1.1                          A bill for an act 
  1.2             relating to human services; modifying provisions for 
  1.3             developmental disabilities; clarifying the intent of 
  1.4             consolidated standards; clarifying who may administer 
  1.5             medication; requiring written authorization for 
  1.6             safekeeping of consumer funds; changing provisions for 
  1.7             the family support program and personal care services; 
  1.8             amending Minnesota Statutes 1998, sections 245B.05, 
  1.9             subdivision 7; 245B.07, subdivisions 5, 8, and 10; 
  1.10            252.32, subdivision 3a; 256B.04, subdivision 16; 
  1.11            256B.0625, subdivisions 6a and 19c; 256B.0627, 
  1.12            subdivisions 1, 2, 4, 5, 8, and by adding 
  1.13            subdivisions; 256B.501, subdivision 8a; and 256B.77, 
  1.14            subdivisions 7a, 8, 10, 14, and by adding subdivisions.
  1.15  BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MINNESOTA: 
  1.16     Section 1.  Minnesota Statutes 1998, section 245B.05, 
  1.17  subdivision 7, is amended to read: 
  1.18     Subd. 7.  [REPORTING INCIDENTS AND EMERGENCIES.] The 
  1.19  license holder must report the following incidents to the 
  1.20  consumer's legal representative, caregiver, and case manager 
  1.21  within 24 hours of the occurrence, or within 24 hours of receipt 
  1.22  of the information: 
  1.23     (1) the death of a consumer; 
  1.24     (2) any medical emergencies, unexpected serious illnesses, 
  1.25  or accidents that require physician treatment or 
  1.26  hospitalization; 
  1.27     (3) a consumer's unauthorized absence; or 
  1.28     (4) any fires and incidents involving a law enforcement 
  1.29  agency. 
  1.30     Death or serious injury of the consumer must also be 
  2.1   reported to the commissioner department of human services 
  2.2   licensing division and the ombudsman, as required under sections 
  2.3   245.91 and 245.94, subdivision 2a. 
  2.4      Sec. 2.  Minnesota Statutes 1998, section 245B.07, 
  2.5   subdivision 5, is amended to read: 
  2.6      Subd. 5.  [STAFF ORIENTATION.] (a) Within 60 days of hiring 
  2.7   staff who provide direct service, the license holder must 
  2.8   provide 30 hours of staff orientation.  Direct care staff must 
  2.9   complete 15 of the 30 hours orientation before providing any 
  2.10  unsupervised direct service to a consumer.  If the staff person 
  2.11  has received orientation training from a license holder licensed 
  2.12  under this chapter, or provides semi-independent living services 
  2.13  only, the 15-hour requirement may be reduced to eight hours.  
  2.14  The total orientation of 30 hours may be reduced to 15 hours if 
  2.15  the staff person has previously received orientation training 
  2.16  from a license holder licensed under this chapter. 
  2.17     (b) The 30 hours of orientation must combine supervised 
  2.18  on-the-job training with coverage of the following material: 
  2.19     (1) review of the consumer's service plans and risk 
  2.20  management plan to achieve an understanding of the consumer as a 
  2.21  unique individual; 
  2.22     (2) review and instruction on the license holder's policies 
  2.23  and procedures, including their location and access; 
  2.24     (3) emergency procedures; 
  2.25     (4) explanation of specific job functions, including 
  2.26  implementing objectives from the consumer's individual service 
  2.27  plan; 
  2.28     (5) explanation of responsibilities related to section 
  2.29  245A.65; sections 626.556 and 626.557, governing maltreatment 
  2.30  reporting and service planning for children and vulnerable 
  2.31  adults; and section 245.825, governing use of aversive and 
  2.32  deprivation procedures; 
  2.33     (6) medication administration as it applies to the 
  2.34  individual consumer, from a training curriculum developed by a 
  2.35  health services professional described in section 245B.05, 
  2.36  subdivision 5, and when the consumer meets the criteria of 
  3.1   having overriding health care needs, then medication 
  3.2   administration taught by a health services professional.  Staff 
  3.3   may administer medications only after they demonstrate the 
  3.4   ability, as defined in the license holder's medication 
  3.5   administration policy and procedures.  Once a consumer with 
  3.6   overriding health care needs is admitted, staff will be provided 
  3.7   with remedial training as deemed necessary by the license holder 
  3.8   and the health professional to meet the needs of that consumer. 
  3.9      For purposes of this section, overriding health care needs 
  3.10  means a health care condition that affects the service options 
  3.11  available to the consumer because the condition requires: 
  3.12     (i) specialized or intensive medical or nursing 
  3.13  supervision; and 
  3.14     (ii) nonmedical service providers to adapt their services 
  3.15  to accommodate the health and safety needs of the consumer; 
  3.16     (7) consumer rights; and 
  3.17     (8) other topics necessary as determined by the consumer's 
  3.18  individual service plan or other areas identified by the license 
  3.19  holder. 
  3.20     (c) The license holder must document each employee's 
  3.21  orientation received. 
  3.22     Sec. 3.  Minnesota Statutes 1998, section 245B.07, 
  3.23  subdivision 8, is amended to read: 
  3.24     Subd. 8.  [POLICIES AND PROCEDURES.] The license holder 
  3.25  must develop and implement the policies and procedures in 
  3.26  paragraphs (1) to (3). 
  3.27     (1) policies and procedures that promote consumer health 
  3.28  and safety by ensuring: 
  3.29     (i) consumer safety in emergency situations as identified 
  3.30  in section 245B.05, subdivision 7; 
  3.31     (ii) consumer health through sanitary practices; 
  3.32     (iii) safe transportation, when the license holder is 
  3.33  responsible for transportation of consumers, with provisions for 
  3.34  handling emergency situations; 
  3.35     (iv) a system of recordkeeping for both individuals and the 
  3.36  organization, for review of incidents and emergencies, and 
  4.1   corrective action if needed; 
  4.2      (v) a plan for responding to and reporting all emergencies, 
  4.3   including deaths, medical emergencies, illnesses, accidents, 
  4.4   missing consumers, fires, severe weather and natural disasters, 
  4.5   bomb threats, and other threats; 
  4.6      (vi) safe medication administration as identified in 
  4.7   section 245B.05, subdivision 5, incorporating an observed skill 
  4.8   assessment to ensure that staff demonstrate the ability to 
  4.9   administer medications consistent with the license holder's 
  4.10  policy and procedures; 
  4.11     (vii) psychotropic medication monitoring when the consumer 
  4.12  is prescribed a psychotropic medication, including the use of 
  4.13  the psychotropic medication use checklist.  If the 
  4.14  responsibility for implementing the psychotropic medication use 
  4.15  checklist has not been assigned in the individual service plan 
  4.16  and the consumer lives in a licensed site, the residential 
  4.17  license holder shall be designated; and 
  4.18     (viii) criteria for admission or service initiation 
  4.19  developed by the license holder; 
  4.20     (2) policies and procedures that protect consumer rights 
  4.21  and privacy by ensuring: 
  4.22     (i) consumer data privacy, in compliance with the Minnesota 
  4.23  Data Practices Act, chapter 13; and 
  4.24     (ii) that complaint procedures provide consumers with a 
  4.25  simple process to bring grievances and consumers receive a 
  4.26  response to the grievance within a reasonable time period.  The 
  4.27  license holder must provide a copy of the program's grievance 
  4.28  procedure and time lines for addressing grievances.  The 
  4.29  program's grievance procedure must permit consumers served by 
  4.30  the program and the authorized representatives to bring a 
  4.31  grievance to the highest level of authority in the program; and 
  4.32     (3) policies and procedures that promote continuity and 
  4.33  quality of consumer supports by ensuring: 
  4.34     (i) continuity of care and service coordination, including 
  4.35  provisions for service termination, temporary service 
  4.36  suspension, and efforts made by the license holder to coordinate 
  5.1   services with other vendors who also provide support to the 
  5.2   consumer.  The policy must include the following requirements: 
  5.3      (A) the license holder must notify the consumer or 
  5.4   consumer's legal representative and the consumer's case manager 
  5.5   in writing of the intended termination or temporary service 
  5.6   suspension and the consumer's right to seek a temporary order 
  5.7   staying the termination or suspension of service according to 
  5.8   the procedures in section 256.045, subdivision 4a or subdivision 
  5.9   6, paragraph (c); 
  5.10     (B) notice of the proposed termination of services, 
  5.11  including those situations that began with a temporary service 
  5.12  suspension, must be given at least 60 days before the proposed 
  5.13  termination is to become effective, unless services are 
  5.14  temporarily suspended according to the license holder's written 
  5.15  temporary service suspension procedures, in which case notice 
  5.16  must be given as soon as possible; 
  5.17     (C) the license holder must provide information requested 
  5.18  by the consumer or consumer's legal representative or case 
  5.19  manager when services are temporarily suspended or upon notice 
  5.20  of termination; 
  5.21     (D) use of temporary service suspension procedures are 
  5.22  restricted to situations in which the consumer's behavior causes 
  5.23  immediate and serious danger to the health and safety of the 
  5.24  individual or others; 
  5.25     (E) prior to giving notice of service termination or 
  5.26  temporary service suspension, the license holder must document 
  5.27  actions taken to minimize or eliminate the need for service 
  5.28  termination or temporary service suspension; and 
  5.29     (F) during the period of temporary service suspension, the 
  5.30  license holder will work with the appropriate county agency to 
  5.31  develop reasonable alternatives to protect the individual and 
  5.32  others; and 
  5.33     (ii) quality services measured through a program evaluation 
  5.34  process including regular evaluations of consumer satisfaction 
  5.35  and sharing the results of the evaluations with the consumers 
  5.36  and legal representatives. 
  6.1      Sec. 4.  Minnesota Statutes 1998, section 245B.07, 
  6.2   subdivision 10, is amended to read: 
  6.3      Subd. 10.  [CONSUMER FUNDS.] (a) The license holder must 
  6.4   ensure that consumers retain the use and availability of 
  6.5   personal funds or property unless restrictions are justified in 
  6.6   the consumer's individual service plan. 
  6.7      (b) The license holder must ensure separation of resident 
  6.8   consumer funds from funds of the license holder, the residential 
  6.9   program, or program staff. 
  6.10     (c) Whenever the license holder assists a consumer with the 
  6.11  safekeeping of funds or other property, the license holder 
  6.12  must have written authorization to do so by the consumer or the 
  6.13  consumer's legal representative, and the case manager.  In 
  6.14  addition, the license holder must: 
  6.15     (1) document receipt and disbursement of the consumer's 
  6.16  funds or the property, and include the signature of the 
  6.17  consumer, conservator, or payee; 
  6.18     (2) provide a statement at least quarterly itemizing 
  6.19  annually survey, document, and implement the preferences of the 
  6.20  consumer, consumer's legal representative, and the case manager 
  6.21  for frequency of receiving a statement that itemizes receipts 
  6.22  and disbursements of resident consumer funds or other property; 
  6.23  and 
  6.24     (3) return to the consumer upon the consumer's request, 
  6.25  funds and property in the license holder's possession subject to 
  6.26  restrictions in the consumer's individual service plan, as soon 
  6.27  as possible, but no later than three working days after the date 
  6.28  of the request. 
  6.29     (d) License holders and program staff must not: 
  6.30     (1) borrow money from a consumer; 
  6.31     (2) purchase personal items from a consumer; 
  6.32     (3) sell merchandise or personal services to a consumer; 
  6.33     (4) require a resident consumer to purchase items for which 
  6.34  the license holder is eligible for reimbursement; or 
  6.35     (5) use resident consumer funds in a manner that would 
  6.36  violate section 256B.04, or any rules promulgated under that 
  7.1   section. 
  7.2      Sec. 5.  Minnesota Statutes 1998, section 252.32, 
  7.3   subdivision 3a, is amended to read: 
  7.4      Subd. 3a.  [REPORTS AND ALLOCATIONS.] (a) The commissioner 
  7.5   shall specify requirements for quarterly fiscal and annual 
  7.6   program reports according to section 256.01, subdivision 2, 
  7.7   paragraph (17).  Program reports shall include data which will 
  7.8   enable the commissioner to evaluate program effectiveness and to 
  7.9   audit compliance.  The commissioner shall reimburse county costs 
  7.10  on a quarterly basis. 
  7.11     (b) Beginning January 1, 1998, The commissioner shall 
  7.12  allocate state funds made available under this section to county 
  7.13  social service agencies on a calendar year basis.  The 
  7.14  commissioner shall allocate to each county first in amounts 
  7.15  equal to each county's guaranteed floor as described in clause 
  7.16  (1), and second, any remaining funds, after the allocation of 
  7.17  funds to the newly participating counties as provided for in 
  7.18  clause (3), shall be allocated in proportion to each county's 
  7.19  total number of families receiving a grant on July 1 of the most 
  7.20  recent calendar year will be allocated to county agencies to 
  7.21  support children in their family homes.  
