HF 2044

as introduced - 80th Legislature (1997 - 1998) Posted on 12/15/2009 12:00am

  1.1                          A bill for an act 
  1.2             relating to human services; adding services paid by 
  1.3             medical assistance under home care services; 
  1.4             establishing qualification requirements for case 
  1.5             management services under the alternative care 
  1.6             program; establishing the statewide maximum rate for 
  1.7             Ramsey county's homemaker services; requiring federal 
  1.8             waiver for needs-based definition of elderly for the 
  1.9             elderly waiver program; amending Minnesota Statutes 
  1.10            1996, sections 256B.0627, subdivision 5; 256B.0913, 
  1.11            subdivision 7, and by adding a subdivision; and 
  1.12            256B.0915, subdivision 1b, and by adding a subdivision.
  1.13  BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MINNESOTA: 
  1.14     Section 1.  Minnesota Statutes 1996, section 256B.0627, 
  1.15  subdivision 5, is amended to read: 
  1.16     Subd. 5.  [LIMITATION ON PAYMENTS.] Medical assistance 
  1.17  payments for home care services shall be limited according to 
  1.18  this subdivision.  
  1.19     (a)  [LIMITS ON SERVICES WITHOUT PRIOR AUTHORIZATION.] A 
  1.20  recipient may receive the following home care services during a 
  1.21  calendar year: 
  1.22     (1) any initial assessment; and 
  1.23     (2) up to two reassessments per year done to determine a 
  1.24  recipient's need for personal care services; and 
  1.25     (3) up to five home health aide visits or skilled nurse 
  1.26  visits, if these visits are authorized by a city or county board 
  1.27  of health or an entity under contract with a city or county 
  1.28  board of health.  
  1.29     (b)  [PRIOR AUTHORIZATION; EXCEPTIONS.] All home care 
  2.1   services above the limits in paragraph (a) must receive the 
  2.2   commissioner's prior authorization, except when: 
  2.3      (1) the home care services were required to treat an 
  2.4   emergency medical condition that if not immediately treated 
  2.5   could cause a recipient serious physical or mental disability, 
  2.6   continuation of severe pain, or death.  The provider must 
  2.7   request retroactive authorization no later than five working 
  2.8   days after giving the initial service.  The provider must be 
  2.9   able to substantiate the emergency by documentation such as 
  2.10  reports, notes, and admission or discharge histories; 
  2.11     (2) the home care services were provided on or after the 
  2.12  date on which the recipient's eligibility began, but before the 
  2.13  date on which the recipient was notified that the case was 
  2.14  opened.  Authorization will be considered if the request is 
  2.15  submitted by the provider within 20 working days of the date the 
  2.16  recipient was notified that the case was opened; 
  2.17     (3) a third-party payor for home care services has denied 
  2.18  or adjusted a payment.  Authorization requests must be submitted 
  2.19  by the provider within 20 working days of the notice of denial 
  2.20  or adjustment.  A copy of the notice must be included with the 
  2.21  request; 
  2.22     (4) the commissioner has determined that a county or state 
  2.23  human services agency has made an error; or 
  2.24     (5) the professional nurse determines an immediate need for 
  2.25  up to 40 skilled nursing or home health aide visits per calendar 
  2.26  year and submits a request for authorization within 20 working 
  2.27  days of the initial service date, and medical assistance is 
  2.28  determined to be the appropriate payer. 
  2.29     (c)  [RETROACTIVE AUTHORIZATION.] A request for retroactive 
  2.30  authorization will be evaluated according to the same criteria 
  2.31  applied to prior authorization requests.  
