HF 2203

as introduced - 79th Legislature (1995 - 1996) Posted on 12/15/2009 12:00am

  1.1                          A bill for an act 
  1.2             relating to human services; making agency technical 
  1.3             changes; changing provisions related to health and 
  1.4             continuing care for medical assistance and general 
  1.5             assistance medical care recipients; adding provisions 
  1.6             for one state system to purchase health care and 
  1.7             related services; amending Minnesota Statutes 1994, 
  1.8             sections 62D.04, subdivision 5; 62N.10, subdivision 4; 
  1.9             245.462, subdivision 4; 245.4871, subdivision 4; 
  1.10            256.9355, subdivision 3; 256B.03, by adding a 
  1.11            subdivision; 256B.0627, subdivisions 1, as amended; 5, 
  1.12            as amended; and by adding a subdivision; 256B.0913, 
  1.13            subdivision 7; 256B.0915, subdivision 1b; 256B.15, by 
  1.14            adding subdivisions; 256B.37, subdivision 5; 256B.49, 
  1.15            by adding a subdivision; 256I.04, subdivision 1; and 
  1.16            256I.05, by adding a subdivision; Minnesota Statutes 
  1.17            1995 Supplement, sections 256.969, subdivisions 1, 2b, 
  1.18            and 10; 256B.0628, subdivision 2; 256B.0913, 
  1.19            subdivision 5; 256B.0915, subdivision 3; 256B.093, 
  1.20            subdivision 3; 256B.432, subdivision 2; 256B.434, 
  1.21            subdivision 10; 256B.49, subdivisions 6 and 7; 
  1.22            256B.501, subdivisions 5b and 5c; 256B.69, 
  1.23            subdivisions 4 and 6; 256D.03, subdivision 4; and 
  1.24            256I.04, subdivisions 2b and 3; proposing coding for 
  1.25            new law in Minnesota Statutes, chapter 256B; proposing 
  1.26            coding for new law as Minnesota Statutes, chapters 
  1.27            252B; and 256J; repealing Minnesota Statutes 1995 
  1.28            Supplement, section 256B.69, subdivision 4a; Minnesota 
  1.29            Rules, parts 9500.1452, subpart 2, items G and H; 
  1.30            9505.5230; 9525.0215; 9525.0225; 9525.0235; 9525.0243; 
  1.31            9525.0245; 9525.0255; 9525.0265; 9525.0275; 9525.0285; 
  1.32            9525.0295; 9525.0305; 9525.0315; 9525.0325; 9525.0335; 
  1.33            9525.0345; 9525.0355; 9525.0500; 9525.0510; 9525.0520; 
  1.34            9525.0530; 9525.0540; 9525.0550; 9525.0560; 9525.0570; 
  1.35            9525.0580; 9525.0590; 9525.0600; 9525.0610; 9525.0620; 
  1.36            9525.0630; 9525.0640; 9525.0650; 9525.0660; 9525.1500; 
  1.37            9525.1510; 9525.1520; 9525.1530; 9525.1540; 9525.1550; 
  1.38            9525.1560; 9525.1570; 9525.1580; 9525.1590; 9525.1600; 
  1.39            9525.1610; 9525.1620; 9525.1630; 9525.1640; 9525.1650; 
  1.40            9525.1660; 9525.1670; 9525.1680; 9525.1690; 9525.2000; 
  1.41            9525.2010; 9525.2020; 9525.2025; 9525.2030; 9525.2040; 
  1.42            9525.2050; 9525.2060; 9525.2070; 9525.2080; 9525.2090; 
  1.43            9525.2100; 9525.2110; 9525.2120; 9525.2130; and 
  1.44            9525.2140. 
  1.45  BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MINNESOTA: 
  2.1                              ARTICLE 1 
  2.2                       AGENCY TECHNICAL CHANGES 
  2.3      Section 1.  Minnesota Statutes 1994, section 245.462, 
  2.4   subdivision 4, is amended to read: 
  2.5      Subd. 4.  [CASE MANAGER.] "Case manager" means an 
  2.6   individual employed by the county or other entity authorized by 
  2.7   the county board to provide case management services specified 
  2.8   in section 245.4711.  A case manager must have a bachelor's 
  2.9   degree in one of the behavioral sciences or related fields from 
  2.10  an accredited college or university and have at least 2,000 
  2.11  hours of supervised experience in the delivery of services to 
  2.12  adults with mental illness, must be skilled in the process of 
  2.13  identifying and assessing a wide range of client needs, and must 
  2.14  be knowledgeable about local community resources and how to use 
  2.15  those resources for the benefit of the client.  The case manager 
  2.16  shall meet in person with a mental health professional at least 
  2.17  once each month to obtain clinical supervision of the case 
  2.18  manager's activities.  Case managers with a bachelor's degree 
  2.19  but without 2,000 hours of supervised experience in the delivery 
  2.20  of services to adults with mental illness must complete 40 hours 
  2.21  of training approved by the commissioner of human services in 
  2.22  case management skills and in the characteristics and needs of 
  2.23  adults with serious and persistent mental illness and must 
  2.24  receive clinical supervision regarding individual service 
  2.25  delivery from a mental health professional at least once each 
  2.26  week until the requirement of 2,000 hours of supervised 
  2.27  experience is met.  Clinical supervision must be documented in 
  2.28  the client record. 
  2.29     Until June 30, 1996 1999, a refugee who does not have the 
  2.30  qualifications specified in this subdivision may provide case 
  2.31  management services to adult refugees with serious and 
  2.32  persistent mental illness who are members of the same ethnic 
  2.33  group as the case manager if the person:  (1) is actively 
  2.34  pursuing credits toward the completion of a bachelor's degree in 
  2.35  one of the behavioral sciences or a related field from an 
  2.36  accredited college or university; (2) completes 40 hours of 
  3.1   training as specified in this subdivision; and (3) receives 
  3.2   clinical supervision at least once a week until the requirements 
  3.3   of obtaining a bachelor's degree and 2,000 hours of supervised 
  3.4   experience are met. 
  3.5      Sec. 2.  Minnesota Statutes 1994, section 245.4871, 
  3.6   subdivision 4, is amended to read: 
  3.7      Subd. 4.  [CASE MANAGER.] (a) "Case manager" means an 
  3.8   individual employed by the county or other entity authorized by 
  3.9   the county board to provide case management services specified 
  3.10  in subdivision 3 for the child with severe emotional disturbance 
  3.11  and the child's family.  A case manager must have experience and 
  3.12  training in working with children. 
  3.13     (b) A case manager must: 
  3.14     (1) have at least a bachelor's degree in one of the 
  3.15  behavioral sciences or a related field from an accredited 
  3.16  college or university; 
  3.17     (2) have at least 2,000 hours of supervised experience in 
  3.18  the delivery of mental health services to children; 
  3.19     (3) have experience and training in identifying and 
  3.20  assessing a wide range of children's needs; and 
  3.21     (4) be knowledgeable about local community resources and 
  3.22  how to use those resources for the benefit of children and their 
  3.23  families.  
  3.24     (c) The case manager may be a member of any professional 
  3.25  discipline that is part of the local system of care for children 
  3.26  established by the county board. 
  3.27     (d) The case manager must meet in person with a mental 
  3.28  health professional at least once each month to obtain clinical 
  3.29  supervision. 
  3.30     (e) Case managers with a bachelor's degree but without 
  3.31  2,000 hours of supervised experience in the delivery of mental 
  3.32  health services to children with emotional disturbance must: 
  3.33     (1) begin 40 hours of training approved by the commissioner 
  3.34  of human services in case management skills and in the 
  3.35  characteristics and needs of children with severe emotional 
  3.36  disturbance before beginning to provide case management 
  4.1   services; and 
  4.2      (2) receive clinical supervision regarding individual 
  4.3   service delivery from a mental health professional at least once 
  4.4   each week until the requirement of 2,000 hours of experience is 
  4.5   met. 
  4.6      (f) Clinical supervision must be documented in the child's 
  4.7   record.  When the case manager is not a mental health 
  4.8   professional, the county board must provide or contract for 
  4.9   needed clinical supervision. 
  4.10     (g) The county board must ensure that the case manager has 
  4.11  the freedom to access and coordinate the services within the 
  4.12  local system of care that are needed by the child. 
  4.13     (h) Until June 30, 1996 1999, a refugee who does not have 
  4.14  the qualifications specified in this subdivision may provide 
  4.15  case management services to child refugees with severe emotional 
  4.16  disturbance of the same ethnic group as the refugee if the 
  4.17  person:  
  4.18     (1) is actively pursuing credits toward the completion of a 
  4.19  bachelor's degree in one of the behavioral sciences or related 
  4.20  fields at an accredited college or university; 
  4.21     (2) completes 40 hours of training as specified in this 
  4.22  subdivision; and 
  4.23     (3) receives clinical supervision at least once a week 
  4.24  until the requirements of obtaining a bachelor's degree and 
  4.25  2,000 hours of supervised experience are met. 
  4.26     Sec. 3.  Minnesota Statutes 1994, section 256B.15, is 
  4.27  amended by adding a subdivision to read: 
  4.28     Subd. 6.  [NOTICE.] (a) Upon being appointed, the personal 
  4.29  representative for the estate of a deceased recipient or the 
  4.30  estate of a deceased spouse who survived the recipient shall 
  4.31  notify the county agency which administered the deceased 
  4.32  recipient's medical assistance of the death of the recipient or 
  4.33  surviving spouse of the recipient. 
  4.34     (b) The notice shall be in writing, addressed to the county 
  4.35  agency, sent by certified mail, return receipt requested, and 
  4.36  shall state the deceased medical recipient's full name, date of 
  5.1   birth, social security number, address at the time of death, the 
  5.2   name of the county agency which administered the recipient's 
  5.3   medical assistance, the county and district court in which the 
  5.4   deceased recipient's estate has been opened, the probate number 
  5.5   assigned to that estate, and the name, address, and telephone 
  5.6   number of the personal representative and attorney for the 
  5.7   estate. 
  5.8      If the decedent was the surviving spouse of a deceased 
  5.9   recipient, the notice shall also state the surviving spouse's 
  5.10  full name, date of birth, social security number, date of death, 
  5.11  the county and district court in which the estate has been 
  5.12  opened, the probate number assigned to the estate, and the name, 
  5.13  address, and telephone number of the personal representative and 
  5.14  the attorney for the estate. 
  5.15     (c) Notwithstanding the provisions in chapter 524 or 525, 
  5.16  or any will or other instrument, no one may, without the consent 
  5.17  of the county agency, sell, assign, convey, transfer, 
  5.18  distribute, or otherwise dispose of any real or personal 
  5.19  property subject to administration by the estate until at least 
  5.20  60 days after the county agency has received the notice required 
  5.21  by this subdivision.  
  5.22     Sec. 4.  Minnesota Statutes 1994, section 256B.15, is 
  5.23  amended by adding a subdivision to read: 
  5.24     Subd. 7.  [PRIORITY OF CLAIM.] Notwithstanding any other 
  5.25  law to the contrary, payment of claims filed arising under this 
  5.26  section shall have priority over the payment of any and all 
  5.27  amounts payable under section 524.2-403. 
  5.28     Sec. 5.  Minnesota Statutes 1995 Supplement, section 
  5.29  256B.434, subdivision 10, is amended to read: 
  5.30     Subd. 10.  [EXEMPTIONS.] (a) To the extent permitted by 
  5.31  federal law, (1) a facility that has entered into a contract 
  5.32  under this section is not required to file a cost report, as 
  5.33  defined in Minnesota Rules, part 9549.0020, subpart 13, for any 
  5.34  year after the base year that is the basis for the calculation 
  5.35  of the contract payment rate for the first rate year of the 
  5.36  alternative payment demonstration project contract; and (2) a 
  6.1   facility under contract is not subject to audits of historical 
  6.2   costs or revenues, or paybacks or retroactive adjustments based 
  6.3   on these costs or revenues, except audits, paybacks, or 
  6.4   adjustments relating to the cost report that is the basis for 
  6.5   calculation of the first rate year under the contract. 
  6.6      (b) A facility that is under contract with the commissioner 
  6.7   under this section is not subject to the moratorium on licensure 
  6.8   or certification of new nursing home beds in section 144A.071, 
  6.9   unless the project results in a net increase in bed capacity or 
  6.10  involves relocation of beds from one site to another.  Contract 
  6.11  payment rates must not be adjusted to reflect any additional 
  6.12  costs that a nursing facility incurs as a result of a 
  6.13  construction project undertaken under this paragraph.  In 
  6.14  addition, as a condition of entering into a contract under this 
  6.15  section, a nursing facility must agree that any future medical 
  6.16  assistance payments for nursing facility services will not 
  6.17  reflect any additional costs attributable to the sale of a 
  6.18  nursing facility under this section and to construction 
  6.19  undertaken under this paragraph that otherwise would not be 
  6.20  authorized under the moratorium in sections 144A.071 and section 
  6.21  144A.073.  Nothing in this section prevents a nursing facility 
  6.22  participating in the alternative payment demonstration project 
  6.23  under this section from seeking approval of an exception to the 
  6.24  moratorium through the process established in section 144A.071 
  6.25  144A.073, and if approved the facility's rates shall be adjusted 
  6.26  to reflect the cost of the project. 
  6.27     (c) Notwithstanding section 256B.48, subdivision 6, 
  6.28  paragraphs (c), (d), and (e), and pursuant to any terms and 
  6.29  conditions contained in the facility's contract, a nursing 
  6.30  facility that is under contract with the commissioner under this 
  6.31  section is in compliance with section 256B.48, subdivision 6, 
  6.32  paragraph (b), if the facility is Medicare certified. 
  6.33     (d) Notwithstanding paragraph (a), if by April 1, 1996, the 
  6.34  health care financing administration has not approved a required 
  6.35  waiver, or the health care financing administration otherwise 
  6.36  requires cost reports to be filed prior to the waiver's 
  7.1   approval, the commissioner shall require a cost report for the 
  7.2   rate year. 
  7.3      Sec. 6.  Minnesota Statutes 1994, section 256I.04, 
  7.4   subdivision 1, is amended to read: 
  7.5      Subdivision 1.  [INDIVIDUAL ELIGIBILITY REQUIREMENTS.] An 
  7.6   individual is eligible for and entitled to a group residential 
  7.7   housing payment to be made on the individual's behalf if the 
  7.8   county agency has approved the individual's residence in a group 
  7.9   residential housing setting and the individual meets the 
  7.10  requirements in paragraph (a) or (b).  
  7.11     (a) The individual is aged, blind, or is over 18 years of 
  7.12  age and disabled as determined under the criteria used by the 
  7.13  title II program of the Social Security Act, and meets the 
  7.14  resource restrictions and standards of the supplemental security 
  7.15  income program, and the individual's countable income after 
  7.16  deducting the exclusions and disregards of the SSI program and 
  7.17  the medical assistance personal needs allowance under section 
  7.18  256B.35 is less than the monthly rate specified in the county 
  7.19  agency's agreement with the provider of group residential 
  7.20  housing in which the individual resides.  
  7.21     (b) The individual meets a category of eligibility under 
  7.22  section 256D.05, subdivision 1, paragraph (a), and the 
  7.23  individual's resources are less than the standards specified by 
  7.24  section 256D.08, and the individual's countable income as 
  7.25  determined under sections 256D.01 to 256D.21, less the medical 
  7.26  assistance personal needs allowance under section 256B.35 is 
  7.27  less than the monthly rate specified in the county agency's 
  7.28  agreement with the provider of group residential housing in 
  7.29  which the individual resides. 
  7.30     Sec. 7.  Minnesota Statutes 1995 Supplement, section 
  7.31  256I.04, subdivision 2b, is amended to read: 
  7.32     Subd. 2b.  [GROUP RESIDENTIAL HOUSING AGREEMENTS.] 
  7.33  Agreements between county agencies and providers of group 
  7.34  residential housing must be in writing and must specify the name 
  7.35  and address under which the establishment subject to the 
  7.36  agreement does business and under which the establishment, or 
  8.1   service provider, if different from the group residential 
  8.2   housing establishment, is licensed by the department of health 
  8.3   or the department of human services; the specific license or 
  8.4   registration from the department of health or the department of 
  8.5   human services held by the provider and the number of beds 
  8.6   subject to that license; the address of the location or 
  8.7   locations at which group residential housing is provided under 
  8.8   this agreement; the per diem and monthly rates that are to be 
  8.9   paid from group residential housing funds for each eligible 
  8.10  resident at each location; the number of beds at each location 
  8.11  which are subject to the group residential housing agreement; 
  8.12  whether the license holder is a not-for-profit corporation under 
  8.13  section 501(c)(3) of the Internal Revenue Code; and a statement 
  8.14  that the agreement is subject to the provisions of sections 
  8.15  256I.01 to 256I.06 and subject to any changes to those sections. 
  8.16  Group residential housing agreements may be terminated with or 
  8.17  without cause by either the county or the provider with two 
  8.18  calendar months prior notice. 
  8.19     Sec. 8.  Minnesota Statutes 1995 Supplement, section 
  8.20  256I.04, subdivision 3, is amended to read: 
  8.21     Subd. 3.  [MORATORIUM ON THE DEVELOPMENT OF GROUP 
  8.22  RESIDENTIAL HOUSING BEDS.] (a) County agencies shall not enter 
  8.23  into agreements for new group residential housing beds with 
  8.24  total rates in excess of the MSA equivalent rate except:  (1) 
  8.25  for group residential housing establishments meeting the 
  8.26  requirements of subdivision 2a, clause (2) with department 
  8.27  approval; (2) for group residential housing establishments 
  8.28  licensed under Minnesota Rules, parts 9525.0215 to 9525.0355, 
  8.29  provided the facility is needed to meet the census reduction 
  8.30  targets for persons with mental retardation or related 
  8.31  conditions at regional treatment centers; (3) to ensure 
  8.32  compliance with the federal Omnibus Budget Reconciliation Act 
  8.33  alternative disposition plan requirements for inappropriately 
  8.34  placed persons with mental retardation or related conditions or 
  8.35  mental illness; (4) up to 80 beds in a single, specialized 
  8.36  facility located in Hennepin county that will provide housing 
  9.1   for chronic inebriates who are repetitive users of 
  9.2   detoxification centers and are refused placement in emergency 
  9.3   shelters because of their state of intoxication.  Planning for 
  9.4   the specialized facility must have been initiated before July 1, 
  9.5   1991, in anticipation of receiving a grant from the housing 
  9.6   finance agency under section 462A.05, subdivision 20a, paragraph 
  9.7   (b); or (5) notwithstanding the provisions of subdivision 2a, 
  9.8   for up to 180 supportive housing units in Anoka, Dakota, 
  9.9   Hennepin, or Ramsey county for homeless adults with a mental 
  9.10  illness, a history of substance abuse, or human immunodeficiency 
  9.11  virus or acquired immunodeficiency syndrome.  For purposes of 
  9.12  this section, "homeless adult" means a person who is living on 
  9.13  the street or in a shelter or is about to be evicted from a 
  9.14  dwelling unit or about to be discharged from a regional 
  9.15  treatment center, community hospital, or residential treatment 
  9.16  program and has no appropriate housing available and lacks the 
  9.17  resources and support necessary to access appropriate 
  9.18  housing.  At least 70 percent of the supportive housing units 
  9.19  must serve homeless adults with mental illness, substance abuse 
  9.20  problems, or human immunodeficiency virus or acquired 
  9.21  immunodeficiency syndrome who are about to be discharged from a 
  9.22  regional treatment center, or a state-contracted psychiatric bed 
  9.23  in a community hospital, or a residential mental health or 
  9.24  chemical dependency treatment program.  If a person meets the 
  9.25  requirements of subdivision 1, paragraph (a), and receives a 
  9.26  federal Section 8 housing subsidy, the group residential housing 
  9.27  rate for that person is limited to the supplementary rate under 
  9.28  section 256I.05, subdivision 1a, and is determined by 
  9.29  subtracting the amount of the person's countable income that 
  9.30  exceeds the MSA equivalent rate from the group residential 
  9.31  housing supplementary rate.  A resident in a demonstration 
  9.32  project site who no longer participates in the demonstration 
  9.33  program shall retain eligibility for a group residential housing 
  9.34  payment in an amount determined under section 256I.06, 
  9.35  subdivision 8, using the MSA equivalent rate.  Service funding 
  9.36  under section 256I.05, subdivision 1a, must end June 30, 1997.  