  7.22     (1) Each county's guaranteed floor shall be calculated as 
  7.23  follows:  
  7.24     (i) 95 percent of the county's allocation received in the 
  7.25  preceding calendar year.  For the calendar year 1998 allocation, 
  7.26  the preceding calendar year shall be considered to be double the 
  7.27  six-month allocation as provided in clause (2); 
  7.28     (ii) when the amount of funds available for allocation is 
  7.29  less than the amount available in the preceding year, each 
  7.30  county's previous year allocation shall be reduced in proportion 
  7.31  to the reduction in statewide funding, for the purpose of 
  7.32  establishing the guaranteed floor.  
  7.33     (2) For the period July 1, 1997, to December 31, 1997, the 
  7.34  commissioner shall allocate to each county an amount equal to 
  7.35  the actual, state approved grants issued to the families for the 
  7.36  month of January 1997, multiplied by six.  This six-month 
  8.1   allocation shall be combined with the calendar year 1998 
  8.2   allocation and be administered as an 18-month allocation.  
  8.3      (3) At the commissioner's discretion, funds may be 
  8.4   allocated to any nonparticipating county that requests an 
  8.5   allocation under this section.  Allocations to newly 
  8.6   participating counties are dependent upon the availability of 
  8.7   funds, as determined by the actual expenditure amount of the 
  8.8   participating counties for the most recently completed calendar 
  8.9   year.  
  8.10     (4) The commissioner shall regularly review the use of 
  8.11  family support fund allocations by county.  The commissioner may 
  8.12  reallocate unexpended or unencumbered money at any time to those 
  8.13  counties that have a demonstrated need for additional funding.  
  8.14     (c) County allocations under this section will be adjusted 
  8.15  for transfers that occur according to section 256.476 or when 
  8.16  the county of financial responsibility changes according to 
  8.17  chapter 256G for eligible recipients. 
  8.18     Sec. 6.  Minnesota Statutes 1998, section 256B.04, 
  8.19  subdivision 16, is amended to read: 
  8.20     Subd. 16.  [PERSONAL CARE SERVICES.] (a) Notwithstanding 
  8.21  any contrary language in this paragraph, the commissioner of 
  8.22  human services and the commissioner of health shall jointly 
  8.23  promulgate rules to be applied to the licensure of personal care 
  8.24  services provided under the medical assistance program.  The 
  8.25  rules shall consider standards for personal care services that 
  8.26  are based on the World Institute on Disability's recommendations 
  8.27  regarding personal care services.  These rules shall at a 
  8.28  minimum consider the standards and requirements adopted by the 
  8.29  commissioner of health under section 144A.45, which the 
  8.30  commissioner of human services determines are applicable to the 
  8.31  provision of personal care services, in addition to other 
  8.32  standards or modifications which the commissioner of human 
  8.33  services determines are appropriate. 
  8.34     The commissioner of human services shall establish an 
  8.35  advisory group including personal care consumers and providers 
  8.36  to provide advice regarding which standards or modifications 
  9.1   should be adopted.  The advisory group membership must include 
  9.2   not less than 15 members, of which at least 60 percent must be 
  9.3   consumers of personal care services and representatives of 
  9.4   recipients with various disabilities and diagnoses and ages.  At 
  9.5   least 51 percent of the members of the advisory group must be 
  9.6   recipients of personal care. 
  9.7      The commissioner of human services may contract with the 
  9.8   commissioner of health to enforce the jointly promulgated 
  9.9   licensure rules for personal care service providers. 
  9.10     Prior to final promulgation of the joint rule the 
  9.11  commissioner of human services shall report preliminary findings 
  9.12  along with any comments of the advisory group and a plan for 
  9.13  monitoring and enforcement by the department of health to the 
  9.14  legislature by February 15, 1992. 
  9.15     Limits on the extent of personal care services that may be 
  9.16  provided to an individual must be based on the 
  9.17  cost-effectiveness of the services in relation to the costs of 
  9.18  inpatient hospital care, nursing home care, and other available 
  9.19  types of care.  The rules must provide, at a minimum:  
  9.20     (1) that agencies be selected to contract with or employ 
  9.21  and train staff to provide and supervise the provision of 
  9.22  personal care services; 
  9.23     (2) that agencies employ or contract with a qualified 
  9.24  applicant that a qualified recipient proposes to the agency as 
  9.25  the recipient's choice of assistant; 
  9.26     (3) that agencies bill the medical assistance program for a 
  9.27  personal care service by a personal care assistant and 
  9.28  supervision by the registered nurse a qualified professional 
  9.29  supervising the personal care assistant unless the recipient 
  9.30  selects the fiscal agent option under section 256B.0627, 
  9.31  subdivision 10; 
  9.32     (4) that agencies establish a grievance mechanism; and 
  9.33     (5) that agencies have a quality assurance program.  
  9.34     (b) The commissioner may waive the requirement for the 
  9.35  provision of personal care services through an agency in a 
  9.36  particular county, when there are less than two agencies 
 10.1   providing services in that county and shall waive the 
 10.2   requirement for personal care assistants required to join an 
 10.3   agency for the first time during 1993 when personal care 
 10.4   services are provided under a relative hardship waiver under 
 10.5   section 256B.0627, subdivision 4, paragraph (b), clause (7), and 
 10.6   at least two agencies providing personal care services have 
 10.7   refused to employ or contract with the independent personal care 
 10.8   assistant. 
 10.9      Sec. 7.  Minnesota Statutes 1998, section 256B.0625, 
 10.10  subdivision 6a, is amended to read: 
 10.11     Subd. 6a.  [HOME HEALTH SERVICES.] Home health services are 
 10.12  those services specified in Minnesota Rules, part 9505.0290. 
 10.13  Medical assistance covers home health services at a recipient's 
 10.14  home residence.  Medical assistance does not cover home health 
 10.15  services for residents of a hospital, nursing facility, or 
 10.16  intermediate care facility, or a health care facility licensed 
 10.17  by the commissioner of health, unless the program is funded 
 10.18  under a home and community-based services waiver or unless the 
 10.19  commissioner of human services has prior authorized skilled 
 10.20  nurse visits for less than 90 days for a resident at an 
 10.21  intermediate care facility for persons with mental retardation, 
 10.22  to prevent an admission to a hospital or nursing facility or 
 10.23  unless a resident who is otherwise eligible is on leave from the 
 10.24  facility and the facility either pays for the home health 
 10.25  services or forgoes the facility per diem for the leave days 
 10.26  that home health services are used.  Home health services must 
 10.27  be provided by a Medicare certified home health agency.  All 
 10.28  nursing and home health aide services must be provided according 
 10.29  to section 256B.0627. 
 10.30     Sec. 8.  Minnesota Statutes 1998, section 256B.0625, 
 10.31  subdivision 19c, is amended to read: 
 10.32     Subd. 19c.  [PERSONAL CARE.] Medical assistance covers 
 10.33  personal care services provided by an individual who is 
 10.34  qualified to provide the services according to subdivision 19a 
 10.35  and section 256B.0627, where the services are prescribed by a 
 10.36  physician in accordance with a plan of treatment and are 
 11.1   supervised by a registered nurse the recipient under the fiscal 
 11.2   agent option according to section 256B.0627, subdivision 10, or 
 11.3   a qualified professional.  "Qualified professional" means a 
 11.4   mental health professional as defined in section 245.462, 
 11.5   subdivision 18, or 245.4871, subdivision 26; or a registered 
 11.6   nurse as defined in sections 148.171 to 148.285.  As part of the 
 11.7   assessment, the county public health nurse will consult with the 
 11.8   recipient or responsible party and identify the most appropriate 
 11.9   person to provide supervision of the personal care assistant.  
 11.10  The qualified professional shall perform the duties described in 
 11.11  Minnesota Rules, part 9505.0335, subpart 4.  
 11.12     Sec. 9.  Minnesota Statutes 1998, section 256B.0627, 
 11.13  subdivision 1, is amended to read: 
 11.14     Subdivision 1.  [DEFINITION.] (a) "Assessment" means a 
 11.15  review and evaluation of a recipient's need for home care 
 11.16  services conducted in person.  Assessments for private duty 
 11.17  nursing shall be conducted by a registered private duty nurse.  
 11.18  Assessments for home health agency services shall be conducted 
 11.19  by a home health agency nurse.  Assessments for personal 
 11.20  care assistant services shall be conducted by the county public 
 11.21  health nurse or a certified public health nurse under contract 
 11.22  with the county.  An initial assessment for personal care 
 11.23  services is conducted on individuals who are requesting personal 
 11.24  care services or for those consumers who have never had a public 
 11.25  health nurse assessment.  The initial A face-to-face assessment 
 11.26  must include:  a face-to-face health status assessment and 
 11.27  determination of baseline need, evaluation of service outcomes, 
 11.28  collection of initial case data, identification of appropriate 
 11.29  services and service plan development or modification, 
 11.30  coordination of initial services, referrals and follow-up to 
 11.31  appropriate payers and community resources, completion of 
 11.32  required reports, obtaining service authorization, and consumer 
 11.33  education.  A reassessment visit face-to-face assessment for 
 11.34  personal care services is conducted on those recipients who have 
 11.35  never had a county public health nurse assessment, at least 
 11.36  annually or when there is a significant change in consumer 
 12.1   condition and or a change in the need for personal care 
 12.2   assistant services.  The reassessment visit A service update may 
 12.3   substitute for the annual face-to-face assessment when there is 
 12.4   not a significant change in recipient condition or a change in 
 12.5   the need for personal care assistant service.  A service update 
 12.6   or review for temporary increase includes a review of initial 
 12.7   baseline data, evaluation of service outcomes, redetermination 
 12.8   of service need, modification of service plan and appropriate 
 12.9   referrals, update of initial forms, obtaining service 
 12.10  authorization, and on going consumer education.  Assessments for 
 12.11  medical assistance home care services for mental retardation or 
 12.12  related conditions and alternative care services for 
 12.13  developmentally disabled home and community-based waivered 
 12.14  recipients may be conducted by the county public health nurse to 
 12.15  ensure coordination and avoid duplication.  Assessments must be 
 12.16  completed on forms provided by the commissioner within 30 days 
 12.17  of a request for home care services by a recipient or 
 12.18  responsible party. 
 12.19     (b) "Care plan" means a written description of personal 
 12.20  care assistant services developed by the agency nurse qualified 
 12.21  professional with the recipient or responsible party under the 
 12.22  fiscal agent option to be used by the personal care assistant 
 12.23  with a copy provided to the recipient or responsible party. 
 12.24     (c) "Home care services" means a health service, determined 
 12.25  by the commissioner as medically necessary, that is ordered by a 
 12.26  physician and documented in a service plan that is reviewed by 
 12.27  the physician at least once every 60 62 days for the provision 
 12.28  of home health services, or private duty nursing, or at least 
 12.29  once every 365 days for personal care.  Home care services are 
 12.30  provided to the recipient at the recipient's residence that is a 
 12.31  place other than a hospital or long-term care facility or as 
 12.32  specified in section 256B.0625.  
 12.33     (d) "Medically necessary" has the meaning given in 
 12.34  Minnesota Rules, parts 9505.0170 to 9505.0475.  
 12.35     (e) "Personal care assistant" means a person who:  (1) is 
 12.36  at least 18 years old, except for persons 16 to 18 years of age 
 13.1   who participated in a related school-based job training program 
 13.2   or have completed a certified home health aide competency 
 13.3   evaluation; (2) is able to effectively communicate with the 
 13.4   recipient and personal care provider organization; (3) effective 
 13.5   July 1, 1996, has completed one of the training requirements as 
 13.6   specified in Minnesota Rules, part 9505.0335, subpart 3, items A 
 13.7   to D; (4) has the ability to, and provides covered personal care 
 13.8   services according to the recipient's care plan, responds 
 13.9   appropriately to recipient needs, and reports changes in the 
 13.10  recipient's condition to the supervising registered nurse 
 13.11  qualified professional or recipient under the fiscal agent 
 13.12  option; (5) is not a consumer of personal care services; and (6) 
 13.13  is subject to criminal background checks and procedures 
 13.14  specified in section 245A.04.  An individual who has been 
 13.15  convicted of a crime specified in Minnesota Rules, part 
 13.16  4668.0020, subpart 14, or a comparable crime in another 
 13.17  jurisdiction is disqualified from being a personal care 
 13.18  assistant, unless the individual meets the rehabilitation 
 13.19  criteria specified in Minnesota Rules, part 4668.0020, subpart 
 13.20  15. 