  2.32     (d)  [ASSESSMENT AND SERVICE PLAN.] Assessments under 
  2.33  section 256B.0627, subdivision 1, paragraph (a), shall be 
  2.34  conducted initially, and at least annually thereafter, in person 
  2.35  with the recipient and result in a completed service plan using 
  2.36  forms specified by the commissioner.  Within 30 days of 
  3.1   recipient or responsible party request for home care services, 
  3.2   the assessment, the service plan, and other information 
  3.3   necessary to determine medical necessity such as diagnostic or 
  3.4   testing information, social or medical histories, and hospital 
  3.5   or facility discharge summaries shall be submitted to the 
  3.6   commissioner.  For personal care services: 
  3.7      (1) The amount and type of service authorized based upon 
  3.8   the assessment and service plan will follow the recipient if the 
  3.9   recipient chooses to change providers.  
  3.10     (2) If the recipient's medical need changes, the 
  3.11  recipient's provider may assess the need for a change in service 
  3.12  authorization and request the change from the county public 
  3.13  health nurse.  Within 30 days of the request, the public health 
  3.14  nurse will determine whether to request the change in services 
  3.15  based upon the provider assessment, or conduct a home visit to 
  3.16  assess the need and determine whether the change is appropriate. 
  3.17     (3) To continue to receive personal care services when the 
  3.18  recipient displays no significant change, the county public 
  3.19  health nurse has the option to review with the commissioner, or 
  3.20  the commissioner's designee, the service plan on record and 
  3.21  receive authorization for up to an additional 12 months at a 
  3.22  time for up to three years. 
  3.23     (e)  [PRIOR AUTHORIZATION.] The commissioner, or the 
  3.24  commissioner's designee, shall review the assessment, the 
  3.25  service plan, and any additional information that is submitted.  
  3.26  The commissioner shall, within 30 days after receiving a 
  3.27  complete request, assessment, and service plan, authorize home 
  3.28  care services as follows:  
  3.29     (1)  [HOME HEALTH SERVICES.] All home health services 
  3.30  provided by a licensed nurse or a home health aide must be prior 
  3.31  authorized by the commissioner or the commissioner's designee.  
  3.32  Prior authorization must be based on medical necessity and 
  3.33  cost-effectiveness when compared with other care options.  When 
  3.34  home health services are used in combination with personal care 
  3.35  and private duty nursing, the cost of all home care services 
  3.36  shall be considered for cost-effectiveness.  The commissioner 
  4.1   shall limit nurse and home health aide visits to no more than 
  4.2   one visit each per day. 
  4.3      (2)  [PERSONAL CARE SERVICES.] (i) All personal care 
  4.4   services and registered nurse supervision must be prior 
  4.5   authorized by the commissioner or the commissioner's designee 
  4.6   except for the assessments established in paragraph (a).  The 
  4.7   amount of personal care services authorized must be based on the 
  4.8   recipient's home care rating.  A child may not be found to be 
  4.9   dependent in an activity of daily living if because of the 
  4.10  child's age an adult would either perform the activity for the 
  4.11  child or assist the child with the activity and the amount of 
  4.12  assistance needed is similar to the assistance appropriate for a 
  4.13  typical child of the same age.  Based on medical necessity, the 
  4.14  commissioner may authorize: 
  4.15     (A) up to two times the average number of direct care hours 
  4.16  provided in nursing facilities for the recipient's comparable 
  4.17  case mix level; or 
  4.18     (B) up to three times the average number of direct care 
  4.19  hours provided in nursing facilities for recipients who have 
  4.20  complex medical needs or are dependent in at least seven 
  4.21  activities of daily living and need physical assistance with 
  4.22  eating or have a neurological diagnosis; or 
  4.23     (C) up to 60 percent of the average reimbursement rate, as 
  4.24  of July 1, 1991, for care provided in a regional treatment 
  4.25  center for recipients who have Level I behavior, plus any 
  4.26  inflation adjustment as provided by the legislature for personal 
  4.27  care service; or 
  4.28     (D) up to the amount the commissioner would pay, as of July 
  4.29  1, 1991, plus any inflation adjustment provided for home care 
  4.30  services, for care provided in a regional treatment center for 
  4.31  recipients referred to the commissioner by a regional treatment 
  4.32  center preadmission evaluation team.  For purposes of this 
  4.33  clause, home care services means all services provided in the 
  4.34  home or community that would be included in the payment to a 
  4.35  regional treatment center; or 
  4.36     (E) up to the amount medical assistance would reimburse for 
  5.1   facility care for recipients referred to the commissioner by a 
  5.2   preadmission screening team established under section 256B.0911 
  5.3   or 256B.092; and 
  5.4      (F) a reasonable amount of time for the provision of 
  5.5   nursing supervision of personal care services.  