 10.1   Effective July 1, 1997, services to persons in these settings 
 10.2   must be provided through a managed care entity.  This provision 
 10.3   is subject to the availability of matching federal funds. 
 10.4      (b) A county agency may enter into a group residential 
 10.5   housing agreement for beds with rates in excess of the MSA 
 10.6   equivalent rate in addition to those currently covered under a 
 10.7   group residential housing agreement if the additional beds are 
 10.8   only a replacement of beds with rates in excess of the MSA 
 10.9   equivalent rate which have been made available due to closure of 
 10.10  a setting, a change of licensure or certification which removes 
 10.11  the beds from group residential housing payment, or as a result 
 10.12  of the downsizing of a group residential housing setting.  The 
 10.13  transfer of available beds from one county to another can only 
 10.14  occur by the agreement of both counties. 
 10.15                             ARTICLE 2 
 10.16         HEALTH AND CONTINUING CARE RELATED TO MA AND GAMC 
 10.17     Section 1.  Minnesota Statutes 1994, section 62D.04, 
 10.18  subdivision 5, is amended to read: 
 10.19     Subd. 5.  [PARTICIPATION; GOVERNMENT PROGRAMS.] Health 
 10.20  maintenance organizations shall, as a condition of receiving and 
 10.21  retaining a certificate of authority, participate in the medical 
 10.22  assistance, general assistance medical care, and MinnesotaCare 
 10.23  programs program and provide coverage under chapter 256J.  The 
 10.24  participation required from health maintenance organizations 
 10.25  shall be pursuant to rules adopted under section 256B.0644 A 
 10.26  health maintenance organization is required to submit proposals 
 10.27  in good faith to serve individuals eligible for the above 
 10.28  programs in a geographic region of the state if, at the time of 
 10.29  publication of a request for proposal, the HMO's percentage of 
 10.30  enrollment in the above programs is lower than its percentage of 
 10.31  enrollment from other payors.  Geographic regions shall be 
 10.32  defined by the commissioner of human services in the request for 
 10.33  proposals. 
 10.34     Sec. 2.  Minnesota Statutes 1994, section 62N.10, 
 10.35  subdivision 4, is amended to read: 
 10.36     Subd. 4.  [PARTICIPATION; GOVERNMENT PROGRAMS.] Integrated 
 11.1   service networks shall, as a condition of licensure, participate 
 11.2   in the medical assistance, general assistance medical care, and 
 11.3   MinnesotaCare programs, and provide coverage under chapter 
 11.4   256J.  An integrated service network, including a community 
 11.5   integrated service network is required to submit proposals in 
 11.6   good faith to serve persons who are eligible for the above 
 11.7   programs if, at the time of publication of a request for 
 11.8   proposal, the integrated service network's percentage of 
 11.9   enrollment in these programs is lower than its percentage of 
 11.10  enrollment from other payors.  Geographic regions shall be 
 11.11  defined by the commissioner of human services in the request for 
 11.12  proposals.  The commissioner shall adopt rules specifying the 
 11.13  participation required of the networks.  The rules must be 
 11.14  consistent with Minnesota Rules, parts 9505.5200 to 9505.5260, 
 11.15  governing participation by health maintenance organizations in 
 11.16  public health care programs. 
 11.17     Sec. 3.  [252B.01] [RULE CONSOLIDATION.] 
 11.18     This chapter establishes new methods to assure the quality 
 11.19  of services to persons with mental retardation or related 
 11.20  conditions, and streamlines and simplifies regulation of 
 11.21  services and supports for persons with mental retardation or 
 11.22  related conditions.  Sections 252B.02 to 252B.07 establish new 
 11.23  standards that eliminate duplication and overlap of regulatory 
 11.24  requirements by consolidating, replacing, and repealing four 
 11.25  rules.  Section 252B.08 authorizes the commissioner of human 
 11.26  services to develop and use new regulatory strategies to 
 11.27  maintain compliance with the streamlined requirements.  Sections 
 11.28  252B.02 to 252B.07 remain in effect until a rule is promulgated 
 11.29  to govern these services. 
 11.30     Sec. 4.  [252B.02] [DEFINITIONS.] 
 11.31     Subdivision 1.  [SCOPE.] The terms used in this chapter 
 11.32  have the meanings given them in this section. 
 11.33     Subd. 2.  [APPLICANT.] "Applicant" has the meaning given in 
 11.34  section 245A.02, subdivision 3. 
 11.35     Subd. 3.  [CASE MANAGER.] "Case manager" means the 
 11.36  individual designated by the county board under rules of the 
 12.1   commissioner to provide case management services as delineated 
 12.2   in section 256B.092. 
 12.3      Subd. 4.  [CONSUMER.] "Consumer" means a person who has 
 12.4   been determined eligible to receive and is receiving services or 
 12.5   support for persons with mental retardation or related 
 12.6   conditions. 
 12.7      Subd. 5.  [COMMISSIONER.] "Commissioner" means the 
 12.8   commissioner of the department of human services or the 
 12.9   commissioner's designated representative. 
 12.10     Subd. 6.  [COUNTY OF FINANCIAL RESPONSIBILITY.] "County of 
 12.11  financial responsibility" means the county responsible for the 
 12.12  payment of individual client social services as specified in 
 12.13  section 256G.02, subdivision 4. 
 12.14     Subd. 7.  [DAY TRAINING AND HABILITATION SERVICES FOR 
 12.15  ADULTS WITH MENTAL RETARDATION OR RELATED CONDITIONS.] "Day 
 12.16  training and habilitation services for adults with mental 
 12.17  retardation or related conditions" has the meaning given in 
 12.18  sections 252.40 to 252.47. 
 12.19     Subd. 8.  [DEPARTMENT.] "Department" means the Minnesota 
 12.20  department of human services. 
 12.21     Subd. 9.  [DIRECT SERVICE.] "Direct service" means, for a 
 12.22  consumer receiving residential-based services, day training and 
 12.23  habilitation services, or respite care services, one or more of 
 12.24  the following:  supervision, assistance, or training. 
 12.25     Subd. 10.  [HEALTH SERVICES.] "Health services" means any 
 12.26  service or treatment that promotes and maintains the health and 
 12.27  wellness of the consumer such as medication administration, 
 12.28  medical, dental, and nutritional services, and exercise. 
 12.29     Subd. 11.  [HOST COUNTY.] "Host county" means the county in 
 12.30  which the services described in a consumer's personal support 
 12.31  plan are provided. 
 12.32     Subd. 12.  [INCIDENT.] "Incident" means any serious injury 
 12.33  as determined by section 245.91, subdivision 6; accident; report 
 12.34  of a child or vulnerable adult maltreatment; circumstances that 
 12.35  involve a law enforcement agency; or a consumer's death. 
 12.36     Subd. 13.  [INDIVIDUAL WHO IS RELATED.] "Individual who is 
 13.1   related" has the meaning given in section 245A.02, subdivision 
 13.2   13. 
 13.3      Subd. 14.  [INTERMEDIATE CARE FACILITY FOR PERSONS WITH 
 13.4   MENTAL RETARDATION OR RELATED CONDITIONS OR 
 13.5   ICF/MR.] "Intermediate care facility for persons with mental 
 13.6   retardation or related conditions or ICF/MR" means a residential 
 13.7   program licensed to provide services to persons with mental 
 13.8   retardation or related conditions under section 252.28 and 
 13.9   chapter 245A and a physical facility licensed as a supervised 
 13.10  living facility under chapter 144, which together are certified 
 13.11  by the Minnesota department of health as an intermediate care 
 13.12  facility for persons with mental retardation or related 
 13.13  conditions. 
 13.14     Subd. 15.  [LEGAL REPRESENTATIVE.] "Legal representative" 
 13.15  means the parent or parents of a consumer who is under 18 years 
 13.16  of age or a guardian, conservator, or guardian ad litem 
 13.17  authorized by the court, or other legally authorized 
 13.18  representative to make decisions about services for a consumer. 
 13.19     Subd. 16.  [LICENSE.] "License" has the meaning given in 
 13.20  section 245A.02, subdivision 8. 
 13.21     Subd. 17.  [LICENSE HOLDER.] "License holder" has the 
 13.22  meaning given in section 245A.02, subdivision 9. 
 13.23     Subd. 18.  [OBJECTIVE.] "Objective" means a short-term 
 13.24  expectation, accompanied by measurable criteria, that is 
 13.25  incorporated in the personal support plan.  Objectives are 
 13.26  designed to result in achieving the consumer's outcomes in the 
 13.27  personal support plan. 
 13.28     Subd. 19.  [OUTCOME.] "Outcome" means the behavior, action, 
 13.29  or status attained by the consumer that can be observed, 
 13.30  measured, or otherwise reliably determined, as demonstrated by 
 13.31  typical life activities of an individual who does not have a 
 13.32  disability.  Outcomes are the equivalent of the long-range goals 
 13.33  and short-term goals referenced in section 256B.092 and 
 13.34  Minnesota Rules, chapter 9525. 
 13.35     Subd. 20.  [PERSON WITH MENTAL RETARDATION OR A RELATED 
 13.36  CONDITION.] "Person with mental retardation or a related 
 14.1   condition" means a person who is determined to be eligible for 
 14.2   case management services under section 256B.092 and Minnesota 
 14.3   Rules, parts 9525.0004 to 9525.0036, because the person meets 
 14.4   the diagnostic definition from sections 252.27 and 256B.092 and 
 14.5   Minnesota Rules, part 9525.0016, items A and B. 
 14.6      Subd. 21.  [PERSONAL SUPPORT PLAN.] "Personal support plan" 
 14.7   means a document which describes the environments in which the 
 14.8   consumer will live, work, and spend leisure time and specifies 
 14.9   the formal and informal supports that will assist the consumer 
 14.10  within that environment.  The personal support plan is developed 
 14.11  by the case manager and consumer or the consumer's legal 
 14.12  representative to specify needs, supports, and vendors.  The 
 14.13  personal support plan is the equivalent of the individual 
 14.14  service plan referenced in section 256B.092 and Minnesota Rules, 
 14.15  chapter 9525. 
 14.16     Subd. 22.  [PSYCHOTROPIC MEDICATION USE CHECKLIST.] 
 14.17  "Psychotropic medication use checklist" means the checklist 
 14.18  developed as part of the Welsch vs. Gardebring Negotiated 
 14.19  Settlement, United States District Court, District of Minnesota, 
 14.20  Fourth Division, No. 4-72 Civil 451, 1987, Part V, Section B, to 
 14.21  govern the administration of psychotropic medications. 
 14.22     Subd. 23.  [RESIDENTIAL-BASED 
 14.23  HABILITATION.] "Residential-based habilitation" means care, 
 14.24  supervision, and training provided primarily in the consumer's 
 14.25  own home or place of residence but also including 
 14.26  community-integrated activities in accordance with the personal 
 14.27  support plan. 
 14.28     Subd. 24.  [RESPITE CARE.] "Respite care" means services 
 14.29  that provide short-term care to a consumer due to the absence or 
 14.30  need for relief of the family members or primary caregivers who 
 14.31  normally provide the care.  For purposes of this section, a 
 14.32  primary caregiver is an individual who: 
 14.33     (1) is principally responsible for the care and supervision 
 14.34  of the consumer; 
 14.35     (2) maintains the individual's primary residence at the 
 14.36  same address as the consumer; and 
 15.1      (3) is named as an owner or lessor of the primary residence.
 15.2      Subd. 25.  [SERVICE.] "Service" means care, supervision, 
 15.3   and activities designed to achieve the outcomes assigned to the 
 15.4   license holder. 
 15.5      Subd. 26.  [SEMI-INDEPENDENT LIVING SERVICES OR SILS.] 
 15.6   "Semi-independent living services or SILS" has the meaning given 
 15.7   in section 252.275. 
 15.8      Subd. 27.  [VOLUNTEER.] "Volunteer" means an individual 
 15.9   who, under the direction of the license holder, provides direct 
 15.10  services without pay to consumers served by the license holder. 
 15.11     Sec. 5.  [252B.03] [APPLICABILITY AND EFFECT.] 
 15.12     Subdivision 1.  [APPLICABILITY.] The standards in this 
 15.13  chapter govern services to persons with mental retardation or 
 15.14  related conditions receiving services from license holders of 
 15.15  semi-independent living services; residential programs that 
 15.16  serve more than four consumers, including intermediate care 
 15.17  facilities for persons with mental retardation; day training and 
 15.18  habilitation services for adults; residential-based 
 15.19  habilitation; and respite care provided outside the consumer's 
 15.20  home for more than four consumers at the same time. 
 15.21     Subd. 2.  [RELATIONSHIP TO OTHER STANDARDS GOVERNING 
 15.22  SERVICES FOR PERSONS WITH MENTAL RETARDATION OR RELATED 
 15.23  CONDITIONS.] (a) The standards in this chapter consolidate or 
 15.24  replace the standards previously found in the four program rules 
 15.25  repealed by this chapter:  Minnesota Rules, parts 9525.0500 to 
 15.26  9525.0660; 9525.0215 to 9525.0355; 9525.1500 to 9525.1690; and 
 15.27  9525.2000 to 9525.2140, with the exceptions noted in paragraphs 
 15.28  (b) and (c).  
 15.29     (b) ICFs/MR are exempt from: 
 15.30     (1) section 252B.04; 
 15.31     (2) section 252B.06, subdivision 3; 
 15.32     (3) section 252B.06, subdivision 6; 
 15.33     (4) section 252B.07, subdivision 5, paragraphs (b) and (c); 
 15.34     (5) section 252B.07, subdivision 8; 
 15.35     (6) section 252B.07, subdivision 9, paragraph (a), clause 
 15.36  (4); 
 16.1      (7) section 252B.07, subdivision 9, paragraph (b), clause 
 16.2   (1); and 
 16.3      (8) section 252B.07, subdivision 11.  
 16.4      (c) License holders also licensed under chapter 144 as a 
 16.5   supervised living facility are exempted from section 252.04.  
 16.6      (d) All other rule requirements governing programs for 
 16.7   persons with mental retardation or related conditions in effect 
 16.8   on the effective date of this chapter continue to apply with the 
 16.9   following exception:  residential service sites, excluding 
 16.10  ICFs/MR, that are controlled by the license holder and that 
 16.11  serve four or fewer adult consumers are exempt from compliance 
 16.12  with Minnesota Rules, parts 9555.5050 to 9555.6125, subpart 2, 
 16.13  and 9555.6125, subpart 3, item B, to 9555.6195 and 9555.6225 to 
 16.14  9555.6265.  These service sites continue to be licensed as 
 16.15  foster care for purposes of this chapter.  
 16.16     (e) The commissioner may exempt license holders from 
 16.17  applicable licensing standards of this chapter when the license 
 16.18  holder meets the standards of an independent accreditation body 
 16.19  using the criteria and procedures of section 245A.09, 
 16.20  subdivision 7. 
 16.21     (f) License holders governed by sections 252B.02 to 252B.07 
 16.22  must also: 
 16.23     (1) meet the licensure requirements in sections 245A.01 to 
 16.24  245A.16, the human services licensing act, and Minnesota Rules, 
 16.25  parts 9543.1000 to 9543.1060, promulgated thereunder; and 
 16.26     (2) assess and document the susceptibility for risk of 
 16.27  abuse to the consumer as required by sections 626.556 and 
 16.28  626.557, subdivision 14, and Minnesota Rules, parts 9555.8000 to 
 16.29  9555.8500. 
 16.30  License holders jointly providing services to a consumer shall 
 16.31  coordinate and use the resulting assessments of risk areas for 
 16.32  the abuse prevention plan required by section 626.557, 
 16.33  subdivision 14. 
 16.34     (g) Nothing in this chapter prohibits license holders from 
 16.35  concurrently serving consumers with and without mental 
 16.36  retardation or related conditions provided this chapter's 
 17.1   standards are met as well as other relevant standards. 
 17.2      (h) The documentation that sections 252B.02 to 252B.07 
 17.3   requires the license holder to incorporate in the personal 
 17.4   support plan serves as the individual program plan required in 
 17.5   section 256B.092. 
 17.6      Sec. 6.  [252B.04] [CONSUMER RIGHTS.] 
 17.7      Subdivision 1.  [LICENSE HOLDER'S RESPONSIBILITY FOR 
 17.8   CONSUMERS' RIGHTS.] The license holder must: 
 17.9      (1) inform the consumer or the consumer's legal 
 17.10  representative of the rights in subdivisions 2 and 3 before 
 17.11  providing services; 
 17.12     (2) document giving the consumer or the consumer's legal 
 17.13  representative a copy of the rights and explaining the rights; 
 17.14  and 
 17.15     (3) comply with the rights. 
 17.16     Subd. 2.  [SERVICE-RELATED RIGHTS.] A consumer's 
 17.17  service-related rights include the right to: 
 17.18     (1) refuse services and be informed of the consequences of 
 17.19  refusing services; 
 17.20     (2) know, in advance, any limits to the services available 
 17.21  from the license holder; 
 17.22     (3) know all conditions and terms governing the provision 
 17.23  of services, including those related to initiation and 
 17.24  termination; 
 17.25     (4) know what the charges are for services, regardless of 
 17.26  who will be paying for the services, and be notified of any 
 17.27  changes in those charges; 
 17.28     (5) know, in advance, whether services are covered by 
 17.29  insurance, government funding, or other sources and be told of 
 17.30  any charges the consumer or other private party may have to pay 
 17.31  for; and 
 17.32     (6) receive services from license holders who are competent 
 17.33  and trained, who have professional certification or licensure, 
 17.34  as appropriate, and who meet the qualifications identified in 
 17.35  the personal support plan. 
 17.36     Subd. 3.  [PROTECTION-RELATED RIGHTS.] The consumer also 
 18.1   has the right to: 
 18.2      (1) have personal, financial, service, and medical 
 18.3   information kept confidential, and to be advised of the license 
 18.4   holder's policies and procedures regarding disclosure of such 
 18.5   information; 
 18.6      (2) access records and written information; 
 18.7      (3) be free from abuse and neglect; 
 18.8      (4) be treated with courtesy and respect for the consumer's 
 18.9   individuality and receive respectful treatment of the consumer's 
 18.10  property; 
 18.11     (5) voice grievances, know the contact persons responsible 
 18.12  for addressing problems, how to contact those persons, and any 
 18.13  procedures for grievance or complaint resolution; 
 18.14     (6) know the name and address of the state or county agency 
 18.15  to contact for additional information or assistance; 
 18.16     (7) assert these rights personally, or have them asserted 
 18.17  by the consumer's family or legal representative, without 
 18.18  retaliation; and 
 18.19     (8) give written informed consent to participate in any 
 18.20  research or experimental treatment. 
 18.21     Sec. 7.  [252B.05] [HEALTH AND SAFETY STANDARDS.] 
 18.22     Subdivision 1.  [ENVIRONMENT.] The license holder must: 
 18.23     (1) ensure that services are provided in a safe and 
 18.24  hazard-free environment; 
 18.25     (2) not use locked doors to restrict a consumer's movement 
 18.26  or as a substitute for staff interactions with consumers; 
 18.27     (3) follow procedures that minimize the consumer's health 
 18.28  risk from communicable diseases; and 
 18.29     (4) maintain equipment, vehicles, supplies, and materials 
 18.30  owned or leased by the license holder in good condition. 
 18.31     Subd. 2.  [LICENSED CAPACITY FOR FACILITY-BASED DAY 
 18.32  TRAINING AND HABILITATION SERVICES.] Licensed capacity of day 
 18.33  training and habilitation service sites owned or leased by the 
 18.34  license holder must be determined by the amount of primary space 
 18.35  available, the scheduling of activities at other service sites, 
 18.36  and the space requirements of consumers receiving services.  
