugs cleared by the FDA shall be available to2.4qualified senior citizens enrolled in the program without2.5restriction when prescribed for medically accepted indication as2.6defined in the federal rebate program under section 1927 of2.7title XIX of the federal Social Security Act.Coverage under 2.8 the program shall be limited to those prescription drugs that: 2.9 (1) are covered under the medical assistance program as 2.10 described in section 256B.0625, subdivision 13; and 2.11 (2) are provided by manufacturers that have fully executed 2.12 senior drug rebate agreements with the commissioner and comply 2.13 with such agreements. 2.14 Sec. 2. Minnesota Statutes 1998, section 256.955, 2.15 subdivision 4, is amended to read: 2.16 Subd. 4. [APPLICATION PROCEDURES AND COORDINATION WITH 2.17 MEDICAL ASSISTANCE.] Applications and information on the program 2.18 must be made available at county social service agencies, health 2.19 care provider offices, and agencies and organizations serving 2.20 senior citizens. Senior citizens shall submit applications and 2.21 any information specified by the commissioner as being necessary 2.22 to verify eligibility directly to the county social service 2.23 agencies: 2.24 (1) beginning January 1, 1999, the county social service 2.25 agency shall determine medical assistance spenddown eligibility 2.26 of individuals who qualify for the senior citizen drug program 2.27 of individuals; and 2.28 (2) program payments will be used to reduce the spenddown 2.29 obligations of individuals who are determined to be eligible for 2.30 medical assistance with a spenddown as defined in section 2.31 256B.056, subdivision 5. 2.32 Seniors who are eligible for medical assistance with a spenddown 2.33 shall be financially responsible for the deductible amount up to 2.34 the satisfaction of the spenddown. No deductible applies once 2.35 the spenddown has been met. Payments to providers for 2.36 prescription drugs for persons eligible under this subdivision 3.1 shall be reduced by the deductible. 3.2 County social service agencies shall determine an 3.3 applicant's eligibility for the program within 30 days from the 3.4 date the application is received. Eligibility begins the month 3.5 after approval. 3.6 Sec. 3. Minnesota Statutes 1998, section 256.955, 3.7 subdivision 7, is amended to read: 3.8 Subd. 7. [COST SHARING.] (a)EnrolleesAt the time of 3.9 application, applicants shall pay an annualpremiumenrollment 3.10 fee of $120 that is nonrefundable except if an applicant is 3.11 found ineligible. 3.12 (b) Program enrollees must satisfy a $300 annual 3.13 deductible, based upon expenditures for prescription drugs, to 3.14 be paidas follows:in $25 monthly increments. 3.15(1) $25 monthly deductible for persons with a monthly3.16spenddown; or3.17(2) $150 biannual deductible for persons with a six-month3.18spenddown.3.19 Sec. 4. Minnesota Statutes 1998, section 256.955, 3.20 subdivision 8, is amended to read: 3.21 Subd. 8. [REPORT.] The commissioner shall annually report 3.22 to the legislature on the senior citizen drug program. The 3.23 report must include demographic information on enrollees, 3.24 per-prescription expenditures, total program expenditures, 3.25 hospital and nursing home costs avoided by enrollees, any 3.26 savings to medical assistance and Medicare resulting from the 3.27 provision of prescription drug coverage under Medicare by health 3.28 maintenance organizations, other public and private options for 3.29 drug assistance to the senior population, any hardships caused 3.30 by the annualpremiumenrollment fee and deductible, and any 3.31 recommendations for changes in the senior drug program. 3.32 Sec. 5. Minnesota Statutes 1998, section 256.955, 3.33 subdivision 9, is amended to read: 3.34 Subd. 9. [PROGRAM LIMITATION.] The commissioner shall 3.35 administer the senior drug program so that the costs total no 3.36 more than funds appropriated plus the drug rebate proceeds. 4.1 Senior drug program rebate revenues are appropriated to the 4.2 commissioner and shall be expended to augment funding of the 4.3 senior drug program. New enrollment shall cease if the 4.4 commissioner determines that, given current enrollment, costs of 4.5 the program will exceed appropriated funds and rebate proceeds. 4.6 This section shall be repealed upon federal approval of the 4.7 waiver to allow the commissioner to provide prescription drug 4.8 coverage for qualified Medicare beneficiaries whose income is 4.9 less than 150 percent of the federal poverty guidelines. 4.10 Sec. 6. Minnesota Statutes 1998, section 256.9685, 4.11 subdivision 1a, is amended to read: 4.12 Subd. 1a. [ADMINISTRATIVE RECONSIDERATION.] 4.13 Notwithstanding sections 256B.04, subdivision 15, and 256D.03, 4.14 subdivision 7, the commissioner shall establish an 4.15 administrative reconsideration process for appeals of inpatient 4.16 hospital services determined to be medically unnecessary. A 4.17 physician or hospital may request a reconsideration of the 4.18 decision that inpatient hospital services are not medically 4.19 necessary by submitting a written request for review to the 4.20 commissioner within 30 days after receiving notice of the 4.21 decision. The reconsideration process shall take place prior to 4.22 the procedures of subdivision 1b and shall be conducted by 4.23 physicians that are independent of the case under 4.24 reconsideration. A majority decision by the physicians is 4.25 necessary to make a determination that the services were not 4.26 medically necessary. 4.27 Sec. 7. Minnesota Statutes 1998, section 256.969, 4.28 subdivision 1, is amended to read: 4.29 Subdivision 1. [HOSPITAL COST INDEX.] (a) The hospital 4.30 cost index shall be the change in the Consumer Price Index-All 4.31 Items (United States city average) (CPI-U) forecasted by Data 4.32 Resources, Inc. The commissioner shall use the indices as 4.33 forecasted in the third quarter of the calendar year prior to 4.34 the rate year. The hospital cost index may be used to adjust 4.35 the base year operating payment rate through the rate year on an 4.36 annually compounded basis. 5.1 (b) For fiscal years beginning on or after July 1, 1993, 5.2 the commissioner of human services shall not provide automatic 5.3 annual inflation adjustments for hospital payment rates under 5.4 medical assistance, nor under general assistance medical care, 5.5 except that the inflation adjustments under paragraph (a) for 5.6 medical assistance, excluding general assistance medical care, 5.7 shall apply through calendar year19992001. The index for 5.8 calendar year 2000 shall be reduced 2.5 percentage points to 5.9 recover overprojections of the index from 1994 to 1996. The 5.10 commissioner of finance shall include as a budget change request 5.11 in each biennial detailed expenditure budget submitted to the 5.12 legislature under section 16A.11 annual adjustments in hospital 5.13 payment rates under medical assistance and general assistance 5.14 medical care, based upon the hospital cost index. 5.15 Sec. 8. Minnesota Statutes 1998, section 256B.04, is 5.16 amended by adding a subdivision to read: 5.17 Subd. 19. [PERFORMANCE DATA REPORTING UNIT.] The 5.18 commissioner of human services shall establish a performance 5.19 data reporting unit that serves counties and the state. The 5.20 department shall support this unit and provide counties 5.21 technical assistance and access to the data warehouse. The 5.22 performance data reporting unit, which will operate within the 5.23 department's central office and consist of both county and 5.24 department staff, shall provide performance data reports to 5.25 individual counties, share expertise from counties and the 5.26 department perspective, and participate in joint planning to 5.27 link with county databases and other county data sources in 5.28 order to provide information on services provided to public 5.29 clients from state, federal, and county funding sources. 5.30 Sec. 9. Minnesota Statutes 1998, section 256B.055, 5.31 subdivision 3a, is amended to read: 5.32 Subd. 3a. [MFIP-S FAMILIES; FAMILIES ELIGIBLE UNDER PRIOR 5.33 AFDC RULES.] (a) Beginning January 1, 1998, or on the date that 5.34 MFIP-S is implemented in counties, medical assistance may be 5.35 paid for a person receiving public assistance under the MFIP-S 5.36 program. 