 13.21     (f) "Personal care provider organization" means an 
 13.22  organization enrolled to provide personal care services under 
 13.23  the medical assistance program that complies with the 
 13.24  following:  (1) owners who have a five percent interest or more, 
 13.25  and managerial officials are subject to a background study as 
 13.26  provided in section 245A.04.  This applies to currently enrolled 
 13.27  personal care provider organizations and those agencies seeking 
 13.28  enrollment as a personal care provider organization.  An 
 13.29  organization will be barred from enrollment if an owner or 
 13.30  managerial official of the organization has been convicted of a 
 13.31  crime specified in section 245A.04, or a comparable crime in 
 13.32  another jurisdiction, unless the owner or managerial official 
 13.33  meets the reconsideration criteria specified in section 245A.04; 
 13.34  (2) the organization must maintain a surety bond and liability 
 13.35  insurance throughout the duration of enrollment and provides 
 13.36  proof thereof.  The insurer must notify the department of human 
 14.1   services of the cancellation or lapse of policy; and (3) the 
 14.2   organization must maintain documentation of services as 
 14.3   specified in Minnesota Rules, part 9505.2175, subpart 7, as well 
 14.4   as evidence of compliance with personal care assistant training 
 14.5   requirements. 
 14.6      (g) "Responsible party" means an individual residing with a 
 14.7   recipient of personal care services who is capable of providing 
 14.8   the supportive care necessary to assist the recipient to live in 
 14.9   the community, is at least 18 years old, and is not a personal 
 14.10  care assistant.  Responsible parties who are parents of minors 
 14.11  or guardians of minors or incapacitated persons may delegate the 
 14.12  responsibility to another adult during a temporary absence of at 
 14.13  least 24 hours but not more than six months.  The person 
 14.14  delegated as a responsible party must be able to meet the 
 14.15  definition of responsible party, except that the delegated 
 14.16  responsible party is required to reside with the recipient only 
 14.17  while serving as the responsible party.  Foster care license 
 14.18  holders may be designated the responsible party for residents of 
 14.19  the foster care home if case management is provided as required 
 14.20  in section 256B.0625, subdivision 19a.  For persons who, as of 
 14.21  April 1, 1992, are sharing personal care services in order to 
 14.22  obtain the availability of 24-hour coverage, an employee of the 
 14.23  personal care provider organization may be designated as the 
 14.24  responsible party if case management is provided as required in 
 14.25  section 256B.0625, subdivision 19a. 
 14.26     (h) "Service plan" means a written description of the 
 14.27  services needed based on the assessment developed by the nurse 
 14.28  who conducts the assessment together with the recipient or 
 14.29  responsible party.  The service plan shall include a description 
 14.30  of the covered home care services, frequency and duration of 
 14.31  services, and expected outcomes and goals.  The recipient and 
 14.32  the provider chosen by the recipient or responsible party must 
 14.33  be given a copy of the completed service plan within 30 calendar 
 14.34  days of the request for home care services by the recipient or 
 14.35  responsible party. 
 14.36     (i) "Skilled nurse visits" are provided in a recipient's 
 15.1   residence under a plan of care or service plan that specifies a 
 15.2   level of care which the nurse is qualified to provide.  These 
 15.3   services are: 
 15.4      (1) nursing services according to the written plan of care 
 15.5   or service plan and accepted standards of medical and nursing 
 15.6   practice in accordance with chapter 148; 
 15.7      (2) services which due to the recipient's medical condition 
 15.8   may only be safely and effectively provided by a registered 
 15.9   nurse or a licensed practical nurse; 
 15.10     (3) assessments performed only by a registered nurse; and 
 15.11     (4) teaching and training the recipient, the recipient's 
 15.12  family, or other caregivers requiring the skills of a registered 
 15.13  nurse or licensed practical nurse.  
 15.14     Sec. 10.  Minnesota Statutes 1998, section 256B.0627, 
 15.15  subdivision 2, is amended to read: 
 15.16     Subd. 2.  [SERVICES COVERED.] Home care services covered 
 15.17  under this section include:  
 15.18     (1) nursing services under section 256B.0625, subdivision 
 15.19  6a; 
 15.20     (2) private duty nursing services under section 256B.0625, 
 15.21  subdivision 7; 
 15.22     (3) home health aide services under section 256B.0625, 
 15.23  subdivision 6a; 
 15.24     (4) personal care services under section 256B.0625, 
 15.25  subdivision 19a; 
 15.26     (5) nursing supervision of personal care assistant services 
 15.27  provided by a qualified professional under section 256B.0625, 
 15.28  subdivision 19a; and 
 15.29     (6) consulting professional of personal care assistant 
 15.30  services under the fiscal agent option as specified in 
 15.31  subdivision 10; 
 15.32     (7) face-to-face assessments by county public health nurses 
 15.33  for services under section 256B.0625, subdivision 19a; and 
 15.34     (8) service updates and review of temporary increases for 
 15.35  personal care assistant services by the county public health 
 15.36  nurse for services under section 256B.0625, subdivision 19a. 
 16.1      Sec. 11.  Minnesota Statutes 1998, section 256B.0627, 
 16.2   subdivision 4, is amended to read: 
 16.3      Subd. 4.  [PERSONAL CARE SERVICES.] (a) The personal care 
 16.4   services that are eligible for payment are the following:  
 16.5      (1) bowel and bladder care; 
 16.6      (2) skin care to maintain the health of the skin; 
 16.7      (3) repetitive maintenance range of motion, muscle 
 16.8   strengthening exercises, and other tasks specific to maintaining 
 16.9   a recipient's optimal level of function; 
 16.10     (4) respiratory assistance; 
 16.11     (5) transfers and ambulation; 
 16.12     (6) bathing, grooming, and hairwashing necessary for 
 16.13  personal hygiene; 
 16.14     (7) turning and positioning; 
 16.15     (8) assistance with furnishing medication that is 
 16.16  self-administered; 
 16.17     (9) application and maintenance of prosthetics and 
 16.18  orthotics; 
 16.19     (10) cleaning medical equipment; 
 16.20     (11) dressing or undressing; 
 16.21     (12) assistance with eating and meal preparation and 
 16.22  necessary grocery shopping; 
 16.23     (13) accompanying a recipient to obtain medical diagnosis 
 16.24  or treatment; 
 16.25     (14) assisting, monitoring, or prompting the recipient to 
 16.26  complete the services in clauses (1) to (13); 
 16.27     (15) redirection, monitoring, and observation that are 
 16.28  medically necessary and an integral part of completing the 
 16.29  personal care services described in clauses (1) to (14); 
 16.30     (16) redirection and intervention for behavior, including 
 16.31  observation and monitoring; 
 16.32     (17) interventions for seizure disorders, including 
 16.33  monitoring and observation if the recipient has had a seizure 
 16.34  that requires intervention within the past three months; 
 16.35     (18) tracheostomy suctioning using a clean procedure if the 
 16.36  procedure is properly delegated by a registered nurse.  Before 
 17.1   this procedure can be delegated to a personal care assistant, a 
 17.2   registered nurse must determine that the tracheostomy suctioning 
 17.3   can be accomplished utilizing a clean rather than a sterile 
 17.4   procedure and must ensure that the personal care assistant has 
 17.5   been taught the proper procedure; and 
 17.6      (19) incidental household services that are an integral 
 17.7   part of a personal care service described in clauses (1) to (18).
 17.8   For purposes of this subdivision, monitoring and observation 
 17.9   means watching for outward visible signs that are likely to 
 17.10  occur and for which there is a covered personal care service or 
 17.11  an appropriate personal care intervention.  For purposes of this 
 17.12  subdivision, a clean procedure refers to a procedure that 
 17.13  reduces the numbers of microorganisms or prevents or reduces the 
 17.14  transmission of microorganisms from one person or place to 
 17.15  another.  A clean procedure may be used beginning 14 days after 
 17.16  insertion. 
 17.17     (b) The personal care services that are not eligible for 
 17.18  payment are the following:  
 17.19     (1) services not ordered by the physician; 
 17.20     (2) assessments by personal care provider organizations or 
 17.21  by independently enrolled registered nurses; 
 17.22     (3) services that are not in the service plan; 
 17.23     (4) services provided by the recipient's spouse, legal 
 17.24  guardian for an adult or child recipient, or parent of a 
 17.25  recipient under age 18; 
 17.26     (5) services provided by a foster care provider of a 
 17.27  recipient who cannot direct the recipient's own care, unless 
 17.28  monitored by a county or state case manager under section 
 17.29  256B.0625, subdivision 19a; 
 17.30     (6) services provided by the residential or program license 
 17.31  holder in a residence for more than four persons; 
 17.32     (7) services that are the responsibility of a residential 
 17.33  or program license holder under the terms of a service agreement 
 17.34  and administrative rules; 
 17.35     (8) sterile procedures; 
 17.36     (9) injections of fluids into veins, muscles, or skin; 
 18.1      (10) services provided by parents of adult recipients, 
 18.2   adult children, or adult siblings of the recipient, unless these 
 18.3   relatives meet one of the following hardship criteria and the 
 18.4   commissioner waives this requirement: 
 18.5      (i) the relative resigns from a part-time or full-time job 
 18.6   to provide personal care for the recipient; 
 18.7      (ii) the relative goes from a full-time to a part-time job 
 18.8   with less compensation to provide personal care for the 
 18.9   recipient; 
 18.10     (iii) the relative takes a leave of absence without pay to 
 18.11  provide personal care for the recipient; 
 18.12     (iv) the relative incurs substantial expenses by providing 
 18.13  personal care for the recipient; or 
 18.14     (v) because of labor conditions, special language needs, or 
 18.15  intermittent hours of care needed, the relative is needed in 
 18.16  order to provide an adequate number of qualified personal care 
 18.17  assistants to meet the medical needs of the recipient; 
 18.18     (11) homemaker services that are not an integral part of a 
 18.19  personal care services; 
 18.20     (12) home maintenance, or chore services; 
 18.21     (13) services not specified under paragraph (a); and 
 18.22     (14) services not authorized by the commissioner or the 
 18.23  commissioner's designee. 
 18.24     Sec. 12.  Minnesota Statutes 1998, section 256B.0627, 
 18.25  subdivision 5, is amended to read: 
 18.26     Subd. 5.  [LIMITATION ON PAYMENTS.] Medical assistance 
 18.27  payments for home care services shall be limited according to 
 18.28  this subdivision.  
 18.29     (a)  [LIMITS ON SERVICES WITHOUT PRIOR AUTHORIZATION.] A 
 18.30  recipient may receive the following home care services during a 
 18.31  calendar year: 
 18.32     (1) any initial assessment up to two face-to-face 
 18.33  assessments to determine a recipient's need for personal care 
 18.34  assistant services; 
 18.35     (2) up to two reassessments per year one service update 
 18.36  done to determine a recipient's need for personal care services; 
 19.1   and 
 19.2      (3) up to five skilled nurse visits.  
 19.3      (b)  [PRIOR AUTHORIZATION; EXCEPTIONS.] All home care 
 19.4   services above the limits in paragraph (a) must receive the 
 19.5   commissioner's prior authorization, except when: 
 19.6      (1) the home care services were required to treat an 
 19.7   emergency medical condition that if not immediately treated 
 19.8   could cause a recipient serious physical or mental disability, 
 19.9   continuation of severe pain, or death.  The provider must 
 19.10  request retroactive authorization no later than five working 
 19.11  days after giving the initial service.  The provider must be 
 19.12  able to substantiate the emergency by documentation such as 
 19.13  reports, notes, and admission or discharge histories; 
 19.14     (2) the home care services were provided on or after the 
 19.15  date on which the recipient's eligibility began, but before the 
 19.16  date on which the recipient was notified that the case was 
 19.17  opened.  Authorization will be considered if the request is 
 19.18  submitted by the provider within 20 working days of the date the 
 19.19  recipient was notified that the case was opened; 
 19.20     (3) a third-party payor for home care services has denied 
 19.21  or adjusted a payment.  Authorization requests must be submitted 
 19.22  by the provider within 20 working days of the notice of denial 
 19.23  or adjustment.  A copy of the notice must be included with the 
 19.24  request; 
 19.25     (4) the commissioner has determined that a county or state 
 19.26  human services agency has made an error; or 
 19.27     (5) the professional nurse determines an immediate need for 
 19.28  up to 40 skilled nursing or home health aide visits per calendar 
 19.29  year and submits a request for authorization within 20 working 
 19.30  days of the initial service date, and medical assistance is 
 19.31  determined to be the appropriate payer. 
