1.1                          A bill for an act 
  1.2             relating to health care; alternative care program and 
  1.3             waivered service programs; appropriating money; 
  1.4             amending Minnesota Statutes 1994, sections 256B.0913, 
  1.5             subdivisions 1, 2, 4, 5, 8, and 12; and 256B.0915, 
  1.6             subdivisions 3, 5, and by adding a subdivision; 
  1.7             proposing coding for new law in Minnesota Statutes, 
  1.8             chapter 256B. 
  1.9   BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MINNESOTA: 
  1.10     Section 1.  [256B.0912] [ALTERNATIVE CARE AND WAIVERED 
  1.11  SERVICE PROGRAMS.] 
  1.12     Subdivision 1.  [COVERED SERVICES.] Funding for the 
  1.13  alternative care program, the elderly waiver, the community 
  1.14  alternatives for disabled individuals waiver, and the traumatic 
  1.15  brain injury waiver may be used for payments of the costs of: 
  1.16     (1) case management; 
  1.17     (2) the following caregiver training and support services: 
  1.18  caregiver training and education and family counseling and 
  1.19  training; 
  1.20     (3) the following day programs:  adult day care and 
  1.21  structured day programs; 
  1.22     (4) the following in-home services: 
  1.23     (i) behavioral programming; 
  1.24     (ii) home health aide or extended home health aide; 
  1.25     (iii) nursing or extended nursing; 
  1.26     (iv) home health therapies, including occupational therapy, 
  1.27  physical therapy, respiratory therapy, and speech therapy or 
  2.1   extended therapies; 
  2.2      (v) night supervision; 
  2.3      (vi) personal care assistant services or extended personal 
  2.4   care assistant services; 
  2.5      (vii) companion services; 
  2.6      (viii) home delivered meals; 
  2.7      (ix) nutrition services; 
  2.8      (x) homemaker services; and 
  2.9      (xi) chore services; 
  2.10     (5) the following independent living skills services: 
  2.11  independent living skills training and independent living skills 
  2.12  therapies in recreation, music, and art; 
  2.13     (6) the following mental health services:  cognitive 
  2.14  rehabilitation therapy and psychological testing and explanation 
  2.15  of findings; 
  2.16     (7) modifications and adaptations to the home, to vehicles, 
  2.17  and to equipment; 
  2.18     (8) the following residential services:  assisted living 
  2.19  services, foster care services, and residential care services; 
  2.20     (9) respite care, in-home and out-of-home; 
  2.21     (10) supplies and equipment; and 
  2.22     (11) transportation. 
  2.23     Subd. 2.  [RATE CONSOLIDATION AFTER JUNE 30, 1995.] (a) The 
  2.24  commissioner shall consolidate payment rates for alternative 
  2.25  care services, elderly waiver services, community alternatives 
  2.26  for disabled individuals services, traumatic brain injury 
  2.27  services, and comparable medical assistance services provided 
  2.28  after June 30, 1995, that: 
  2.29     (1) provides a three percent rate increase for all 
  2.30  services; 
  2.31     (2) establishes a statewide rate cap for each individual 
  2.32  service that is equal to the highest rate cap in any program for 
  2.33  that service; and 
  2.34     (3) allows each county to establish a payment rate for each 
  2.35  service that is equal to at least 65 percent of the statewide 
  2.36  rate cap. 
  3.1      (b) The commissioner shall provide an additional three 
  3.2   percent rate increase for all services provided after June 30, 
  3.3   1996. 
  3.4      Subd. 3.  [TRAINING REQUIREMENTS FOR HOME MANAGEMENT 
  3.5   TASKS.] The training requirements in the alternative care, 
  3.6   elderly waiver, community alternatives for disabled individuals 
  3.7   waiver, and traumatic brain injury waiver for persons performing 
  3.8   home management tasks, including housekeeping, meal preparation, 
  3.9   and shopping, shall be the training requirements established for 
  3.10  home management tasks in the home care licensure rule under 
  3.11  Minnesota Rules, part 4668.0120. 
  3.12     Subd. 4.  [WAIVER PROGRAM MODIFICATIONS.] The commissioner 
  3.13  of human services shall make the following modifications in 
  3.14  medical assistance waiver programs, effective for services 
  3.15  rendered after June 30, 1995, or, if necessary, after federal 
  3.16  approval is granted: 
  3.17     (a) The elderly waiver shall cover the services listed in 
  3.18  subdivision 1. 