  5.6      (ii) The number of direct care hours shall be determined 
  5.7   according to the annual cost report submitted to the department 
  5.8   by nursing facilities.  The average number of direct care hours, 
  5.9   as established by May 1, 1992, shall be calculated and 
  5.10  incorporated into the home care limits on July 1, 1992.  These 
  5.11  limits shall be calculated to the nearest quarter hour. 
  5.12     (iii) The home care rating shall be determined by the 
  5.13  commissioner or the commissioner's designee based on information 
  5.14  submitted to the commissioner by the county public health nurse 
  5.15  on forms specified by the commissioner.  The home care rating 
  5.16  shall be a combination of current assessment tools developed 
  5.17  under sections 256B.0911 and 256B.501 with an addition for 
  5.18  seizure activity that will assess the frequency and severity of 
  5.19  seizure activity and with adjustments, additions, and 
  5.20  clarifications that are necessary to reflect the needs and 
  5.21  conditions of recipients who need home care including children 
  5.22  and adults under 65 years of age.  The commissioner shall 
  5.23  establish these forms and protocols under this section and shall 
  5.24  use an advisory group, including representatives of recipients, 
  5.25  providers, and counties, for consultation in establishing and 
  5.26  revising the forms and protocols. 
  5.27     (iv) A recipient shall qualify as having complex medical 
  5.28  needs if the care required is difficult to perform and because 
  5.29  of recipient's medical condition requires more time than 
  5.30  community-based standards allow or requires more skill than 
  5.31  would ordinarily be required and the recipient needs or has one 
  5.32  or more of the following: 
  5.33     (A) daily tube feedings; 
  5.34     (B) daily parenteral therapy; 
  5.35     (C) wound or decubiti care; 
  5.36     (D) postural drainage, percussion, nebulizer treatments, 
  6.1   suctioning, tracheotomy care, oxygen, mechanical ventilation; 
  6.2      (E) catheterization; 
  6.3      (F) ostomy care; 
  6.4      (G) quadriplegia; or 
  6.5      (H) other comparable medical conditions or treatments the 
  6.6   commissioner determines would otherwise require institutional 
  6.7   care.  
  6.8      (v) A recipient shall qualify as having Level I behavior if 
  6.9   there is reasonable supporting evidence that the recipient 
  6.10  exhibits, or that without supervision, observation, or 
  6.11  redirection would exhibit, one or more of the following 
  6.12  behaviors that cause, or have the potential to cause: 
  6.13     (A) injury to the recipient's own body; 
  6.14     (B) physical injury to other people; or 
  6.15     (C) destruction of property. 
  6.16     (vi) Time authorized for personal care relating to Level I 
  6.17  behavior in subclause (v), items (A) to (C), shall be based on 
  6.18  the predictability, frequency, and amount of intervention 
  6.19  required. 
  6.20     (vii) A recipient shall qualify as having Level II behavior 
  6.21  if the recipient exhibits on a daily basis one or more of the 
  6.22  following behaviors that interfere with the completion of 
  6.23  personal care services under subdivision 4, paragraph (a): 
  6.24     (A) unusual or repetitive habits; 
  6.25     (B) withdrawn behavior; or 
  6.26     (C) offensive behavior. 
  6.27     (viii) A recipient with a home care rating of Level II 
  6.28  behavior in subclause (vii), items (A) to (C), shall be rated as 
  6.29  comparable to a recipient with complex medical needs under 
  6.30  subclause (iv).  If a recipient has both complex medical needs 
  6.31  and Level II behavior, the home care rating shall be the next 
  6.32  complex category up to the maximum rating under subclause (i), 
  6.33  item (B). 