6.1 (b) Beginning January 1, 1998, medical assistance may be 6.2 paid for a person who would have been eligible for public 6.3 assistance under the income and resource standardsand6.4deprivation requirements, or who would have been eligible but 6.5 for excess income or assets, under the state's AFDC plan in 6.6 effect as of July 16, 1996, as required by the Personal 6.7 Responsibility and Work Opportunity Reconciliation Act of 1996 6.8 (PRWORA), Public Law Number 104-193. 6.9 Sec. 10. Minnesota Statutes 1998, section 256B.056, 6.10 subdivision 4, is amended to read: 6.11 Subd. 4. [INCOME.] To be eligible for medical assistance, 6.12 a person eligible under section 256B.055, subdivision 7, not 6.13 receiving supplemental security income program payments, and 6.14 families and children may have an income up to 133-1/3 percent 6.15 of the AFDC income standard in effect under the July 16, 1996, 6.16 AFDC state plan. For rate years beginning on or after July 1, 6.17 1999, the commissioner shall consider increasing the base AFDC 6.18 standard in effect on July 16, 1996, by an amount equal to the 6.19 percent change in the Consumer Price Index for All Urban 6.20 Consumers for the previous October compared to one year 6.21 earlier. Effective January 1, 2000, and each successive 6.22 January, recipients of supplemental security income may have an 6.23 income up to the supplemental security income standard in effect 6.24 on that date. In computing income to determine eligibility of 6.25 persons who are not residents of long-term care facilities, the 6.26 commissioner shall disregard increases in income as required by 6.27 Public Law Numbers 94-566, section 503; 99-272; and 99-509. 6.28 Veterans aid and attendance benefits and Veterans Administration 6.29 unusual medical expense payments are considered income to the 6.30 recipient. 6.31 Sec. 11. Minnesota Statutes 1998, section 256B.057, is 6.32 amended by adding a subdivision to read: 6.33 Subd. 9. [EMPLOYED INDIVIDUALS WITH DISABILITIES.] (a) 6.34 Medical assistance may be paid for an employed individual: (1) 6.35 who meets the definition of disabled under the supplemental 6.36 security income program; (2) whose countable family income, 7.1 excluding the unearned income of the individual, is below 250 7.2 percent of the federal poverty guidelines for the applicable 7.3 family size; and (3) who pays a premium as provided in paragraph 7.4 (c). 7.5 (b) For purposes of determining eligibility under this 7.6 subdivision, the asset limitations under section 256B.056, 7.7 subdivision 3, are increased by $20,000, and any retirement 7.8 account of the individual is excluded. Retirement accounts 7.9 include individual retirement accounts, 401(k) plans, 403(b) 7.10 plans, Keogh plans, pension plans, and other retirement funds 7.11 held by the individual. 7.12 (c) The premium shall be equal to ten percent of the amount 7.13 of the family's annual gross earned income above 250 percent of 7.14 the federal poverty guidelines for the applicable family size, 7.15 but shall not exceed the maximum MinnesotaCare premium for one 7.16 person under section 256L.15, subdivision 2. 7.17 (d) An individual's eligibility and premium amount shall be 7.18 determined by the county agency. Premiums are paid to the 7.19 commissioner and dedicated to the commissioner. 7.20 (e) The required premium amount is determined at 7.21 application and redetermined at annual recertification or when a 7.22 change in gross earned income occurs. Premium payment is due 7.23 upon notification and may be accepted in installments at the 7.24 commissioner's discretion. 7.25 (f) Nonpayment of the premium will result in denial or 7.26 termination of medical assistance. Nonpayment of the premium 7.27 includes payment with a returned, refused, or dishonored 7.28 instrument. The commissioner may require a guaranteed form of 7.29 payment as the only means to replace a returned, refused, or 7.30 dishonored instrument. 7.31 Sec. 12. Minnesota Statutes 1998, section 256B.0575, is 7.32 amended to read: 7.33 256B.0575 [AVAILABILITY OF INCOME FOR INSTITUTIONALIZED 7.34 PERSONS.] 7.35 When an institutionalized person is determined eligible for 7.36 medical assistance, the income that exceeds the deductions in 8.1 paragraphs (a) and (b) must be applied to the cost of 8.2 institutional care. 8.3 (a) The following amounts must be deducted from the 8.4 institutionalized person's income in the following order: 8.5 (1) the personal needs allowance under section 256B.35 or, 8.6 for a veteran who does not have a spouse or child, or a 8.7 surviving spouse of a veteran having no child, the amount of an 8.8 improved pension received from the veteran's administration not 8.9 exceeding $90 per month; 8.10 (2) the personal allowance for disabled individuals under 8.11 section 256B.36; 8.12 (3) if the institutionalized person has a legally appointed 8.13 guardian or conservator, five percent of the recipient's gross 8.14 monthly income up to $100 as reimbursement for guardianship or 8.15 conservatorship services; 8.16 (4) a monthly income allowance determined under section 8.17 256B.058, subdivision 2, but only to the extent income of the 8.18 institutionalized spouse is made available to the community 8.19 spouse; 8.20 (5) a monthly allowance for children under age 18 which, 8.21 together with the net income of the children, would provide 8.22 income equal to the medical assistance standard for families and 8.23 children according to section 256B.056, subdivision 4, for a 8.24 family size that includes only the minor children. This 8.25 deduction applies only if the children do not live with the 8.26 community spouse and only to the extent that the deduction is 8.27 not included in the personal needs allowance under section 8.28 256B.35, subdivision 1, as child support garnished under a court 8.29 order; 8.30 (6) a monthly family allowance for other family members, 8.31 equal to one-third of the difference between 122 percent of the 8.32 federal poverty guidelines and the monthly income for that 8.33 family member; 8.34 (7) reparations payments made by the Federal Republic of 8.35 Germany and reparations payments made by the Netherlands for 8.36 victims of Nazi persecution between 1940 and 1945;and9.1 (8) all other exclusions from income for institutionalized 9.2 persons as mandated by federal law; and 9.3(8)(9) amounts for reasonable expenses incurred for 9.4 necessary medical or remedial care for the institutionalized 9.5 spouse that are not medical assistance covered expenses and that 9.6 are not subject to payment by a third party. 9.7 For purposes of clause (6), "other family member" means a 9.8 person who resides with the community spouse and who is a minor 9.9 or dependent child, dependent parent, or dependent sibling of 9.10 either spouse. "Dependent" means a person who could be claimed 9.11 as a dependent for federal income tax purposes under the 9.12 Internal Revenue Code. 9.13 (b) Income shall be allocated to an institutionalized 9.14 person for a period of up to three calendar months, in an amount 9.15 equal to the medical assistance standard for a family size of 9.16 one if: 9.17 (1) a physician certifies that the person is expected to 9.18 reside in the long-term care facility for three calendar months 9.19 or less; 9.20 (2) if the person has expenses of maintaining a residence 9.21 in the community; and 9.22 (3) if one of the following circumstances apply: 9.23 (i) the person was not living together with a spouse or a 9.24 family member as defined in paragraph (a) when the person 9.25 entered a long-term care facility; or 9.26 (ii) the person and the person's spouse become 9.27 institutionalized on the same date, in which case the allocation 9.28 shall be applied to the income of one of the spouses. 