 19.32     (c)  [RETROACTIVE AUTHORIZATION.] A request for retroactive 
 19.33  authorization will be evaluated according to the same criteria 
 19.34  applied to prior authorization requests.  
 19.35     (d)  [ASSESSMENT AND SERVICE PLAN.] Assessments under 
 19.36  section 256B.0627, subdivision 1, paragraph (a), shall be 
 20.1   conducted initially, and at least annually thereafter, in person 
 20.2   with the recipient and result in a completed service plan using 
 20.3   forms specified by the commissioner.  Within 30 days of 
 20.4   recipient or responsible party request for home care services, 
 20.5   the assessment, the service plan, and other information 
 20.6   necessary to determine medical necessity such as diagnostic or 
 20.7   testing information, social or medical histories, and hospital 
 20.8   or facility discharge summaries shall be submitted to the 
 20.9   commissioner.  For personal care services: 
 20.10     (1) The amount and type of service authorized based upon 
 20.11  the assessment and service plan will follow the recipient if the 
 20.12  recipient chooses to change providers.  
 20.13     (2) If the recipient's medical need changes, the 
 20.14  recipient's provider may assess the need for a change in service 
 20.15  authorization and request the change from the county public 
 20.16  health nurse.  Within 30 days of the request, the public health 
 20.17  nurse will determine whether to request the change in services 
 20.18  based upon the provider assessment, or conduct a home visit to 
 20.19  assess the need and determine whether the change is appropriate. 
 20.20     (3) To continue to receive personal care services after the 
 20.21  first year, the recipient or the responsible party, in 
 20.22  conjunction with the public health nurse, may complete a service 
 20.23  update on forms developed by the commissioner.  The service 
 20.24  update may substitute for the annual reassessment described in 
 20.25  subdivision 1. 
 20.26     (e)  [PRIOR AUTHORIZATION.] The commissioner, or the 
 20.27  commissioner's designee, shall review the assessment, the 
 20.28  service update, request for temporary services, service plan, 
 20.29  and any additional information that is submitted.  The 
 20.30  commissioner shall, within 30 days after receiving a complete 
 20.31  request, assessment, and service plan, authorize home care 
 20.32  services as follows:  
 20.33     (1)  [HOME HEALTH SERVICES.] All home health services 
 20.34  provided by a licensed nurse or a home health aide must be prior 
 20.35  authorized by the commissioner or the commissioner's designee.  
 20.36  Prior authorization must be based on medical necessity and 
 21.1   cost-effectiveness when compared with other care options.  When 
 21.2   home health services are used in combination with personal care 
 21.3   and private duty nursing, the cost of all home care services 
 21.4   shall be considered for cost-effectiveness.  The commissioner 
 21.5   shall limit nurse and home health aide visits to no more than 
 21.6   one visit each per day. 
 21.7      (2)  [PERSONAL CARE SERVICES.] (i) All personal care 
 21.8   services and registered nurse supervision by a qualified 
 21.9   professional must be prior authorized by the commissioner or the 
 21.10  commissioner's designee except for the assessments established 
 21.11  in paragraph (a).  The amount of personal care services 
 21.12  authorized must be based on the recipient's home care rating.  A 
 21.13  child may not be found to be dependent in an activity of daily 
 21.14  living if because of the child's age an adult would either 
 21.15  perform the activity for the child or assist the child with the 
 21.16  activity and the amount of assistance needed is similar to the 
 21.17  assistance appropriate for a typical child of the same age.  
 21.18  Based on medical necessity, the commissioner may authorize: 
 21.19     (A) up to two times the average number of direct care hours 
 21.20  provided in nursing facilities for the recipient's comparable 
 21.21  case mix level; or 
 21.22     (B) up to three times the average number of direct care 
 21.23  hours provided in nursing facilities for recipients who have 
 21.24  complex medical needs or are dependent in at least seven 
 21.25  activities of daily living and need physical assistance with 
 21.26  eating or have a neurological diagnosis; or 
 21.27     (C) up to 60 percent of the average reimbursement rate, as 
 21.28  of July 1, 1991, for care provided in a regional treatment 
 21.29  center for recipients who have Level I behavior, plus any 
 21.30  inflation adjustment as provided by the legislature for personal 
 21.31  care service; or 
 21.32     (D) up to the amount the commissioner would pay, as of July 
 21.33  1, 1991, plus any inflation adjustment provided for home care 
 21.34  services, for care provided in a regional treatment center for 
 21.35  recipients referred to the commissioner by a regional treatment 
 21.36  center preadmission evaluation team.  For purposes of this 
 22.1   clause, home care services means all services provided in the 
 22.2   home or community that would be included in the payment to a 
 22.3   regional treatment center; or 
 22.4      (E) up to the amount medical assistance would reimburse for 
 22.5   facility care for recipients referred to the commissioner by a 
 22.6   preadmission screening team established under section 256B.0911 
 22.7   or 256B.092; and 
 22.8      (F) a reasonable amount of time for the provision of 
 22.9   nursing supervision by a qualified professional of personal care 
 22.10  services.  
 22.11     (ii) The number of direct care hours shall be determined 
 22.12  according to the annual cost report submitted to the department 
 22.13  by nursing facilities.  The average number of direct care hours, 
 22.14  as established by May 1, 1992, shall be calculated and 
 22.15  incorporated into the home care limits on July 1, 1992.  These 
 22.16  limits shall be calculated to the nearest quarter hour. 
 22.17     (iii) The home care rating shall be determined by the 
 22.18  commissioner or the commissioner's designee based on information 
 22.19  submitted to the commissioner by the county public health nurse 
 22.20  on forms specified by the commissioner.  The home care rating 
 22.21  shall be a combination of current assessment tools developed 
 22.22  under sections 256B.0911 and 256B.501 with an addition for 
 22.23  seizure activity that will assess the frequency and severity of 
 22.24  seizure activity and with adjustments, additions, and 
 22.25  clarifications that are necessary to reflect the needs and 
 22.26  conditions of recipients who need home care including children 
 22.27  and adults under 65 years of age.  The commissioner shall 
 22.28  establish these forms and protocols under this section and shall 
 22.29  use an advisory group, including representatives of recipients, 
 22.30  providers, and counties, for consultation in establishing and 
 22.31  revising the forms and protocols. 
 22.32     (iv) A recipient shall qualify as having complex medical 
 22.33  needs if the care required is difficult to perform and because 
 22.34  of recipient's medical condition requires more time than 
 22.35  community-based standards allow or requires more skill than 
 22.36  would ordinarily be required and the recipient needs or has one 
 23.1   or more of the following: 
 23.2      (A) daily tube feedings; 
 23.3      (B) daily parenteral therapy; 
 23.4      (C) wound or decubiti care; 
 23.5      (D) postural drainage, percussion, nebulizer treatments, 
 23.6   suctioning, tracheotomy care, oxygen, mechanical ventilation; 
 23.7      (E) catheterization; 
 23.8      (F) ostomy care; 
 23.9      (G) quadriplegia; or 
 23.10     (H) other comparable medical conditions or treatments the 
 23.11  commissioner determines would otherwise require institutional 
 23.12  care.  
 23.13     (v) A recipient shall qualify as having Level I behavior if 
 23.14  there is reasonable supporting evidence that the recipient 
 23.15  exhibits, or that without supervision, observation, or 
 23.16  redirection would exhibit, one or more of the following 
 23.17  behaviors that cause, or have the potential to cause: 
 23.18     (A) injury to the recipient's own body; 
 23.19     (B) physical injury to other people; or 
 23.20     (C) destruction of property. 
 23.21     (vi) Time authorized for personal care relating to Level I 
 23.22  behavior in subclause (v), items (A) to (C), shall be based on 
 23.23  the predictability, frequency, and amount of intervention 
 23.24  required. 
 23.25     (vii) A recipient shall qualify as having Level II behavior 
 23.26  if the recipient exhibits on a daily basis one or more of the 
 23.27  following behaviors that interfere with the completion of 
 23.28  personal care services under subdivision 4, paragraph (a): 
 23.29     (A) unusual or repetitive habits; 
 23.30     (B) withdrawn behavior; or 
 23.31     (C) offensive behavior. 
 23.32     (viii) A recipient with a home care rating of Level II 
 23.33  behavior in subclause (vii), items (A) to (C), shall be rated as 
 23.34  comparable to a recipient with complex medical needs under 
 23.35  subclause (iv).  If a recipient has both complex medical needs 
 23.36  and Level II behavior, the home care rating shall be the next 
 24.1   complex category up to the maximum rating under subclause (i), 
 24.2   item (B). 
 24.3      (3)  [PRIVATE DUTY NURSING SERVICES.] All private duty 
 24.4   nursing services shall be prior authorized by the commissioner 
 24.5   or the commissioner's designee.  Prior authorization for private 
 24.6   duty nursing services shall be based on medical necessity and 
 24.7   cost-effectiveness when compared with alternative care options.  
 24.8   The commissioner may authorize medically necessary private duty 
 24.9   nursing services in quarter-hour units when: 
 24.10     (i) the recipient requires more individual and continuous 
 24.11  care than can be provided during a nurse visit; or 
 24.12     (ii) the cares are outside of the scope of services that 
 24.13  can be provided by a home health aide or personal care assistant.
 24.14     The commissioner may authorize: 
 24.15     (A) up to two times the average amount of direct care hours 
 24.16  provided in nursing facilities statewide for case mix 
 24.17  classification "K" as established by the annual cost report 
 24.18  submitted to the department by nursing facilities in May 1992; 
 24.19     (B) private duty nursing in combination with other home 
 24.20  care services up to the total cost allowed under clause (2); 
 24.21     (C) up to 16 hours per day if the recipient requires more 
 24.22  nursing than the maximum number of direct care hours as 
 24.23  established in item (A) and the recipient meets the hospital 
 24.24  admission criteria established under Minnesota Rules, parts 
 24.25  9505.0500 to 9505.0540.  
 24.26     The commissioner may authorize up to 16 hours per day of 
 24.27  medically necessary private duty nursing services or up to 24 
 24.28  hours per day of medically necessary private duty nursing 
 24.29  services until such time as the commissioner is able to make a 
 24.30  determination of eligibility for recipients who are 
 24.31  cooperatively applying for home care services under the 
 24.32  community alternative care program developed under section 
 24.33  256B.49, or until it is determined by the appropriate regulatory 
 24.34  agency that a health benefit plan is or is not required to pay 
 24.35  for appropriate medically necessary health care services.  
 24.36  Recipients or their representatives must cooperatively assist 
 25.1   the commissioner in obtaining this determination.  Recipients 
 25.2   who are eligible for the community alternative care program may 
 25.3   not receive more hours of nursing under this section than would 
 25.4   otherwise be authorized under section 256B.49. 
 25.5      (4)  [VENTILATOR-DEPENDENT RECIPIENTS.] If the recipient is 
 25.6   ventilator-dependent, the monthly medical assistance 
 25.7   authorization for home care services shall not exceed what the 
 25.8   commissioner would pay for care at the highest cost hospital 
 25.9   designated as a long-term hospital under the Medicare program.  
 25.10  For purposes of this clause, home care services means all 
 25.11  services provided in the home that would be included in the 
 25.12  payment for care at the long-term hospital.  
 25.13  "Ventilator-dependent" means an individual who receives 
 25.14  mechanical ventilation for life support at least six hours per 
 25.15  day and is expected to be or has been dependent for at least 30 
 25.16  consecutive days.  
 25.17     (f)  [PRIOR AUTHORIZATION; TIME LIMITS.] The commissioner 
 25.18  or the commissioner's designee shall determine the time period 
 25.19  for which a prior authorization shall be effective.  If the 
 25.20  recipient continues to require home care services beyond the 
 25.21  duration of the prior authorization, the home care provider must 
 25.22  request a new prior authorization.  Under no circumstances, 
 25.23  other than the exceptions in paragraph (b), shall a prior 
 25.24  authorization be valid prior to the date the commissioner 
 25.25  receives the request or for more than 12 months.  A recipient 
 25.26  who appeals a reduction in previously authorized home care 
 25.27  services may continue previously authorized services, other than 
 25.28  temporary services under paragraph (h), pending an appeal under 
 25.29  section 256.045.  The commissioner must provide a detailed 
 25.30  explanation of why the authorized services are reduced in amount 
 25.31  from those requested by the home care provider.  