  6.34     (3)  [PRIVATE DUTY NURSING SERVICES.] All private duty 
  6.35  nursing services shall be prior authorized by the commissioner 
  6.36  or the commissioner's designee.  Prior authorization for private 
  7.1   duty nursing services shall be based on medical necessity and 
  7.2   cost-effectiveness when compared with alternative care options.  
  7.3   The commissioner may authorize medically necessary private duty 
  7.4   nursing services in quarter-hour units when: 
  7.5      (i) the recipient requires more individual and continuous 
  7.6   care than can be provided during a nurse visit; or 
  7.7      (ii) the cares are outside of the scope of services that 
  7.8   can be provided by a home health aide or personal care assistant.
  7.9      The commissioner may authorize: 
  7.10     (A) up to two times the average amount of direct care hours 
  7.11  provided in nursing facilities statewide for case mix 
  7.12  classification "K" as established by the annual cost report 
  7.13  submitted to the department by nursing facilities in May 1992; 
  7.14     (B) private duty nursing in combination with other home 
  7.15  care services up to the total cost allowed under clause (2); 
  7.16     (C) up to 16 hours per day if the recipient requires more 
  7.17  nursing than the maximum number of direct care hours as 
  7.18  established in item (A) and the recipient meets the hospital 
  7.19  admission criteria established under Minnesota Rules, parts 
  7.20  9505.0500 to 9505.0540.  
  7.21     The commissioner may authorize up to 16 hours per day of 
  7.22  medically necessary private duty nursing services or up to 24 
  7.23  hours per day of medically necessary private duty nursing 
  7.24  services until such time as the commissioner is able to make a 
  7.25  determination of eligibility for recipients who are 
  7.26  cooperatively applying for home care services under the 
  7.27  community alternative care program developed under section 
  7.28  256B.49, or until it is determined by the appropriate regulatory 
  7.29  agency that a health benefit plan is or is not required to pay 
  7.30  for appropriate medically necessary health care services.  
  7.31  Recipients or their representatives must cooperatively assist 
  7.32  the commissioner in obtaining this determination.  Recipients 
  7.33  who are eligible for the community alternative care program may 
  7.34  not receive more hours of nursing under this section than would 
  7.35  otherwise be authorized under section 256B.49. 
  7.36     (4)  [VENTILATOR-DEPENDENT RECIPIENTS.] If the recipient is 
  8.1   ventilator-dependent, the monthly medical assistance 
  8.2   authorization for home care services shall not exceed what the 
  8.3   commissioner would pay for care at the highest cost hospital 
  8.4   designated as a long-term hospital under the Medicare program.  
  8.5   For purposes of this clause, home care services means all 
  8.6   services provided in the home that would be included in the 
  8.7   payment for care at the long-term hospital.  
  8.8   "Ventilator-dependent" means an individual who receives 
  8.9   mechanical ventilation for life support at least six hours per 
  8.10  day and is expected to be or has been dependent for at least 30 
  8.11  consecutive days.  
  8.12     (f)  [PRIOR AUTHORIZATION; TIME LIMITS.] The commissioner 
  8.13  or the commissioner's designee shall determine the time period 
  8.14  for which a prior authorization shall be effective.  If the 
  8.15  recipient continues to require home care services beyond the 
  8.16  duration of the prior authorization, the home care provider must 
  8.17  request a new prior authorization.  Under no circumstances, 
  8.18  other than the exceptions in paragraph (b), shall a prior 
  8.19  authorization be valid prior to the date the commissioner 
  8.20  receives the request or for more than 12 months.  A recipient 
  8.21  who appeals a reduction in previously authorized home care 
  8.22  services may continue previously authorized services, other than 
  8.23  temporary services under paragraph (h), pending an appeal under 
  8.24  section 256.045.  The commissioner must provide a detailed 
  8.25  explanation of why the authorized services are reduced in amount 
  8.26  from those requested by the home care provider.  