  3.19     (b) The community alternatives for disabled individuals 
  3.20  waiver shall: 
  3.21     (1) cover the services listed in subdivision 1; 
  3.22     (2) have a monthly spending cap that does not exceed the 
  3.23  greater of either the statewide or any of the geographic groups' 
  3.24  weighted average monthly medical assistance payments for nursing 
  3.25  facility care at the individual's case mix classification to 
  3.26  which the individual would be assigned under Minnesota Rules, 
  3.27  parts 9549.0050 to 9549.0059.  If the person is a nursing home 
  3.28  resident at the time of requesting a determination of 
  3.29  eligibility for waivered services, the monthly cost of waivered 
  3.30  services may not exceed (i) the greater of either the statewide 
  3.31  or any of the geographic groups' weighted average payment rate 
  3.32  of the case mix resident class to which the waiver client would 
  3.33  be assigned; or (ii) the monthly payment for the resident class 
  3.34  assigned under Minnesota Rules, parts 9549.0050 to 9549.0059, 
  3.35  for that resident in the home where the resident currently 
  3.36  resides, whichever is higher.  If medical supplies and equipment 
  4.1   or adaptations are or will be purchased for a waiver services 
  4.2   recipient, the costs may be prorated on a monthly basis 
  4.3   throughout the year in which they are purchased.  If the monthly 
  4.4   cost of a recipient's other waivered services exceeds the 
  4.5   monthly limit established in this paragraph, the annual cost of 
  4.6   the waivered services shall be determined.  In this event, the 
  4.7   annual cost of waivered services shall not exceed 12 times the 
  4.8   monthly limit calculated in this paragraph; 
  4.9      (3) require client reassessments once every 12 months; 
  4.10     (4) deduct the personal needs allowance from average 
  4.11  monthly nursing home resident income when determining the client 
  4.12  spending cap; 
  4.13     (5) permit the purchase of supplies and equipment costing 
  4.14  $250 or less without prior approval of the commissioner of human 
  4.15  services and without having a contract with the supplier.  The 
  4.16  $250 limit shall be increased on an annual basis according to 
  4.17  section 256B.0913, subdivision 5; and 
  4.18     (6) allow the implementation of care plans without the 
  4.19  approval of the county of financial responsibility when the 
  4.20  client receives services from another county. 
  4.21     (c) The traumatic brain injury waiver shall: 
  4.22     (1) cover the services listed in subdivision 1; 
  4.23     (2) require client reassessments once every 12 months; 
  4.24     (3) permit the purchase of supplies and equipment costing 
  4.25  $250 or less without prior approval of the commissioner of human 
  4.26  services and without having a contract with the supplier.  The 
  4.27  $250 limit shall be increased on an annual basis according to 
  4.28  section 5; and 
  4.29     (4) allow the implementation of care plans without the 
  4.30  approval of the county of financial responsibility when the 
  4.31  client receives services from another county. 
  4.32     Sec. 2.  Minnesota Statutes 1994, section 256B.0913, 
  4.33  subdivision 1, is amended to read: 
  4.34     Subdivision 1.  [PURPOSE AND GOALS.] The purpose of the 
  4.35  alternative care program is to provide funding for or access to 
  4.36  home and community-based services for frail elderly persons, in 
  5.1   order to limit nursing facility placements.  The program is 
  5.2   designed to support frail elderly persons in their desire to 
  5.3   remain in the community as independently and as long as possible 
  5.4   and to support informal caregivers in their efforts to provide 
  5.5   care for frail elderly people.  Further, the goals of the 
  5.6   program are: 
  5.7      (1) to contain medical assistance expenditures by providing 
  5.8   care in the community at a cost the same or less than nursing 
  5.9   facility costs; and 
  5.10     (2) to maintain the moratorium on new construction of 
  5.11  nursing home beds. 
  5.12     Sec. 3.  Minnesota Statutes 1994, section 256B.0913, 
  5.13  subdivision 2, is amended to read: 
  5.14     Subd. 2.  [ELIGIBILITY FOR SERVICES.] Alternative care 
  5.15  services are available to all frail older Minnesotans.  This 
  5.16  includes: 
  5.17     (1) persons who are receiving medical assistance and served 
  5.18  under the medical assistance program or the Medicaid waiver 
  5.19  program; 
  5.20     (2) persons who would be eligible for medical assistance 
  5.21  within 180 days of admission to a nursing facility and served 
  5.22  under subdivisions 4 to 13; and 
  5.23     (3) persons who are paying for their services out-of-pocket.