9.29 For purposes of this paragraph, a person is determined to be 9.30 residing in a licensed nursing home, regional treatment center, 9.31 or medical institution if the person is expected to remain for a 9.32 period of one full calendar month or more. 9.33 Sec. 13. Minnesota Statutes 1998, section 256B.0625, 9.34 subdivision 8, is amended to read: 9.35 Subd. 8. [PHYSICAL THERAPY.] Medical assistance covers 9.36 physical therapy and related services, including specialized 10.1 maintenance therapy. Services provided by a physical therapy 10.2 assistant shall be reimbursed at the same rate as services 10.3 performed by a physical therapist when the services of the 10.4 physical therapy assistant are provided under the direction of a 10.5 physical therapist who is on the premises. Services provided by 10.6 a physical therapy assistant that are provided under the 10.7 direction of a physical therapist who is not on the premises 10.8 shall be reimbursed at 65 percent of the physical therapist rate. 10.9 Sec. 14. Minnesota Statutes 1998, section 256B.0625, 10.10 subdivision 8a, is amended to read: 10.11 Subd. 8a. [OCCUPATIONAL THERAPY.] Medical assistance 10.12 covers occupational therapy and related services, including 10.13 specialized maintenance therapy. Services provided by an 10.14 occupational therapy assistant shall be reimbursed at the same 10.15 rate as services performed by an occupational therapist when the 10.16 services of the occupational therapy assistant are provided 10.17 under the direction of the occupational therapist who is on the 10.18 premises. Services provided by an occupational therapy 10.19 assistant that are provided under the direction of an 10.20 occupational therapist who is not on the premises shall be 10.21 reimbursed at 65 percent of the occupational therapist rate. 10.22 Sec. 15. Minnesota Statutes 1998, section 256B.0625, is 10.23 amended by adding a subdivision to read: 10.24 Subd. 8b. [SPEECH LANGUAGE PATHOLOGY.] Medical assistance 10.25 covers speech language pathology and related services, including 10.26 specialized maintenance therapy. 10.27 Sec. 16. Minnesota Statutes 1998, section 256B.0625, is 10.28 amended by adding a subdivision to read: 10.29 Subd. 8c. [CARE MANAGEMENT; REHABILITATION SERVICES.] (a) 10.30 Effective July 1, 1999, one-time thresholds shall replace annual 10.31 thresholds for provision of rehabilitation services described in 10.32 subdivisions 8, 8a, and 8b. The one-time thresholds will be the 10.33 same in amount and description as the thresholds prescribed by 10.34 the department of human services health care programs provider 10.35 manual for calendar year 1997, except they will not be renewed 10.36 annually, and they will include sensory skills and cognitive 11.1 training skills. 11.2 (b) A care management approach for authorization of 11.3 services beyond the threshold shall be instituted in conjunction 11.4 with the one-time thresholds. The care management approach 11.5 shall require the provider and the department rehabilitation 11.6 reviewer to work together directly through written 11.7 communication, or telephone communication when appropriate, to 11.8 establish a medically necessary care management plan. 11.9 (c) The department shall implement an expedited five-day 11.10 turnaround time to review authorization requests for recipients 11.11 who need emergency rehabilitation services and who have 11.12 exhausted their one-time threshold limit for those services. 11.13 Sec. 17. Minnesota Statutes 1998, section 256B.0625, is 11.14 amended by adding a subdivision to read: 11.15 Subd. 8d. [TELEMEDICINE CONSULTATIONS.] Medical assistance 11.16 covers telemedicine consultations. Telemedicine consultations 11.17 must be made via two-way, interactive video. Payments will be 11.18 made to both the referring provider and the consulting physician 11.19 specialist. Physician specialist includes any physician 11.20 consulting with an emergency department provider. 11.21 Sec. 18. Minnesota Statutes 1998, section 256B.0625, is 11.22 amended by adding a subdivision to read: 11.23 Subd. 8e. [CONSULTATION SERVICES BY PHYSICIANS 11.24 SPECIALIZING IN CHILD ABUSE AND NEGLECT.] Medical assistance 11.25 covers consultation services by physicians specializing in child 11.26 abuse and neglect. Alternative media formats may be used when 11.27 the patient is a child being examined for potential abuse or 11.28 neglect, the consulting physician is a specialist in child abuse 11.29 and neglect, and the use of two-way, interactive video or the 11.30 occurrence of a second exam would be medically counter indicated 11.31 for the child. 11.32 Sec. 19. Minnesota Statutes 1998, section 256B.0625, is 11.33 amended by adding a subdivision to read: 11.34 Subd. 9a. [DENTAL HYGIENIST SERVICES.] Medical assistance 11.35 covers preventive dental services provided by dental hygienists 11.36 if the services are otherwise covered under this chapter as 12.1 dental services, and if the services are within the scope of 12.2 practice of a licensed dental hygienist, as defined in section 12.3 150A.05. 12.4 Sec. 20. Minnesota Statutes 1998, section 256B.0625, 12.5 subdivision 13, is amended to read: 12.6 Subd. 13. [DRUGS.] (a) Medical assistance covers drugs, 12.7 except for fertility drugs when specifically used to enhance 12.8 fertility, if prescribed by a licensed practitioner and 12.9 dispensed by a licensed pharmacist, by a physician enrolled in 12.10 the medical assistance program as a dispensing physician, or by 12.11 a physician or a nurse practitioner employed by or under 12.12 contract with a community health board as defined in section 12.13 145A.02, subdivision 5, for the purposes of communicable disease 12.14 control. The commissioner, after receiving recommendations from 12.15 professional medical associations and professional pharmacist 12.16 associations, shall designate a formulary committee to advise 12.17 the commissioner on the names of drugs for which payment is 12.18 made, recommend a system for reimbursing providers on a set fee 12.19 or charge basis rather than the present system, and develop 12.20 methods encouraging use of generic drugs when they are less 12.21 expensive and equally effective as trademark drugs. The 12.22 formulary committee shall consist of nine members, four of whom 12.23 shall be physicians who are not employed by the department of 12.24 human services, and a majority of whose practice is for persons 12.25 paying privately or through health insurance, three of whom 12.26 shall be pharmacists who are not employed by the department of 12.27 human services, and a majority of whose practice is for persons 12.28 paying privately or through health insurance, a consumer 12.29 representative, and a nursing home representative. Committee 12.30 members shall serve three-year terms and shall serve without 12.31 compensation. Members may be reappointed once. 12.32 (b) The commissioner shall establish a drug formulary. Its 12.33 establishment and publication shall not be subject to the 12.34 requirements of the Administrative Procedure Act, but the 12.35 formulary committee shall review and comment on the formulary 12.36 contents. The formulary committee shall review and recommend 13.1 drugs which require prior authorization. The formulary 13.2 committee may recommend drugs for prior authorization directly 13.3 to the commissioner, as long as opportunity for public input is 13.4 provided. Prior authorization may be requested by the 13.5 commissioner based on medical and clinical criteria before 13.6 certain drugs are eligible for payment. Before a drug may be 13.7 considered for prior authorization at the request of the 13.8 commissioner: 13.9 (1) the drug formulary committee must develop criteria to 13.10 be used for identifying drugs; the development of these criteria 13.11 is not subject to the requirements of chapter 14, but the 13.12 formulary committee shall provide opportunity for public input 13.13 in developing criteria; 13.14 (2) the drug formulary committee must hold a public forum 13.15 and receive public comment for an additional 15 days; and 13.16 (3) the commissioner must provide information to the 13.17 formulary committee on the impact that placing the drug on prior 13.18 authorization will have on the quality of patient care and 13.19 information regarding whether the drug is subject to clinical 13.20 abuse or misuse. Prior authorization may be required by the 13.21 commissioner before certain formulary drugs are eligible for 13.22 payment. The formulary shall not include: 13.23 (i) drugs or products for which there is no federal 13.24 funding; 13.25 (ii) over-the-counter drugs, except for antacids, 13.26 acetaminophen, family planning products, aspirin, insulin, 13.27 products for the treatment of lice, vitamins for adults with 13.28 documented vitamin deficiencies, vitamins for children under the 13.29 age of seven and pregnant or nursing women, and any other 13.30 over-the-counter drug identified by the commissioner, in 13.31 consultation with the drug formulary committee, as necessary, 13.32 appropriate, and cost-effective for the treatment of certain 13.33 specified chronic diseases, conditions or disorders, and this 13.34 determination shall not be subject to the requirements of 13.35 chapter 14; 13.36 (iii) anorectics; 14.1 (iv) drugs for which medical value has not been 14.2 established; and 14.3 (v) drugs from manufacturers who have not signed a rebate 14.4 agreement with the Department of Health and Human Services 14.5 pursuant to section 1927 of title XIX of the Social Security Act 14.6and who have not signed an agreement with the state for drugs14.7purchased pursuant to the senior citizen drug program14.8established under section 256.955. 