  8.27     (g)  [APPROVAL OF HOME CARE SERVICES.] The commissioner or 
  8.28  the commissioner's designee shall determine the medical 
  8.29  necessity of home care services, the level of caregiver 
  8.30  according to subdivision 2, and the institutional comparison 
  8.31  according to this subdivision, the cost-effectiveness of 
  8.32  services, and the amount, scope, and duration of home care 
  8.33  services reimbursable by medical assistance, based on the 
  8.34  assessment, primary payer coverage determination information as 
  8.35  required, the service plan, the recipient's age, the cost of 
  8.36  services, the recipient's medical condition, and diagnosis or 
  9.1   disability.  The commissioner may publish additional criteria 
  9.2   for determining medical necessity according to section 256B.04. 
  9.3      (h)  [PRIOR AUTHORIZATION REQUESTS; TEMPORARY SERVICES.] 
  9.4   The agency nurse, the independently enrolled private duty nurse, 
  9.5   or county public health nurse may request a temporary 
  9.6   authorization for home care services by telephone.  The 
  9.7   commissioner may approve a temporary level of home care services 
  9.8   based on the assessment, and service or care plan information, 
  9.9   and primary payer coverage determination information as required.
  9.10  Authorization for a temporary level of home care services 
  9.11  including nurse supervision is limited to the time specified by 
  9.12  the commissioner, but shall not exceed 45 days, unless extended 
  9.13  because the county public health nurse has not completed the 
  9.14  required assessment and service plan, or the commissioner's 
  9.15  determination has not been made.  The level of services 
  9.16  authorized under this provision shall have no bearing on a 
  9.17  future prior authorization. 
  9.18     (i)  [PRIOR AUTHORIZATION REQUIRED IN FOSTER CARE SETTING.] 
  9.19  Home care services provided in an adult or child foster care 
  9.20  setting must receive prior authorization by the department 
  9.21  according to the limits established in paragraph (a). 
  9.22     The commissioner may not authorize: 
  9.23     (1) home care services that are the responsibility of the 
  9.24  foster care provider under the terms of the foster care 
  9.25  placement agreement and administrative rules.  Requests for home 
  9.26  care services for recipients residing in a foster care setting 
  9.27  must include the foster care placement agreement and 
  9.28  determination of difficulty of care; 
  9.29     (2) personal care services when the foster care license 
  9.30  holder is also the personal care provider or personal care 
  9.31  assistant unless the recipient can direct the recipient's own 
  9.32  care, or case management is provided as required in section 
  9.33  256B.0625, subdivision 19a; 
  9.34     (3) personal care services when the responsible party is an 
  9.35  employee of, or under contract with, or has any direct or 
  9.36  indirect financial relationship with the personal care provider 
 10.1   or personal care assistant, unless case management is provided 
 10.2   as required in section 256B.0625, subdivision 19a; 
 10.3      (4) home care services when the number of foster care 
 10.4   residents is greater than four unless the county responsible for 
 10.5   the recipient's foster placement made the placement prior to 
 10.6   April 1, 1992, requests that home care services be provided, and 
 10.7   case management is provided as required in section 256B.0625, 
 10.8   subdivision 19a; or 
 10.9      (5) home care services when combined with foster care 
 10.10  payments, other than room and board payments that exceed the 
 10.11  total amount that public funds would pay for the recipient's 
 10.12  care in a medical institution. 
 10.13     Sec. 2.  Minnesota Statutes 1996, section 256B.0913, 
 10.14  subdivision 7, is amended to read: 
 10.15     Subd. 7.  [CASE MANAGEMENT.] The lead agency shall appoint 
 10.16  a social worker from the county agency or a registered nurse 
 10.17  from the county public health nursing service of the local board 
 10.18  of health to be the case manager for any person receiving 
 10.19  services funded by the alternative care program.  Providers of 
 10.20  case management services for persons receiving services funded 
 10.21  by the alternative care program must meet the qualification 
 10.22  requirements and standards specified in section 256B.0915, 
 10.23  subdivision 1b.  The case manager must ensure the health and 
 10.24  safety of the individual client and is responsible for the 
 10.25  cost-effectiveness of the alternative care individual care 
 10.26  plan.  The county may allow a case manager employed by the 
 10.27  county to delegate certain aspects of the case management 
 10.28  activity to another individual employed by the county provided 
 10.29  there is oversight of the individual by the case manager.  The 
 10.30  case manager may not delegate those aspects which require 
 10.31  professional judgment including assessments, reassessments, and 
 10.32  care plan development. 