 25.32     (g)  [APPROVAL OF HOME CARE SERVICES.] The commissioner or 
 25.33  the commissioner's designee shall determine the medical 
 25.34  necessity of home care services, the level of caregiver 
 25.35  according to subdivision 2, and the institutional comparison 
 25.36  according to this subdivision, the cost-effectiveness of 
 26.1   services, and the amount, scope, and duration of home care 
 26.2   services reimbursable by medical assistance, based on the 
 26.3   assessment, primary payer coverage determination information as 
 26.4   required, the service plan, the recipient's age, the cost of 
 26.5   services, the recipient's medical condition, and diagnosis or 
 26.6   disability.  The commissioner may publish additional criteria 
 26.7   for determining medical necessity according to section 256B.04. 
 26.8      (h)  [PRIOR AUTHORIZATION REQUESTS; TEMPORARY SERVICES.] 
 26.9   The agency nurse, the independently enrolled private duty nurse, 
 26.10  or county public health nurse may request a temporary 
 26.11  authorization for home care services by telephone.  The 
 26.12  commissioner may approve a temporary level of home care services 
 26.13  based on the assessment, and service or care plan information, 
 26.14  and primary payer coverage determination information as required.
 26.15  Authorization for a temporary level of home care services 
 26.16  including nurse supervision is limited to the time specified by 
 26.17  the commissioner, but shall not exceed 45 days, unless extended 
 26.18  because the county public health nurse has not completed the 
 26.19  required assessment and service plan, or the commissioner's 
 26.20  determination has not been made.  The level of services 
 26.21  authorized under this provision shall have no bearing on a 
 26.22  future prior authorization. 
 26.23     (i)  [PRIOR AUTHORIZATION REQUIRED IN FOSTER CARE SETTING.] 
 26.24  Home care services provided in an adult or child foster care 
 26.25  setting must receive prior authorization by the department 
 26.26  according to the limits established in paragraph (a). 
 26.27     The commissioner may not authorize: 
 26.28     (1) home care services that are the responsibility of the 
 26.29  foster care provider under the terms of the foster care 
 26.30  placement agreement and administrative rules.  Requests for home 
 26.31  care services for recipients residing in a foster care setting 
 26.32  must include the foster care placement agreement and 
 26.33  determination of difficulty of care; 
 26.34     (2) personal care services when the foster care license 
 26.35  holder is also the personal care provider or personal care 
 26.36  assistant unless the recipient can direct the recipient's own 
 27.1   care, or case management is provided as required in section 
 27.2   256B.0625, subdivision 19a; 
 27.3      (3) personal care services when the responsible party is an 
 27.4   employee of, or under contract with, or has any direct or 
 27.5   indirect financial relationship with the personal care provider 
 27.6   or personal care assistant, unless case management is provided 
 27.7   as required in section 256B.0625, subdivision 19a; 
 27.8      (4) home care services when the number of foster care 
 27.9   residents is greater than four unless the county responsible for 
 27.10  the recipient's foster placement made the placement prior to 
 27.11  April 1, 1992, requests that home care services be provided, and 
 27.12  case management is provided as required in section 256B.0625, 
 27.13  subdivision 19a; or 
 27.14     (5) home care services when combined with foster care 
 27.15  payments, other than room and board payments that exceed the 
 27.16  total amount that public funds would pay for the recipient's 
 27.17  care in a medical institution. 
 27.18     Sec. 13.  Minnesota Statutes 1998, section 256B.0627, 
 27.19  subdivision 8, is amended to read: 
 27.20     Subd. 8.  [SHARED PERSONAL CARE ASSISTANT SERVICES; SHARED 
 27.21  CARE.] (a) Medical assistance payments for shared personal care 
 27.22  assistance shared care services shall be limited according to 
 27.23  this subdivision. 
 27.24     (b) Recipients of personal care assistant services may 
 27.25  share staff and the commissioner shall provide a rate system for 
 27.26  shared personal care assistant services.  For two persons 
 27.27  sharing care services, the rate paid to a provider shall not 
 27.28  exceed 1-1/2 times the rate paid for serving a single 
 27.29  individual, and for three persons sharing care services, the 
 27.30  rate paid to a provider shall not exceed twice the rate paid for 
 27.31  serving a single individual.  These rates apply only to 
 27.32  situations in which all recipients were present and received 
 27.33  shared care services on the date for which the service is 
 27.34  billed.  No more than three persons may receive shared care 
 27.35  services from a personal care assistant in a single setting. 
 27.36     (c) Shared care service is the provision of personal care 
 28.1   services by a personal care assistant to two or three recipients 
 28.2   at the same time and in the same setting.  For the purposes of 
 28.3   this subdivision, "setting" means: 
 28.4      (1) the home or foster care home of one of the individual 
 28.5   recipients; or 
 28.6      (2) a child care program in which all recipients served by 
 28.7   one personal care assistant are participating, which is licensed 
 28.8   under chapter 245A or operated by a local school district or 
 28.9   private school.  
 28.10     The provisions of this subdivision do not apply when a 
 28.11  personal care assistant is caring for multiple recipients in 
 28.12  more than one setting. 
 28.13     (d) The recipient or the recipient's responsible party, in 
 28.14  conjunction with the county public health nurse, shall determine:
 28.15     (1) whether shared care personal care assistant services is 
 28.16  an appropriate option based on the individual needs and 
 28.17  preferences of the recipient; and 
 28.18     (2) the amount of shared care services allocated as part of 
 28.19  the overall authorization of personal care services. 
 28.20     The recipient or the responsible party, in conjunction with 
 28.21  the supervising registered nurse qualified professional, shall 
 28.22  approve arrange the setting, and grouping, and arrangement of 
 28.23  shared care services based on the individual needs and 
 28.24  preferences of the recipients.  Decisions on the selection of 
 28.25  recipients to share care services must be based on the ages of 
 28.26  the recipients, compatibility, and coordination of their care 
 28.27  needs. 
 28.28     (e) The following items must be considered by the recipient 
 28.29  or the responsible party and the supervising nurse qualified 
 28.30  professional, and documented in the recipient's care plan health 
 28.31  service record: 
 28.32     (1) the additional qualifications needed by the personal 
 28.33  care assistant to provide care to several recipients in the same 
 28.34  setting; 
 28.35     (2) the additional training and supervision needed by the 
 28.36  personal care assistant to ensure that the needs of the 
 29.1   recipient are met appropriately and safely.  The provider must 
 29.2   provide on-site supervision by a registered nurse qualified 
 29.3   professional within the first 14 days of shared care services, 
 29.4   and monthly thereafter; 
 29.5      (3) the setting in which the shared care services will be 
 29.6   provided; 
 29.7      (4) the ongoing monitoring and evaluation of the 
 29.8   effectiveness and appropriateness of the service and process 
 29.9   used to make changes in service or setting; and 
 29.10     (5) a contingency plan which accounts for absence of the 
 29.11  recipient in a shared care services setting due to illness or 
 29.12  other circumstances and staffing contingencies. 
 29.13     (f) The provider must offer the recipient or the 
 29.14  responsible party the option of shared or individual one-on-one 
 29.15  personal care assistant care services.  The recipient or the 
 29.16  responsible party can withdraw from participating in a shared 
 29.17  care services arrangement at any time. 
 29.18     (g) In addition to documentation requirements under 
 29.19  Minnesota Rules, part 9505.2175, a personal care provider must 
 29.20  meet documentation requirements for shared personal 
 29.21  care assistant services and must document the following in the 
 29.22  health service record for each individual recipient sharing care 
 29.23  services: 
 29.24     (1) authorization permission by the recipient or the 
 29.25  recipient's responsible party, if any, for the maximum number of 
 29.26  shared care services hours per week chosen by the recipient; 
 29.27     (2) authorization permission by the recipient or the 
 29.28  recipient's responsible party, if any, for personal 
 29.29  care assistant services provided outside the recipient's 
 29.30  residence; 
 29.31     (3) authorization permission by the recipient or the 
 29.32  recipient's responsible party, if any, for others to receive 
 29.33  shared care services in the recipient's residence; 
 29.34     (4) revocation by the recipient or the recipient's 
 29.35  responsible party, if any, of the shared care service 
 29.36  authorization, or the shared care service to be provided to 
 30.1   others in the recipient's residence, or the shared care service 
 30.2   to be provided outside the recipient's residence; 
 30.3      (5) supervision of the shared care personal care assistant 
 30.4   services by the supervisory nurse qualified professional, 
 30.5   including the date, time of day, number of hours spent 
 30.6   supervising the provision of shared care services, whether the 
 30.7   supervision was face-to-face or another method of supervision, 
 30.8   changes in the recipient's condition, shared care services 
 30.9   scheduling issues and recommendations; 
 30.10     (6) documentation by the personal care assistant of 
 30.11  telephone calls or other discussions with the supervisory nurse 
 30.12  qualified professional regarding services being provided to the 
 30.13  recipient; and 
 30.14     (7) daily documentation of the shared care services 
 30.15  provided by each identified personal care assistant including: 
 30.16     (i) the names of each recipient receiving shared care 
 30.17  services together; 
 30.18     (ii) the setting for the day's care shared services, 
 30.19  including the starting and ending times that the recipient 
 30.20  received shared care services; and 
 30.21     (iii) notes by the personal care assistant regarding 
 30.22  changes in the recipient's condition, problems that may arise 
 30.23  from the sharing of care services, scheduling issues, care 
 30.24  issues, and other notes as required by the supervising nurse 
 30.25  qualified professional. 
 30.26     (h) Unless otherwise provided in this subdivision, all 
 30.27  other statutory and regulatory provisions relating to personal 
 30.28  care services apply to shared care services. 
 30.29     Nothing in this subdivision shall be construed to reduce 
 30.30  the total number of hours authorized for an individual recipient.
 30.31     Sec. 14.  Minnesota Statutes 1998, section 256B.0627, is 
 30.32  amended by adding a subdivision to read: 
 30.33     Subd. 9.  [FLEXIBLE USE OF PERSONAL CARE ASSISTANT 
 30.34  HOURS.] (a) The commissioner may allow for the flexible use of 
 30.35  personal care assistant hours.  "Flexible use" means the 
 30.36  scheduled use of authorized hours of personal care assistant 
 31.1   services which vary within the length of the service 
 31.2   authorization in order to more effectively meet the needs and 
 31.3   schedule of the recipient or responsible party.  Recipients may 
 31.4   use their approved hours flexibly within the service 
 31.5   authorization period for medically necessary covered services 
 31.6   specified in the assessment required in subdivision 1.  The 
 31.7   flexible use of authorized hours does not increase the total 
 31.8   amount of authorized hours available to a recipient as 
 31.9   determined under subdivision 5.  The commissioner may not 
 31.10  authorize additional personal care assistant services to 
 31.11  supplement a service authorization that is exhausted before the 
 31.12  end date under a flexible service use plan, unless the county 
 31.13  public health nurse determines a change in condition and a need 
 31.14  for increased services is established. 
 31.15     (b) The recipient or responsible party, together with the 
 31.16  county public health nurse, shall determine whether flexible use 
 31.17  is an appropriate option based on the needs and preferences of 
 31.18  the recipient or responsible party, and, if appropriate, must 
 31.19  ensure that the allocation of hours covers the ongoing needs of 
 31.20  the recipient over the entire service authorization period.  As 
 31.21  part of the assessment and service planning process, the 
 31.22  recipient works with the county public health nurse to develop a 
 31.23  written month-to-month plan of the projected use of personal 
 31.24  care assistant services that describes how the: 
 31.25     (1) health and safety needs of the recipient will be met; 
 31.26     (2) total annual authorization is not exceeded before the 
 31.27  end date; and 
 31.28     (3) how actual use of hours will be monitored. 
 31.29     (c) If the actual use of personal care assistant service 
 31.30  varies significantly from the use projected in the plan, the 
 31.31  written plan must be updated by the recipient or responsible 
 31.32  party and the county public health nurse. 
 31.33     (d) The recipient or responsible party, together with the 
 31.34  provider, must work to monitor and document the use of 
 31.35  authorized hours and ensure that a recipient is able to manage 
 31.36  services effectively throughout the authorized period.  Upon 
 32.1   request of the recipient or responsible party, the provider must 
 32.2   furnish regular updates to the recipient or responsible party on 
 32.3   the amount of personal care assistant services used. 
 32.4      (e) The recipient or responsible party may revoke the 
 32.5   authorization for flexible use of hours by notifying the 
 32.6   provider and the county public health nurse in writing. 
 32.7      (f) If the requirements in paragraphs (a) to (e) have not 
 32.8   been met, the commissioner may deny, revoke, or suspend the 
 32.9   authorization to use their authorized hours flexibly.  The 
 32.10  recipient or responsible party may appeal the commissioner's 
 32.11  action according to section 256.045.  The denial, revocation, or 
 32.12  suspension to use the flexible hours option shall not affect the 
 32.13  recipient's authorized level of personal care assistant services 
 32.14  as determined under subdivision 5. 