  5.24     Sec. 4.  Minnesota Statutes 1994, section 256B.0913, 
  5.25  subdivision 4, is amended to read: 
  5.26     Subd. 4.  [ELIGIBILITY FOR FUNDING FOR SERVICES FOR 
  5.27  NONMEDICAL ASSISTANCE RECIPIENTS.] (a) Funding for services 
  5.28  under the alternative care program is available to persons who 
  5.29  meet the following criteria: 
  5.30     (1) the person has been screened by the county screening 
  5.31  team or, if previously screened and served under the alternative 
  5.32  care program, assessed by the local county social worker or 
  5.33  public health nurse; 
  5.34     (2) the person is age 65 or older; 
  5.35     (3) the person would be financially eligible for medical 
  5.36  assistance within 180 days of admission to a nursing facility; 
  6.1      (4) (3) the person meets the asset transfer requirements of 
  6.2   the medical assistance program; 
  6.3      (5) (4) the screening team would recommend nursing facility 
  6.4   admission or continued stay for the person if alternative care 
  6.5   services were not available; 
  6.6      (6) (5) the person needs services that are not available at 
  6.7   that time in the county through other county, state, or federal 
  6.8   funding sources; and 
  6.9      (7) (6) the monthly cost of the alternative care services 
  6.10  funded by the program for this person does not exceed 75 percent 
  6.11  of the statewide the greater of either the statewide or any of 
  6.12  the geographic groups' weighted average monthly medical 
  6.13  assistance payment rates for nursing facility care at the 
  6.14  individual's case mix classification to which the individual 
  6.15  would be assigned under Minnesota Rules, parts 9549.0050 to 
  6.16  9549.0059, except that the monthly cost of the alternative care 
  6.17  services for a person who is a nursing home resident at the time 
  6.18  of requesting a determination of eligibility for the alternative 
  6.19  care program shall not exceed (i) the greater of either the 
  6.20  statewide or any of the geographic groups' weighted average 
  6.21  payment rate of the case mix resident class to which the waiver 
  6.22  client would be assigned; or (ii) the monthly payment rate for 
  6.23  the resident class assigned under Minnesota Rules, parts 
  6.24  9549.0050 to 9549.0059, for that resident in the nursing home 
  6.25  where the resident currently resides, whichever is higher.  If 
  6.26  medical supplies and equipment or adaptations are or will be 
  6.27  purchased for an alternative care services recipient, the costs 
  6.28  may be prorated on a monthly basis throughout the year in which 
  6.29  they are purchased.  If the monthly cost of a recipient's other 
  6.30  alternative care services exceeds the monthly limit established 
  6.31  in this paragraph, the annual cost of the alternative care 
  6.32  services shall be determined.  In this event, the annual cost of 
  6.33  alternative care services shall not exceed 12 times the monthly 
  6.34  limit calculated in this paragraph. 
  6.35     (b) Individuals who meet the criteria in paragraph (a) and 
  6.36  who have been approved for alternative care funding are called 
  7.1   180-day eligible clients. 
  7.2      (c) The statewide average payment for nursing facility care 
  7.3   is the statewide average monthly nursing facility rate in effect 
  7.4   on July 1 of the fiscal year in which the cost is incurred, less 
  7.5   the statewide average monthly income of nursing facility 
  7.6   residents who are age 65 or older and who are medical assistance 
  7.7   recipients in the month of March of the previous fiscal 
  7.8   year.  For the purposes of this paragraph, the average monthly 
  7.9   income of nursing facility residents shall be reduced by the 
  7.10  amount of the personal needs allowance under section 256B.35.  
  7.11  This monthly limit does not prohibit the 180-day eligible client 
  7.12  from paying for additional services needed or desired.  
  7.13     (d) In determining the total costs of alternative care 
  7.14  services for one month, the costs of all services funded by the 
  7.15  alternative care program, including supplies and equipment, must 
  7.16  be included. 
  7.17     (e) Alternative care funding under this subdivision is not 
  7.18  available for a person who is a medical assistance recipient or 
  7.19  who would be eligible for medical assistance without a spenddown 
  7.20  if the person applied, unless authorized by the commissioner.  A 
  7.21  person whose application for medical assistance is being 
  7.22  processed may be served under the alternative care program for a 
  7.23  period up to 60 days.  If the individual is found to be eligible 
  7.24  for medical assistance, the county must bill medical assistance 
  7.25  from the date the individual was found eligible for the medical 
  7.26  assistance services provided that are reimbursable under the 
  7.27  elderly waiver program.  
  7.28     (f) Alternative care funding is not available for a person 
  7.29  who resides in a licensed nursing home or boarding care home, 
  7.30  except for case management services which are being provided in 
  7.31  support of the discharge planning process.  
  7.32     Sec. 5.  Minnesota Statutes 1994, section 256B.0913, 
  7.33  subdivision 5, is amended to read: 
  7.34     Subd. 5.  [SERVICES COVERED UNDER ALTERNATIVE CARE.] (a) 
  7.35  Alternative care funding may be used for payment of costs of: 
  7.36     (1) adult foster care; 
  8.1      (2) adult day care; 
  8.2      (3) home health aide; 
  8.3      (4) homemaker services; 
  8.4      (5) personal care; 
  8.5      (6) case management; 
  8.6      (7) respite care; 
  8.7      (8) assisted living; 
  8.8      (9) residential care services; 
  8.9      (10) care-related supplies and equipment; 
  8.10     (11) meals delivered to the home; 
  8.11     (12) transportation; 
  8.12     (13) skilled nursing; 
  8.13     (14) chore services; 
  8.14     (15) companion services; 
  8.15     (16) nutrition services; and 
  8.16     (17) training for direct informal caregivers services 
  8.17  listed in section 256B.0912, subdivision 1, and registered nurse 
  8.18  supervision of personal care assistant services. 
  8.19     (b) The county agency must ensure that the funds are used 
  8.20  only to supplement and not supplant services available through 
  8.21  other public assistance or services programs. 