 19.1   Primary space does not include hallways, stairways, closets, 
 19.2   utility areas, bathrooms, kitchens, and floor area beneath 
 19.3   stationary equipment.  A minimum of at least 40 square feet of 
 19.4   primary space must be available for each consumer who is engaged 
 19.5   in a day training and habilitation activity at the site for 
 19.6   which the licensed capacity must be determined. 
 19.7      Subd. 3.  [RESIDENTIAL SERVICE SITES FOR MORE THAN FOUR 
 19.8   CONSUMERS, AND FOUR-BED ICFS/MR.] Sites must meet the fire 
 19.9   protection provisions of either the Residential Board and Care 
 19.10  Occupancies Chapter or the Health Care Occupancies Chapter of 
 19.11  the Life Safety Code (LSC), National Fire Protection 
 19.12  Association, 1985 edition, or its successors.  Sites meeting the 
 19.13  definition of a residential board and care occupancy for 16 or 
 19.14  less beds must have the emergency evacuation capability of 
 19.15  residents evaluated in accordance with Appendix F of the LSC, 
 19.16  except for those sites that meet the LSC Health Care Occupancies 
 19.17  Chapter, or its successors. 
 19.18     Subd. 4.  [RESIDENTIAL SERVICE SITES FOR FOUR OR FEWER 
 19.19  ADULT CONSUMERS, EXCEPT FOR ICFS/MR OR SILS, THAT ARE CONTROLLED 
 19.20  BY THE LICENSE HOLDER.] Residential service sites for four or 
 19.21  fewer adult consumers, except for ICFs/MR or SILS, that are 
 19.22  controlled by the license holder must comply with Minnesota 
 19.23  Rules, parts 9555.6205 to 9555.6215.  For purposes of this 
 19.24  subdivision, "controlled" means the license holder has a legal 
 19.25  right to possession of the premises such as ownership or a 
 19.26  leasehold of the premises and the consumer does not have a 
 19.27  leasehold in the consumer's name, or any other legal right to 
 19.28  possession of the property in the consumer's name.  
 19.29     Subd. 5.  [MEETING FIRE AND SAFETY CODES.] An applicant for 
 19.30  licensure under sections 245A.01 to 245A.16 and Minnesota Rules, 
 19.31  parts 9543.1000 to 9543.1060, must document compliance with 
 19.32  applicable building codes, fire and safety codes, health rules, 
 19.33  and zoning ordinances, or document that an appropriate waiver 
 19.34  has been granted. 
 19.35     Subd. 6.  [HEALTH SERVICES.] The license holder is 
 19.36  responsible for implementing the health services assigned to the 
 20.1   license holder in the personal support plan and for documenting 
 20.2   how the services will be implemented within the parameters 
 20.3   established by the case manager and the consumer.  Required 
 20.4   documentation must include a description of procedures the 
 20.5   license holder will follow regarding medication administration.  
 20.6   The procedures must be established in consultation with a 
 20.7   registered nurse, nurse practitioner, physicians' assistant, or 
 20.8   medical doctor. 
 20.9      Subd. 7.  [FIRST AID.] When the license holder is providing 
 20.10  direct service and supervision to a consumer, the license holder 
 20.11  must have available a staff person trained in first aid and 
 20.12  cardiopulmonary resuscitation. 
 20.13     Subd. 8.  [EMERGENCY PROCEDURES.] The license holder must 
 20.14  develop and follow a written plan and procedures for responding 
 20.15  to and reporting all emergencies, including deaths, medical 
 20.16  emergencies, illnesses, accidents, missing consumers, fires, 
 20.17  severe weather and natural disaster, bomb threats, and other 
 20.18  threats. 
 20.19     Subd. 9.  [REPORTING INCIDENTS AND EMERGENCIES.] The 
 20.20  license holder must report the following incidents in writing to 
 20.21  the consumer's legal representative, caregiver, and case manager 
 20.22  within 24 hours of the occurrence:  deaths, medical emergencies, 
 20.23  illnesses or accidents that require hospitalization, missing 
 20.24  consumers, and fires.  Any incident resulting in the death of a 
 20.25  consumer must also be reported to the commissioner.  Death or 
 20.26  serious injury must be reported to the ombudsman for mental 
 20.27  health and mental retardation. 
 20.28     Sec. 8.  [252B.06] [SERVICE STANDARDS.] 
 20.29     Subdivision 1.  [OUTCOME-BASED SERVICES.] The license 
 20.30  holder must provide services in accordance with the consumer's 
 20.31  individual needs as specified in the consumer's personal support 
 20.32  plan.  Services must be outcome-based for the consumer and 
 20.33  designed to achieve: 
 20.34     (1) personal health, safety, and comfort; 
 20.35     (2) personal growth, independence, and productivity; 
 20.36     (3) consumer choice and control over daily life decisions; 
 21.1      (4) consumer, legal representative, and the case manager's 
 21.2   satisfaction with services; and 
 21.3      (5) community inclusion, including social relationships and 
 21.4   participation in valued community roles. 
 21.5      Subd. 2.  [ASSESSMENTS.] (a) The license holder shall 
 21.6   assess and reassess the consumer within time lines and 
 21.7   assessment areas specified in the personal support plan or as 
 21.8   requested in writing by the case manager. 
 21.9      (b) For each area of assessment, the license holder must 
 21.10  incorporate into the personal support plan a written summary, 
 21.11  analysis, and recommendations. 
 21.12     (c) All assessments must include information about the 
 21.13  consumer that is descriptive of: 
 21.14     (1) the consumer's strengths and functional skills; and 
 21.15     (2) the level of support and supervision the consumer needs 
 21.16  to achieve the outcomes in subdivision 1. 
 21.17     Subd. 3.  [OBJECTIVES.] The license holder must develop and 
 21.18  document in writing for incorporation into the personal support 
 21.19  plan: 
 21.20     (1) measurable objectives and measurable criteria for 
 21.21  determining whether objectives are met that are designed to 
 21.22  result in achieving the outcomes specified as the license 
 21.23  holder's responsibility in the personal support plan; 
 21.24     (2) the methods that will be used to accomplish each 
 21.25  objective, including information about physical and social 
 21.26  environments, the equipment and materials required, and 
 21.27  techniques that are consistent with the consumer's communication 
 21.28  mode and learning style; 
 21.29     (3) the projected starting date and conditions for progress 
 21.30  review and actions to be taken for achieving each objective with 
 21.31  the approval of the consumer or the consumer's legal 
 21.32  representative; and 
 21.33     (4) the names of the staff or contractors responsible for 
 21.34  implementing each objective. 
 21.35     Subd. 4.  [PROGRESS REVIEWS.] The license holder must 
 21.36  participate in progress reviews following time lines established 
 22.1   in the consumer's personal support plan or as requested in 
 22.2   writing by the case manager, at a minimum of once a year.  The 
 22.3   license holder must summarize the progress of the objectives and 
 22.4   make recommendations in a written report sent to the consumer or 
 22.5   the consumer's legal representative and case manager prior to a 
 22.6   review meeting.  The written report shall be incorporated as 
 22.7   part of the personal support plan. 
 22.8      Subd. 5.  [REPORTS.] The license holder shall provide 
 22.9   written reports regarding the consumer's status, progress, or 
 22.10  other issues related to the personal support plan, as requested 
 22.11  by the case manager or consumer or the consumer's legal 
 22.12  representative. 
 22.13     Subd. 6.  [MINIMUM STAFFING REQUIREMENTS.] The license 
 22.14  holder must provide supervision to assure the health, safety, 
 22.15  and protection of rights of each consumer and to be able to 
 22.16  implement each consumer's personal support plan. 
 22.17     Subd. 7.  [LEAVING THE RESIDENCE.] As specified in each 
 22.18  consumer's personal support plan, each consumer must leave the 
 22.19  residence to participate in regular education, employment, or 
 22.20  community activities. 
 22.21     Sec. 9.  [252B.07] [MANAGEMENT STANDARDS.] 
 22.22     Subdivision 1.  [CONSUMER DATA FILE.] The license holder 
 22.23  must maintain the following information for each consumer: 
 22.24     (1) identifying information that includes date of birth, 
 22.25  medications, legal representative, history, medical, and other 
 22.26  individual-specific information, and names and telephone numbers 
 22.27  of contacts; 
 22.28     (2) the consumer's personal support plan.  When a 
 22.29  consumer's case manager does not provide a current personal 
 22.30  support plan, the license holder shall make a written request to 
 22.31  the case manager to provide a copy of the personal support plan 
 22.32  and inform the consumer or the consumer's legal representative 
 22.33  of their right to a personal support plan; 
 22.34     (3) consumer-specific medication administration plan; 
 22.35     (4) copies of assessments, analyses, summaries, and 
 22.36  recommendations; 
 23.1      (5) progress review reports; 
 23.2      (6) incident and emergency reports involving the consumer; 
 23.3      (7) health records; 
 23.4      (8) discharge summary, when applicable; and 
 23.5      (9) record of other license holders serving the consumer 
 23.6   that includes a contact person and telephone number, services 
 23.7   being provided, services that require coordination between the 
 23.8   two license holders, and name of staff responsible for 
 23.9   coordination. 
 23.10     Subd. 2.  [ACCESS TO RECORDS.] The license holder must 
 23.11  ensure that the following people have access to the information 
 23.12  in subdivision 1:  
 23.13     (1) the consumer and the consumer's legal representative; 
 23.14     (2) the commissioner; 
 23.15     (3) the consumer's case manager; and 
 23.16     (4) staff providing direct services to the consumer unless 
 23.17  the information is not relevant to carrying out the personal 
 23.18  support plan. 
 23.19     Subd. 3.  [RETENTION OF CONSUMER'S RECORDS.] The license 
 23.20  holder must retain the records required for consumers for at 
 23.21  least three years following termination of services. 
 23.22     Subd. 4.  [CONFLICT OF INTEREST.] The license holder shall 
 23.23  not employ an individual who is related to the consumer to 
 23.24  provide oversight or direct care services to the related 
 23.25  consumer.  An exception to this provision may be allowed if the 
 23.26  license holder has developed procedures to minimize potential 
 23.27  conflicts of interests. 
 23.28     Subd. 5.  [STAFF QUALIFICATIONS.] (a) The license holder 
 23.29  must ensure that staff is competent through training, 
 23.30  experience, and education to meet the consumer's needs as 
 23.31  written in the personal support plan.  The staff qualifications 
 23.32  must be documented. 
 23.33     (b) Delivery and evaluation of services provided by the 
 23.34  license holder to a consumer must be coordinated by a designated 
 23.35  person.  This designated person or coordinator must minimally 
 23.36  have a two-year degree in a field related to service provision 
 24.1   and two years work experience with consumers with mental 
 24.2   retardation or related conditions.  The coordinator must provide 
 24.3   supervision, support, and evaluation of activities that include: 
 24.4      (1) oversight of the license holder's responsibilities 
 24.5   designated in the personal support plan; 
 24.6      (2) instructions and assistance to staff implementing the 
 24.7   personal support plan areas; 
 24.8      (3) evaluation of the effectiveness of service delivery, 
 24.9   methodologies, and progress on consumer outcomes based on the 
 24.10  condition set for objective change; and 
 24.11     (4) review of incident and emergency reports, 
 24.12  identification of incident patterns, and implementation of 
 24.13  corrective action as necessary to reduce occurrences. 
 24.14     (c) The coordinator is responsible for taking necessary 
 24.15  actions to facilitate the accomplishment of the outcomes for 
 24.16  each consumer as specified in the consumer's personal support 
 24.17  plan. 
 24.18     (d) The license holder must provide for adequate 
 24.19  supervision for direct care staff to ensure implementation of 
 24.20  the personal support plan. 
 24.21     Subd. 6.  [STAFF ORIENTATION.] (a) Within 60 days of hiring 
 24.22  staff who provide direct service, the license holder must 
 24.23  provide 30 hours of orientation.  Direct care staff must 
 24.24  complete 15 of the 30 hours before providing any direct service 
 24.25  to a consumer without direct supervision.  If the staff member 
 24.26  has one year or more of prior experience providing direct care 
 24.27  to persons with mental retardation or related conditions, the 
 24.28  15-hour requirement may be reduced to eight hours. 
 24.29     (b) The 30 hours of orientation must combine supervised 
 24.30  on-the-job training with coverage of the material in clauses (1) 
 24.31  to (7); 
 24.32     (1) review of the consumer's complete personal support plan 
 24.33  to achieve an understanding of the consumer as a unique 
 24.34  individual; 
 24.35     (2) review and instructions regarding the license holder's 
 24.36  policies and procedures including their location and access; 
 25.1      (3) emergency procedures; 
 25.2      (4) explanation of specific job functions including 
 25.3   implementing objectives from the consumer's personal support 
 25.4   plan; 
 25.5      (5) explanation of responsibilities related to sections 
 25.6   626.556 and 626.557, and Minnesota Rules, parts 9555.8000 to 
 25.7   9555.8500, including requirements of rules promulgated 
 25.8   thereunder; sections 245A.01 to 245A.16, the human services 
 25.9   licensing act; and Minnesota Rules, parts 9525.2700 to 
 25.10  9525.2810, governing use of aversive and deprivation procedures; 
 25.11     (6) medication administration as it applies to the 
 25.12  individual consumer; and 
 25.13     (7) other topics necessary as determined by the consumer's 
 25.14  personal support plan or other areas identified by the license 
 25.15  holder. 
 25.16     (c) The license holder must document each employee's 
 25.17  orientation received. 
 25.18     Subd. 7.  [STAFF TRAINING.] (a) The license holder shall 
 25.19  ensure that direct service staff annually complete hours of 
 25.20  training equal to two percent of the number of hours the staff 
 25.21  person worked. 
 25.22     (b) The license holder must document the training completed 
 25.23  by each employee. 
 25.24     (c) Training shall address the staff competencies necessary 
 25.25  to address the consumer needs as identified in the consumer's 
 25.26  personal support plan and ensure consumer health, safety, and 
 25.27  protection of rights.  Training may also include other areas 
 25.28  identified by the license holder. 
 25.29     Subd. 8.  [VOLUNTEERS.] The license holder must ensure that 
 25.30  volunteers who provide direct services to consumers receive the 
 25.31  training and orientation necessary to fulfill their 
 25.32  responsibilities. 
 25.33     Subd. 9.  [POLICIES AND PROCEDURES.] The license holder 
 25.34  must develop and implement the policies and procedures in 
 25.35  paragraphs (a) to (c). 
 25.36     (a) Policies and procedures that promote consumer health 
 26.1   and safety by ensuring: 
 26.2      (1) consumer safety in emergency situations as identified 
 26.3   in section 252B.05, subdivision 8; 
 26.4      (2) consumer health through sanitary practices; 
 26.5      (3) safe transportation, when the license holder is 
 26.6   responsible for transportation of consumers, with provisions for 
 26.7   handling emergency situations; 
 26.8      (4) a system of recordkeeping, review of incidents and 
 26.9   emergencies, and corrective action; and 
 26.10     (5) safe medication administration as identified in section 
 26.11  252B.05, subdivision 6, including use of the psychotropic 
 26.12  medication use checklist when applicable, if the license holder 
 26.13  is assigned those responsibilities in the personal support 
 26.14  plan.  If the responsibility for implementing the psychotropic 
 26.15  medication use checklist has not been assigned in the personal 
 26.16  support plan, and the consumer lives in a licensed site, the 
 26.17  residential license holder shall be designated. 
 26.18     (b) Policies and procedures that protect consumer rights 
 26.19  and privacy by ensuring: 
 26.20     (1) consumer data privacy, in compliance with chapter 13; 
 26.21  and 
 26.22     (2) complaint procedures provide consumers with a simple 
 26.23  process to voice grievances and consumers receive a response to 
 26.24  the grievance within a reasonable time period as specified in 
 26.25  Minnesota Rules, part 9543.1020, subpart 2, item F. 
 26.26     (c) Policies and procedures that promote continuity and 
 26.27  quality of consumer supports by ensuring: 
 26.28     (1) continuity of care and service coordination including 
 26.29  provisions for service termination.  Policy and procedures must 
 26.30  include emergency termination and actions the license holder 
 26.31  will take to meet consumer needs and minimize termination 
 26.32  action; 
 26.33     (2) quality services measured through a program evaluation 
 26.34  process including regular evaluations of consumer satisfaction; 
 26.35  and 
 26.36     (3) service continuity and choice regarding service 
 27.1   initiation. 
 27.2      Subd. 10.  [AVAILABILITY OF CURRENT WRITTEN POLICIES AND 
 27.3   PROCEDURES.] The license holder must: 
 27.4      (1) review and update, as needed, the written policies and 
 27.5   procedures in subdivision 9 and inform all consumers or their 
 27.6   legal representatives, case managers, and employees of the 
 27.7   revised policies and procedures when they affect the service 
 27.8   provision; 
 27.9      (2) inform and provide the written policies and procedures 
 27.10  in subdivision 9 upon service initiation to consumers or their 
 27.11  legal representative.  Copies must also be available to case 
 27.12  managers, the host county, and the commissioner upon request; 
 27.13  and 
 27.14     (3) document and maintain all relevant information related 
 27.15  to the policies and procedures in subdivision 9. 
 27.16     Subd. 11.  [CONSUMER FUNDS.] All license holders must 
 27.17  comply with Minnesota Rules, part 9543.1020, subpart 15. 
 27.18     Subd. 12.  [TERMINATING SERVICES.] The license holder must 
 27.19  notify the consumer or consumer's legal representative and the 
 27.20  consumer's case manager in writing of the intended termination.  
 27.21  Notice of the proposed termination of services must be given at 
 27.22  least 60 days before the proposed termination is to become 
 27.23  effective, unless services are terminated according to the 
 27.24  license holder's written emergency termination procedures.  The 
 27.25  license holder must provide information requested by the 
 27.26  consumer or consumer's legal representative or case manager in 
 27.27  the event of planning services termination.  The license holder 
 27.28  shall not adopt policies that require advance notice of 
 27.29  termination of services from the consumer or consumer's legal 
 27.30  representative. 
 27.31     Subd. 13.  [TRAVEL TIME TO AND FROM A DAY TRAINING AND 
 27.32  HABILITATION SITE.] Except in unusual circumstances, the license 
 27.33  holder must not transport a consumer receiving services for 
 27.34  longer than one hour per one-way trip. 
 27.35     Subd. 14.  [SEPARATE LICENSE REQUIRED FOR SEPARATE 
 27.36  SITES.] The license holder shall apply for separate licenses for 
 28.1   each day training and habilitation service site owned or leased 
 28.2   by the license holder, each residential service site serving 
 28.3   more than four consumers, and each four-bed ICF/MR in which the 
 28.4   license holder will provide services. 
 28.5      Subd. 15.  [VARIANCE.] The commissioner may grant a 
 28.6   variance to any of the requirements in sections 252B.02 to 
 28.7   252B.07 using the process and criteria from section 245A.04, 
 28.8   subdivision 9. 