 32.15     Sec. 15.  Minnesota Statutes 1998, section 256B.0627, is 
 32.16  amended by adding a subdivision to read: 
 32.17     Subd. 10.  [FISCAL AGENT OPTION AVAILABLE FOR PERSONAL CARE 
 32.18  ASSISTANT SERVICES.] (a) "Fiscal agent option" is an option that 
 32.19  allows the recipient to: 
 32.20     (1) use a fiscal agent instead of a personal care provider 
 32.21  organization; 
 32.22     (2) supervise the personal care assistant; and 
 32.23     (3) use a consulting professional. 
 32.24     Notwithstanding any provisions to the contrary, the 
 32.25  commissioner may allow a recipient of personal care assistant 
 32.26  services to use a fiscal agent to assist the recipient in paying 
 32.27  and accounting for medically necessary covered personal care 
 32.28  assistant services authorized in subdivision 4 and within the 
 32.29  payment parameters of subdivision 5. 
 32.30     (b) The recipient or responsible party shall: 
 32.31     (1) request and secure background checks on the personal 
 32.32  care assistants; 
 32.33     (2) recruit, hire, and terminate the personal care 
 32.34  assistant and consulting professional; 
 32.35     (3) orient and train the personal care assistant in areas 
 32.36  that do not require professional delegation as determined by the 
 33.1   county public health nurse; 
 33.2      (4) supervise and evaluate the personal care assistant in 
 33.3   areas that do not require professional delegation as determined 
 33.4   in the assessment; 
 33.5      (5) cooperate with a professional and implement 
 33.6   recommendations pertaining to the health and safety of the 
 33.7   recipient; 
 33.8      (6) hire a qualified professional to train and supervise 
 33.9   the performance of delegated tasks done by the personal care 
 33.10  assistant; 
 33.11     (7) monitor services and verify in writing the hours worked 
 33.12  by the personal care assistant and the consulting professional; 
 33.13     (8) develop and revise a care plan with assistance from a 
 33.14  consulting professional; 
 33.15     (9) verify and document the credentials of the consulting 
 33.16  professional; and 
 33.17     (10) enter into a written agreement with the fiscal agent. 
 33.18     (c) The duties of the fiscal agent shall be to: 
 33.19     (1) bill the commissioner for personal care assistant and 
 33.20  consulting professional services; 
 33.21     (2) pay the personal care assistant and consulting 
 33.22  professional based on actual hours of services provided; 
 33.23     (3) withhold and pay federal and state taxes; 
 33.24     (4) verify and document hours worked by the personal care 
 33.25  assistant and consulting professional; 
 33.26     (5) make the arrangements and pay unemployment insurance, 
 33.27  taxes, workers' compensation, liability insurance, and other 
 33.28  benefits, if any; 
 33.29     (6) enroll in the medical assistance program as a fiscal 
 33.30  agent; and 
 33.31     (7) enter into a written agreement with the recipient or 
 33.32  responsible party before services are provided. 
 33.33     (d) The fiscal agent: 
 33.34     (1) may not be related to the recipient or the personal 
 33.35  care assistant; 
 33.36     (2) must ensure arm's length transactions with the 
 34.1   recipient and personal care assistant; and 
 34.2      (3) shall be considered a joint employer of the personal 
 34.3   care assistant and consulting professional to the extent 
 34.4   specified in this section. 
 34.5      The fiscal agent or owner of the company that provides 
 34.6   fiscal agent services under this subdivision must pass a 
 34.7   criminal background check as required in section 256B.0627, 
 34.8   subdivision 1, paragraph (e). 
 34.9      (e) The professional providing assistance to the recipient 
 34.10  shall meet the qualifications specified in section 256B.0625, 
 34.11  subdivision 19c.  The professional shall assist the recipient in 
 34.12  developing and revising a plan to meet the recipient's assessed 
 34.13  needs, and supervise the performance of delegated tasks, as 
 34.14  determined by the public health nurse.  In performing this 
 34.15  function, the professional must visit the recipient in the 
 34.16  recipient's home at least once annually.  The professional must 
 34.17  report to the local county public health nurse concerns relating 
 34.18  to the health and safety of the recipient, and any suspected 
 34.19  abuse, neglect, or financial exploitation of the recipient to 
 34.20  the appropriate authorities.  
 34.21     (f) The fiscal agent and recipient shall enter into a 
 34.22  written agreement before services are started.  The agreement 
 34.23  shall include: 
 34.24     (1) the duties of the recipient, professional, and fiscal 
 34.25  agent based on paragraphs (a) to (d); 
 34.26     (2) the salary and benefits for the personal care assistant 
 34.27  and those providing professional consultation; 
 34.28     (3) the administrative fee of the fiscal agent and services 
 34.29  paid for with that fee, including background check fees; 
 34.30     (4) procedures to respond to billing or payment complaints; 
 34.31  and 
 34.32     (5) procedures for hiring and terminating the personal care 
 34.33  assistant and those providing professional consultation. 
 34.34     (g) The rate paid for personal care services and 
 34.35  professional assistance under this subdivision shall be the same 
 34.36  rate paid for personal care services and consulting professional 
 35.1   under subdivision 2.  Except for the administrative fee of the 
 35.2   fiscal agent specified in paragraph (f), the remainder of the 
 35.3   rate paid to the fiscal agent must be used to pay for the salary 
 35.4   and benefits for the personal care assistant or those providing 
 35.5   professional consultation. 
 35.6      (h) As part of the assessment defined in subdivision 1, the 
 35.7   following conditions must be met to use or continue use of a 
 35.8   fiscal agent: 
 35.9      (1) the recipient must be able to direct the recipient's 
 35.10  own care, or the responsible party for the recipient must be 
 35.11  readily available to direct the care of the personal care 
 35.12  assistant; 
 35.13     (2) the recipient or responsible party must be 
 35.14  knowledgeable of the health care needs of the recipient and be 
 35.15  able to effectively communicate those needs; 
 35.16     (3) a face-to-face assessment must be conducted by the 
 35.17  local county public health nurse at least annually, or when 
 35.18  there is a significant change in the recipient's condition or 
 35.19  change in the need for personal care assistant services.  The 
 35.20  county public health nurse shall determine the services that 
 35.21  require professional delegation, if any, and the amount and 
 35.22  frequency of related supervision; 
 35.23     (4) the recipient cannot select the shared services option 
 35.24  as specified in subdivision 8; and 
 35.25     (5) parties must be in compliance with the written 
 35.26  agreement specified in paragraph (e). 
 35.27     (i) The commissioner may deny, revoke, or suspend the 
 35.28  authorization to use the fiscal agent option if: 
 35.29     (1) it has been determined by the consulting professional 
 35.30  or local county public health nurse that the use of this option 
 35.31  jeopardizes the recipient's health and safety; 
 35.32     (2) the parties have failed to comply with the written 
 35.33  agreement specified in paragraph (e); or 
 35.34     (3) the use of the option has led to abusive or fraudulent 
 35.35  billing for personal care assistant services.  
 35.36     The recipient or responsible party may appeal the 
 36.1   commissioner's action according to section 256.045.  The denial, 
 36.2   revocation, or suspension to use the fiscal agent option shall 
 36.3   not affect the recipient's authorized level of personal care 
 36.4   assistant services as determined in subdivision 5. 
 36.5      Sec. 16.  Minnesota Statutes 1998, section 256B.0627, is 
 36.6   amended by adding a subdivision to read: 
 36.7      Subd. 11.  [SHARED PRIVATE DUTY NURSING CARE OPTION.] (a) 
 36.8   Medical assistance payments for shared private duty nursing 
 36.9   services by a private duty nurse shall be limited according to 
 36.10  this subdivision.  For the purposes of this section, "private 
 36.11  duty nursing agency" means an agency licensed under chapter 144A 
 36.12  to provide private duty nursing services. 
 36.13     (b) Recipients of private duty nursing services may share 
 36.14  nursing staff and the commissioner shall provide a rate 
 36.15  methodology for shared private duty nursing.  For two persons 
 36.16  sharing nursing care, the rate paid to a provider shall not 
 36.17  exceed 1.5 times the nonwaivered private duty nursing rates paid 
 36.18  for serving a single individual who is not vent-dependent, by a 
 36.19  registered nurse or licensed practical nurse.  These rates apply 
 36.20  only to situations in which both recipients are present and 
 36.21  receive shared private duty nursing care on the date for which 
 36.22  the service is billed.  No more than two persons may receive 
 36.23  shared private duty nursing services from a private duty nurse 
 36.24  in a single setting. 
 36.25     (c) Shared private duty nursing care is the provision of 
 36.26  nursing services by a private duty nurse to two recipients at 
 36.27  the same time and in the same setting.  For the purposes of this 
 36.28  subdivision, "setting" means: 
 36.29     (1) the home or foster care home of one of the individual 
 36.30  recipients; or 
 36.31     (2) a child care program licensed under chapter 245A or 
 36.32  operated by a local school district or private school; or 
 36.33     (3) an adult day care service licensed under chapter 245A. 
 36.34     This subdivision does not apply when a private duty nurse 
 36.35  is caring for multiple recipients in more than one setting. 
 36.36     (d) The recipient or the recipient's legal representative, 
 37.1   and the recipient's physician, in conjunction with the home 
 37.2   health care agency, shall determine: 
 37.3      (1) whether shared private duty nursing care is an 
 37.4   appropriate option based on the individual needs and preferences 
 37.5   of the recipient; and 
 37.6      (2) the amount of shared private duty nursing services 
 37.7   authorized as part of the overall authorization of nursing 
 37.8   services. 
 37.9      (e) The recipient or the recipient's legal representative, 
 37.10  in conjunction with the private duty nursing agency, shall 
 37.11  approve the setting, grouping, and arrangement of shared private 
 37.12  duty nursing care based on the individual needs and preferences 
 37.13  of the recipients.  Decisions on the selection of recipients to 
 37.14  share services must be based on the ages of the recipients, 
 37.15  compatibility, and coordination of their care needs. 
 37.16     (f) The following items must be considered by the recipient 
 37.17  or the recipient's legal representative and the private duty 
 37.18  nursing agency, and documented in the recipient's health service 
 37.19  record: 
 37.20     (1) the additional training needed by the private duty 
 37.21  nurse to provide care to several recipients in the same setting 
 37.22  and to ensure that the needs of the recipients are met 
 37.23  appropriately and safely; 
 37.24     (2) the setting in which the shared private duty nursing 
 37.25  care will be provided; 
 37.26     (3) the ongoing monitoring and evaluation of the 
 37.27  effectiveness and appropriateness of the service and process 
 37.28  used to make changes in service or setting; 
 37.29     (4) a contingency plan which accounts for absence of the 
 37.30  recipient in a shared private duty nursing setting due to 
 37.31  illness or other circumstances; 
 37.32     (5) staffing backup contingencies in the event of employee 
 37.33  illness or absence; and 
 37.34     (6) arrangements for additional assistance to respond to 
 37.35  urgent or emergency care needs of the recipients. 
 37.36     (g) The provider must offer the recipient or responsible 
 38.1   party the option of shared or one-on-one private duty nursing 
 38.2   services.  The recipient or responsible party can withdraw from 
 38.3   participating in a shared service arrangement at any time. 
 38.4      (h) The private duty nursing agency must document the 
 38.5   following in the health service record for each individual 
 38.6   recipient sharing private duty nursing care: 
 38.7      (1) permission by the recipient or the recipient's legal 
 38.8   representative for the maximum number of shared nursing care 
 38.9   hours per week chosen by the recipient; 
 38.10     (2) permission by the recipient or the recipient's legal 
 38.11  representative for shared private duty nursing services provided 
 38.12  outside the recipient's residence; 
 38.13     (3) permission by the recipient or the recipient's legal 
 38.14  representative for others to receive shared private duty nursing 
 38.15  services in the recipient's residence; 
 38.16     (4) revocation by the recipient or the recipient's legal 
 38.17  representative of the shared private duty nursing care 
 38.18  authorization, or the shared care to be provided to others in 
 38.19  the recipient's residence, or the shared private duty nursing 
 38.20  services to be provided outside the recipient's residence; and 
 38.21     (5) daily documentation of the shared private duty nursing 
 38.22  services provided by each identified private duty nurse, 
 38.23  including: 
 38.24     (i) the names of each recipient receiving shared private 
 38.25  duty nursing services together; 
 38.26     (ii) the setting for the shared services, including the 
 38.27  starting and ending times that the recipient received shared 
 38.28  private duty nursing care; and 
 38.29     (iii) notes by the private duty nurse regarding changes in 
 38.30  the recipient's condition, problems that may arise from the 
 38.31  sharing of private duty nursing services, and scheduling and 
 38.32  care issues. 