 10.33     Sec. 3.  Minnesota Statutes 1996, section 256B.0913, is 
 10.34  amended by adding a subdivision to read: 
 10.35     Subd. 15d.  [REIMBURSEMENT RATE; RAMSEY COUNTY.] 
 10.36  Notwithstanding subdivision 14, paragraph (e), effective July 1, 
 11.1   1997, Ramsey county's maximum allowed rate for homemaker 
 11.2   services shall be adjusted to the statewide maximum rate. 
 11.3      Sec. 4.  Minnesota Statutes 1996, section 256B.0915, 
 11.4   subdivision 1b, is amended to read: 
 11.5      Subd. 1b.  [PROVIDER QUALIFICATIONS AND STANDARDS.] The 
 11.6   commissioner must enroll qualified providers of elderly case 
 11.7   management services under the home and community-based waiver 
 11.8   for the elderly under section 1915(c) of the Social Security 
 11.9   Act.  The enrollment process shall ensure the provider's ability 
 11.10  to meet the qualification requirements and standards in this 
 11.11  subdivision and other federal and state requirements of this 
 11.12  service.  An elderly case management provider is an enrolled 
 11.13  medical assistance provider who is determined by the 
 11.14  commissioner to have all of the following characteristics: 
 11.15     (1) the legal authority for alternative care program 
 11.16  administration under section 256B.0913; 
 11.17     (2) the demonstrated capacity and experience to provide the 
 11.18  components of case management to coordinate and link community 
 11.19  resources needed by the eligible population; 
 11.20     (3) (2) administrative capacity and experience in serving 
 11.21  the target population for whom it will provide services and in 
 11.22  ensuring quality of services under state and federal 
 11.23  requirements; 
 11.24     (4) the legal authority to provide preadmission screening 
 11.25  under section 256B.0911, subdivision 4; 
 11.26     (5) (3) a financial management system that provides 
 11.27  accurate documentation of services and costs under state and 
 11.28  federal requirements; 
 11.29     (6) (4) the capacity to document and maintain individual 
 11.30  case records under state and federal requirements; and 
 11.31     (7) (5) the county may allow a case manager employed by the 
 11.32  county to delegate certain aspects of the case management 
 11.33  activity to another individual employed by the county provided 
 11.34  there is oversight of the individual by the case manager.  The 
 11.35  case manager may not delegate those aspects which require 
 11.36  professional judgment including assessments, reassessments, and 
 12.1   care plan development. 
 12.2      Sec. 5.  Minnesota Statutes 1996, section 256B.0915, is 
 12.3   amended by adding a subdivision to read: 
 12.4      Subd. 3d.  [REIMBURSEMENT RATE; RAMSEY COUNTY.] 
 12.5   Notwithstanding subdivision 3, paragraph (h), effective July 1, 
 12.6   1997, Ramsey county's maximum allowed rate for homemaker 
 12.7   services shall be adjusted to the statewide maximum rate. 
 12.8      Sec. 6.  [NEEDS-BASED DEFINITION OF ELDERLY.] 
 12.9      The commissioner of human services, in consultation with 
 12.10  representatives of Minnesota counties, shall seek any federal 
 12.11  waivers and approvals necessary to adopt a needs-based 
 12.12  definition of elderly for the elderly waiver program that would 
 12.13  allow persons over age 55 and at risk of nursing home placement 
 12.14  as determined by a preadmission screening team to qualify for 
 12.15  services. 
 12.16     Sec. 7.  [EFFECTIVE DATE.] 
 12.17     Section 6 is effective the day following final enactment.