 28.9      Sec. 10.  [252B.08] [NEW REGULATORY STRATEGIES.] 
 28.10     Subdivision 1.  [ALTERNATIVE METHODS OF DETERMINING 
 28.11  COMPLIANCE.] In addition to those methods specified in chapter 
 28.12  245A, the commissioner may use alternative methods and new 
 28.13  regulatory strategies to determine compliance with this 
 28.14  section.  The commissioner may use sampling techniques to ensure 
 28.15  compliance with this section across services provided by a 
 28.16  license holder.  Notwithstanding the provisions of section 
 28.17  245A.09, subdivision 7, paragraph (d), the commissioner may also 
 28.18  extend periods of licensure, not to exceed five years, for 
 28.19  license holders who have demonstrated substantial and consistent 
 28.20  compliance with sections 252B.02 to 252B.07 and have 
 28.21  consistently maintained the health and safety of consumers and 
 28.22  have agreed to conduct their own inspections using self 
 28.23  assessments and peer reviews of the licensing standards of this 
 28.24  chapter and share the results of those inspections with 
 28.25  consumers, their families, and others as requested.  The 
 28.26  commissioner may use self assessments, consumer feedback, and 
 28.27  peer reviews as a substitute for inspections for a license 
 28.28  holder who has maintained substantial and consistent compliance 
 28.29  with this section and has consistently maintained the health and 
 28.30  safety of consumers.  For the purposes of this section, the term 
 28.31  substantial and consistent compliance means during the current 
 28.32  licensing period: 
 28.33     (1) the license holder's license has not been made 
 28.34  provisional, suspended, or revoked; 
 28.35     (2) there have been no allegations or maltreatment 
 28.36  substantiated; 
 29.1      (3) there have been no program deficiencies that have been 
 29.2   identified that would jeopardize the health or safety of 
 29.3   consumers being served; 
 29.4      (4) the license holder has not knowingly given false 
 29.5   information on the license application; 
 29.6      (5) the license holder has not refused to provide the 
 29.7   commissioner access to any service site, documents, staff, or 
 29.8   consumers served; 
 29.9      (6) the license holder has not been disqualified under the 
 29.10  applicant background study provisions of Minnesota Rules, parts 
 29.11  9543.3000 to 9543.3090, or has not continued to employ a staff 
 29.12  person who has been disqualified; and 
 29.13     (7) the license holder has no fines that have been imposed 
 29.14  per provision of chapter 245A. 
 29.15     Subd. 2.  [ADDITIONAL MEASURES.] The commissioner may 
 29.16  require the license holder to implement additional measures on a 
 29.17  time-limited basis to ensure the health and safety of consumers 
 29.18  when the health and safety of consumers have been determined to 
 29.19  be at risk as determined by substantiated incidents of 
 29.20  maltreatment under sections 626.556 and 626.557.  The license 
 29.21  holder may request reconsideration of the actions taken by the 
 29.22  commissioner under this subdivision pursuant to section 245A.06. 
 29.23     Subd. 3.  [SANCTIONS AVAILABLE.] Nothing in this 
 29.24  subdivision shall be construed to limit the commissioner's 
 29.25  authority to suspend at any time, revoke, or make probationary a 
 29.26  license under section 245A.07; make correction orders and 
 29.27  require fines for failure to comply with applicable laws or 
 29.28  rules under section 245A.06; or deny an application for license 
 29.29  under section 245A.05. 
 29.30     Subd. 4.  [EFFICIENT APPLICATION.] The commissioner shall 
 29.31  establish application procedures for license holders licensed 
 29.32  under this chapter to reduce the need to submit duplicative 
 29.33  material. 
 29.34     Subd. 5.  [INFORMATION.] The commissioner shall make 
 29.35  information available to the consumers and interested others 
 29.36  regarding the licensing status of a license holder.  The 
 30.1   information may include specific citations that affect service 
 30.2   delivery. 
 30.3      Sec. 11.  Minnesota Statutes 1994, section 256.9355, 
 30.4   subdivision 3, is amended to read: 
 30.5      Subd. 3.  [EFFECTIVE DATE OF COVERAGE.] The effective date 
 30.6   of coverage is the first day of the month following the month in 
 30.7   which eligibility is approved and the first premium payment has 
 30.8   been received.  The effective date of coverage for eligible 
 30.9   newborns or eligible newly adoptive children added to a family 
 30.10  receiving covered health services is the date of entry into the 
 30.11  family.  The effective date of coverage for other new recipients 
 30.12  added to the family receiving covered health services is the 
 30.13  first day of the month following the month in which eligibility 
 30.14  is approved and the first premium payment has been 
 30.15  received.  The commissioner may alter the effective date of 
 30.16  coverage for MinnesotaCare enrollees who are enrolled in managed 
 30.17  care plans.  Benefits are not available until the day following 
 30.18  discharge if an enrollee is hospitalized on the first day of 
 30.19  coverage.  Notwithstanding any other law to the contrary, 
 30.20  benefits under sections 256.9351 to 256.9361 are secondary to a 
 30.21  plan of insurance or benefit program under which an eligible 
 30.22  person may have coverage and the commissioner shall use cost 
 30.23  avoidance techniques to ensure coordination of any other health 
 30.24  coverage for eligible persons.  The commissioner shall identify 
 30.25  eligible persons who may have coverage or benefits under other 
 30.26  plans of insurance or who become eligible for medical assistance.
 30.27     Sec. 12.  Minnesota Statutes 1995 Supplement, section 
 30.28  256.969, subdivision 1, is amended to read: 
 30.29     Subdivision 1.  [HOSPITAL COST INDEX.] (a) The hospital 
 30.30  cost index shall be the change in the Consumer Price Index-All 
 30.31  Items (United States city average) (CPI-U) forecasted by Data 
 30.32  Resources, Inc.  The commissioner shall use the indices as 
 30.33  forecasted in the third quarter of the calendar year prior to 
 30.34  the rate year.  The hospital cost index may be used to adjust 
 30.35  the base year operating payment rate through the rate year on an 
 30.36  annually compounded basis.  
 31.1      (b) For fiscal years beginning on or after July 1, 1993, 
 31.2   the commissioner of human services shall not provide automatic 
 31.3   annual inflation adjustments for hospital payment rates under 
 31.4   medical assistance, nor under general assistance medical care, 
 31.5   except that the inflation adjustments under paragraph (a) for 
 31.6   medical assistance, excluding general assistance medical care, 
 31.7   shall apply for the biennium ending June 30, 1997 through 
 31.8   calendar year 1997.  The commissioner of finance shall include 
 31.9   as a budget change request in each biennial detailed expenditure 
 31.10  budget submitted to the legislature under section 16A.11 annual 
 31.11  adjustments in hospital payment rates under medical assistance 
 31.12  and general assistance medical care, based upon the hospital 
 31.13  cost index. 
 31.14     Sec. 13.  Minnesota Statutes 1995 Supplement, section 
 31.15  256.969, subdivision 2b, is amended to read: 
 31.16     Subd. 2b.  [OPERATING PAYMENT RATES.] In determining 
 31.17  operating payment rates for admissions occurring on or after the 
 31.18  rate year beginning January 1, 1991, and every two years after, 
 31.19  or more frequently as determined by the commissioner, the 
 31.20  commissioner shall obtain operating data from an updated base 
 31.21  year and establish operating payment rates per admission for 
 31.22  each hospital based on the cost-finding methods and allowable 
 31.23  costs of the Medicare program in effect during the base year.  
 31.24  Rates under the general assistance medical care program, medical 
 31.25  assistance, and MinnesotaCare programs shall not be rebased to 
 31.26  more current data on January 1, 1997.  The base year operating 
 31.27  payment rate per admission is standardized by the case mix index 
 31.28  and adjusted by the hospital cost index, relative values, and 
 31.29  disproportionate population adjustment.  The cost and charge 
 31.30  data used to establish operating rates shall only reflect 
 31.31  inpatient services covered by medical assistance and shall not 
 31.32  include property cost information and costs recognized in 
 31.33  outlier payments. 
 31.34     Sec. 14.  Minnesota Statutes 1995 Supplement, section 
 31.35  256.969, subdivision 10, is amended to read: 
 31.36     Subd. 10.  [SEPARATE BILLING BY CERTIFIED REGISTERED NURSE 
 32.1   ANESTHETISTS.] Hospitals may exclude certified registered nurse 
 32.2   anesthetist costs from the operating payment rate as allowed by 
 32.3   section 256B.0625, subdivision 11.  To be eligible, a hospital 
 32.4   must notify the commissioner in writing by October 1 of the year 
 32.5   preceding the rebased rate year of the request to exclude 
 32.6   certified registered nurse anesthetist costs.  The hospital must 
 32.7   agree that all hospital claims for the cost and charges of 
 32.8   certified registered nurse anesthetist services will not be 
 32.9   included as part of the rates for inpatient services provided 
 32.10  during the rate year.  In this case, the operating payment rate 
 32.11  shall be adjusted to exclude the cost of certified registered 
 32.12  nurse anesthetist services.  
 32.13     For admissions occurring on or after July 1, 1991, and 
 32.14  until the expiration date of section 256.9695, subdivision 3, 
 32.15  services of certified registered nurse anesthetists provided on 
 32.16  an inpatient basis may be paid as allowed by section 256B.0625, 
 32.17  subdivision 11, when the hospital's base year did not include 
 32.18  the cost of these services.  To be eligible, a hospital must 
 32.19  notify the commissioner in writing by July 1, 1991, of the 
 32.20  request and must comply with all other requirements of this 
 32.21  subdivision. 
 32.22     Sec. 15.  Minnesota Statutes 1994, section 256B.03, is 
 32.23  amended by adding a subdivision to read: 
 32.24     Subd. 3.  [AMERICAN INDIAN HEALTH FUNDING.] Notwithstanding 
 32.25  subdivision 1 and sections 256B.0625 and 256D.03, paragraph (f), 
 32.26  the commissioner may make payments to federally recognized 
 32.27  Indian tribes with a reservation in the state to provide medical 
 32.28  assistance to Indian tribal members who reside on the 
 32.29  reservation.  The payments may be made in the form of a block 
 32.30  grant or other payment mechanism determined in consultation with 
 32.31  the tribe.  To the extent that the payment mechanism differs 
 32.32  from the manner in which payments are otherwise made under the 
 32.33  program, payments may not exceed state fiscal year 1995 
 32.34  expenditures for the same population, with an inflation 
 32.35  adjustment. 
 32.36     For purposes of this subdivision, "Indian tribe" means a 
 33.1   tribe, band, or nation, or other organized group or community of 
 33.2   Indians that is recognized as eligible for the special programs 
 33.3   and services provided by the United States to Indians because of 
 33.4   their status as Indians and for which a reservation exists as is 
 33.5   consistent with Public Law Number 100-485, as amended. 
 33.6      For purposes of this subdivision, "state fiscal year 1995 
 33.7   expenditures" include state and federal payments made for 
 33.8   administration of the program and for covered services. 
 33.9      Sec. 16.  Minnesota Statutes 1994, section 256B.0627, 
 33.10  subdivision 1, as amended by Laws 1995, chapter 207, article 6, 
 33.11  sections 52 and 125, subdivision 9, is amended to read: 
 33.12     Subdivision 1.  [DEFINITION�.] (a) "Assessment" means a 
 33.13  review and evaluation of a recipient's need for home care 
 33.14  services conducted in person.  Assessments for private duty 
 33.15  nursing shall be conducted by a private duty nurse.  Assessments 
 33.16  for home health agency services shall be conducted by a home 
 33.17  health agency nurse.  Assessments for personal care services 
 33.18  shall be conducted by the county public health nurse or a 
 33.19  certified public health nurse under contract with the county.  
 33.20  Assessments for medical assistance home care services for mental 
 33.21  retardation or related conditions and alternative care services 
 33.22  for developmentally disabled home and community-based waiver 
 33.23  recipients may be conducted by the county public health nurse to 
 33.24  assure coordination and avoid duplication.  Assessments must be 
 33.25  completed on forms provided by the commissioner within 30 days 
 33.26  of a request for home care services by a recipient or 
 33.27  responsible party. 
 33.28     (b) "Care plan" means a written description of personal 
 33.29  care assistant services developed by the agency nurse with the 
 33.30  recipient or responsible party to be used by the personal care 
 33.31  assistant with a copy provided to the recipient or responsible 
 33.32  party. 
 33.33     (c) "Home care services" means a health service, determined 
 33.34  by the commissioner as medically necessary, that is ordered by a 
 33.35  physician and documented in a care service plan that is reviewed 
 33.36  by the physician at least once every 60 days for the provision 
 34.1   of home health services, or private duty nursing, or at least 
 34.2   once every 365 days for personal care.  Home care services are 
 34.3   provided to the recipient at the recipient's residence that is a 
 34.4   place other than a hospital or long-term care facility or as 
 34.5   specified in section 256B.0625.  
 34.6      (d) "Medically necessary" has the meaning given in 
 34.7   Minnesota Rules, parts 9505.0170 to 9505.0475.  
 34.8      (e) "Personal care assistant" means a person who:  (1) is 
 34.9   at least 18 years old; (2) is able to read, write, and speak 
 34.10  English, or effectively communicate with sign language, as well 
 34.11  as communicate with the recipient and personal care provider 
 34.12  organization; (3) effective July 1, 1996, has completed one of 
 34.13  the training requirements as specified in Minnesota Rules, part 
 34.14  9505.0335, subpart 3, items A to D; (4) has the ability to, and 
 34.15  provides covered personal care services according to the 
 34.16  recipient's care plan, responds appropriately to recipient 
 34.17  needs, and reports changes in the recipient's condition to the 
 34.18  supervising registered nurse; (5) is not a consumer of personal 
 34.19  care services; and (6) is subject to criminal background 
 34.20  checks.  An individual who has ever been convicted of a crime 
 34.21  specified in Minnesota Rules, part 4668.0020, subpart 14, or a 
 34.22  comparable crime in another jurisdiction is disqualified from 
 34.23  being a personal care assistant, unless the individual meets the 
 34.24  rehabilitation criteria specified in Minnesota Rules, part 
 34.25  4668.0020, subpart 15. 
 34.26     (f) "Personal care provider organization" means an 
 34.27  organization enrolled to provide personal care services under 
 34.28  the medical assistance program that complies with the 
 34.29  following:  (1) owners who have a five percent interest or more, 
 34.30  and managerial officials are subject to a criminal history check 
 34.31  as provided in section 245A.04 at the time of 
 34.32  application background checks.  This applies to currently 
 34.33  enrolled personal care provider organizations and those agencies 
 34.34  seeking enrollment as a personal care provider organization.  An 
 34.35  organization will be barred from enrollment if an owner or 
 34.36  managerial official of the organization has ever been convicted 
 35.1   of a crime specified in Minnesota Rules, part 4668.0020, subpart 
 35.2   14, or a comparable crime in another jurisdiction, unless the 
 35.3   owner or managerial official meets the rehabilitation criteria 
 35.4   specified in Minnesota Rules, part 4668.0020, subpart 15; (2) 
 35.5   the organization must maintain a surety bond and liability 
 35.6   insurance throughout the duration of enrollment and provides 
 35.7   proof thereof.  The insurer must notify the department of human 
 35.8   services of the cancellation or lapse of policy; and (3) the 
 35.9   organization must maintain documentation of services as 
 35.10  specified in Minnesota Rules, part 9505.2175, subpart 7, as well 
 35.11  as evidence of compliance with personal care assistant training 
 35.12  requirements. 
 35.13     (g) "Service plan" means a written description of the 
 35.14  services needed based on the assessment developed by the nurse 
 35.15  who conducts the assessment together with the recipient.  The 
 35.16  service plan shall include a description of the covered home 
 35.17  care services, frequency and duration of services, and expected 
 35.18  outcomes and goals.  The recipient and the provider chosen by 
 35.19  the recipient or responsible party must be given a copy of the 
 35.20  completed service plan within 30 calendar days of the request 
 35.21  for home care services by the recipient or responsible party. 
 35.22     (h) "Skilled nurse visits" are provided in a recipient's 
 35.23  residence under a plan of care or service plan that specifies a 
 35.24  level of care which the nurse is qualified to provide.  These 
 35.25  services are: 
 35.26     (1) nursing services according to the written plan of care 
 35.27  or service plan and accepted standards of medical and nursing 
 35.28  practice in accordance with chapter 148; 
 35.29     (2) services which due to the recipient's medical condition 
 35.30  may only be safely and effectively provided by a registered 
 35.31  nurse or a licensed practical nurse; 
 35.32     (3) assessments performed only by a registered nurse; 
 35.33     (4) teaching and training the recipient, the recipient's 
 35.34  family, or other caregivers requiring the skills of a registered 
 35.35  nurse or licensed practical nurse.  Teaching and training 
 35.36  activities are only covered when provided in conjunction with 
 36.1   other skilled nursing care provided to the recipient. 
 36.2      Sec. 17.  Minnesota Statutes 1994, section 256B.0627, 
 36.3   subdivision 5, as amended by Laws 1995, chapter 207, article 6, 
 36.4   sections 55 and 125, subdivision 12, is amended to read: 
 36.5      Subd. 5.  [LIMITATION ON PAYMENTS.] Medical assistance 
 36.6   payments for home care services shall be limited according to 
 36.7   this subdivision.  
 36.8      (a)  [LIMITS ON SERVICES WITHOUT PRIOR AUTHORIZATION.] A 
 36.9   recipient may receive the following amounts of home care 
 36.10  services during a calendar year: 
 36.11     (1) a total of 40 home health aide visits or skilled nurse 
 36.12  visits under section 256B.0625, subdivision 6a; and 
 36.13     (2) assessments and reassessments done to determine a 
 36.14  recipient's need for personal care services.  
 36.15     (b)  [PRIOR AUTHORIZATION; EXCEPTIONS.] All home care 
 36.16  services above the limits in paragraph (a) must receive the 
 36.17  commissioner's prior authorization, except when: 
 36.18     (1) the home care services were required to treat an 
 36.19  emergency medical condition that if not immediately treated 
 36.20  could cause a recipient serious physical or mental disability, 
 36.21  continuation of severe pain, or death.  The provider must 
 36.22  request retroactive authorization no later than five working 
 36.23  days after giving the initial service.  The provider must be 
 36.24  able to substantiate the emergency by documentation such as 
 36.25  reports, notes, and admission or discharge histories; 
 36.26     (2) the home care services were provided on or after the 
 36.27  date on which the recipient's eligibility began, but before the 
 36.28  date on which the recipient was notified that the case was 
 36.29  opened.  Authorization will be considered if the request is 
 36.30  submitted by the provider within 20 working days of the date the 
 36.31  recipient was notified that the case was opened; 
 36.32     (3) a third-party payor for home care services has denied 
 36.33  or adjusted a payment.  Authorization requests must be submitted 
 36.34  by the provider within 20 working days of the notice of denial 
 36.35  or adjustment.  A copy of the notice must be included with the 
 36.36  request; or 
 37.1      (4) the commissioner has determined that a county or state 
 37.2   human services agency has made an error. 
 37.3      (c)  [RETROACTIVE AUTHORIZATION.] A request for retroactive 
 37.4   authorization will be evaluated according to the same criteria 
 37.5   applied to prior authorization requests.  
 37.6      (d)  [ASSESSMENT AND SERVICE PLAN.] Assessments under 
 37.7   section 256B.0627, subdivision 1, paragraph (a), shall be 
 37.8   conducted initially, and at least annually thereafter, in person 
 37.9   with the recipient and result in a completed service plan using 
 37.10  forms specified by the commissioner.  Within 30 days of 
 37.11  recipient or responsible party request for home care services, 
 37.12  the assessment, the service plan, and other information 
 37.13  necessary to determine medical necessity such as diagnostic or 
 37.14  testing information, social or medical histories, and hospital 
 37.15  or facility discharge summaries shall be submitted to the 
 37.16  commissioner.  For personal care services: 
 37.17     (1) The amount and type of service authorized based upon 
 37.18  the assessment and service plan will follow the recipient if the 
 37.19  recipient chooses to change providers.  
 37.20     (2) If the recipient's medical need changes, the 
 37.21  recipient's provider may assess the need for a change in service 
 37.22  authorization and request the change from the county public 
 37.23  health nurse.  Within 30 days of the request, the public health 
 37.24  nurse will determine whether to request the change in services 
 37.25  based upon the provider assessment, or conduct a home visit to 
 37.26  assess the need and determine whether the change is appropriate. 
 37.27     (3) To continue to receive personal care services when the 
 37.28  recipient displays no significant change, the county public 
 37.29  health nurse has the option to review with the commissioner, or 
 37.30  the commissioner's designee, the service plan on record and 
 37.31  receive authorization for up to an additional 12 months. 
 37.32     (e)  [PRIOR AUTHORIZATION.] The commissioner, or the 
 37.33  commissioner's designee, shall review the assessment, the 
 37.34  service plan, and any additional information that is submitted.  