14.9 The commissioner shall publish conditions for prohibiting 14.10 payment for specific drugs after considering the formulary 14.11 committee's recommendations. 14.12 (c) The basis for determining the amount of payment shall 14.13 be the lower of the actual acquisition costs of the drugs plus a 14.14 fixed dispensing fee; the maximum allowable cost set by the 14.15 federal government or by the commissioner plus the fixed 14.16 dispensing fee; or the usual and customary price charged to the 14.17 public. The pharmacy dispensing fee shall be $3.65. Actual 14.18 acquisition cost includes quantity and other special discounts 14.19 except time and cash discounts. The actual acquisition cost of 14.20 a drug shall be estimated by the commissioner, at average 14.21 wholesale price minus nine percent. The maximum allowable cost 14.22 of a multisource drug may be set by the commissioner and it 14.23 shall be comparable to, but no higher than, the maximum amount 14.24 paid by other third-party payors in this state who have maximum 14.25 allowable cost programs. The commissioner shall set maximum 14.26 allowable costs for multisource drugs that are not on the 14.27 federal upper limit list as described in United States Code, 14.28 title 42, chapter 7, section 1396r-8(e), the Social Security 14.29 Act, and Code of Federal Regulations, title 42, part 447, 14.30 section 447.332. Establishment of the amount of payment for 14.31 drugs shall not be subject to the requirements of the 14.32 Administrative Procedure Act. An additional dispensing fee of 14.33 $.30 may be added to the dispensing fee paid to pharmacists for 14.34 legend drug prescriptions dispensed to residents of long-term 14.35 care facilities when a unit dose blister card system, approved 14.36 by the department, is used. Under this type of dispensing 15.1 system, the pharmacist must dispense a 30-day supply of drug. 15.2 The National Drug Code (NDC) from the drug container used to 15.3 fill the blister card must be identified on the claim to the 15.4 department. The unit dose blister card containing the drug must 15.5 meet the packaging standards set forth in Minnesota Rules, part 15.6 6800.2700, that govern the return of unused drugs to the 15.7 pharmacy for reuse. The pharmacy provider will be required to 15.8 credit the department for the actual acquisition cost of all 15.9 unused drugs that are eligible for reuse. Over-the-counter 15.10 medications must be dispensed in the manufacturer's unopened 15.11 package. The commissioner may permit the drug clozapine to be 15.12 dispensed in a quantity that is less than a 30-day supply. 15.13 Whenever a generically equivalent product is available, payment 15.14 shall be on the basis of the actual acquisition cost of the 15.15 generic drug, unless the prescriber specifically indicates 15.16 "dispense as written - brand necessary" on the prescription as 15.17 required by section 151.21, subdivision 2. 15.18 Sec. 21. Minnesota Statutes 1998, section 256B.0625, 15.19 subdivision 26, is amended to read: 15.20 Subd. 26. [SPECIAL EDUCATION SERVICES.] (a) Medical 15.21 assistance covers medical services identified in a recipient's 15.22 individualized education plan and covered under the medical 15.23 assistance state plan. The services may be provided by a 15.24 Minnesota school district that is enrolled as a medical 15.25 assistance provider or its subcontractor, and only if the 15.26 services meet all the requirements otherwise applicable if the 15.27 service had been provided by a provider other than a school 15.28 district, in the following areas: medical necessity, 15.29 physician's orders, documentation, personnel qualifications, and 15.30 prior authorization requirements. Services of a speech-language 15.31 pathologist provided under this section are covered 15.32 notwithstanding Minnesota Rules, part 9505.0390, subpart 1, item 15.33 L, if the person: 15.34 (1) holds a masters degree in speech-language pathology; 15.35 (2) is licensed by the Minnesota board of teaching as an 15.36 educational speech-language pathologist; and 16.1 (3) either has a certificate of clinical competence from 16.2 the American Speech and Hearing Association, has completed the 16.3 equivalent educational requirements and work experience 16.4 necessary for the certificate or has completed the academic 16.5 program and is acquiring supervised work experience to qualify 16.6 for the certificate. Medical assistance coverage for medically 16.7 necessary services provided under other subdivisions in this 16.8 section may not be denied solely on the basis that the same or 16.9 similar services are covered under this subdivision. 16.10 (b) Effective July 1, 2000, medical assistance coverage of 16.11 eligible local educational agency services shall be paid at the 16.12 rate of 95 percent of the federal share of reimbursement. The 16.13 department of human services shall amend its federal waiver 16.14 allowing the state to carve out individual education plan and 16.15 individualized family service plan services for children 16.16 enrolled in the prepaid medical assistance program and 16.17 MinnesotaCare program. Effective July 1, 2000, or upon federal 16.18 approval, medical assistance coverage of eligible individual 16.19 education plan and individualized family service plan services 16.20 shall not be included in the capitated services for children 16.21 enrolled in health plans through the prepaid medical assistance 16.22 program and the MinnesotaCare program. Upon federal approval, 16.23 local educational agencies shall bill the department of human 16.24 services for these services and claims will be paid on a 16.25 fee-for-service basis. The department of human service shall 16.26 develop a methodology for payment of individual education plan 16.27 and individualized family service plan services that is packaged 16.28 based on the child's needs, for ease of billing, and seek 16.29 approval of this rate methodology from the health care finance 16.30 agency. The department of human services shall develop a 16.31 cost-based payment structure for payment of these services. 16.32 Effective July 1, 2000, medical assistance services provided by 16.33 the local educational agencies shall not count against medical 16.34 assistance threshholds for that child. 16.35 (c) The local educational agency receiving medical 16.36 assistant payment for individual educational plan and 17.1 individualized family service plan services shall comply with 17.2 all health care finance agency requirements for receiving 17.3 federal financial participation. The nonfederal share of 17.4 medical assistance coverage shall be paid by the local 17.5 educational agency providing individual educational plan and 17.6 individualized family service plan services. Expenditures for 17.7 local educational agency services eligible for federal 17.8 reimbursement under this section must not be made from federal 17.9 funds or funds used to match other federal funds. The 17.10 department of children, families, and learning and the 17.11 department of human services shall enter into an interagency 17.12 agreement by July 1, 2000, outlining data sharing, and family 17.13 consent arrangements whereby local educational agencies may 17.14 receive payment for medical assistance eligible individual 17.15 educational plan and individualized family service plan services 17.16 for children receiving special education services as authorized 17.17 by section 1903 of the Social Security Act, as amended. 