 38.33     (i) Unless otherwise provided in this subdivision, all 
 38.34  other statutory and regulatory provisions relating to private 
 38.35  duty nursing services apply to shared private duty nursing 
 38.36  services. 
 39.1      Nothing in this subdivision shall be construed to reduce 
 39.2   the total number of private duty nursing hours authorized for an 
 39.3   individual recipient under subdivision 5. 
 39.4      Sec. 17.  Minnesota Statutes 1998, section 256B.501, 
 39.5   subdivision 8a, is amended to read: 
 39.6      Subd. 8a.  [PAYMENT FOR PERSONS WITH SPECIAL NEEDS FOR 
 39.7   CRISIS INTERVENTION SERVICES.] State-operated, Community-based 
 39.8   crisis services provided in accordance with section 252.50, 
 39.9   subdivision 7, to authorized by the commissioner or the 
 39.10  commissioner's designee for a resident of an intermediate care 
 39.11  facility for persons with mental retardation (ICF/MR) reimbursed 
 39.12  under this section shall be paid by medical assistance in 
 39.13  accordance with the paragraphs (a) to (h) (g). 
 39.14     (a) "Crisis services" means the specialized services listed 
 39.15  in clauses (1) to (3) provided to prevent the recipient from 
 39.16  requiring placement in a more restrictive institutional setting 
 39.17  such as an inpatient hospital or regional treatment center and 
 39.18  to maintain the recipient in the present community setting. 
 39.19     (1) The crisis services provider shall assess the 
 39.20  recipient's behavior and environment to identify factors 
 39.21  contributing to the crisis. 
 39.22     (2) The crisis services provider shall develop a 
 39.23  recipient-specific intervention plan in coordination with the 
 39.24  service planning team and provide recommendations for revisions 
 39.25  to the individual service plan if necessary to prevent or 
 39.26  minimize the likelihood of future crisis situations.  The 
 39.27  intervention plan shall include a transition plan to aid the 
 39.28  recipient in returning to the community-based ICF/MR if the 
 39.29  recipient is receiving residential crisis services.  
 39.30     (3) The crisis services provider shall consult with and 
 39.31  provide training and ongoing technical assistance to the 
 39.32  recipient's service providers to aid in the implementation of 
 39.33  the intervention plan and revisions to the individual service 
 39.34  plan. 
 39.35     (b) "Residential crisis services" means crisis services 
 39.36  that are provided to a recipient admitted to the crisis services 
 40.1   foster care setting an alternative, state licensed site approved 
 40.2   by the commissioner, because the ICF/MR receiving reimbursement 
 40.3   under this section is not able, as determined by the 
 40.4   commissioner, to provide the intervention and protection of the 
 40.5   recipient and others living with the recipient that is necessary 
 40.6   to prevent the recipient from requiring placement in a more 
 40.7   restrictive institutional setting. 
 40.8      (c) Residential crisis services providers must be licensed 
 40.9   by maintain a license from the commissioner under section 
 40.10  245A.03 to provide foster care, must exclusively provide for the 
 40.11  residence when providing crisis services for short-term crisis 
 40.12  intervention, and must not be located in a private residence. 
 40.13     (d) Payment rates are determined annually for each crisis 
 40.14  services provider based on cost of care for each provider as 
 40.15  defined in section 246.50.  Interim payment rates are calculated 
 40.16  on a per diem basis by dividing the projected cost of providing 
 40.17  care by the projected number of contact days for the fiscal 
 40.18  year, as estimated by the commissioner.  Final payment rates are 
 40.19  calculated by dividing the actual cost of providing care by the 
 40.20  actual number of contact days in the applicable fiscal year will 
 40.21  be established consistent with county negotiated crisis 
 40.22  intervention services.  
 40.23     (e) Payment shall be made for each contact day.  "Contact 
 40.24  day" means any day in which the crisis services provider has 
 40.25  face-to-face contact with the recipient or any of the 
 40.26  recipient's medical assistance service providers for the purpose 
 40.27  of providing crisis services as defined in paragraph (c). 
 40.28     (f) Payment for residential crisis services is limited to 
 40.29  21 days, unless an additional period is authorized by the 
 40.30  commissioner or part of an approved regional plan.  The 
 40.31  additional period may not exceed 21 days. 
 40.32     (g) (f) Payment for crisis services shall be made only for 
 40.33  services provided while the ICF/MR receiving reimbursement under 
 40.34  this section: 
 40.35     (1) has a shared services agreement with the crisis 
 40.36  services provider in effect in accordance with under section 
 41.1   246.57; and 
 41.2      (2) has reassigned payment for the provision of the crisis 
 41.3   services under this subdivision to the commissioner in 
 41.4   accordance with Code of Federal Regulations, title 42, section 
 41.5   447.10(e); and 
 41.6      (3) has executed a cooperative agreement with the crisis 
 41.7   services provider to implement the intervention plan and 
 41.8   revisions to the individual service plan as necessary to prevent 
 41.9   or minimize the likelihood of future crisis situations, to 
 41.10  maintain the recipient in the present community setting, and to 
 41.11  prevent the recipient from requiring a more restrictive 
 41.12  institutional setting. 
 41.13     (h) (g) Payment to the ICF/MR receiving reimbursement under 
 41.14  this section shall be made for up to 18 therapeutic leave days 
 41.15  during which the recipient is receiving residential crisis 
 41.16  services, if the ICF/MR is otherwise eligible to receive payment 
 41.17  for a therapeutic leave day under Minnesota Rules, part 
 41.18  9505.0415.  Payment under this paragraph shall be terminated if 
 41.19  the commissioner determines that the ICF/MR is not meeting the 
 41.20  terms of the cooperative shared service agreement under 
 41.21  paragraph (g) (f) or that the recipient will not return to the 
 41.22  ICF/MR. 
 41.23     Sec. 18.  Minnesota Statutes 1998, section 256B.77, 
 41.24  subdivision 7a, is amended to read: 
 41.25     Subd. 7a.  [ELIGIBLE INDIVIDUALS.] (a) Persons are eligible 
 41.26  for the demonstration project as provided in this subdivision. 
 41.27     (b) "Eligible individuals" means those persons living in 
 41.28  the demonstration site who are eligible for medical assistance 
 41.29  and are disabled based on a disability determination under 
 41.30  section 256B.055, subdivisions 7 and 12, or who are eligible for 
 41.31  medical assistance and have been diagnosed as having: 
 41.32     (1) serious and persistent mental illness as defined in 
 41.33  section 245.462, subdivision 20; 
 41.34     (2) severe emotional disturbance as defined in section 
 41.35  245.487 245.4871, subdivision 6; or 
 41.36     (3) mental retardation, or being a mentally retarded person 
 42.1   as defined in section 252A.02, or a related condition as defined 
 42.2   in section 252.27, subdivision 1a. 
 42.3   Other individuals may be included at the option of the county 
 42.4   authority based on agreement with the commissioner. 
 42.5      (c) Eligible individuals residing on a federally recognized 
 42.6   Indian reservation may be excluded from participation in the 
 42.7   demonstration project at the discretion of the tribal government 
 42.8   based on agreement with the commissioner, in consultation with 
 42.9   the county authority. 
 42.10     (d) Eligible individuals include individuals in excluded 
 42.11  time status, as defined in chapter 256G.  Enrollees in excluded 
 42.12  time at the time of enrollment shall remain in excluded time 
 42.13  status as long as they live in the demonstration site and shall 
 42.14  be eligible for 90 days after placement outside the 
 42.15  demonstration site if they move to excluded time status in a 
 42.16  county within Minnesota other than their county of financial 
 42.17  responsibility. 
 42.18     (e) (d) A person who is a sexual psychopathic personality 
 42.19  as defined in section 253B.02, subdivision 18a, or a sexually 
 42.20  dangerous person as defined in section 253B.02, subdivision 18b, 
 42.21  is excluded from enrollment in the demonstration project. 
 42.22     Sec. 19.  Minnesota Statutes 1998, section 256B.77, is 
 42.23  amended by adding a subdivision to read: 
 42.24     Subd. 7b.  [AMERICAN INDIAN RECIPIENTS.] (a) Beginning on 
 42.25  or after July 1, 1999, for American Indian recipients of medical 
 42.26  assistance who are required to enroll with a county 
 42.27  administrative entity or service delivery organization under 
 42.28  subdivision 7, medical assistance shall cover health care 
 42.29  services provided at American Indian health services facilities 
 42.30  and facilities operated by a tribe or tribal organization under 
 42.31  funding authorized by United States Code, title 25, sections 
 42.32  450f to 450n, or title III of the Indian Self-Determination and 
 42.33  Education Assistance Act, Public Law Number 93-638, if those 
 42.34  services would otherwise be covered under section 256B.0625.  
 42.35  Payments for services provided under this subdivision shall be 
 42.36  made on a fee-for-service basis, and may, at the option of the 
 43.1   tribe or tribal organization, be made according to rates 
 43.2   authorized under sections 256.969, subdivision 16, and 
 43.3   256B.0625, subdivision 34.  Implementation of this purchasing 
 43.4   model is contingent on federal approval. 
 43.5      (b) The commissioner of human services, in consultation 
 43.6   with tribal governments, shall develop a plan for tribes to 
 43.7   assist in the enrollment process for American Indian recipients 
 43.8   enrolled in the demonstration project for people with 
 43.9   disabilities under this section.  This plan also shall address 
 43.10  how tribes will be included in ensuring the coordination of care 
 43.11  for American Indian recipients between Indian health service or 
 43.12  tribal providers and other providers. 
 43.13     (c) For purposes of this subdivision, "American Indian" has 
 43.14  the meaning given to persons to whom services will be provided 
 43.15  for in Code of Federal Regulations, title 42, section 36.12. 
 43.16     Sec. 20.  Minnesota Statutes 1998, section 256B.77, 
 43.17  subdivision 8, is amended to read: 
 43.18     Subd. 8.  [RESPONSIBILITIES OF THE COUNTY ADMINISTRATIVE 
 43.19  ENTITY.] (a) The county administrative entity shall meet the 
 43.20  requirements of this subdivision, unless the county authority or 
 43.21  the commissioner, with written approval of the county authority, 
 43.22  enters into a service delivery contract with a service delivery 
 43.23  organization for any or all of the requirements contained in 
 43.24  this subdivision. 
 43.25     (b) The county administrative entity shall enroll eligible 
 43.26  individuals regardless of health or disability status. 
 43.27     (c) The county administrative entity shall provide all 
 43.28  enrollees timely access to the medical assistance benefit set.  
 43.29  Alternative services and additional services are available to 
 43.30  enrollees at the option of the county administrative entity and 
 43.31  may be provided if specified in the personal support plan.  
 43.32  County authorities are not required to seek prior authorization 
 43.33  from the department as required by the laws and rules governing 
 43.34  medical assistance. 
 43.35     (d) The county administrative entity shall cover necessary 
 43.36  services as a result of an emergency without prior 
 44.1   authorization, even if the services were rendered outside of the 
 44.2   provider network. 
 44.3      (e) The county administrative entity shall authorize 
 44.4   necessary and appropriate services when needed and requested by 
 44.5   the enrollee or the enrollee's legal representative in response 
 44.6   to an urgent situation.  Enrollees shall have 24-hour access to 
 44.7   urgent care services coordinated by experienced disability 
 44.8   providers who have information about enrollees' needs and 
 44.9   conditions. 
 44.10     (f) The county administrative entity shall accept the 
 44.11  capitation payment from the commissioner in return for the 
 44.12  provision of services for enrollees. 
 44.13     (g) The county administrative entity shall maintain 
 44.14  internal grievance and complaint procedures, including an 
 44.15  expedited informal complaint process in which the county 
 44.16  administrative entity must respond to verbal complaints within 
 44.17  ten calendar days, and a formal grievance process, in which the 
 44.18  county administrative entity must respond to written complaints 
 44.19  within 30 calendar days. 
 44.20     (h) The county administrative entity shall provide a 
 44.21  certificate of coverage, upon enrollment, to each enrollee and 
 44.22  the enrollee's legal representative, if any, which describes the 
 44.23  benefits covered by the county administrative entity, any 
 44.24  limitations on those benefits, and information about providers 
 44.25  and the service delivery network.  This information must also be 
 44.26  made available to prospective enrollees.  This certificate must 
 44.27  be approved by the commissioner. 
 44.28     (i) The county administrative entity shall present evidence 
 44.29  of an expedited process to approve exceptions to benefits, 
 44.30  provider network restrictions, and other plan limitations under 
 44.31  appropriate circumstances. 