 37.35  The commissioner shall, within 30 days after receiving a 
 37.36  complete request, assessment, and service plan, authorize home 
 38.1   care services as follows:  
 38.2      (1)  [HOME HEALTH SERVICES.] All home health services 
 38.3   provided by a licensed nurse or a home health aide that exceed 
 38.4   the limits established in paragraph (a) must be prior authorized 
 38.5   by the commissioner or the commissioner's designee.  Prior 
 38.6   authorization must be based on medical necessity and 
 38.7   cost-effectiveness when compared with other care options.  When 
 38.8   home health services are used in combination with personal care 
 38.9   and private duty nursing, the cost of all home care services 
 38.10  shall be considered for cost-effectiveness.  The commissioner 
 38.11  shall limit nurse and home health aide visits to no more than 
 38.12  one visit each per day. 
 38.13     (2)  [PERSONAL CARE SERVICES.] (i) All personal care 
 38.14  services and registered nurse supervision must be prior 
 38.15  authorized by the commissioner or the commissioner's designee 
 38.16  except for the assessments established in paragraph (a).  The 
 38.17  amount of personal care services authorized must be based on the 
 38.18  recipient's home care rating.  A child may not be found to be 
 38.19  dependent in an activity of daily living if because of the 
 38.20  child's age an adult would either perform the activity for the 
 38.21  child or assist the child with the activity and the amount of 
 38.22  assistance needed is similar to the assistance appropriate for a 
 38.23  typical child of the same age.  Based on medical necessity, the 
 38.24  commissioner may authorize: 
 38.25     (A) up to 1.75 times the average number of direct care 
 38.26  hours provided in nursing facilities for the recipient's 
 38.27  comparable case mix level; or 
 38.28     (B) up to 2.625 times the average number of direct care 
 38.29  hours provided in nursing facilities for recipients who have 
 38.30  complex medical needs or are dependent in at least seven 
 38.31  activities of daily living and need physical assistance with 
 38.32  eating or have a neurological diagnosis but in no case shall the 
 38.33  dollar amount authorized exceed the statewide weighted average 
 38.34  nursing facility payment rate for fiscal year 1995; or 
 38.35     (C) up to the amount the commissioner would pay, as of July 
 38.36  1, 1991, plus any inflation adjustment provided for home care 
 39.1   services, for care provided in a regional treatment center for 
 39.2   recipients referred to the commissioner by a regional treatment 
 39.3   center preadmission evaluation team.  For purposes of this 
 39.4   clause, home care services means all services provided in the 
 39.5   home or community that would be included in the payment to a 
 39.6   regional treatment center; or 
 39.7      (D) up to the amount medical assistance would reimburse for 
 39.8   facility care for recipients referred to the commissioner by a 
 39.9   preadmission screening team established under section 256B.0911 
 39.10  or 256B.092; and 
 39.11     (E) a reasonable amount of time for the provision of 
 39.12  nursing supervision of personal care services.  
 39.13     (ii) The number of direct care hours shall be determined 
 39.14  according to the annual cost report submitted to the department 
 39.15  by nursing facilities.  The average number of direct care hours, 
 39.16  for the report year 1993, as established by July 11, 1994, shall 
 39.17  be calculated and incorporated into the home care limits on July 
 39.18  1, 1996.  These limits shall be calculated to the nearest 
 39.19  quarter hour. 
 39.20     (iii) The home care rating shall be determined by the 
 39.21  commissioner or the commissioner's designee based on information 
 39.22  submitted to the commissioner by the county public health nurse 
 39.23  on forms specified by the commissioner.  The home care rating 
 39.24  shall be a combination of current assessment tools developed 
 39.25  under sections 256B.0911 and 256B.501 and with adjustments, 
 39.26  additions, and clarifications that are necessary to reflect the 
 39.27  needs and conditions of recipients who need home care.  The 
 39.28  commissioner shall establish these forms and protocols under 
 39.29  this section and shall use an advisory group, including 
 39.30  representatives of recipients, providers, and counties, for 
 39.31  consultation in establishing and revising the forms and 
 39.32  protocols. 
 39.33     (iv) A recipient shall qualify as having complex medical 
 39.34  needs if the care required is difficult to perform and because 
 39.35  of recipient's medical condition requires more time than 
 39.36  community-based standards allow or requires more skill than 
 40.1   would ordinarily be required and the recipient needs or has one 
 40.2   or more of the following: 
 40.3      (A) daily tube feedings; 
 40.4      (B) daily parenteral therapy; 
 40.5      (C) wound or decubiti care; 
 40.6      (D) postural drainage, percussion, nebulizer treatments, 
 40.7   suctioning, tracheotomy care, oxygen, mechanical ventilation; 
 40.8      (E) catheterization; 
 40.9      (F) ostomy care; 
 40.10     (G) quadriplegia; or 
 40.11     (H) other comparable medical conditions or treatments the 
 40.12  commissioner determines would otherwise require institutional 
 40.13  care.  
 40.14     (3) [PRIVATE DUTY NURSING SERVICES.] All private duty 
 40.15  nursing services shall be prior authorized by the commissioner 
 40.16  or the commissioner's designee.  Prior authorization for private 
 40.17  duty nursing services shall be based on medical necessity and 
 40.18  cost-effectiveness when compared with alternative care options.  
 40.19  The commissioner may authorize medically necessary private duty 
 40.20  nursing services in quarter-hour units when: 
 40.21     (i) the recipient requires more individual and continuous 
 40.22  care than can be provided during a nurse visit; or 
 40.23     (ii) the cares are outside of the scope of services that 
 40.24  can be provided by a home health aide or personal care assistant.
 40.25     The commissioner may authorize: 
 40.26     (A) up to two times the average amount of direct care hours 
 40.27  provided in nursing facilities statewide for case mix 
 40.28  classification "K" as established by the annual cost report 
 40.29  submitted to the department by nursing facilities in May 1992; 
 40.30     (B) private duty nursing in combination with other home 
 40.31  care services up to the total cost allowed under clause (2); 
 40.32     (C) up to 16 hours per day if the recipient requires more 
 40.33  nursing than the maximum number of direct care hours as 
 40.34  established in item (A) and the recipient meets the hospital 
 40.35  admission criteria established under Minnesota Rules, parts 
 40.36  9505.0500 to 9505.0540.  
 41.1      The commissioner may authorize up to 16 hours per day of 
 41.2   medically necessary private duty nursing services or up to 24 
 41.3   hours per day of medically necessary private duty nursing 
 41.4   services until such time as the commissioner is able to make a 
 41.5   determination of eligibility for recipients who are 
 41.6   cooperatively applying for home care services under the 
 41.7   community alternative care program developed under section 
 41.8   256B.49, or until it is determined by the appropriate regulatory 
 41.9   agency that a health benefit plan is or is not required to pay 
 41.10  for appropriate medically necessary health care services.  
 41.11  Recipients or their representatives must cooperatively assist 
 41.12  the commissioner in obtaining this determination.  Recipients 
 41.13  who are eligible for the community alternative care program may 
 41.14  not receive more hours of nursing under this section than would 
 41.15  otherwise be authorized under section 256B.49. 
 41.16     (4) [VENTILATOR-DEPENDENT RECIPIENTS.] If the recipient is 
 41.17  ventilator-dependent, the monthly medical assistance 
 41.18  authorization for home care services shall not exceed what the 
 41.19  commissioner would pay for care at the highest cost hospital 
 41.20  designated as a long-term hospital under the Medicare program.  
 41.21  For purposes of this clause, home care services means all 
 41.22  services provided in the home that would be included in the 
 41.23  payment for care at the long-term hospital.  
 41.24  "Ventilator-dependent" means an individual who receives 
 41.25  mechanical ventilation for life support at least six hours per 
 41.26  day and is expected to be or has been dependent for at least 30 
 41.27  consecutive days.  
 41.28     (f) [PRIOR AUTHORIZATION; TIME LIMITS.] The commissioner or 
 41.29  the commissioner's designee shall determine the time period for 
 41.30  which a prior authorization shall be effective. If the recipient 
 41.31  continues to require home care services beyond the duration of 
 41.32  the prior authorization, the home care provider must request a 
 41.33  new prior authorization.  Under no circumstances, other than the 
 41.34  exceptions in paragraph (b), shall a prior authorization be 
 41.35  valid prior to the date the commissioner receives the request or 
 41.36  for more than 12 months.  A recipient who appeals a reduction in 
 42.1   previously authorized home care services may continue previously 
 42.2   authorized services, other than temporary services under 
 42.3   paragraph (h), pending an appeal under section 256.045.  The 
 42.4   commissioner must provide a detailed explanation of why the 
 42.5   authorized services are reduced in amount from those requested 
 42.6   by the home care provider.  
 42.7      (g) [APPROVAL OF HOME CARE SERVICES.] The commissioner or 
 42.8   the commissioner's designee shall determine the medical 
 42.9   necessity of home care services, the level of caregiver 
 42.10  according to subdivision 2, and the institutional comparison 
 42.11  according to this subdivision, the cost-effectiveness of 
 42.12  services, and the amount, scope, and duration of home care 
 42.13  services reimbursable by medical assistance, based on the 
 42.14  assessment, primary payer coverage determination information as 
 42.15  required, the care service plan, the recipient's age, the cost 
 42.16  of services, the recipient's medical condition, and diagnosis or 
 42.17  disability.  The commissioner may publish additional criteria 
 42.18  for determining medical necessity according to section 256B.04. 
 42.19     (h) [PRIOR AUTHORIZATION REQUESTS; TEMPORARY SERVICES.] The 
 42.20  agency nurse, the independently enrolled private duty nurse, or 
 42.21  county public health nurse may request a temporary authorization 
 42.22  for home care services by telephone.  The commissioner may 
 42.23  approve a temporary level of home care services based on the 
 42.24  assessment, and service or care plan information, and primary 
 42.25  payer coverage determination information as required.  
 42.26  Authorization for a temporary level of home care services 
 42.27  including nurse supervision is limited to the time specified by 
 42.28  the commissioner, but shall not exceed 45 days, unless extended 
 42.29  because the county public health nurse has not completed the 
 42.30  required assessment and service plan, or the commissioner's 
 42.31  determination has not been made.  The level of services 
 42.32  authorized under this provision shall have no bearing on a 
 42.33  future prior authorization. 
 42.34     (i) [PRIOR AUTHORIZATION REQUIRED IN FOSTER CARE SETTING.] 
 42.35  Home care services provided in an adult or child foster care 
 42.36  setting must receive prior authorization by the department 
 43.1   according to the limits established in paragraph (a). 
 43.2      The commissioner may not authorize: 
 43.3      (1) home care services that are the responsibility of the 
 43.4   foster care provider under the terms of the foster care 
 43.5   placement agreement and administrative rules.  Requests for home 
 43.6   care services for recipients residing in a foster care setting 
 43.7   must include the foster care placement agreement and 
 43.8   determination of difficulty of care; 
 43.9      (2) home care services when the foster care license holder 
 43.10  is also the home care provider; 
 43.11     (3) home care services when the number of foster care 
 43.12  residents is greater than four; or 
 43.13     (3) (4) home care services when combined with foster care 
 43.14  payments, other than room and board payments that exceed the 
 43.15  total amount that public funds would pay for the recipient's 
 43.16  care in a medical institution. 
 43.17     Sec. 18.  Minnesota Statutes 1994, section 256B.0627, is 
 43.18  amended by adding a subdivision to read: 
 43.19     Subd. 7.  [NONCOVERED HOME CARE SERVICES.] The following 
 43.20  home care services are not eligible for payment under medical 
 43.21  assistance:  
 43.22     (1)  skilled nurse visits for the sole purpose of 
 43.23  supervision of the home health aide; 
 43.24     (2) a skilled nursing visit:  
 43.25     (i) solely for the purpose of ensuring that a recipient who 
 43.26  has a demonstrated history of noncompliance complies with the 
 43.27  medications program; 
 43.28     (ii) to administer or assist with medication administration 
 43.29  of an adult recipient who is capable of self-administering a 
 43.30  medication, as described and documented by the registered nurse; 
 43.31     (iii) to inject medication for a recipient who is capable 
 43.32  of safely self-injecting a medication; 
 43.33     (iv) to prefill syringes for self-administration when, as 
 43.34  determined and documented by the registered nurse, the recipient 
 43.35  is capable of prefilling or a pharmacy is available to prefill; 
 43.36     (v) to set up medication for self-administration when, as 
 44.1   determined by the registered nurse, the recipient is capable, or 
 44.2   a pharmacy is available to assist the recipient; 
 44.3      (3) home care services to a recipient who is eligible for 
 44.4   covered services including hospice, under the Medicare program 
 44.5   or any other insurance held by the recipient; 
 44.6      (4) parenting; 
 44.7      (5) services to other members of the recipient's household; 
 44.8      (6) a visit made by a skilled nurse solely to train other 
 44.9   home health agency workers; 
 44.10     (7) any home care service included in the daily rate of the 
 44.11  community-based residential facility where the recipient is 
 44.12  residing; 
 44.13     (8) home care services provided to a recipient who is not 
 44.14  confined to a place of residence when services are reasonably 
 44.15  available outside the residence; and 
 44.16     (9) any home health agency service which is performed in a 
 44.17  place other than the recipient's residence. 
 44.18     Sec. 19.  Minnesota Statutes 1995 Supplement, section 
 44.19  256B.0628, subdivision 2, is amended to read: 
 44.20     Subd. 2.  [DUTIES.] (a) The commissioner may contract with 
 44.21  or employ qualified registered nurses and necessary support 
 44.22  staff, or contract with qualified agencies, to provide home care 
 44.23  prior authorization and review services for medical assistance 
 44.24  recipients who are receiving home care services. 
 44.25     (b) Reimbursement for the prior authorization function 
 44.26  shall be made through the medical assistance administrative 
 44.27  authority.  The state shall pay the nonfederal share.  The 
 44.28  functions will be to: 
 44.29     (1) assess the recipient's individual need for services 
 44.30  required to be cared for safely in the community; 
 44.31     (2) ensure that a service plan that meets the recipient's 
 44.32  needs is developed by the appropriate agency or individual; 
 44.33     (3) ensure cost-effectiveness of medical assistance home 
 44.34  care services; 
 44.35     (4) recommend the approval or denial of the use of medical 
 44.36  assistance funds to pay for home care services; 
 45.1      (5) reassess the recipient's need for and level of home 
 45.2   care services at a frequency determined by the commissioner; and 
 45.3      (6) conduct on-site assessments when determined necessary 
 45.4   by the commissioner and recommend changes to care plans that 
 45.5   will provide more efficient and appropriate home care. 
 45.6      (c) In addition, the commissioner or the commissioner's 
 45.7   designee may: 
 45.8      (1) review service plans and reimbursement data for 
 45.9   utilization of services that exceed community-based standards 
 45.10  for home care, inappropriate home care services, medical 
 45.11  necessity, home care services that do not meet quality of care 
 45.12  standards, or unauthorized services and make appropriate 
 45.13  referrals within the department or to other appropriate entities 
 45.14  based on the findings; 
 45.15     (2) assist the recipient in obtaining services necessary to 
 45.16  allow the recipient to remain safely in or return to the 
 45.17  community; 
 45.18     (3) coordinate home care services with other medical 
 45.19  assistance services under section 256B.0625; 
 45.20     (4) assist the recipient with problems related to the 
 45.21  provision of home care services; and 
 45.22     (5) assure the quality of home care services.; and 
 45.23     (6) Assure that all liable third-party payers including 
 45.24  Medicare have been used prior to medical assistance for home 
 45.25  care services including but not limited to, home health agency, 
 45.26  hospice, waivered, and personal care services. 
 45.27     (d) For the purposes of this section, "home care services"  
 45.28  means medical assistance services defined under section 
 45.29  256B.0625, subdivisions 6a, 7, and 19a. 
 45.30     Sec. 20.  [256B.07] [MEDICARE MAXIMIZATION METHOD.] 
 45.31     Subdivision 1.  [DEFINITION.] (a) "Dual entitlees" means 
 45.32  recipients eligible for either the medical assistance program or 
 45.33  the alternative care program who are also eligible for the 
 45.34  federal Medicare program.  
 45.35     (b) For purposes of this section "home care services" means 
 45.36  home health agency services, private duty nursing services, 
 46.1   personal care assistant services, waivered services, hospice 
 46.2   services, rehabilitation therapy services, and medical supplies 
 46.3   and equipment. 
 46.4      Subd. 2.  [METHOD REQUIRED.] Any provider of home care 
 46.5   services enrolled in the medical assistance program, or county 
 46.6   public health nursing agency responsible for personal care 
 46.7   assessments, or county case managers for alternative care or 
 46.8   medical assistance waiver programs, is required to use the 
 46.9   method developed by the department of human services for 
 46.10  determining Medicare coverage for home care equipment and 
 46.11  services provided to dual entitlees to ensure appropriate 
 46.12  billing of Medicare.  The method will be developed in two 
 46.13  phases; the first phase is a manual system effective July 1, 
 46.14  1996, and the second phase will automate the manual procedure by 
 46.15  expanding the current Medicaid Management Information System 
 46.16  (MMIS) effective January 1, 1997.  Both methods will determine 
 46.17  Medicare coverage for the dates of service, Medicare coverage 
 46.18  for home care services, and create an audit trail including 
 46.19  reports.  Both methods will be linked to prior authorization, 
 46.20  therefore, either method must be used before home care services 
 46.21  are authorized and when there is a change of condition affecting 
 46.22  medical assistance authorization.  The department will conduct 
 46.23  periodic reviews of participant performance with the method and 
 46.24  upon demonstrating appropriate referral and billing of Medicare, 
 46.25  participants may be determined exempt from regular performance 
 46.26  audits.  
 46.27     Subd. 3.  [REFERRALS TO MEDICARE CERTIFIED PROVIDERS 
 46.28  REQUIRED.] Non-Medicare certified and nonparticipating Medicare 
 46.29  certified home care service providers must refer dual eligible 
 46.30  recipients to Medicare certified providers when Medicare is 
 46.31  determined to be the appropriate payer for supplies and 
 46.32  equipment or services.  Non-Medicare certified and 
 46.33  nonparticipating Medicare certified home care service providers 
 46.34  will be terminated from participation in the medical assistance 
 46.35  program for failure to make such referrals. 
 46.36     Subd. 4.  [MEDICARE CERTIFICATION REQUIREMENT.] Medicare 
 47.1   certification is required of all medical assistance enrolled 
 47.2   home care service providers as defined in subdivision 1 within 
 47.3   one year of the date the Minnesota department of health gives 
 47.4   notice to the department that initial Medicare surveys will 
 47.5   resume. 
 47.6      Sec. 21.  Minnesota Statutes 1995 Supplement, section 
 47.7   256B.0913, subdivision 5, is amended to read: 
 47.8      Subd. 5.  [SERVICES COVERED UNDER ALTERNATIVE CARE.] (a) 
 47.9   Alternative care funding may be used for payment of costs of: 
 47.10     (1) adult foster care; 
 47.11     (2) adult day care; 
 47.12     (3) home health aide; 
 47.13     (4) homemaker services; 
 47.14     (5) personal care; 
 47.15     (6) case management; 
 47.16     (7) respite care; 
 47.17     (8) assisted living; 
 47.18     (9) residential care services; 
 47.19     (10) care-related supplies and equipment; 
 47.20     (11) meals delivered to the home; 
 47.21     (12) transportation; 
 47.22     (13) skilled nursing; 
 47.23     (14) chore services; 
 47.24     (15) companion services; 
 47.25     (16) nutrition services; and 
 47.26     (17) training for direct informal caregivers. 
 47.27     (b) The county agency must ensure that the funds are used 
 47.28  only to supplement and not supplant services available through 
 47.29  other public assistance or services programs. 
 47.30     (c) Unless specified in statute, the service standards for 
 47.31  alternative care services shall be the same as the service 
 47.32  standards defined in the elderly waiver.  Persons or agencies 
 47.33  must be employed by or under a contract with the county agency 
 47.34  or the public health nursing agency of the local board of health 
 47.35  in order to receive funding under the alternative care program. 