17.18 Sec. 22. Minnesota Statutes 1998, section 256B.0625, 17.19 subdivision 32, is amended to read: 17.20 Subd. 32. [NUTRITIONAL PRODUCTS.](a)Medical assistance 17.21 covers nutritional products needed for nutritional 17.22 supplementation because solid food or nutrients thereof cannot 17.23 be properly absorbed by the body or needed for treatment of 17.24 phenylketonuria, hyperlysinemia, maple syrup urine disease, a 17.25 combined allergy to human milk, cow's milk, and soy formula, or 17.26 any other childhood or adult diseases, conditions, or disorders 17.27 identified by the commissioner as requiring a similarly 17.28 necessary nutritional product. Nutritional products needed for 17.29 the treatment of a combined allergy to human milk, cow's milk, 17.30 and soy formula require prior authorization. Separate payment 17.31 shall not be made for nutritional products for residents of 17.32 long-term care facilities. Payment for dietary requirements is 17.33 a component of the per diem rate paid to these facilities. 17.34(b) The commissioner shall designate a nutritional17.35supplementation products advisory committee to advise the17.36commissioner on nutritional supplementation products for which18.1payment is made. The committee shall consist of nine members,18.2one of whom shall be a physician, one of whom shall be a18.3pharmacist, two of whom shall be registered dietitians, one of18.4whom shall be a public health nurse, one of whom shall be a18.5representative of a home health care agency, one of whom shall18.6be a provider of long-term care services, and two of whom shall18.7be consumers of nutritional supplementation products. Committee18.8members shall serve two-year terms and shall serve without18.9compensation.18.10(c) The advisory committee shall review and recommend18.11nutritional supplementation products which require prior18.12authorization. The commissioner shall develop procedures for18.13the operation of the advisory committee so that the advisory18.14committee operates in a manner parallel to the drug formulary18.15committee.18.16 Sec. 23. Minnesota Statutes 1998, section 256B.0625, 18.17 subdivision 35, is amended to read: 18.18 Subd. 35. [FAMILY COMMUNITY SUPPORT SERVICES.] Medical 18.19 assistance covers family community support services as defined 18.20 in section 245.4871, subdivision 17. In addition to the 18.21 provisions of section 245.4871, and to the extent authorized by 18.22 rules promulgated by the state agency, medical assistance covers 18.23 the following services as family community support services: 18.24 (1) services identified in an individual treatment plan 18.25 when provided by a trained behavioral aide under the direction 18.26 of a mental health practitioner or mental health professional; 18.27 (2) mental health crisis intervention and crisis 18.28 stabilization services provided outside of hospital inpatient 18.29 settings; and 18.30 (3) the therapeutic components of preschool and therapeutic 18.31 camp programs. 18.32 Sec. 24. Minnesota Statutes 1998, section 256B.0635, 18.33 subdivision 3, is amended to read: 18.34 Subd. 3. [MEDICAL ASSISTANCE FOR MFIP-S PARTICIPANTS WHO 18.35 OPT TO DISCONTINUE MONTHLY CASH ASSISTANCE.]Upon federal18.36approval,Medical assistance is available to persons who 19.1received MFIP-S in at least three of the six months preceding19.2the month in which the person optedopt to discontinue receiving 19.3 MFIP-S cash assistance under section 256J.31, subdivision 12. A 19.4 person who is eligible for medical assistance under this section 19.5 may receive medical assistance without reapplication as long as 19.6 the person meets MFIP-S eligibility requirements, unless the19.7assistance unit does not include a dependent child. Medical 19.8 assistance may be paid pursuant to subdivisions 1 and 2 for 19.9 persons who are no longer eligible for MFIP-S due to increased 19.10 employment or child support. A person may be eligible for 19.11 MinnesotaCare due to increased employment or child support, and 19.12 as such must be informed of the option to transition onto 19.13 MinnesotaCare. 19.14 Sec. 25. Minnesota Statutes 1998, section 256B.75, is 19.15 amended to read: 19.16 256B.75 [HOSPITAL OUTPATIENT REIMBURSEMENT.] 19.17 For outpatient hospital facility fee payments for services 19.18 rendered on or after October 1, 1992, the commissioner of human 19.19 services shall pay the lower of (1) submitted charge, or (2) 32 19.20 percent above the rate in effect on June 30, 1992, except for 19.21 those services for which there is a federal maximum allowable 19.22 payment. Effective for services rendered on or after January 1, 19.23 2000, payment rates for nonsurgical outpatient hospital facility 19.24 fees and emergency room facility fees shall be increased by ten 19.25 percent over the rates in effect on December 31, 1999, except 19.26 for those services for which there is a federal maximum 19.27 allowable payment. Services for which there is a federal 19.28 maximum allowable payment shall be paid at the lower of (1) 19.29 submitted charge, or (2) the federal maximum allowable payment. 19.30 Total aggregate payment for outpatient hospital facility fee 19.31 services shall not exceed the Medicare upper limit. If it is 19.32 determined that a provision of this section conflicts with 19.33 existing or future requirements of the United States government 19.34 with respect to federal financial participation in medical 19.35 assistance, the federal requirements prevail. The commissioner 19.36 may, in the aggregate, prospectively reduce payment rates to 20.1 avoid reduced federal financial participation resulting from 20.2 rates that are in excess of the Medicare upper limitations. 20.3 Sec. 26. Minnesota Statutes 1998, section 256B.76, is 20.4 amended to read: 20.5 256B.76 [PHYSICIAN AND DENTAL REIMBURSEMENT.] 20.6 (a) The physician reimbursement increase provided in 20.7 section 256B.74, subdivision 2, shall not be implemented. 20.8 Effective for services rendered on or after October 1, 1992, the 20.9 commissioner shall make payments for physician services as 20.10 follows: 20.11 (1) payment for level one Health Care Finance 20.12 Administration's common procedural coding system (HCPCS) codes 20.13 titled "office and other outpatient services," "preventive 20.14 medicine new and established patient," "delivery, antepartum, 20.15 and postpartum care," "critical care," Caesarean delivery and 20.16 pharmacologic management provided to psychiatric patients, and 20.17 HCPCS level three codes for enhanced services for prenatal high 20.18 risk, shall be paid at the lower of (i) submitted charges, or 20.19 (ii) 25 percent above the rate in effect on June 30, 1992. If 20.20 the rate on any procedure code within these categories is 20.21 different than the rate that would have been paid under the 20.22 methodology in section 256B.74, subdivision 2, then the larger 20.23 rate shall be paid; 20.24 (2) payments for all other services shall be paid at the 20.25 lower of (i) submitted charges, or (ii) 15.4 percent above the 20.26 rate in effect on June 30, 1992;and20.27 (3) all physician rates shall be converted from the 50th 20.28 percentile of 1982 to the 50th percentile of 1989, less the 20.29 percent in aggregate necessary to equal the above increases 20.30 except that payment rates for home health agency services shall 20.31 be the rates in effect on September 30, 1992.; 20.32 (4) effective for services rendered on or after October 1, 20.33 1999, payment rates for physician and professional services 20.34 shall be increased by four percent over the rates in effect on 20.35 September 30, 1999, except for home health agency services; 20.36 (5) the department shall present a proposal during the year 21.1 2000 legislative session detailing physician and professional 21.2 services payment methodology conversion to Resource Based 21.3 Relative Value Scale; and 21.4 (6) the increases in clause (4) shall be implemented 21.5 January 1, 2000, for managed care. 21.6 (b) The dental reimbursement increase provided in section 21.7 256B.74, subdivision 5, shall not be implemented. Effective for 21.8 services rendered on or after October 1, 1992, the commissioner 21.9 shall make payments for dental services as follows: 21.10 (1) dental services shall be paid at the lower of (i) 21.11 submitted charges, or (ii) 25 percent above the rate in effect 21.12 on June 30, 1992;and21.13 (2) dental rates shall be converted from the 50th 21.14 percentile of 1982 to the 50th percentile of 1989, less the 21.15 percent in aggregate necessary to