  8.22     (c) Unless specified in statute, the service standards for 
  8.23  alternative care services shall be the same as the service 
  8.24  standards defined in the elderly waiver.  Persons or agencies 
  8.25  must be employed by or under a contract with the county agency 
  8.26  or the public health nursing agency of the local board of health 
  8.27  in order to receive funding under the alternative care program. 
  8.28     (d) The adult foster care rate shall be considered a 
  8.29  difficulty of care payment and shall not include room and 
  8.30  board.  The adult foster care daily rate shall be negotiated 
  8.31  between the county agency and the foster care provider.  The 
  8.32  rate established under this section shall not exceed 75 percent 
  8.33  of the state average monthly nursing home payment for the case 
  8.34  mix classification to which the individual receiving foster care 
  8.35  is assigned, and it must allow for other alternative care 
  8.36  services to be authorized by the case manager. 
  9.1      (e) Personal care services may be provided by a personal 
  9.2   care provider organization.  A county agency may contract with a 
  9.3   relative of the client to provide personal care services, but 
  9.4   must ensure nursing supervision.  Covered personal care services 
  9.5   defined in section 256B.0627, subdivision 4, must meet 
  9.6   applicable standards in Minnesota Rules, part 9505.0335. 
  9.7      (f) Costs for supplies and equipment that exceed $150 $250 
  9.8   per item per month must have prior approval from the 
  9.9   commissioner.  The $250 limit must be increased annually, 
  9.10  beginning July 1, 1996, based on the forecast percentage change 
  9.11  in the Home Health Agency Market Basket of Operating Costs, for 
  9.12  the fiscal year beginning July 1, published by Data Resources, 
  9.13  Inc.  A county may use alternative care funds to purchase 
  9.14  supplies and equipment from a non-Medicaid certified vendor if 
  9.15  the cost for the items is less than that of a Medicaid 
  9.16  vendor.  A county is not required to contract with a provider of 
  9.17  supplies and equipment if the monthly cost of the supplies and 
  9.18  equipment is less than the limit for prior approval established 
  9.19  in this paragraph. 
  9.20     (g) For purposes of this section, residential care services 
  9.21  are services which are provided to individuals living in 
  9.22  residential care homes.  Residential care homes are currently 
  9.23  licensed as board and lodging establishments and are registered 
  9.24  with the department of health as providing special services.  
  9.25  Residential care services are defined as "supportive services" 
  9.26  and "health-related services."  "Supportive services" means the 
  9.27  provision of up to 24-hour supervision and oversight.  
  9.28  Supportive services includes:  (1) transportation, when provided 
  9.29  by the residential care center only; (2) socialization, when 
  9.30  socialization is part of the plan of care, has specific goals 
  9.31  and outcomes established, and is not diversional or recreational 
  9.32  in nature; (3) assisting clients in setting up meetings and 
  9.33  appointments; (4) assisting clients in setting up medical and 
  9.34  social services; (5) providing assistance with personal laundry, 
  9.35  such as carrying the client's laundry to the laundry room.  
  9.36  Assistance with personal laundry does not include any laundry, 
 10.1   such as bed linen, that is included in the room and board rate.  
 10.2   Health-related services are limited to minimal assistance with 
 10.3   dressing, grooming, and bathing and providing reminders to 
 10.4   residents to take medications that are self-administered or 
 10.5   providing storage for medications, if requested.  Individuals 
 10.6   receiving residential care services cannot receive both personal 
 10.7   care services and residential care services.  
 10.8      (h) For the purposes of this section, "assisted living" 
 10.9   refers to supportive services provided by a single vendor to 
 10.10  clients who reside in the same apartment building of three or 
 10.11  more units.  Assisted living services are defined as up to 
 10.12  24-hour supervision, and oversight, supportive services as 
 10.13  defined in clause (1), individualized home care aide tasks as 
 10.14  defined in clause (2), and individualized home management tasks 
 10.15  as defined in clause (3) provided to residents of a residential 
 10.16  center living in their units or apartments with a full kitchen 
 10.17  and bathroom.  A full kitchen includes a stove, oven, 
 10.18  refrigerator, food preparation counter space, and a kitchen 
 10.19  utensil storage compartment.  Assisted living services must be 
 10.20  provided by the management of the residential center or by 
 10.21  providers under contract with the management or with the county. 
 10.22     (1) Supportive services include:  
 10.23     (i) socialization, when socialization is part of the plan 
 10.24  of care, has specific goals and outcomes established, and is not 
 10.25  diversional or recreational in nature; 
 10.26     (ii) assisting clients in setting up meetings and 
 10.27  appointments; and 
 10.28     (iii) providing transportation, when provided by the 
 10.29  residential center only.  
 10.30     Individuals receiving assisted living services will not 
 10.31  receive both assisted living services and homemaking or personal 
 10.32  care services.  Individualized means services are chosen and 
 10.33  designed specifically for each resident's needs, rather than 
 10.34  provided or offered to all residents regardless of their 
 10.35  illnesses, disabilities, or physical conditions.  