 47.36     (d) The adult foster care rate shall be considered a 
 48.1   difficulty of care payment and shall not include room and 
 48.2   board.  The adult foster care daily rate shall be negotiated 
 48.3   between the county agency and the foster care provider.  The 
 48.4   rate established under this section shall not exceed 75 percent 
 48.5   of the state average monthly nursing home payment for the case 
 48.6   mix classification to which the individual receiving foster care 
 48.7   is assigned, and it must allow for other alternative care 
 48.8   services to be authorized by the case manager. 
 48.9      (e) Personal care services may be provided by a personal 
 48.10  care provider organization.  A county agency may contract with a 
 48.11  relative of the client to provide personal care services, but 
 48.12  must ensure nursing supervision.  Covered personal care services 
 48.13  defined in section 256B.0627, subdivision 4, must meet 
 48.14  applicable standards in Minnesota Rules, part 9505.0335. 
 48.15     (f) Costs for supplies and equipment that exceed $150 per 
 48.16  item per month must have prior approval from the 
 48.17  commissioner.  A county may use alternative care funds to 
 48.18  purchase medical supplies and equipment without prior approval 
 48.19  from the commissioner when:  (1) there is no other funding 
 48.20  source; (2) the supplies and equipment are specified in the 
 48.21  individual's care plan as medically necessary to enable the 
 48.22  individual to remain in the community according to the criteria 
 48.23  in Minnesota Rules, part 9505.0210, item A; and (3) the supplies 
 48.24  and equipment represent an effective and appropriate use of 
 48.25  alternative care funds.  A county may use alternative care funds 
 48.26  to purchase supplies and equipment from a non-Medicaid certified 
 48.27  vendor if the cost for the items is less than that of a Medicaid 
 48.28  vendor.  A county is not required to contract with a provider of 
 48.29  supplies and equipment if the monthly cost of the supplies and 
 48.30  equipment is less than $250.  
 48.31     (g) For purposes of this section, residential care services 
 48.32  are services which are provided to individuals living in 
 48.33  residential care homes.  Residential care homes are currently 
 48.34  licensed as board and lodging establishments and are registered 
 48.35  with the department of health as providing special services.  
 48.36  Residential care services are defined as "supportive services" 
 49.1   and "health-related services."  "Supportive services" means the 
 49.2   provision of up to 24-hour supervision and oversight.  
 49.3   Supportive services includes:  (1) transportation, when provided 
 49.4   by the residential care center only; (2) socialization, when 
 49.5   socialization is part of the plan of care, has specific goals 
 49.6   and outcomes established, and is not diversional or recreational 
 49.7   in nature; (3) assisting clients in setting up meetings and 
 49.8   appointments; (4) assisting clients in setting up medical and 
 49.9   social services; (5) providing assistance with personal laundry, 
 49.10  such as carrying the client's laundry to the laundry room.  
 49.11  Assistance with personal laundry does not include any laundry, 
 49.12  such as bed linen, that is included in the room and board rate.  
 49.13  Health-related services are limited to minimal assistance with 
 49.14  dressing, grooming, and bathing and providing reminders to 
 49.15  residents to take medications that are self-administered or 
 49.16  providing storage for medications, if requested.  Individuals 
 49.17  receiving residential care services cannot receive both personal 
 49.18  care services and residential care services.  
 49.19     (h) For the purposes of this section, "assisted living" 
 49.20  refers to supportive services provided by a single vendor to 
 49.21  clients who reside in the same apartment building of three or 
 49.22  more units.  Assisted living services are defined as up to 
 49.23  24-hour supervision, and oversight, supportive services as 
 49.24  defined in clause (1), individualized home care aide tasks as 
 49.25  defined in clause (2), and individualized home management tasks 
 49.26  as defined in clause (3) provided to residents of a residential 
 49.27  center living in their units or apartments with a full kitchen 
 49.28  and bathroom.  A full kitchen includes a stove, oven, 
 49.29  refrigerator, food preparation counter space, and a kitchen 
 49.30  utensil storage compartment.  Assisted living services must be 
 49.31  provided by the management of the residential center or by 
 49.32  providers under contract with the management or with the county. 
 49.33     (1) Supportive services include:  
 49.34     (i) socialization, when socialization is part of the plan 
 49.35  of care, has specific goals and outcomes established, and is not 
 49.36  diversional or recreational in nature; 
 50.1      (ii) assisting clients in setting up meetings and 
 50.2   appointments; and 
 50.3      (iii) providing transportation, when provided by the 
 50.4   residential center only.  
 50.5      Individuals receiving assisted living services will not 
 50.6   receive both assisted living services and homemaking or personal 
 50.7   care services.  Individualized means services are chosen and 
 50.8   designed specifically for each resident's needs, rather than 
 50.9   provided or offered to all residents regardless of their 
 50.10  illnesses, disabilities, or physical conditions.  
 50.11     (2) Home care aide tasks means:  
 50.12     (i) preparing modified diets, such as diabetic or low 
 50.13  sodium diets; 
 50.14     (ii) reminding residents to take regularly scheduled 
 50.15  medications or to perform exercises; 
 50.16     (iii) household chores in the presence of technically 
 50.17  sophisticated medical equipment or episodes of acute illness or 
 50.18  infectious disease; 
 50.19     (iv) household chores when the resident's care requires the 
 50.20  prevention of exposure to infectious disease or containment of 
 50.21  infectious disease; and 
 50.22     (v) assisting with dressing, oral hygiene, hair care, 
 50.23  grooming, and bathing, if the resident is ambulatory, and if the 
 50.24  resident has no serious acute illness or infectious disease.  
 50.25  Oral hygiene means care of teeth, gums, and oral prosthetic 
 50.26  devices.  
 50.27     (3) Home management tasks means:  
 50.28     (i) housekeeping; 
 50.29     (ii) laundry; 
 50.30     (iii) preparation of regular snacks and meals; and 
 50.31     (iv) shopping.  
 50.32     Assisted living services as defined in this section shall 
 50.33  not be authorized in boarding and lodging establishments 
 50.34  licensed according to sections 157.03 and 157.15 to 157.22. 
 50.35     (i) For the purposes of this section, reimbursement for 
 50.36  assisted living services and residential care services shall be 
 51.1   a monthly rate negotiated and authorized by the county agency.  
 51.2   The rate shall not exceed the nonfederal share of the greater of 
 51.3   either the statewide or any of the geographic groups' weighted 
 51.4   average monthly medical assistance nursing facility payment rate 
 51.5   of the case mix resident class to which the 180-day eligible 
 51.6   client would be assigned under Minnesota Rules, parts 9549.0050 
 51.7   to 9549.0059.  For alternative care assisted living projects 
 51.8   established under Laws 1988, chapter 689, article 2, section 
 51.9   256, monthly rates may not exceed 65 percent of the greater of 
 51.10  either statewide or any of the geographic groups' weighted 
 51.11  average monthly medical assistance nursing facility payment rate 
 51.12  of the case mix resident class to which the 180-day eligible 
 51.13  client would be assigned under Minnesota Rules, parts 9549.0050 
 51.14  to 9549.0059.  The rate may not cover rent and direct food costs.
 51.15     (j) For purposes of this section, companion services are 
 51.16  defined as nonmedical care, supervision and oversight, provided 
 51.17  to a functionally impaired adult.  Companions may assist the 
 51.18  individual with such tasks as meal preparation, laundry and 
 51.19  shopping, but do not perform these activities as discrete 
 51.20  services.  The provision of companion services does not entail 
 51.21  hands-on medical care.  Providers may also perform light 
 51.22  housekeeping tasks which are incidental to the care and 
 51.23  supervision of the recipient.  This service must be approved by 
 51.24  the case manager as part of the care plan.  Companion services 
 51.25  must be provided by individuals or nonprofit organizations who 
 51.26  are under contract with the local agency to provide the 
 51.27  service.  Any person related to the waiver recipient by blood, 
 51.28  marriage or adoption cannot be reimbursed under this service.  
 51.29  Persons providing companion services will be monitored by the 
 51.30  case manager. 
 51.31     (k) For purposes of this section, training for direct 
 51.32  informal caregivers is defined as a classroom or home course of 
 51.33  instruction which may include:  transfer and lifting skills, 
 51.34  nutrition, personal and physical cares, home safety in a home 
 51.35  environment, stress reduction and management, behavioral 
 51.36  management, long-term care decision making, care coordination 
 52.1   and family dynamics.  The training is provided to an informal 
 52.2   unpaid caregiver of a 180-day eligible client which enables the 
 52.3   caregiver to deliver care in a home setting with high levels of 
 52.4   quality.  The training must be approved by the case manager as 
 52.5   part of the individual care plan.  Individuals, agencies, and 
 52.6   educational facilities which provide caregiver training and 
 52.7   education will be monitored by the case manager. 
 52.8      Sec. 22.  Minnesota Statutes 1994, section 256B.0913, 
 52.9   subdivision 7, is amended to read: 
 52.10     Subd. 7.  [CASE MANAGEMENT.] The lead agency shall appoint 
 52.11  a social worker from the county agency or a registered nurse 
 52.12  from the county public health nursing service of the local board 
 52.13  of health to be the case manager for any person receiving 
 52.14  services funded by the alternative care program.  The case 
 52.15  manager must ensure the health and safety of the individual 
 52.16  client and is responsible for the cost-effectiveness of the 
 52.17  alternative care individual care plan.  The county may allow a 
 52.18  case manager to delegate certain aspects of the case management 
 52.19  activity to another individual employed by the county provided 
 52.20  there is oversight of the individual by the case manager.  The 
 52.21  case manager may not delegate those aspects which require 
 52.22  professional judgment including assessments, reassessments, and 
 52.23  care plan development. 
 52.24     Sec. 23.  Minnesota Statutes 1994, section 256B.0915, 
 52.25  subdivision 1b, is amended to read: 
 52.26     Subd. 1b.  [PROVIDER QUALIFICATIONS AND STANDARDS.] The 
 52.27  commissioner must enroll qualified providers of elderly case 
 52.28  management services under the home and community-based waiver 
 52.29  for the elderly under section 1915(c) of the Social Security 
 52.30  Act.  The enrollment process shall ensure the provider's ability 
 52.31  to meet the qualification requirements and standards in this 
 52.32  subdivision and other federal and state requirements of this 
 52.33  service.  An elderly case management provider is an enrolled 
 52.34  medical assistance provider who is determined by the 
 52.35  commissioner to have all of the following characteristics: 
 52.36     (1) the legal authority for alternative care program 
 53.1   administration under section 256B.0913; 
 53.2      (2) the demonstrated capacity and experience to provide the 
 53.3   components of case management to coordinate and link community 
 53.4   resources needed by the eligible population; 
 53.5      (3) administrative capacity and experience in serving the 
 53.6   target population for whom it will provide services and in 
 53.7   ensuring quality of services under state and federal 
 53.8   requirements; 
 53.9      (4) the legal authority to provide preadmission screening 
 53.10  under section 256B.0911, subdivision 4; 
 53.11     (5) a financial management system that provides accurate 
 53.12  documentation of services and costs under state and federal 
 53.13  requirements; and 
 53.14     (6) the capacity to document and maintain individual case 
 53.15  records under state and federal requirements; and 
 53.16     (7) the county may allow a case manager to delegate certain 
 53.17  aspects of the case management activity to another individual 
 53.18  employed by the county provided there is oversight of the 
 53.19  individual by the case manager.  The case manager may not 
 53.20  delegate those aspects which require professional judgment 
 53.21  including assessments, and care plan development. 
 53.22     Sec. 24.  Minnesota Statutes 1995 Supplement, section 
 53.23  256B.0915, subdivision 3, is amended to read: 
 53.24     Subd. 3.  [LIMITS OF CASES, RATES, REIMBURSEMENT, AND 
 53.25  FORECASTING.] (a) The number of medical assistance waiver 
 53.26  recipients that a county may serve must be allocated according 
 53.27  to the number of medical assistance waiver cases open on July 1 
 53.28  of each fiscal year.  Additional recipients may be served with 
 53.29  the approval of the commissioner. 
 53.30     (b) The monthly limit for the cost of waivered services to 
 53.31  an individual waiver client shall be the statewide average 
 53.32  payment rate of the case mix resident class to which the waiver 
 53.33  client would be assigned under the medical assistance case mix 
 53.34  reimbursement system.  If medical supplies and equipment or 
 53.35  adaptations are or will be purchased for an elderly waiver 
 53.36  services recipient, the costs may be prorated on a monthly basis 
 54.1   throughout the year in which they are purchased.  If the monthly 
 54.2   cost of a recipient's other waivered services exceeds the 
 54.3   monthly limit established in this paragraph, the annual cost of 
 54.4   the waivered services shall be determined.  In this event, the 
 54.5   annual cost of waivered services shall not exceed 12 times the 
 54.6   monthly limit calculated in this paragraph.  The statewide 
 54.7   average payment rate is calculated by determining the statewide 
 54.8   average monthly nursing home rate, effective July 1 of the 
 54.9   fiscal year in which the cost is incurred, less the statewide 
 54.10  average monthly income of nursing home residents who are age 65 
 54.11  or older, and who are medical assistance recipients in the month 
 54.12  of March of the previous state fiscal year.  The annual cost 
 54.13  divided by 12 of elderly or disabled waivered services for a 
 54.14  person who is a nursing facility resident at the time of 
 54.15  requesting a determination of eligibility for elderly or 
 54.16  disabled waivered services shall not exceed the monthly payment 
 54.17  for the resident class assigned under Minnesota Rules, parts 
 54.18  9549.0050 to 9549.0059, for that resident in the nursing 
 54.19  facility where the resident currently resides.  The following 
 54.20  costs must be included in determining the total monthly costs 
 54.21  for the waiver client: 
 54.22     (1) cost of all waivered services, including extended 
 54.23  medical supplies and equipment; and 
 54.24     (2) cost of skilled nursing, home health aide, and personal 
 54.25  care services reimbursable by medical assistance.  
 54.26     (c) Medical assistance funding for skilled nursing 
 54.27  services, private duty nursing, home health aide, and personal 
 54.28  care services for waiver recipients must be approved by the case 
 54.29  manager and included in the individual care plan. 
 54.30     (d) Expenditures for extended medical supplies and 
 54.31  equipment that cost over $150 per month For both the elderly 
 54.32  waiver and the nursing facility disabled waiver must have the 
 54.33  commissioner's prior approval waivers, a county may purchase 
 54.34  extended supplies and equipment without prior approval from the 
 54.35  commissioner when there is no other funding source and the 
 54.36  supplies and equipment are specified in the individual's care 
 55.1   plan as medically necessary to enable the individual to remain 
 55.2   in the community according to the criteria in Minnesota Rules, 
 55.3   part 9505.0210, items A and B.  A county is not required to 
 55.4   contract with a provider of supplies and equipment if the 
 55.5   monthly cost of the supplies and equipment is less than $250.  
 55.6      (e) For the fiscal year beginning on July 1, 1993, and for 
 55.7   subsequent fiscal years, the commissioner of human services 
 55.8   shall not provide automatic annual inflation adjustments for 
 55.9   home and community-based waivered services.  The commissioner of 
 55.10  finance shall include as a budget change request in each 
 55.11  biennial detailed expenditure budget submitted to the 
 55.12  legislature under section 16A.11, annual adjustments in 
 55.13  reimbursement rates for home and community-based waivered 
 55.14  services, based on the forecasted percentage change in the Home 
 55.15  Health Agency Market Basket of Operating Costs, for the fiscal 
 55.16  year beginning July 1, compared to the previous fiscal year, 
 55.17  unless otherwise adjusted by statute.  The Home Health Agency 
 55.18  Market Basket of Operating Costs is published by Data Resources, 
 55.19  Inc.  The forecast to be used is the one published for the 
 55.20  calendar quarter beginning January 1, six months prior to the 
 55.21  beginning of the fiscal year for which rates are set.  The adult 
 55.22  foster care rate shall be considered a difficulty of care 
 55.23  payment and shall not include room and board. 
 55.24     (f) The adult foster care daily rate for the elderly and 
 55.25  disabled waivers shall be negotiated between the county agency 
 55.26  and the foster care provider.  The rate established under this 
 55.27  section shall not exceed the state average monthly nursing home 
 55.28  payment for the case mix classification to which the individual 
 55.29  receiving foster care is assigned; the rate must allow for other 
 55.30  waiver and medical assistance home care services to be 
 55.31  authorized by the case manager. 
 55.32     (g) The assisted living and residential care service rates 
 55.33  for elderly and community alternatives for disabled individuals 
 55.34  (CADI) waivers shall be made to the vendor as a monthly rate 
 55.35  negotiated with the county agency.  The rate shall not exceed 
 55.36  the nonfederal share of the greater of either the statewide or 
 56.1   any of the geographic groups' weighted average monthly medical 
 56.2   assistance nursing facility payment rate of the case mix 
 56.3   resident class to which the elderly or disabled client would be 
 56.4   assigned under Minnesota Rules, parts 9549.0050 to 9549.0059.  
 56.5   For alternative care assisted living projects established under 
 56.6   Laws 1988, chapter 689, article 2, section 256, monthly rates 
 56.7   may not exceed 65 percent of the greater of either the statewide 
 56.8   or any of the geographic groups' weighted average monthly 
 56.9   medical assistance nursing facility payment rate for the case 
 56.10  mix resident class to which the elderly or disabled client would 
 56.11  be assigned under Minnesota Rules, parts 9549.0050 to 
 56.12  9549.0059.  The rate may not cover direct rent or food costs. 
 56.13     (h) The county shall negotiate individual rates with 
 56.14  vendors and may be reimbursed for actual costs up to the greater 
 56.15  of the county's current approved rate or 60 percent of the 
 56.16  maximum rate in fiscal year 1994 and 65 percent of the maximum 
 56.17  rate in fiscal year 1995 for each service within each program. 
 56.18     (i) On July 1, 1993, the commissioner shall increase the 
 56.19  maximum rate for home-delivered meals to $4.50 per meal. 
 56.20     (j) Reimbursement for the medical assistance recipients 
 56.21  under the approved waiver shall be made from the medical 
 56.22  assistance account through the invoice processing procedures of 
 56.23  the department's Medicaid Management Information System (MMIS), 
 56.24  only with the approval of the client's case manager.  The budget 
 56.25  for the state share of the Medicaid expenditures shall be 
 56.26  forecasted with the medical assistance budget, and shall be 
 56.27  consistent with the approved waiver.  
 56.28     (k) Beginning July 1, 1991, the state shall reimburse 
 56.29  counties according to the payment schedule in section 256.025 
 56.30  for the county share of costs incurred under this subdivision on 
 56.31  or after January 1, 1991, for individuals who are receiving 
 56.32  medical assistance. 
 56.33     Sec. 25.  Minnesota Statutes 1995 Supplement, section 
 56.34  256B.093, subdivision 3, is amended to read: 
 56.35     Subd. 3.  [TRAUMATIC BRAIN INJURY PROGRAM DUTIES.] The 
 56.36  department shall fund administrative case management under this 
 57.1   subdivision using medical assistance administrative funds.  The 
 57.2   traumatic brain injury program duties include: 
 57.3      (1) recommending to the commissioner in consultation with 
 57.4   the medical review agent according to Minnesota Rules, parts 
 57.5   9505.0500 to 9505.0540, the approval or denial of medical 
 57.6   assistance funds to pay for out-of-state placements for 
 57.7   traumatic brain injury services and in-state traumatic brain 
 57.8   injury services provided by designated Medicare long-term care 
 57.9   hospitals; 
 57.10     (2) coordinating the traumatic brain injury home and 
 57.11  community-based waiver; 
 57.12     (3) approving traumatic brain injury waiver eligibility or 
 57.13  care plans or both; 
 57.14     (4) providing ongoing technical assistance and consultation 
 57.15  to county and facility case managers to facilitate care plan 
 57.16  development for appropriate, accessible, and cost-effective 
 57.17  medical assistance services; 
 57.18     (5) providing technical assistance to promote statewide 
 57.19  development of appropriate, accessible, and cost-effective 
 57.20  medical assistance services and related policy; 
 57.21     (6) providing training and outreach to facilitate access to 
 57.22  appropriate home and community-based services to prevent 
 57.23  institutionalization; 
 57.24     (7) facilitating appropriate admissions, continued stay 
 57.25  review, discharges, and utilization review for neurobehavioral 
 57.26  hospitals and other specialized institutions; 
 57.27     (8) providing technical assistance on the use of prior 
 57.28  authorization of home care services and coordination of these 
 57.29  services with other medical assistance services; 
 57.30     (9) developing a system for identification of nursing 
 57.31  facility and hospital residents with traumatic brain injury to 
 57.32  assist in long-term planning for medical assistance services.  