equal the above increases.; 21.16 (3) effective for services rendered on or after October 1, 21.17 1999, payment rates for dental services shall be increased by 21.18 five percent over the rates in effect on September 30, 1999; 21.19 (4) the department shall increase payments by 20 percent 21.20 over the October 1, 1999, fee-for-service rates, for those 21.21 fee-for-service providers for whom public programs under MA, 21.22 GAMC, and MinnesotaCare account for 20 percent or more of their 21.23 practice; 21.24 (5) the commissioner shall award grants to community 21.25 clinics or other nonprofit community organizations which will 21.26 increase the availability of dental services to public program 21.27 recipients. These grants may be used to fund the costs related 21.28 to coordinating access for recipients, developing and 21.29 implementing patient care criteria, establishing new or 21.30 upgrading existing facilities, acquiring furnishings or 21.31 equipment, recruiting new providers, or other development costs 21.32 that will improve access to dental care in that region. The 21.33 commissioner shall consider the following in awarding the 21.34 grants: (i) potential to successfully increase access to an 21.35 underserved population; (ii) the ability to raise matching 21.36 funds; (iii) the long-term viability of the project to improve 22.1 access beyond the period of initial funding; (iv) the efficiency 22.2 in the use of the funding; and (v) the experience of the 22.3 proposers in providing services to the target population. The 22.4 commissioner shall monitor the grants and may terminate a grant 22.5 if the grantee does not increase dental access for public 22.6 program recipients; 22.7 (6) the department shall fund two initiatives to improve 22.8 dental access that will allow the commissioner to increase rates 22.9 if the percentage of public program recipients with at least one 22.10 dental visit per year increases; 22.11 (7) beginning October 1, 1999, the payment for tooth 22.12 sealants and fluoride treatments shall be the lower of (i) 22.13 submitted charge, or (ii) 80 percent of median 1997 charges; and 22.14 (8) the increases listed in clauses (3, (4), and (7) shall 22.15 be implemented January 1, 2000, for managed care. 22.16 (c) An entity that operates both a Medicare certified 22.17 comprehensive outpatient rehabilitation facility and a facility 22.18 which was certified prior to January 1, 1993, that is licensed 22.19 under Minnesota Rules, parts 9570.2000 to 9570.3600, and for 22.20 whom at least 33 percent of the clients receiving rehabilitation 22.21 services in the most recent calendar year are medical assistance 22.22 recipients, shall be reimbursed by the commissioner for 22.23 rehabilitation services at rates that are 38 percent greater 22.24 than the maximum reimbursement rate allowed under paragraph (a), 22.25 clause (2), when those services are (1) provided within the 22.26 comprehensive outpatient rehabilitation facility and (2) 22.27 provided to residents of nursing facilities owned by the entity. 22.28 Sec. 27. Minnesota Statutes 1998, section 256L.03, 22.29 subdivision 5, is amended to read: 22.30 Subd. 5. [COPAYMENTS AND COINSURANCE.] The MinnesotaCare 22.31 benefit plan shall include the following copayments and 22.32 coinsurance requirements for all enrollees except parents and 22.33 relative caretakers of children under 21 in households with 22.34 income at or below 175 percent of the federal poverty guidelines 22.35 and pregnant women and children under 21: 22.36 (1) ten percent of the paid charges for inpatient hospital 23.1 services for adult enrollees, subject to an annual inpatient 23.2 out-of-pocket maximum of $1,000 per individual and $3,000 per 23.3 family; 23.4 (2) $3 per prescription for adult enrollees; 23.5 (3) $25 for eyeglasses for adult enrollees; and 23.6 (4) effective July 1, 1998, 50 percent of the 23.7 fee-for-service rate for adult dental care services other than 23.8 preventive care services for persons eligible under section 23.9 256L.04, subdivisions 1 to 7, with income equal to or less than 23.10 175 percent of the federal poverty guidelines. 23.11 Effective July 1, 1997, adult enrollees with family gross 23.12 income that exceeds 175 percent of the federal poverty 23.13 guidelines and who are not pregnant shall be financially 23.14 responsible for the coinsurance amount and amounts which exceed 23.15 the $10,000 inpatient hospital benefit limit. 23.16 When a MinnesotaCare enrollee becomes a member of a prepaid 23.17 health plan, or changes from one prepaid health plan to another 23.18 during a calendar year, any charges submitted towards the 23.19 $10,000 annual inpatient benefit limit, and any out-of-pocket 23.20 expenses incurred by the enrollee for inpatient services, that 23.21 were submitted or incurred prior to enrollment, or prior to the 23.22 change in health plans, shall be disregarded. 23.23 Sec. 28. Minnesota Statutes 1998, section 256L.04, 23.24 subdivision 2, is amended to read: 23.25 Subd. 2. [COOPERATION IN ESTABLISHING THIRD-PARTY 23.26 LIABILITY, PATERNITY, AND OTHER MEDICAL SUPPORT.] (a) To be 23.27 eligible for MinnesotaCare, individuals and families must 23.28 cooperate with the state agency to identify potentially liable 23.29 third-party payers and assist the state in obtaining third-party 23.30 payments. "Cooperation" includes, but is not limited to, 23.31 identifying any third party who may be liable for care and 23.32 services provided under MinnesotaCare to the enrollee, providing 23.33 relevant information to assist the state in pursuing a 23.34 potentially liable third party, and completing forms necessary 23.35 to recover third-party payments. 23.36 (b) A parent, guardian, relative caretaker, or child 24.1 enrolled in the MinnesotaCare program must cooperate with the 24.2 department of human services and the local agency in 24.3 establishing the paternity of an enrolled child and in obtaining 24.4 medical care support and payments for the child and any other 24.5 person for whom the person can legally assign rights, in 24.6 accordance with applicable laws and rules governing the medical 24.7 assistance program. A child shall not be ineligible for or 24.8 disenrolled from the MinnesotaCare program solely because the 24.9 child's parent, relative caretaker, or guardian fails to 24.10 cooperate in establishing paternity or obtaining medical support. 24.11 Sec. 29. Minnesota Statutes 1998, section 256L.04, 24.12 subdivision 8, is amended to read: 24.13 Subd. 8. [APPLICANTS POTENTIALLY ELIGIBLE FOR MEDICAL 24.14 ASSISTANCE.] (a) Individuals who receive supplemental security 24.15 income or retirement, survivors, or disability benefits due to a 24.16 disability, or other disability-based pension, who qualify under 24.17 subdivision 7, but who are potentially eligible for medical 24.18 assistance without a spenddown shall be allowed to enroll in 24.19 MinnesotaCare for a period of 60 days, so long as the applicant 24.20 meets all other conditions of eligibility. The commissioner 24.21 shall identify and refer the applications of such individuals to 24.22 their county social service agency. The county and the 24.23 commissioner shall cooperate to ensure that the individuals 24.24 obtain medical assistance coverage for any months for which they 24.25 are eligible. 24.26 (b) The enrollee must cooperate with the county social 24.27 service agency in determining medical assistance eligibility 24.28 within the 60-day enrollment period. Enrollees who do not 24.29 cooperate with medical assistance within the 60-day enrollment 24.30 period shall be disenrolled from the plan within one calendar 24.31 month. Persons disenrolled for nonapplication for medical 24.32 assistance may not reenroll until they have obtained a medical 24.33 assistance eligibility determination. Persons disenrolled for 24.34 noncooperation with medical assistance may not reenroll until 24.35 they have cooperated with the county agency and have obtained a 24.36 medical assistance eligibility determination. 25.1 (c) Beginning January 1, 2000, counties that choose to 25.2 become MinnesotaCare enrollment sites shall consider 25.3 MinnesotaCare applications of individuals described in paragraph 25.4 (a) to also be applications for medical assistanceand shall25.5first determine whether medical assistance eligibility exists. 