 10.36     (2) Home care aide tasks means:  
 11.1      (i) preparing modified diets, such as diabetic or low 
 11.2   sodium diets; 
 11.3      (ii) reminding residents to take regularly scheduled 
 11.4   medications or to perform exercises; 
 11.5      (iii) household chores in the presence of technically 
 11.6   sophisticated medical equipment or episodes of acute illness or 
 11.7   infectious disease; 
 11.8      (iv) household chores when the resident's care requires the 
 11.9   prevention of exposure to infectious disease or containment of 
 11.10  infectious disease; and 
 11.11     (v) assisting with dressing, oral hygiene, hair care, 
 11.12  grooming, and bathing, if the resident is ambulatory, and if the 
 11.13  resident has no serious acute illness or infectious disease.  
 11.14  Oral hygiene means care of teeth, gums, and oral prosthetic 
 11.15  devices.  
 11.16     (3) Home management tasks means:  
 11.17     (i) housekeeping; 
 11.18     (ii) laundry; 
 11.19     (iii) preparation of regular snacks and meals; and 
 11.20     (iv) shopping.  
 11.21     A person's eligibility to reside in the building must not 
 11.22  be contingent on the person's acceptance or use of the assisted 
 11.23  living services.  Assisted living services as defined in this 
 11.24  section shall not be authorized in boarding and lodging 
 11.25  establishments licensed according to sections 157.01 to 157.031. 
 11.26     Reimbursement for assisted living services and residential 
 11.27  care services shall be made by the lead agency to the vendor as 
 11.28  a monthly rate negotiated with the county agency.  The rate 
 11.29  shall not exceed the nonfederal share of the greater of either 
 11.30  the statewide or any of the geographic groups' weighted average 
 11.31  monthly medical assistance nursing facility payment rate of the 
 11.32  case mix resident class to which the 180-day eligible client 
 11.33  would be assigned under Minnesota Rules, parts 9549.0050 to 
 11.34  9549.0059, except for alternative care assisted living projects 
 11.35  established under Laws 1988, chapter 689, article 2, section 
 11.36  256, whose rates may not exceed 65 percent of either the 
 12.1   statewide or any of the geographic groups' weighted average 
 12.2   monthly medical assistance nursing facility payment rate of the 
 12.3   case mix resident class to which the 180-day eligible client 
 12.4   would be assigned under Minnesota Rules, parts 9549.0050 to 
 12.5   9549.0059.  The rate may not cover rent and direct food costs. 
 12.6      (i) For purposes of this section, companion services are 
 12.7   defined as nonmedical care, supervision and oversight, provided 
 12.8   to a functionally impaired adult.  Companions may assist the 
 12.9   individual with such tasks as meal preparation, laundry and 
 12.10  shopping, but do not perform these activities as discrete 
 12.11  services.  The provision of companion services does not entail 
 12.12  hands-on medical care.  Providers may also perform light 
 12.13  housekeeping tasks which are incidental to the care and 
 12.14  supervision of the recipient.  This service must be approved by 
 12.15  the case manager as part of the care plan.  Companion services 
 12.16  must be provided by individuals or nonprofit organizations who 
 12.17  are under contract with the local agency to provide the 
 12.18  service.  Any person related to the waiver recipient by blood, 
 12.19  marriage or adoption cannot be reimbursed under this service.  
 12.20  Persons providing companion services will be monitored by the 
 12.21  case manager. 
 12.22     (j) For purposes of this section, training for direct 
 12.23  informal caregivers is defined as a classroom or home course of 
 12.24  instruction which may include:  transfer and lifting skills, 
 12.25  nutrition, personal and physical cares, home safety in a home 
 12.26  environment, stress reduction and management, behavioral 
 12.27  management, long-term care decision making, care coordination 
 12.28  and family dynamics.  The training is provided to an informal 
 12.29  unpaid caregiver of a 180-day eligible client which enables the 
 12.30  caregiver to deliver care in a home setting with high levels of 
 12.31  quality.  The training must be approved by the case manager as 
 12.32  part of the individual care plan.  Individuals, agencies, and 
 12.33  educational facilities which provide caregiver training and 
 12.34  education will be monitored by the case manager. 
 12.35     Sec. 6.  Minnesota Statutes 1994, section 256B.0913, 
 12.36  subdivision 8, is amended to read: 
 13.1      Subd. 8.  [REQUIREMENTS FOR INDIVIDUAL CARE PLAN.] (a) The 
 13.2   case manager shall implement the plan of care for each 180-day 
 13.3   eligible client and ensure that a client's service needs and 
 13.4   eligibility are reassessed at least every six 12 months.  The 
 13.5   plan shall include any services prescribed by the individual's 
 13.6   attending physician as necessary to allow the individual to 
 13.7   remain in a community setting.  In developing the individual's 
 13.8   care plan, the case manager should include the use of volunteers 
 13.9   from families and neighbors, religious organizations, social 
 13.10  clubs, and civic and service organizations to support the formal 
 13.11  home care services.  The county shall be held harmless for 
 13.12  damages or injuries sustained through the use of volunteers 
 13.13  under this subdivision including workers' compensation 
 13.14  liability.  The lead agency shall provide documentation to the 
 13.15  commissioner verifying that the individual's alternative care is 
 13.16  not available at that time through any other public assistance 
 13.17  or service program.  The lead agency shall provide documentation 
 13.18  in each individual's plan of care and to the commissioner that 
 13.19  the most cost-effective alternatives available have been offered 
 13.20  to the individual and that the individual was free to choose 
 13.21  among available qualified providers, both public and private. 