 57.33  Factors will include, but are not limited to, number of 
 57.34  individuals served, length of stay, services received, and 
 57.35  barriers to community placement; and 
 57.36     (10) providing information, referral, and case consultation 
 58.1   to access medical assistance services for recipients without a 
 58.2   county or facility case manager.  Direct access to this 
 58.3   assistance may be limited due to the structure of the program. 
 58.4      Sec. 26.  Minnesota Statutes 1994, section 256B.37, 
 58.5   subdivision 5, is amended to read: 
 58.6      Subd. 5.  [PRIVATE BENEFITS TO BE USED FIRST.] Private 
 58.7   accident and health care coverage including Medicare for medical 
 58.8   services is primary coverage and must be exhausted before 
 58.9   medical assistance is paid for medical services including home 
 58.10  health care, personal care assistant services, hospice, or 
 58.11  services covered under a Health Care Financing Administration 
 58.12  (HCFA) waiver.  When a person who is otherwise eligible for 
 58.13  medical assistance has private accident or health care coverage, 
 58.14  including Medicare or a prepaid health plan, the private health 
 58.15  care benefits available to the person must be used first and to 
 58.16  the fullest extent. 
 58.17     Sec. 27.  Minnesota Statutes 1995 Supplement, section 
 58.18  256B.432, subdivision 2, is amended to read: 
 58.19     Subd. 2.  [EFFECTIVE DATE.] For rate years beginning on or 
 58.20  after July 1, 1990, the central, affiliated, or corporate office 
 58.21  cost allocations in subdivisions 3 to 6 must be used when 
 58.22  determining medical assistance rates under sections section 
 58.23  256B.431 and 256B.50.  
 58.24     Sec. 28.  Minnesota Statutes 1995 Supplement, section 
 58.25  256B.49, subdivision 6, is amended to read: 
 58.26     Subd. 6.  [ADMISSION CERTIFICATION.] In determining an 
 58.27  individual's eligibility for the community alternative care (CAC)
 58.28  waiver program, and an individual's eligibility for medical 
 58.29  assistance under section 256B.055, subdivision 12, paragraph 
 58.30  (b), the commissioner may review or contract for review of the 
 58.31  individual's medical condition to determine level of care using 
 58.32  criteria in Minnesota Rules, parts 9505.0520 to 9505.0540.  
 58.33     For purposes of this subdivision, a person requires 
 58.34  long-term care in an inpatient hospital setting if the person 
 58.35  has an ongoing condition that is expected to last one year or 
 58.36  longer, and would require continuous or frequent 
 59.1   hospitalizations during that period, but for the provision of 
 59.2   home care services under this section.  
 59.3      Sec. 29.  Minnesota Statutes 1995 Supplement, section 
 59.4   256B.49, subdivision 7, is amended to read: 
 59.5      Subd. 7.  [PERSONS WITH DEVELOPMENTAL DISABILITIES OR 
 59.6   RELATED CONDITIONS.] Individuals who apply for services under 
 59.7   the community alternatives for disabled individuals (CADI) 
 59.8   waiver program or the traumatic brain injury nursing facility 
 59.9   waiver program who have developmental disabilities or related 
 59.10  conditions must be screened for the appropriate institutional 
 59.11  level of care in accordance with section 256B.092. 
 59.12     Sec. 30.  Minnesota Statutes 1994, section 256B.49, is 
 59.13  amended by adding a subdivision to read: 
 59.14     Subd. 9.  [CASE MANAGEMENT SERVICES.] The county may allow 
 59.15  a case manager to delegate certain aspects of the case 
 59.16  management activity to another individual employed by the county 
 59.17  provided there is oversight of the individual by the case 
 59.18  manager.  The case manager may not delegate those aspects which 
 59.19  require professional judgment including assessments, 
 59.20  reassessments, and care plan development. 
 59.21     Sec. 31.  Minnesota Statutes 1995 Supplement, section 
 59.22  256B.501, subdivision 5b, is amended to read: 
 59.23     Subd. 5b.  [ICF/MR OPERATING COST LIMITATION AFTER 
 59.24  SEPTEMBER 30, 1995.] (a) For rate years beginning on or after 
 59.25  October 1, 1995, and October 1, 1996, the commissioner shall 
 59.26  limit the allowable operating cost per diems, as determined 
 59.27  under this subdivision and the reimbursement rules, for high 
 59.28  cost ICF's/MR.  Prior to indexing each facility's operating cost 
 59.29  per diems for inflation, the commissioner shall group the 
 59.30  facilities into eight groups.  The commissioner shall then array 
 59.31  all facilities within each grouping by their general operating 
 59.32  cost per service unit per diems. 
 59.33     (b) The commissioner shall annually review and adjust the 
 59.34  general operating costs incurred by the facility during the 
 59.35  reporting year preceding the rate year to determine the 
 59.36  facility's allowable historical general operating costs.  For 
 60.1   this purpose, the term general operating costs means the 
 60.2   facility's allowable operating costs included in the program, 
 60.3   maintenance, and administrative operating costs categories, as 
 60.4   well as the facility's related payroll taxes and fringe 
 60.5   benefits, real estate insurance, and professional liability 
 60.6   insurance.  A facility's total operating cost payment rate shall 
 60.7   be limited according to paragraphs (c) and (d) as follows: 
 60.8      (c) A facility's total operating cost payment rate shall be 
 60.9   equal to its allowable historical operating cost per diems for 
 60.10  program, maintenance, and administrative cost categories 
 60.11  multiplied by the forecasted inflation index in subdivision 3c, 
 60.12  clause (1), subject to the limitations in paragraph (d). 
 60.13     (d) For the rate years beginning on or after October 1, 
 60.14  1995, the commissioner shall establish maximum overall general 
 60.15  operating cost per service unit limits for facilities according 
 60.16  to clauses (1) to (8).  Each facility's allowable historical 
 60.17  general operating costs and client assessment information 
 60.18  obtained from client assessments completed under subdivision 3g 
 60.19  for the reporting year ending December 31, 1994 (the base year), 
 60.20  shall be used for establishing the overall limits.  If a 
 60.21  facility's proportion of temporary care resident days to total 
 60.22  resident days exceeds 80 percent, the commissioner must exempt 
 60.23  that facility from the overall general operating cost per 
 60.24  service unit limits in clauses (1) to (8).  For this purpose, 
 60.25  "temporary care" means care provided by a facility to a client 
 60.26  for less than 30 consecutive resident days. 
 60.27     (1) The commissioner shall determine each facility's 
 60.28  weighted service units for the reporting year by multiplying its 
 60.29  resident days in each client classification level as established 
 60.30  in subdivision 3g, paragraph (d), by the corresponding weights 
 60.31  for that classification level, as established in subdivision 3g, 
 60.32  paragraph (i), and summing the results.  For the reporting year 
 60.33  ending December 31, 1994, the commissioner shall use the service 
 60.34  unit score computed from the client classifications determined 
 60.35  by the Minnesota department of health's annual review, including 
 60.36  those of clients admitted during that year. 
 61.1      (2) The facility's service unit score is equal to its 
 61.2   weighted service units as computed in clause (1), divided by the 
 61.3   facility's total resident days excluding temporary care resident 
 61.4   days, for the reporting year. 
 61.5      (3) For each facility, the commissioner shall determine the 
 61.6   facility's cost per service unit by dividing its allowable 
 61.7   historical general operating costs for the reporting year by the 
 61.8   facility's service unit score in clause (2) multiplied by its 
 61.9   total resident days, or 85 percent of the facility's capacity 
 61.10  days times its service unit score in clause (2), if the 
 61.11  facility's occupancy is less than 85 percent of licensed 
 61.12  capacity.  If a facility reports temporary care resident days, 
 61.13  the temporary care resident days shall be multiplied by the 
 61.14  service unit score in clause (2), and the resulting weighted 
 61.15  resident days shall be added to the facility's weighted service 
 61.16  units in clause (1) prior to computing the facility's cost per 
 61.17  service unit under this clause. 
 61.18     (4) The commissioner shall group facilities based on class 
 61.19  A or class B licensure designation, number of licensed beds, and 
 61.20  geographic location.  For purposes of this grouping, facilities 
 61.21  with six beds or less shall be designated as small facilities 
 61.22  and facilities with more than six beds shall be designated as 
 61.23  large facilities.  If a facility has both class A and class B 
 61.24  licensed beds, the facility shall be considered a class A 
 61.25  facility for this purpose if the number of class A beds is more 
 61.26  than half its total number of ICF/MR beds; otherwise the 
 61.27  facility shall be considered a class B facility.  The 
 61.28  metropolitan geographic designation shall include Anoka, Carver, 
 61.29  Dakota, Hennepin, Ramsey, Scott, and Washington counties.  All 
 61.30  other Minnesota counties shall be designated as the 
 61.31  nonmetropolitan geographic group.  These characteristics result 
 61.32  in the following eight groupings: 
 61.33     (i) small class A metropolitan; 
 61.34     (ii) large class A metropolitan; 
 61.35     (iii) small class B metropolitan; 
 61.36     (iv) large class B metropolitan; 
 62.1      (v) small class A nonmetropolitan; 
 62.2      (vi) large class A nonmetropolitan; 
 62.3      (vii) small class B nonmetropolitan; and 
 62.4      (viii) large class B nonmetropolitan. 
 62.5      (5) The commissioner shall array facilities within each 
 62.6   grouping in clause (4) by each facility's cost per service unit 
 62.7   as determined in clause (3). 
 62.8      (6) In each array established under clause (5), facilities 
 62.9   with a cost per service unit at or above the median shall be 
 62.10  limited to the lesser of:  (i) the current reporting year's cost 
 62.11  per service unit; or (ii) the prior reporting year's allowable 
 62.12  historical general operating cost per service unit plus the 
 62.13  inflation factor as established in subdivision 3c, clause (2), 
 62.14  increased by three percentage points. 
 62.15     (7) The overall operating cost per service unit limit for 
 62.16  each group shall be established as follows: 
 62.17     (i) each array established under clause (5) shall be 
 62.18  arrayed again after the application of clause (6); 
 62.19     (ii) in each array established in clause (5), two general 
 62.20  operating cost limits shall be determined.  The first cost per 
 62.21  service unit limit shall be established at 0.5 and less than or 
 62.22  equal to 1.0 standard deviation above the median of that array.  
 62.23  The second cost per service unit limit shall be established at 
 62.24  1.0 standard deviation above the median of the array; and 
 62.25     (iii) the overall operating cost per service unit limits 
 62.26  shall be indexed for inflation annually beginning with the 
 62.27  reporting year ending December 31, 1995, using the forecasted 
 62.28  inflation index in subdivision 3c, clause (2). 
 62.29     (8) Annually, facilities shall be arrayed using the method 
 62.30  described in clauses (5) and (7).  Each facility with a cost per 
 62.31  service unit at or above its group's first cost per service unit 
 62.32  limit, but less than the second cost per service unit limit for 
 62.33  that group, shall be limited to 98 percent of its total 
 62.34  operating cost per diems then add the forecasted inflation index 
 62.35  in subdivision 3c, clause (1).  Each facility with a cost per 
 62.36  service unit at or above the second cost per service unit limit 
 63.1   will be limited to 97 percent of its total operating cost per 
 63.2   diems, then add the forecasted inflation index in subdivision 
 63.3   3c, clause (1). 
 63.4      (9) The commissioner may rebase these overall limits, using 
 63.5   the method described in this subdivision but no more frequently 
 63.6   than once every three years. 
 63.7      (e) For rate years beginning on or after October 1, 1995, 
 63.8   the facility's efficiency incentive shall be determined as 
 63.9   provided in the reimbursement rule. 
 63.10     (f) The total operating cost payment rate shall be the sum 
 63.11  of paragraphs (c) and (e). 
 63.12     Sec. 32.  Minnesota Statutes 1995 Supplement, section 
 63.13  256B.501, subdivision 5c, is amended to read: 
 63.14     Subd. 5c.  [OPERATING COSTS AFTER SEPTEMBER 30, 1979 1999.] 
 63.15  (a) In general, the commissioner shall establish maximum 
 63.16  standard rates for the prospective reimbursement of facility 
 63.17  costs.  The maximum standard rates must take into account the 
 63.18  level of reimbursement which is adequate to cover the base-level 
 63.19  costs of economically operated facilities.  In determining the 
 63.20  base-level costs, the commissioner shall consider geographic 
 63.21  location, types of facilities (class A or class B), minimum 
 63.22  staffing standards, resident assessment under subdivision 3g, 
 63.23  and other factors as determined by the commissioner. 
 63.24     (b) The commissioner shall may also develop additional 
 63.25  incentive-based payments which, if achieved for specified 
 63.26  outcomes, will be added to the maximum standard rates.  The 
 63.27  specified outcomes must be measurable and shall be based on 
 63.28  criteria to be developed by the commissioner during fiscal year 
 63.29  1996.  The commissioner may establish various levels of 
 63.30  achievement within an outcome.  Once the outcomes are 
 63.31  established, the commissioner shall assign various levels of 
 63.32  payment associated with achieving the outcome.  In establishing 
 63.33  the specified outcomes and the related criteria, the 
 63.34  commissioner shall consider the following state policy 
 63.35  objectives:  
 63.36     (1) resident transitioned into cost-effective community 
 64.1   alternatives; 
 64.2      (2) the results of a uniform consumer satisfaction survey; 
 64.3      (3) the achievement of no major licensure or certification 
 64.4   deficiencies; or 
 64.5      (4) any other outcomes the commissioner finds 
 64.6   desirable.  The commissioner may also consider the findings of 
 64.7   projects examining services to persons with developmental 
 64.8   disabilities, including outcome-based quality assurance methods, 
 64.9   and the inclusion of persons with developmental disabilities in 
 64.10  managed care alternative service delivery models. 
 64.11     (c) In developing the maximum standard rates and the 
 64.12  incentive-based payments, desirable outcomes, and related 
 64.13  criteria, the commissioner, in collaboration with the 
 64.14  commissioner of health, shall form an advisory committee.  The 
 64.15  membership of the advisory committee shall include 
 64.16  representation from the consumers advocacy groups (3), the two 
 64.17  facility trade associations (3 each), counties (3), commissioner 
 64.18  of finance (1), the legislature (2 each from both the house and 
 64.19  senate), and others the commissioners find appropriate. 
 64.20     (d) Beginning July 1, 1996 1998, the commissioner shall 
 64.21  collect the data from the facilities, the department of health, 
 64.22  or others as necessary to determine the extent to which a 
 64.23  facility has met any of the outcomes and related criteria.  
 64.24  Payment rates under this subdivision shall be effective October 
 64.25  1, 1997 1999. 
 64.26     (e) The commissioner shall report to the legislature on the 
 64.27  progress of the advisory committee by January 31, 1996, any 
 64.28  necessary changes to the reimbursement methodology proposed 
 64.29  under this subdivision 1998.  By January 15, 1997 1999, the 
 64.30  commissioner shall recommend to the legislature legislation 
 64.31  which will implement this reimbursement methodology for rate 
 64.32  years beginning on or after the proposed effective date of 
 64.33  October 1, 1997 1999. 
 64.34     Sec. 33.  Minnesota Statutes 1995 Supplement, section 
 64.35  256B.69, subdivision 4, is amended to read: 
 64.36     Subd. 4.  [LIMITATION OF CHOICE.] The commissioner shall 
 65.1   develop criteria to determine when limitation of choice may be 
 65.2   implemented in the experimental counties.  The criteria shall 
 65.3   ensure that all eligible individuals in the county have 
 65.4   continuing access to the full range of medical assistance 
 65.5   services as specified in subdivision 6.  The commissioner shall 
 65.6   exempt the following persons from participation in the project, 
 65.7   in addition to those who do not meet the criteria for limitation 
 65.8   of choice:  (1) persons eligible for medical assistance 
 65.9   according to section 256B.055, subdivision 1; (2) persons 
 65.10  eligible for medical assistance due to blindness or disability 
 65.11  as determined by the social security administration or the state 
 65.12  medical review team, unless:  (i) they are 65 years of age or 
 65.13  older, or (ii) they are eligible for medical assistance 
 65.14  according to section 256B.055, subdivision 12, or (iii) unless 
 65.15  they reside in Itasca county or they reside in a county in which 
 65.16  the commissioner conducts a pilot project under a waiver granted 
 65.17  pursuant to section 1115 of the Social Security Act; 
 65.18  (3) recipients who currently have private coverage through a 
 65.19  health maintenance organization; (4) recipients who are eligible 
 65.20  for medical assistance by spending down excess income for 
 65.21  medical expenses other than the nursing facility per diem 
 65.22  expense; and (5) (4) recipients who receive benefits under the 
 65.23  Refugee Assistance Program, established under United States 
 65.24  Code, title 8, section 1522(e).  Children under age 21 who are 
 65.25  in foster placement may enroll in the project on an elective 
 65.26  basis.  The commissioner may allow persons with a one-month 
 65.27  spenddown who are otherwise eligible to enroll to voluntarily 
 65.28  enroll or remain enrolled, if they elect to prepay their monthly 
 65.29  spenddown to the state.  Beginning on or after January 1, 1997, 
 65.30  the commissioner may require those individuals to enroll in the 
 65.31  prepaid medical assistance program who otherwise would have been 
 65.32  excluded under clauses (1), (3), and (4).  Before limitation of 
 65.33  choice is implemented, eligible individuals shall be notified 
 65.34  and after notification, shall be allowed to choose only among 
 65.35  demonstration providers.  The commissioner may assign an 
 65.36  individual with private coverage through an HMO, to the same HMO 
 66.1   for medical assistance coverage, if the HMO is under contract 
 66.2   for medical assistance in the individual's county of residence.  
 66.3   After initially choosing a provider, the recipient is allowed to 
 66.4   change that choice only at specified times as allowed by the 
 66.5   commissioner.  If a demonstration provider ends participation in 
 66.6   the project for any reason, a recipient enrolled with that 
 66.7   provider must select a new provider but may change providers 
 66.8   without cause once more within the first 60 days after 
 66.9   enrollment with the second provider. 
 66.10     Sec. 34.  Minnesota Statutes 1995 Supplement, section 
 66.11  256B.69, subdivision 6, is amended to read: 
 66.12     Subd. 6.  [SERVICE DELIVERY.] (a) Each demonstration 
 66.13  provider shall be responsible for the health care coordination 
 66.14  for eligible individuals.  Demonstration providers:  
 66.15     (1) shall authorize and arrange for the provision of all 
 66.16  needed health services including but not limited to the full 
 66.17  range of services listed in sections 256B.02, subdivision 8, and 
 66.18  256B.0625 and for children eligible for medical assistance under 
 66.19  section 256B.055, subdivision 12, home care services and 
 66.20  personal care assistant services in order to ensure appropriate 
 66.21  health care is delivered to enrollees; 
 66.22     (2) shall accept the prospective, per capita payment from 
 66.23  the commissioner in return for the provision of comprehensive 
 66.24  and coordinated health care services for eligible individuals 
 66.25  enrolled in the program; 
 66.26     (3) may contract with other health care and social service 
 66.27  practitioners to provide services to enrollees; and 
 66.28     (4) shall institute recipient grievance procedures 
 66.29  according to the method established by the project, utilizing 
 66.30  applicable requirements of chapter 62D.  Disputes not resolved 
 66.31  through this process shall be appealable to the commissioner as 
 66.32  provided in subdivision 11.  