25.6Adults with children with family income under 175 percent of the25.7federal poverty guidelines for the applicable family size,25.8pregnant women, and children who qualify under subdivision 1. 25.9 Applicants who are potentially eligible for medical assistance 25.10 without a spenddown may choose to enroll in either MinnesotaCare 25.11 or medical assistance. 25.12 (d) The commissioner shall redetermine provider payments 25.13 made under MinnesotaCare to the appropriate medical assistance 25.14 payments for those enrollees who subsequently become eligible 25.15 for medical assistance. 25.16 Sec. 30. Minnesota Statutes 1998, section 256L.04, 25.17 subdivision 13, is amended to read: 25.18 Subd. 13. [FAMILIES WITHGRANDPARENTS,RELATIVE 25.19 CARETAKERS, FOSTER PARENTS, OR LEGAL GUARDIANS.] Beginning 25.20 January 1, 1999, in families that include agrandparent,25.21 relative caretaker as defined in the medical assistance program, 25.22 foster parent, or legal guardian, thegrandparent,relative 25.23 caretaker, foster parent, or legal guardian may apply as a 25.24 family or may apply separately for the children. If the 25.25 caretaker applies separately for the children, only the 25.26 children's income is counted and the provisions of subdivision 25.27 1, paragraph (b), do not apply. If thegrandparent,relative 25.28 caretaker, foster parent, or legal guardian applies with the 25.29 children, their income is included in the gross family income 25.30 for determining eligibility and premium amount. 25.31 Sec. 31. Minnesota Statutes 1998, section 256L.05, 25.32 subdivision 4, is amended to read: 25.33 Subd. 4. [APPLICATION PROCESSING.] The commissioner of 25.34 human services shall determine an applicant's eligibility for 25.35 MinnesotaCare no more than 30 days from the date that the 25.36 application is received by the department of human services. 26.1 Beginning January 1, 2000, this requirement also applies to 26.2 local county human services agencies that determine eligibility 26.3 for MinnesotaCare. Once annually for initial applications, to 26.4 prevent processing delays, applicants who, from the information 26.5 provided on the application, appear to meet eligibility 26.6 requirements shall be enrolled upon timely payment of premiums. 26.7 The enrollee must provide all required verifications within 30 26.8 days ofenrollmentnotification of the eligibility determination 26.9 or coverage from the program shall be terminated. Enrollees who 26.10 are determined to be ineligible when verifications are provided 26.11 shall be disenrolled from the program. 26.12 Sec. 32. Minnesota Statutes 1998, section 256L.06, 26.13 subdivision 3, is amended to read: 26.14 Subd. 3. [ADMINISTRATION AND COMMISSIONER'S DUTIES.] (a) 26.15 Premiums are dedicated to the commissioner for MinnesotaCare. 26.16 (b) The commissioner shall develop and implement procedures 26.17 to: (1) require enrollees to report changes in income; (2) 26.18 adjust sliding scale premium payments, based upon changes in 26.19 enrollee income; and (3) disenroll enrollees from MinnesotaCare 26.20 for failure to pay required premiums.Beginning July 1, 1998,26.21 Failure to pay includes payment with a dishonored checkand, a 26.22 returned automatic bank withdrawal, or a refused credit card or 26.23 debit card payment. The commissioner may demand a guaranteed 26.24 form of payment, including a cashier's check or a money order, 26.25 as the only means to replace a dishonoredcheck, returned, or 26.26 refused payment. 26.27 (c) Premiums are calculated on a calendar month basis and 26.28 may be paid on a monthly, quarterly, or annual basis, with the 26.29 first payment due upon notice from the commissioner of the 26.30 premium amount required. The commissioner shall inform 26.31 applicants and enrollees of these premium payment options. 26.32 Premium payment is required before enrollment is complete and to 26.33 maintain eligibility in MinnesotaCare. 26.34 (d) Nonpayment of the premium will result in disenrollment 26.35 from the plan within one calendar month after the due date. 26.36 Persons disenrolled for nonpayment or who voluntarily terminate 27.1coverage from the program may not reenroll until four calendar27.2 months have elapsed. Persons disenrolled for nonpayment who pay 27.3 all past due premiums as well as current premiums due, within 20 27.4 days of disenrollment, shall be reenrolled for the next month. 27.5 Persons disenrolled for nonpayment or who voluntarily terminate 27.6 coverage from the program may not reenroll for four calendar 27.7 months unless the person demonstrates good cause for 27.8 nonpayment. Good cause does not exist if a person chooses to 27.9 pay other family expenses instead of the premium. The 27.10 commissioner shall define good cause in rule. 27.11 Sec. 33. Minnesota Statutes 1998, section 256L.07, is 27.12 amended to read: 27.13 256L.07 [ELIGIBILITY FORSUBSIDIZED PREMIUMS BASED ON27.14SLIDING SCALEMINNESOTACARE.] 27.15 Subdivision 1. [GENERAL REQUIREMENTS.] (a) Children 27.16 enrolled in the original children's health plan as of September 27.17 30, 1992, children who enrolled in the MinnesotaCare program 27.18 after September 30, 1992, pursuant to Laws 1992, chapter 549, 27.19 article 4, section 17, and children who have family gross 27.20 incomes that are equal to or less than 150 percent of the 27.21 federal poverty guidelines are eligiblefor subsidized premium27.22paymentswithout meeting the requirements of subdivision 2, as 27.23 long as they maintain continuous coverage in the MinnesotaCare 27.24 program or medical assistance. Children who apply for 27.25 MinnesotaCare on or after the implementation date of the 27.26 employer-subsidized health coverage program as described in Laws 27.27 1998, chapter 407, article 5, section 45, who have family gross 27.28 incomes that are equal to or less than 150 percent of the 27.29 federal poverty guidelines, must meet the requirements of 27.30 subdivision 2 to be eligible for MinnesotaCare. 27.31 (b) Families enrolled in MinnesotaCare under section 27.32 256L.04, subdivision 1, whose income increases above 275 percent 27.33 of the federal poverty guidelines, are no longer eligible for 27.34 the program and shall be disenrolled by the commissioner. 27.35 Individuals enrolled in MinnesotaCare under section 256L.04, 27.36 subdivision 7, whose income increases above 175 percent of the 28.1 federal poverty guidelines are no longer eligible for the 28.2 program and shall be disenrolled by the commissioner. For 28.3 persons disenrolled under this subdivision, MinnesotaCare 28.4 coverage terminates the last day of the calendar month following 28.5 the month in which the commissioner determines that the income 28.6 of a family or individual, determined over a four-month period28.7as required by section 256L.15, subdivision 2,exceeds program 28.8 income limits. 28.9 (c) Notwithstanding paragraph (b), individuals and families 28.10 may remain enrolled in MinnesotaCare if ten percent of their 28.11 annual income is less than the annual premium for a policy with 28.12 a $500 deductible available through the Minnesota comprehensive 28.13 health association. Individuals and families who are no longer 28.14 eligible for MinnesotaCare under this subdivision shall be given 28.15 an 18-month notice period from the date that ineligibility is 28.16 determined before disenrollment. 28.17 Subd. 2. [MUST NOT HAVE ACCESS TO EMPLOYER-SUBSIDIZED 28.18 COVERAGE.] (a) To be eligiblefor subsidized premium payments28.19based on a sliding scale, a family or individual must not have 28.20 access to subsidized health coverage through an employer. A 28.21 family or individual whose employer-subsidized coverage is lost 28.22 due to an employer terminating health care coverage as an 28.23 employee benefit during the previous 18 months is not eligible. 28.24 (b) For purposes of this requirement, subsidized health 28.25 coverage means health coverage for which the employer pays at 28.26 least 50 percent of the cost of coverage for the employee or 28.27 dependent, or a higher percentage as specified by the 28.28 commissioner. Children are eligible for employer-subsidized 28.29 coverage through either parent, including the noncustodial 28.30 parent. The commissioner must treat employer contributions to 28.31 Internal Revenue Code Section 125 plans and any other employer 28.32 benefits intended to pay health care costs as qualified employer 28.33 subsidies toward the cost of health coverage for employees for 28.34 purposes of this subdivision. 