 13.22  The case manager must give the individual a ten-day written 
 13.23  notice of any decrease in or termination of alternative care 
 13.24  services. 
 13.25     (b) In order to reduce paperwork, the care plan and the 
 13.26  notice of right to appeal the care plan must be combined into 
 13.27  one document by January 1, 1996. 
 13.28     (c) If the county administering alternative care services 
 13.29  is different than the county of financial responsibility, the 
 13.30  care plan may be implemented without the approval of the county 
 13.31  of financial responsibility. 
 13.32     Sec. 7.  Minnesota Statutes 1994, section 256B.0913, 
 13.33  subdivision 12, is amended to read: 
 13.34     Subd. 12.  [CLIENT PREMIUMS.] (a) A premium is required for 
 13.35  all 180-day eligible clients to help pay for the cost of 
 13.36  participating in the program.  The amount of the premium for the 
 14.1   alternative care client shall be determined as follows: 
 14.2      (1) when the alternative care client's income less 
 14.3   recurring and predictable medical expenses is greater than the 
 14.4   medical assistance income standard but less than 150 percent of 
 14.5   the federal poverty guideline, and total assets are less than 
 14.6   $6,000, the fee is zero; 
 14.7      (2) when the alternative care client's income less 
 14.8   recurring and predictable medical expenses is greater than 150 
 14.9   percent of the federal poverty guideline and total assets are 
 14.10  less than $6,000, the fee is 25 percent of the cost of 
 14.11  alternative care services or the difference between 150 percent 
 14.12  of the federal poverty guideline and the client's income less 
 14.13  recurring and predictable medical expenses, whichever is less; 
 14.14  and 
 14.15     (3) when the alternative care client's total assets are 
 14.16  greater than $6,000, the fee is 25 percent of the cost of 
 14.17  alternative care services.  
 14.18     For married persons, total assets are defined as the total 
 14.19  marital assets less the estimated community spouse asset 
 14.20  allowance, under section 256B.059, if applicable.  For married 
 14.21  persons, total income is defined as the client's income less the 
 14.22  monthly spousal allotment, under section 256B.058. 
 14.23     All alternative care services except case management shall 
 14.24  be included in the estimated costs for the purpose of 
 14.25  determining 25 percent of the costs. 
 14.26     The monthly premium shall be calculated and be payable in 
 14.27  the based on the cost of the first full month in which the of 
 14.28  alternative care services begin and shall continue unaltered for 
 14.29  six months until the semiannual reassessment unless the actual 
 14.30  cost of services falls below the fee until the next reassessment 
 14.31  is completed or at the end of 12 months, whichever comes first.  
 14.32  Premiums are due and payable each month alternative care 
 14.33  services are received unless the actual cost of the services is 
 14.34  less than the premium. 
 14.35     (b) The fee shall be waived by the commissioner when: 
 14.36     (1) a person who is residing in a nursing facility is 
 15.1   receiving case management only; 
 15.2      (2) a person is applying for medical assistance; 
 15.3      (3) a married couple is requesting an asset assessment 
 15.4   under the spousal impoverishment provisions; 
 15.5      (4) a person is a medical assistance recipient, but has 
 15.6   been approved for alternative care-funded assisted living 
 15.7   services; 
 15.8      (5) a person is found eligible for alternative care, but is 
 15.9   not yet receiving alternative care services; 
 15.10     (6) a person is an adult foster care resident for whom 
 15.11  alternative care funds are being used to meet a portion of the 
 15.12  person's medical assistance spenddown, as authorized in 
 15.13  subdivision 4; and 
 15.14     (7) a person's fee under paragraph (a) is less than $25. 
 15.15     (c) The county agency must collect the premium from the 
 15.16  client and forward the amounts collected to the commissioner in 
 15.17  the manner and at the times prescribed by the commissioner.  
 15.18  Money collected must be deposited in the general fund and is 
 15.19  appropriated to the commissioner for the alternative care 
 15.20  program.  The client must supply the county with the client's 
 15.21  social security number at the time of application.  If a client 
 15.22  fails or refuses to pay the premium due, the county shall supply 
 15.23  the commissioner with the client's social security number and 
 15.24  other information the commissioner requires to collect the 
 15.25  premium from the client.  The commissioner shall collect unpaid 
 15.26  premiums using the revenue recapture act in chapter 270A and 
 15.27  other methods available to the commissioner.  The commissioner 
 15.28  may require counties to inform clients of the collection 
 15.29  procedures that may be used by the state if a premium is not 
 15.30  paid.  