 44.32     (j) The county administrative entity shall provide 
 44.33  enrollees or their legal representatives with written notice of 
 44.34  their appeal rights under subdivision 16, and of ombudsman and 
 44.35  advocacy programs under subdivisions 13 and 14, at the following 
 44.36  times:  upon enrollment, upon submission of a written complaint, 
 45.1   when a service is reduced, denied, or terminated, or when 
 45.2   renewal of authorization for ongoing service is refused. 
 45.3      (k) The county administrative entity shall determine 
 45.4   immediate needs, including services, support, and assessments, 
 45.5   within 30 calendar days of after enrollment, or within a shorter 
 45.6   time frame if specified in the intergovernmental contract. 
 45.7      (l) The county administrative entity shall assess the need 
 45.8   for services of new enrollees within 60 calendar days of after 
 45.9   enrollment, or within a shorter time frame if specified in the 
 45.10  intergovernmental contract, and periodically reassess the need 
 45.11  for services for all enrollees. 
 45.12     (m) The county administrative entity shall ensure the 
 45.13  development of a personal support plan for each person within 60 
 45.14  calendar days of enrollment, or within a shorter time frame if 
 45.15  specified in the intergovernmental contract, unless otherwise 
 45.16  agreed to by the enrollee and the enrollee's legal 
 45.17  representative, if any.  Until a personal support plan is 
 45.18  developed and agreed to by the enrollee, enrollees must have 
 45.19  access to the same amount, type, setting, duration, and 
 45.20  frequency of covered services that they had at the time of 
 45.21  enrollment unless other covered services are needed.  For an 
 45.22  enrollee who is not receiving covered services at the time of 
 45.23  enrollment and for enrollees whose personal support plan is 
 45.24  being revised, access to the medical assistance benefit set must 
 45.25  be assured until a personal support plan is developed or 
 45.26  revised.  If an enrollee chooses not to develop a personal 
 45.27  support plan, the enrollee will be subject to the network and 
 45.28  prior authorization requirements of the county administrative 
 45.29  entity or service delivery organization 60 days after 
 45.30  enrollment.  An enrollee can choose to have a personal support 
 45.31  plan developed at any time.  The personal support plan must be 
 45.32  based on choices, preferences, and assessed needs and strengths 
 45.33  of the enrollee.  The service coordinator shall develop the 
 45.34  personal support plan, in consultation with the enrollee or the 
 45.35  enrollee's legal representative and other individuals requested 
 45.36  by the enrollee.  The personal support plan must be updated as 
 46.1   needed or as requested by the enrollee.  Enrollees may choose 
 46.2   not to have a personal support plan. 
 46.3      (n) The county administrative entity shall ensure timely 
 46.4   authorization, arrangement, and continuity of needed and covered 
 46.5   supports and services. 
 46.6      (o) The county administrative entity shall offer service 
 46.7   coordination that fulfills the responsibilities under 
 46.8   subdivision 12 and is appropriate to the enrollee's needs, 
 46.9   choices, and preferences, including a choice of service 
 46.10  coordinator. 
 46.11     (p) The county administrative entity shall contract with 
 46.12  schools and other agencies as appropriate to provide otherwise 
 46.13  covered medically necessary medical assistance services as 
 46.14  described in an enrollee's individual family support plan, as 
 46.15  described in sections 125A.26 to 125A.48, or individual 
 46.16  education plan, as described in chapter 125A. 
 46.17     (q) The county administrative entity shall develop and 
 46.18  implement strategies, based on consultation with affected 
 46.19  groups, to respect diversity and ensure culturally competent 
 46.20  service delivery in a manner that promotes the physical, social, 
 46.21  psychological, and spiritual well-being of enrollees and 
 46.22  preserves the dignity of individuals, families, and their 
 46.23  communities. 
 46.24     (r) When an enrollee changes county authorities, county 
 46.25  administrative entities shall ensure coordination with the 
 46.26  entity that is assuming responsibility for administering the 
 46.27  medical assistance benefit set to ensure continuity of supports 
 46.28  and services for the enrollee. 
 46.29     (s) The county administrative entity shall comply with 
 46.30  additional requirements as specified in the intergovernmental 
 46.31  contract.  
 46.32     (t) To the extent that alternatives are approved under 
 46.33  subdivision 17, county administrative entities must provide for 
 46.34  the health and safety of enrollees and protect the rights to 
 46.35  privacy and to provide informed consent. 
 46.36     Sec. 21.  Minnesota Statutes 1998, section 256B.77, 
 47.1   subdivision 10, is amended to read: 
 47.2      Subd. 10.  [CAPITATION PAYMENT.] (a) The commissioner shall 
 47.3   pay a capitation payment to the county authority and, when 
 47.4   applicable under subdivision 6, paragraph (a), to the service 
 47.5   delivery organization for each medical assistance eligible 
 47.6   enrollee.  The commissioner shall develop capitation payment 
 47.7   rates for the initial contract period for each demonstration 
 47.8   site in consultation with an independent actuary, to ensure that 
 47.9   the cost of services under the demonstration project does not 
 47.10  exceed the estimated cost for medical assistance services for 
 47.11  the covered population under the fee-for-service system for the 
 47.12  demonstration period.  For each year of the demonstration 
 47.13  project, the capitation payment rate shall be based on 96 
 47.14  percent of the projected per person costs that would otherwise 
 47.15  have been paid under medical assistance fee-for-service during 
 47.16  each of those years.  Rates shall be adjusted within the limits 
 47.17  of the available risk adjustment technology, as mandated by 
 47.18  section 62Q.03.  In addition, the commissioner shall implement 
 47.19  appropriate risk and savings sharing provisions with county 
 47.20  administrative entities and, when applicable under subdivision 
 47.21  6, paragraph (a), service delivery organizations within the 
 47.22  projected budget limits.  Capitation rates shall be adjusted, at 
 47.23  least annually, to include any rate increases and payments for 
 47.24  expanded or newly covered services for eligible individuals.  
 47.25  The initial demonstration project rate shall include an amount 
 47.26  in addition to the fee-for-service payments to adjust for 
 47.27  underutilization of dental services.  Any savings beyond those 
 47.28  allowed for the county authority, county administrative entity, 
 47.29  or service delivery organization shall be first used to meet the 
 47.30  unmet needs of eligible individuals.  Payments to providers 
 47.31  participating in the project are exempt from the requirements of 
 47.32  sections 256.966 and 256B.03, subdivision 2. 
 47.33     (b) The commissioner shall monitor and evaluate annually 
 47.34  the effect of the discount on consumers, the county authority, 
 47.35  and providers of disability services.  Findings shall be 
 47.36  reported and recommendations made, as appropriate, to ensure 
 48.1   that the discount effect does not adversely affect the ability 
 48.2   of the county administrative entity or providers of services to 
 48.3   provide appropriate services to eligible individuals, and does 
 48.4   not result in cost shifting of eligible individuals to the 
 48.5   county authority. 
 48.6      (c) For risk-sharing to occur under this subdivision, the 
 48.7   aggregate fee-for-service cost of covered services provided by 
 48.8   the county administrative entity under this section must exceed 
 48.9   the aggregate sum of capitation payments made to the county 
 48.10  administrative entity under this section.  The county authority 
 48.11  is required to maintain its current level of nonmedical 
 48.12  assistance spending on enrollees.  If the county authority 
 48.13  spends less in nonmedical assistance dollars on enrollees than 
 48.14  it spent the year prior to the contract year, the amount of 
 48.15  underspending shall be deducted from the aggregate 
 48.16  fee-for-service cost of covered services.  The commissioner 
 48.17  shall then compare the fee-for-service costs and capitation 
 48.18  payments related to the services provided for the term of this 
 48.19  contract.  The commissioner shall base its calculation of the 
 48.20  fee-for-service costs on application of the medical assistance 
 48.21  fee schedule to services identified on the county administrative 
 48.22  entity's encounter claims submitted to the commissioner.  The 
 48.23  aggregate fee-for-service cost shall not include any third-party 
 48.24  recoveries or cost-avoided amounts. 
 48.25     If the commissioner finds that the aggregate 
 48.26  fee-for-service cost is greater than the sum of the capitation 
 48.27  payments, the commissioner shall settle according to the 
 48.28  following schedule: 
 48.29     (1) For the first contract year for each project, the 
 48.30  commissioner shall pay the county administrative entity 100 
 48.31  percent of the difference between the sum of the capitation 
 48.32  payments and 100 percent of projected fee-for-service costs.  
 48.33  For aggregate fee-for-service costs in excess of 100 percent of 
 48.34  projected fee-for-service costs, the commissioner shall pay 50 
 48.35  percent of the difference between the aggregate fee-for-service 
 48.36  cost and the projected fee-for-service cost, up to 104 percent 
 49.1   of the projected fee-for-service costs.  The county 
 49.2   administrative entity shall be responsible for all costs in 
 49.3   excess of 104 percent of projected fee-for-service costs. 
 49.4      (2) For the second contract year for each project, the 
 49.5   commissioner shall pay the county administrative entity 75 
 49.6   percent of the difference between the sum of the capitation 
 49.7   payments and 100 percent of projected fee-for-service costs.  
 49.8   The county administrative entity shall be responsible for all 
 49.9   costs in excess of 100 percent of projected fee-for-service 
 49.10  costs. 
 49.11     (3) For the third contract year for each project, the 
 49.12  commissioner shall pay the county administrative entity 50 
 49.13  percent of the difference between the sum of the capitation 
 49.14  payments and 100 percent of projected fee-for-service costs.  
 49.15  The county administrative entity shall be responsible for all 
 49.16  costs in excess of 100 percent of projected fee-for-service 
 49.17  costs. 
 49.18     (4) For the fourth and subsequent contract years for each 
 49.19  project, the county administrative entity shall be responsible 
 49.20  for all costs in excess of the capitation payments. 
 49.21     (d) In addition to other payments under this subdivision, 
 49.22  the commissioner may increase payments by up to 0.5 percent of 
 49.23  the projected per person costs that would otherwise have been 
 49.24  paid under medical assistance fee-for-service.  The commissioner 
 49.25  may make the increased payments to: 
 49.26     (1) offset rate increases for regional treatment services 
 49.27  under subdivision 22 which are higher than was expected by the 
 49.28  commissioner when the capitation was set at 96 percent; and 
 49.29     (2) implement incentives to encourage appropriate, high 
 49.30  quality, efficient services. 
 49.31     Sec. 22.  Minnesota Statutes 1998, section 256B.77, 
 49.32  subdivision 14, is amended to read: 
 49.33     Subd. 14.  [EXTERNAL ADVOCACY.] In addition to ombudsman 
 49.34  services, enrollees shall have access to advocacy services on a 
 49.35  local or regional basis.  The purpose of external advocacy 
 49.36  includes providing individual advocacy services for enrollees 
 50.1   who have complaints or grievances with the county administrative 
 50.2   entity, service delivery organization, or a service provider; 
 50.3   assisting enrollees to understand the service delivery system 
 50.4   and select providers and, if applicable, a service delivery 
 50.5   organization; and understand and exercise their rights as an 
 50.6   enrollee.  External advocacy contractors must demonstrate that 
 50.7   they have the expertise to advocate on behalf of all categories 
 50.8   of eligible individuals and are independent of the commissioner, 
 50.9   county authority, county administrative entity, service delivery 
 50.10  organization, or any service provider within the demonstration 
 50.11  project.  
 50.12     These advocacy services shall be provided through the 
 50.13  ombudsman for mental health and mental retardation directly, or 
 50.14  under contract with private, nonprofit organizations, with 
 50.15  funding provided through the demonstration project.  The funding 
 50.16  shall be provided annually to the ombudsman's office based on 
 50.17  0.1 0.4 percent of the projected per person costs that would 
 50.18  otherwise have been paid under medical assistance 
 50.19  fee-for-service during those years.  Funding for external 
 50.20  advocacy shall be provided for each year of the demonstration 
 50.21  period.  This funding is in addition to the capitation payment 
 50.22  available under subdivision 10. 
 50.23     Sec. 23.  Minnesota Statutes 1998, section 256B.77, is 
 50.24  amended by adding a subdivision to read: 
 50.25     Subd. 27.  [SERVICE COORDINATION TRANSITION.] Demonstration 
 50.26  sites designated under subdivision 5, with the permission of an 
 50.27  eligible individual, may implement the provisions of subdivision 
 50.28  12 beginning 60 calendar days prior to an individual's 
 50.29  enrollment.  This implementation may occur prior to the 
 50.30  enrollment of eligible individuals, but is restricted to 
 50.31  eligible individuals.