28.35 Subd. 3. [OTHER HEALTH COVERAGE.] (a) Families and 28.36 individuals enrolled in the MinnesotaCare program must have no 29.1 health coverage while enrolled or for at least four months prior 29.2 to application and renewal. Children enrolled in the original 29.3 children's health plan and children in families with income 29.4 equal to or less than 150 percent of the federal poverty 29.5 guidelines, who have other health insurance, are eligible if the 29.6other health coverage meets the requirements of Minnesota Rules,29.7part 9506.0020, subpart 3, item B.coverage: 29.8 (1) lacks two or more of the following: 29.9 (i) basic hospital insurance; 29.10 (ii) medical-surgical insurance; 29.11 (iii) prescription drug coverage; 29.12 (iv) dental coverage; or 29.13 (v) vision coverage; 29.14 (2) requires a deductible of $100 or more per person per 29.15 year; or 29.16 (3) lacks coverage because the child has exceeded the 29.17 maximum coverage for a particular diagnosis or the policy 29.18 excludes a particular diagnosis. 29.19 The commissioner may change this eligibility criterion for 29.20 sliding scale premiums in order to remain within the limits of 29.21 available appropriations. The requirement of no health coverage 29.22 does not apply to newborns. 29.23 (b) For purposes of this section, medical assistance, 29.24 general assistance medical care, and civilian health and medical 29.25 program of the uniformed service, CHAMPUS, are not considered 29.26 insurance or health coverage. 29.27 (c) For purposes of this section, Medicare Part A or B 29.28 coverage under title XVIII of the Social Security Act, United 29.29 States Code, title 42, sections 1395c to 1395w-4, is considered 29.30 health coverage. An applicant or enrollee may not refuse 29.31 Medicare coverage to establish eligibility for MinnesotaCare. 29.32 (d) Applicants who were recipients of medical assistance or 29.33 general assistance medical care within one month of application 29.34 must meet the provisions of this subdivision and subdivision 2. 29.35 Sec. 34. Minnesota Statutes 1998, section 256L.15, 29.36 subdivision 1, is amended to read: 30.1 Subdivision 1. [PREMIUM DETERMINATION.] Families with 30.2 children and individuals shall pay a premium determined 30.3 according to a sliding fee based onthe cost of coverage asa 30.4 percentage of the family's gross family income. Pregnant women 30.5 and children under age two are exempt from the provisions of 30.6 section 256L.06, subdivision 3, paragraph (b), clause (3), 30.7 requiring disenrollment for failure to pay premiums. For 30.8 pregnant women, this exemption continues until the first day of 30.9 the month following the 60th day postpartum. Women who remain 30.10 enrolled during pregnancy or the postpartum period, despite 30.11 nonpayment of premiums, shall be disenrolled on the first of the 30.12 month following the 60th day postpartum for the penalty period 30.13 that otherwise applies under section 256L.06, unless they begin 30.14 paying premiums. 30.15 Sec. 35. Minnesota Statutes 1998, section 256L.15, 30.16 subdivision 1b, is amended to read: 30.17 Subd. 1b. [PAYMENTS NONREFUNDABLE.] Only MinnesotaCare 30.18 premiumsare not refundablepaid for future months of coverage 30.19 for which a health plan capitation fee has not been paid may be 30.20 refunded. 30.21 Sec. 36. Minnesota Statutes 1998, section 256L.15, 30.22 subdivision 2, is amended to read: 30.23 Subd. 2. [SLIDING FEE SCALE TO DETERMINE PERCENTAGE OF 30.24 GROSS INDIVIDUAL OR FAMILY INCOME.] (a) The commissioner shall 30.25 establish a sliding fee scale to determine the percentage of 30.26 gross individual or family income that households at different 30.27 income levels must pay to obtain coverage through the 30.28 MinnesotaCare program. The sliding fee scale must be based on 30.29 the enrollee's gross individual or family incomeduring the30.30previous four months. The sliding fee scale must contain 30.31 separate tables based on enrollment of one, two, or three or 30.32 more persons. The sliding fee scale begins with a premium of 30.33 1.5 percent of gross individual or family income for individuals 30.34 or families with incomes below the limits for the medical 30.35 assistance program for families and children in effect on 30.36 January 1, 1999, and proceeds through the following evenly 31.1 spaced steps: 1.8, 2.3, 3.1, 3.8, 4.8, 5.9, 7.4, and 8.8 31.2 percent. These percentages are matched to evenly spaced income 31.3 steps ranging from the medical assistance income limit for 31.4 families and children in effect on January 1, 1999, to 275 31.5 percent of the federal poverty guidelines for the applicable 31.6 family size, up to a family size of five. The sliding fee scale 31.7 for a family of five must be used for families of more than 31.8 five. The sliding fee scale and percentages are not subject to 31.9 the provisions of chapter 14. If a family or individual reports 31.10 increased income after enrollment, premiums shall not be 31.11 adjusted until eligibility renewal. 31.12 (b) Enrolled individuals whose gross annual income 31.13 increases above 275 percent of the federal poverty guideline 31.14 shall pay the maximum premium. The maximum premium is defined 31.15 as a base charge for one, two, or three or more enrollees so 31.16 that if all MinnesotaCare cases paid the maximum premium, the 31.17 total revenue would equal the total cost of MinnesotaCare 31.18 medical coverage and administration. In this calculation, 31.19 administrative costs shall be assumed to equal ten percent of 31.20 the total. The costs of medical coverage for pregnant women and 31.21 children under age two and the enrollees in these groups shall 31.22 be excluded from the total. The maximum premium for two 31.23 enrollees shall be twice the maximum premium for one, and the 31.24 maximum premium for three or more enrollees shall be three times 31.25 the maximum premium for one. 31.26 Sec. 37. Laws 1995, chapter 178, article 2, section 46, 31.27 subdivision 10, is amended to read: 31.28 Subd. 10. [ADDITIONAL WAIVER REQUEST FOR EMPLOYED DISABLED 31.29 PERSONS.] The commissioner shall seek a federal waiver in order 31.30 to implement a work incentive for disabled personseligible for31.31medical assistancewho are not residents of long-term care 31.32 facilities, when determining their eligibility for medical 31.33 assistance. The waiver shall request authorization to establish 31.34 a medical assistance earned income disregard for employed 31.35 disabled persons who, but for earned income, are eligible for 31.36 SSDI and whoreceiverequire personal care assistance under the 32.1 Medical Assistance Program. The disregard shall be equivalent 32.2 to the threshold amount applied to persons who qualify under 32.3 section 1619(b) of the Social Security Act, except that when a 32.4 disabled person's earned income reaches the maximum income 32.5 permitted at the threshold under section 1619(b), the person 32.6 shall retain medical assistance eligibility and must contribute 32.7 to the costs of medical care on a sliding fee basis. 32.8 Sec. 38. [HOME-BASED MENTAL HEALTH SERVICES.] 32.9 By January 1, 2000, the commissioner shall amend Minnesota 32.10 Rules under the expedited process of Minnesota Statutes, section 32.11 14.389, to effect the following changes: 32.12 (1) amend Minnesota Rules, part 9505.0324, subpart 2, to 32.13 permit a county board to contract with any agency qualified 32.14 under Minnesota Rules, part 9505.0324, subparts 4 and 5, as an 32.15 eligible provider of home-based mental health services; 32.16 (2) amend Minnesota Rules, part 9505.0324, subpart 2, to 32.17 permit children's mental health collaboratives approved by the 32.18 children's cabinet under Minnesota Statutes, section 245.493, to 32.19 provide or to contract with any agency qualified under Minnesota 32.20 Rules, part 9505.0324, subparts 4 and 5, as an eligible provider 32.21 of home-based mental health services. 32.22 Sec. 39. [AMENDING MEDICAL ASSISTANCE RULES.] 32.23 By January 1, 2001, the commissioner shall amend Minnesota 32.24 Rules, parts 9505.0323, 9505.0324, 9505.0326, and 9505.0327, as 32.25 necessary to implement the changes outlined in Minnesota 32.26 Statutes, section 256B.0625, subdivision 35.