 15.31     (d) The commissioner shall begin to adopt emergency or 
 15.32  permanent rules governing client premiums within 30 days after 
 15.33  July 1, 1991, including criteria for determining when services 
 15.34  to a client must be terminated due to failure to pay a premium.  
 15.35     Sec. 8.  Minnesota Statutes 1994, section 256B.0915, 
 15.36  subdivision 3, is amended to read: 
 16.1      Subd. 3.  [LIMITS OF CASES, RATES, REIMBURSEMENT, AND 
 16.2   FORECASTING.] (a) The number of medical assistance waiver 
 16.3   recipients that a county may serve must be allocated according 
 16.4   to the number of medical assistance waiver cases open on July 1 
 16.5   of each fiscal year.  Additional recipients may be served with 
 16.6   the approval of the commissioner. 
 16.7      (b) The monthly limit for the cost of waivered services to 
 16.8   an individual waiver client shall be the statewide not exceed 
 16.9   the greater of either the statewide or any of the geographic 
 16.10  groups' weighted average payment rate rates of the case mix 
 16.11  resident class to which the waiver client would be assigned 
 16.12  under medical assistance case mix reimbursement system.  If the 
 16.13  person is a nursing home resident at the time of requesting a 
 16.14  determination of eligibility for waivered services, the monthly 
 16.15  cost of waivered services may not exceed:  (i) the greater of 
 16.16  either the statewide or any of the geographic groups' weighted 
 16.17  average payment rate of the case mix resident class to which the 
 16.18  waiver client would be assigned; or (ii) the monthly payment for 
 16.19  the resident class assigned under Minnesota Rules, parts 
 16.20  9549.0050 to 9549.0059, for that resident in the home where the 
 16.21  resident currently resides, whichever is higher.  If medical 
 16.22  supplies and equipment or adaptations are or will be purchased 
 16.23  for an elderly waiver services recipient, the costs may be 
 16.24  prorated on a monthly basis throughout the year in which they 
 16.25  are purchased.  If the monthly cost of a recipient's other 
 16.26  waivered services exceeds the monthly limit established in this 
 16.27  paragraph, the annual cost of the waivered services shall be 
 16.28  determined.  In this event, the annual cost of waivered services 
 16.29  shall not exceed 12 times the monthly limit calculated in this 
 16.30  paragraph.  The statewide average payment rate is calculated by 
 16.31  determining the statewide average monthly nursing home rate 
 16.32  effective July 1 of the fiscal year in which the cost is 
 16.33  incurred, less the statewide average monthly income of nursing 
 16.34  home residents who are age 65 or older, and who are medical 
 16.35  assistance recipients in the month of March of the previous 
 16.36  state fiscal year.  For the purposes of this paragraph, the 
 17.1   average monthly income of nursing facility residents shall be 
 17.2   reduced by the amount of the personal needs allowance under 
 17.3   section 256B.35.  The following costs must be included in 
 17.4   determining the total monthly costs for the waiver client: 
 17.5      (1) cost of all waivered services, including extended 
 17.6   medical supplies and equipment; and 
 17.7      (2) cost of skilled nursing, home health aide, and personal 
 17.8   care services reimbursable by medical assistance.  
 17.9      (c) Medical assistance funding for skilled nursing 
 17.10  services, home health aide, and personal care services for 
 17.11  waiver recipients must be approved by the case manager and 
 17.12  included in the individual care plan. 
 17.13     (d) Expenditures for extended medical supplies and 
 17.14  equipment that cost over $150 $250 per month for both the 
 17.15  elderly waiver and the disabled waiver must have the 
 17.16  commissioner's prior approval.  Beginning July 1, 1996, the $250 
 17.17  limit must be increased annually based on the forecast 
 17.18  percentage change in the Home Health Agency Market Basket of 
 17.19  Operating Costs published by Data Resources, Inc., for the 
 17.20  fiscal year beginning July 1.  A county is not required to 
 17.21  contract with a provider of supplies and equipment if the 
 17.22  monthly cost of the supplies and equipment is less than the 
 17.23  limit for prior approval established in this paragraph. 
 17.24     (e) For the fiscal year beginning on July 1, 1993, and for 
 17.25  subsequent fiscal years, the commissioner of human services 
 17.26  shall not provide automatic annual inflation adjustments for 
 17.27  home and community-based waivered services.  The commissioner of 
 17.28  finance shall include as a budget change request in each 
 17.29  biennial detailed expenditure budget submitted to the 
 17.30  legislature under section 16A.11 annual adjustments in 
 17.31  reimbursement rates for home and community-based waivered 
 17.32  services, based on the forecasted percentage change in the Home 
 17.33  Health Agency Market Basket of Operating Costs, for the fiscal 
 17.34  year beginning July 1, compared to the previous fiscal year, 
 17.35  unless otherwise adjusted by statute.  The Home Health Agency 
 17.36  Market Basket of Operating Costs is published by Data Resources, 
 18.1   Inc.  The forecast to be used is the one published for the 
 18.2   calendar quarter beginning January 1, six months prior to the 
 18.3   beginning of the fiscal year for which rates are set.  The adult 
 18.4   foster care rate shall be considered a difficulty of care 
 18.5   payment and shall not include room and board. 
 18.6      (f) The adult foster care daily rate for the elderly and 
 18.7   disabled waivers shall be negotiated between the county agency 
 18.8   and the foster care provider.  The rate established under this 
 18.9   section shall not exceed the state average monthly nursing home 
 18.10  payment for the case mix classification to which the individual 
 18.11  receiving foster care is assigned, and it must allow for other 
 18.12  waiver and medical assistance home care services to be 
 18.13  authorized by the case manager. 
 18.14     (g) The assisted living and residential care service rates 
 18.15  for elderly and disabled waivers shall be made to the vendor as 
 18.16  a monthly rate negotiated with the county agency.  The rate 
 18.17  shall not exceed the nonfederal share of the greater of either 
 18.18  the statewide or any of the geographic groups' weighted average 
 18.19  monthly medical assistance nursing facility payment rate of the 
 18.20  case mix resident class to which the elderly or disabled client 
 18.21  would be assigned under Minnesota Rules, parts 9549.0050 to 
 18.22  9549.0059, except for alternative care assisted living projects 
 18.23  established under Laws 1988, chapter 689, article 2, section 
 18.24  256, whose rates may not exceed 65 percent of the greater of 
 18.25  either the statewide or any of the geographic groups' weighted 
 18.26  average monthly medical assistance nursing facility payment rate 
 18.27  for the case mix resident class to which the elderly or disabled 
 18.28  client would be assigned under Minnesota Rules, parts 9549.0050 
 18.29  to 9549.0059.  The rate may not cover direct rent or food costs. 
 18.30     (h) The county shall negotiate individual rates with 
 18.31  vendors and may be reimbursed for actual costs up to the greater 
 18.32  of the county's current approved rate or 60 percent of the 
 18.33  maximum rate in fiscal year 1994 and 65 percent of the maximum 
 18.34  rate in fiscal year 1995 for each service within each program. 
 18.35     (i) On July 1, 1993, the commissioner shall increase the 
 18.36  maximum rate for home-delivered meals to $4.50 per meal. 
 19.1      (j) Reimbursement for the medical assistance recipients 
 19.2   under the approved waiver shall be made from the medical 
 19.3   assistance account through the invoice processing procedures of 
 19.4   the department's Medicaid Management Information System (MMIS), 
 19.5   only with the approval of the client's case manager.  The budget 
 19.6   for the state share of the Medicaid expenditures shall be 
 19.7   forecasted with the medical assistance budget, and shall be 
 19.8   consistent with the approved waiver.  
 19.9      (k) Beginning July 1, 1991, the state shall reimburse 
 19.10  counties according to the payment schedule in section 256.025 
 19.11  for the county share of costs incurred under this subdivision on 
 19.12  or after January 1, 1991, for individuals who are receiving 
 19.13  medical assistance. 
 19.14     Sec. 9.  Minnesota Statutes 1994, section 256B.0915, 
 19.15  subdivision 5, is amended to read: 
 19.16     Subd. 5.  [REASSESSMENTS FOR WAIVER CLIENTS.] A 
 19.17  reassessment of a client served under the elderly or disabled 
 19.18  waiver must be conducted at least every six 12 months and at 
 19.19  other times when the case manager determines that there has been 
 19.20  significant change in the client's functioning.  This may 
 19.21  include instances where the client is discharged from the 
 19.22  hospital.  
 19.23     Sec. 10.  Minnesota Statutes 1994, section 256B.0915, is 
 19.24  amended by adding a subdivision to read: 
 19.25     Subd. 6.  [INDIVIDUAL CARE PLAN.] (a) In order to reduce 
 19.26  paperwork, the individual care plan and the notice of right to 
 19.27  appeal the care plan must be combined into one document by 
 19.28  January 1, 1996. 
 19.29     (b) If the county administering waivered services is 
 19.30  different than the county of financial responsibility, the care 
 19.31  plan may be implemented without the approval of the county of 
 19.32  financial responsibility.  
 19.33     Sec. 11.  [CONTINUATION OF PILOT PROJECTS.] 
 19.34     The alternative care pilot projects authorized in Laws 
 19.35  1993, First Special Session chapter 1, article 5, section 133, 
 19.36  shall not expire on June 30, 1995, but shall continue until June 
 20.1   30, 1997.  The commissioner shall request additional proposals 
 20.2   in order to establish additional projects. 
 20.3      Sec. 12.  [PREADMISSION SCREENING RATES FOR 1996.] 
 20.4      The preadmission screening payment to a county for fiscal 
 20.5   year 1996 shall be the rate in effect for fiscal year 1995 
 20.6   increased by three percent. 
 20.7      Sec. 13.  [APPROPRIATION.] 
 20.8      $....... is appropriated from the general fund to the 
 20.9   commissioner of human services for the purposes of sections 1 to 
 20.10  12, to be available until June 30, 1997.