 66.33     (b) Demonstration providers must comply with the standards 
 66.34  for claims settlement under section 72A.201, subdivisions 4, 5, 
 66.35  7, and 8, when contracting with other health care and social 
 66.36  service practitioners to provide services to enrollees.  A 
 67.1   demonstration provider must pay a clean claim, as defined in 
 67.2   Code of Federal Regulations, title 42, section 447.45(b), within 
 67.3   30 business days of the date of acceptance of the claim.  
 67.4      Sec. 35.  [256B.77] [DEMONSTRATION PROJECTS FOR PERSONS 
 67.5   WITH DISABILITIES.] 
 67.6      Subdivision 1.  [IN GENERAL.] The commissioner may develop 
 67.7   and implement demonstration projects to create alternative 
 67.8   service delivery systems in which all services covered under the 
 67.9   medical assistance program for disabled individuals are provided 
 67.10  in an integrated manner and funded on a capitation basis.  These 
 67.11  alternative delivery systems shall be designed to increase 
 67.12  coordination of health care services, improve access to quality 
 67.13  health care services, reduce incentives for 
 67.14  institutionalization, and reduce incentives among providers and 
 67.15  payer to shift costs. 
 67.16     Subd. 2.  [WAIVERS.] The commissioner shall request any 
 67.17  authority from the United States Department of Health and Human 
 67.18  Services that is necessary to implement these demonstration 
 67.19  projects under the medical assistance program, and to combine 
 67.20  Medicare and Medicaid funding and services for those disabled 
 67.21  individuals who are eligible for both programs.  Implementation 
 67.22  of these programs may begin without authority to include 
 67.23  Medicare funding and services.  The commissioner may begin 
 67.24  enrollment of individuals in these systems on or after April 1, 
 67.25  1997. 
 67.26     Subd. 3.  [HEALTH CARE SERVICE DELIVERY NETWORKS.] The 
 67.27  commissioner may contract with any entity that demonstrates the 
 67.28  ability to manage all health care services covered under this 
 67.29  chapter through its network of providers, and according to the 
 67.30  terms and conditions of the contract with the commissioner.  The 
 67.31  commissioner must be assured that the contractor has in place an 
 67.32  adequate system for the resolution of enrollee complaints, the 
 67.33  collection of data, quality of care monitoring and improvement, 
 67.34  enrollee education, and the management of services in 
 67.35  coordination with local human services agencies and providers of 
 67.36  related services that are not covered under this chapter.  To 
 68.1   the extent that requirements are waived under subdivision 8, the 
 68.2   commissioner must assure that any alternative plan provides for 
 68.3   the health and safety of enrollees and protects the right to 
 68.4   privacy and to provide informed consent. 
 68.5      Subd. 4.  [PAYMENT RATES.] The commissioner shall develop 
 68.6   capitation payment rates for the initial contract period for 
 68.7   health care service delivery networks, in consultation with an 
 68.8   independent actuary, to ensure that the cost of services under 
 68.9   these demonstration projects do not exceed the estimated cost 
 68.10  for medical assistance services for the covered population under 
 68.11  the fee-for-service system.  Rates will be adjusted within the 
 68.12  limits of the available risk adjustment technology.  The 
 68.13  commissioner may implement appropriate risk and profit sharing 
 68.14  provisions.  For successive contract periods, the commissioner 
 68.15  may implement a payment system that is based on a competitive 
 68.16  bid process that includes considerations of access, quality, 
 68.17  accountability, and affordability. 
 68.18     Subd. 5.  [ENROLLMENT AND CONSUMER CHOICE.] (a) The 
 68.19  commissioner may designate geographic areas in which these 
 68.20  demonstration projects may be implemented.  The commissioner may 
 68.21  require all individuals who are eligible for medical assistance 
 68.22  based on a disability and who reside in the designated 
 68.23  geographic area to obtain services covered under this chapter 
 68.24  through providers participating in the designated health care 
 68.25  service delivery network.  The commissioner may phase in 
 68.26  enrollment of persons with disabilities under these 
 68.27  demonstration projects. 
 68.28     (b) Enrollment into networks shall be conducted according 
 68.29  to the terms of the federal waiver and the Minnesota Medicaid 
 68.30  state plan.  A choice of at least two health care service 
 68.31  delivery networks will be offered, when possible.  One option 
 68.32  will be offered only in geographic areas where there is only one 
 68.33  health care service delivery network that is qualified to 
 68.34  participate.  In geographic areas where there is more than one 
 68.35  qualified health care service delivery network, consumers will 
 68.36  be given the option to change their choice of networks once 
 69.1   within the first 12 months of enrollment in the program.  
 69.2   Consumers will also be given the option to change networks 
 69.3   during an annual open enrollment period. 
 69.4      Subd. 6.  [CONSUMER ROLE.] The health care service delivery 
 69.5   network must demonstrate that enrollees have choices within the 
 69.6   existing network of services.  The health care service delivery 
 69.7   network must also ensure that consumer representatives are 
 69.8   involved in the planning process for the design of these 
 69.9   demonstration projects.  Enrollees will have access to the state 
 69.10  managed care ombudsman services authorized under section 256B.69.
 69.11     Subd. 7.  [COORDINATION WITH LOCAL GOVERNMENT.] (a) The 
 69.12  commissioner may conduct these demonstration projects using 
 69.13  different alternative service delivery models.  The commissioner 
 69.14  may waive requirements in administrative rules and law that the 
 69.15  commissioner determines are incompatible with the implementation 
 69.16  of these demonstration projects if the commissioner determines 
 69.17  that adequate alternative measures are in place to protect the 
 69.18  health, safety, and rights of consumers, and to provide quality 
 69.19  of care.  The commissioner may not waive requirements regarding 
 69.20  the reporting of maltreatment of minors or vulnerable adults 
 69.21  under sections 626.556 and 626.557, and administrative rules 
 69.22  adopted thereunder.  Prior to granting any waiver under this 
 69.23  subdivision, the commissioner must convene a panel to review the 
 69.24  request for waiver and the proposed alternatives to the 
 69.25  requirements being waived and make recommendations to the 
 69.26  commissioner regarding such a waiver.  The panel may include 
 69.27  representation from local human services agencies, the ombudsman 
 69.28  for mental health and mental retardation, legal services, and 
 69.29  advocates, and consumers.  The commissioner may exempt the 
 69.30  participating counties from their social services obligations 
 69.31  and fiscal sanctions for noncompliance with requirements in laws 
 69.32  and rules to the extent that the commissioner determines those 
 69.33  obligations are met under this section and are incompatible with 
 69.34  the implementation of these demonstration projects. 
 69.35     (b) For demonstration projects in which the health care 
 69.36  service delivery network is not a county, the commissioner may 
 70.1   require evidence of a contract with the county human services 
 70.2   agency that delineates the county's role and the network's role 
 70.3   in providing and coordinating health and social services.  For 
 70.4   individuals enrolled in such a demonstration project, 
 70.5   notwithstanding provisions to the contrary, the health care 
 70.6   service delivery network will be responsible for authorizing the 
 70.7   provision of health care services under the medical assistance 
 70.8   program. 
 70.9      Sec. 36.  Minnesota Statutes 1995 Supplement, section 
 70.10  256D.03, subdivision 4, is amended to read: 
 70.11     Subd. 4.  [GENERAL ASSISTANCE MEDICAL CARE; SERVICES.] (a) 
 70.12  For a person who is eligible under subdivision 3, paragraph (a), 
 70.13  clause (3), general assistance medical care covers, except as 
 70.14  provided in paragraph (c): 
 70.15     (1) inpatient hospital services; 
 70.16     (2) outpatient hospital services; 
 70.17     (3) services provided by Medicare certified rehabilitation 
 70.18  agencies; 
 70.19     (4) prescription drugs and other products recommended 
 70.20  through the process established in section 256B.0625, 
 70.21  subdivision 13; 
 70.22     (5) equipment necessary to administer insulin and 
 70.23  diagnostic supplies and equipment for diabetics to monitor blood 
 70.24  sugar level; 
 70.25     (6) eyeglasses and eye examinations provided by a physician 
 70.26  or optometrist; 
 70.27     (7) hearing aids; 
 70.28     (8) prosthetic devices; 
 70.29     (9) laboratory and X-ray services; 
 70.30     (10) physician's services; 
 70.31     (11) medical transportation; 
 70.32     (12) chiropractic services as covered under the medical 
 70.33  assistance program; 
 70.34     (13) podiatric services; 
 70.35     (14) dental services; 
 70.36     (15) outpatient services provided by a mental health center 
 71.1   or clinic that is under contract with the county board and is 
 71.2   established under section 245.62; 
 71.3      (16) day treatment services for mental illness provided 
 71.4   under contract with the county board; 
 71.5      (17) prescribed medications for persons who have been 
 71.6   diagnosed as mentally ill as necessary to prevent more 
 71.7   restrictive institutionalization; 
 71.8      (18) case management services for a person with serious and 
 71.9   persistent mental illness who would be eligible for medical 
 71.10  assistance except that the person resides in an institution for 
 71.11  mental diseases; 
 71.12     (19) psychological services, medical supplies and 
 71.13  equipment, and Medicare premiums, coinsurance and deductible 
 71.14  payments; 
 71.15     (20) medical equipment not specifically listed in this 
 71.16  paragraph when the use of the equipment will prevent the need 
 71.17  for costlier services that are reimbursable under this 
 71.18  subdivision; 
 71.19     (21) services performed by a certified pediatric nurse 
 71.20  practitioner, a certified family nurse practitioner, a certified 
 71.21  adult nurse practitioner, a certified obstetric/gynecological 
 71.22  nurse practitioner, or a certified geriatric nurse practitioner 
 71.23  in independent practice, if the services are otherwise covered 
 71.24  under this chapter as a physician service, and if the service is 
 71.25  within the scope of practice of the nurse practitioner's license 
 71.26  as a registered nurse, as defined in section 148.171; and 
 71.27     (22) services of a certified public health nurse or a 
 71.28  registered nurse practicing in a public health nursing clinic 
 71.29  that is a department of, or that operates under the direct 
 71.30  authority of, a unit of government, if the service is within the 
 71.31  scope of practice of the public health nurse's license as a 
 71.32  registered nurse, as defined in section 148.171.  
 71.33     (b) Except as provided in paragraph (c), for a recipient 
 71.34  who is eligible under subdivision 3, paragraph (a), clause (1) 
 71.35  or (2), general assistance medical care covers the services 
 71.36  listed in paragraph (a) with the exception of special 
 72.1   transportation services. 
 72.2      (c) Gender reassignment surgery and related services are 
 72.3   not covered services under this subdivision unless the 
 72.4   individual began receiving gender reassignment services prior to 
 72.5   July 1, 1995.  
 72.6      (d) In order to contain costs, the commissioner of human 
 72.7   services shall select vendors of medical care who can provide 
 72.8   the most economical care consistent with high medical standards 
 72.9   and shall where possible contract with organizations on a 
 72.10  prepaid capitation basis to provide these services.  The 
 72.11  commissioner shall consider proposals by counties and vendors 
 72.12  for prepaid health plans, competitive bidding programs, block 
 72.13  grants, or other vendor payment mechanisms designed to provide 
 72.14  services in an economical manner or to control utilization, with 
 72.15  safeguards to ensure that necessary services are provided.  
 72.16  Before implementing prepaid programs in counties with a county 
 72.17  operated or affiliated public teaching hospital or a hospital or 
 72.18  clinic operated by the University of Minnesota, the commissioner 
 72.19  shall consider the risks the prepaid program creates for the 
 72.20  hospital and allow the county or hospital the opportunity to 
 72.21  participate in the program in a manner that reflects the risk of 
 72.22  adverse selection and the nature of the patients served by the 
 72.23  hospital, provided the terms of participation in the program are 
 72.24  competitive with the terms of other participants considering the 
 72.25  nature of the population served.  Payment for services provided 
 72.26  pursuant to this subdivision shall be as provided to medical 
 72.27  assistance vendors of these services under sections 256B.02, 
 72.28  subdivision 8, and 256B.0625, and for contracts beginning on or 
 72.29  after July 1, 1995, shall be discounted ten percent from 
 72.30  comparable fee for service payments.  For payments made during 
 72.31  fiscal year 1990 and later years, the commissioner shall consult 
 72.32  with an independent actuary in establishing prepayment rates, 
 72.33  but shall retain final control over the rate methodology.  
 72.34  Notwithstanding the provisions of subdivision 3, an individual 
 72.35  who becomes ineligible for general assistance medical care 
 72.36  because of failure to submit income reports or recertification 
 73.1   forms in a timely manner, shall remain enrolled in the prepaid 
 73.2   health plan and shall remain eligible for general assistance 
 73.3   medical care coverage through the last day of the month in which 
 73.4   the enrollee became ineligible for general assistance medical 
 73.5   care. 
 73.6      (e) The commissioner of human services may reduce payments 
 73.7   provided under sections 256D.01 to 256D.21 and 261.23 in order 
 73.8   to remain within the amount appropriated for general assistance 
 73.9   medical care, within the following restrictions. 
 73.10     For the period July 1, 1985 to December 31, 1985, 
 73.11  reductions below the cost per service unit allowable under 
 73.12  section 256.966, are permitted only as follows:  payments for 
 73.13  inpatient and outpatient hospital care provided in response to a 
 73.14  primary diagnosis of chemical dependency or mental illness may 
 73.15  be reduced no more than 30 percent; payments for all other 
 73.16  inpatient hospital care may be reduced no more than 20 percent.  
 73.17  Reductions below the payments allowable under general assistance 
 73.18  medical care for the remaining general assistance medical care 
 73.19  services allowable under this subdivision may be reduced no more 
 73.20  than ten percent. 
 73.21     For the period January 1, 1986 to December 31, 1986, 
 73.22  reductions below the cost per service unit allowable under 
 73.23  section 256.966 are permitted only as follows:  payments for 
 73.24  inpatient and outpatient hospital care provided in response to a 
 73.25  primary diagnosis of chemical dependency or mental illness may 
 73.26  be reduced no more than 20 percent; payments for all other 
 73.27  inpatient hospital care may be reduced no more than 15 percent.  
 73.28  Reductions below the payments allowable under general assistance 
 73.29  medical care for the remaining general assistance medical care 
 73.30  services allowable under this subdivision may be reduced no more 
 73.31  than five percent. 
 73.32     For the period January 1, 1987 to June 30, 1987, reductions 
 73.33  below the cost per service unit allowable under section 256.966 
 73.34  are permitted only as follows:  payments for inpatient and 
 73.35  outpatient hospital care provided in response to a primary 
 73.36  diagnosis of chemical dependency or mental illness may be 
 74.1   reduced no more than 15 percent; payments for all other 
 74.2   inpatient hospital care may be reduced no more than ten 
 74.3   percent.  Reductions below the payments allowable under medical 
 74.4   assistance for the remaining general assistance medical care 
 74.5   services allowable under this subdivision may be reduced no more 
 74.6   than five percent.  
 74.7      For the period July 1, 1987 to June 30, 1988, reductions 
 74.8   below the cost per service unit allowable under section 256.966 
 74.9   are permitted only as follows:  payments for inpatient and 
 74.10  outpatient hospital care provided in response to a primary 
 74.11  diagnosis of chemical dependency or mental illness may be 
 74.12  reduced no more than 15 percent; payments for all other 
 74.13  inpatient hospital care may be reduced no more than five percent.
 74.14  Reductions below the payments allowable under medical assistance 
 74.15  for the remaining general assistance medical care services 
 74.16  allowable under this subdivision may be reduced no more than 
 74.17  five percent. 
 74.18     For the period July 1, 1988 to June 30, 1989, reductions 
 74.19  below the cost per service unit allowable under section 256.966 
 74.20  are permitted only as follows:  payments for inpatient and 
 74.21  outpatient hospital care provided in response to a primary 
 74.22  diagnosis of chemical dependency or mental illness may be 
 74.23  reduced no more than 15 percent; payments for all other 
 74.24  inpatient hospital care may not be reduced.  Reductions below 
 74.25  the payments allowable under medical assistance for the 
 74.26  remaining general assistance medical care services allowable 
 74.27  under this subdivision may be reduced no more than five percent. 
 74.28     There shall be no copayment required of any recipient of 
 74.29  benefits for any services provided under this subdivision.  A 
 74.30  hospital receiving a reduced payment as a result of this section 
 74.31  may apply the unpaid balance toward satisfaction of the 
 74.32  hospital's bad debts. 
 74.33     (f) Any county may, from its own resources, provide medical 
 74.34  payments for which state payments are not made. 
 74.35     (g) Chemical dependency services that are reimbursed under 
 74.36  chapter 254B must not be reimbursed under general assistance 
 75.1   medical care. 
 75.2      (h) The maximum payment for new vendors enrolled in the 
 75.3   general assistance medical care program after the base year 
 75.4   shall be determined from the average usual and customary charge 
 75.5   of the same vendor type enrolled in the base year. 
 75.6      (i) The conditions of payment for services under this 
 75.7   subdivision are the same as the conditions specified in rules 
 75.8   adopted under chapter 256B governing the medical assistance 
 75.9   program, unless otherwise provided by statute or rule. 
 75.10     Sec. 37.  Minnesota Statutes 1994, section 256I.05, is 
 75.11  amended by adding a subdivision to read: 
 75.12     Subd. 7c.  [DEMONSTRATION PROJECT.] The commissioner is 
 75.13  authorized to pursue a demonstration project under federal food 
 75.14  stamp regulation for the purpose of gaining federal 
 75.15  reimbursement of food and nutritional costs currently paid by 
 75.16  the state group residential housing program.  Any revenues 
 75.17  received from this demonstration project may be retained to 
 75.18  offset the costs of development, implementation, administration, 
 75.19  and group residential housing expenditures. 
 75.20     Sec. 38.  [REPEALER.] 
 75.21     Minnesota Rules, parts 9525.0215; 9525.0225; 9525.0235; 
 75.22  9525.0243; 9525.0245; 9525.0255; 9525.0265; 9525.0275; 
 75.23  9525.0285; 9525.0295; 9525.0305; 9525.0315; 9525.0325; 
 75.24  9525.0335; 9525.0345; 9525.0355; 9525.0500; 9525.0510; 
 75.25  9525.0520; 9525.0530; 9525.0540; 9525.0550; 9525.0560; 
 75.26  9525.0570; 9525.0580; 9525.0590; 9525.0600; 9525.0610; 
 75.27  9525.0620; 9525.0630; 9525.0640; 9525.0650; 9525.0660; 
 75.28  9525.1500; 9525.1510; 9525.1520; 9525.1530; 9525.1540; 
 75.29  9525.1550; 9525.1560; 9525.1570; 9525.1580; 9525.1590; 
 75.30  9525.1600; 9525.1610; 9525.1620; 9525.1630; 9525.1640; 
 75.31  9525.1650; 9525.1660; 9525.1670; 9525.1680; 9525.1690; 
 75.32  9525.2000; 9525.2010; 9525.2020; 9525.2025; 9525.2030; 
 75.33  9525.2040; 9525.2050; 9525.2060; 9525.2070; 9525.2080; 
 75.34  9525.2090; 9525.2100; 9525.2110; 9525.2120; 9525.2130; and 
 75.35  9525.2140, are repealed. 
 75.36     Minnesota Rules, part 9505.5230, is repealed effective July 
 76.1   1, 1996.  Minnesota Rules, part 9500.1452, subpart 2, items G 
 76.2   and H, are repealed effective July 1, 1996. 
 76.3      Minnesota Statutes 1995 Supplement, section 256B.69, 
 76.4   subdivision 4a, is repealed. 
 76.5      Sec. 39.  [EFFECTIVE DATES.] 
 76.6      Sections 3 to 10 are effective July 1, 1996.  The 
 76.7   provisions of sections 252B.01 to 252B.08 shall continue to be 
 76.8   in effect until the commissioner promulgates permanent rules to 
 76.9   govern the services in those sections.  The commissioner shall 
 76.10  notify the revisor of statutes in writing and publish a notice 
 76.11  in the State Register when sections 252B.01 to 252B.08 are 
 76.12  repealed by promulgation of the permanent rules. 
 76.13     Section 15 is effective October 1, 1996, or upon receipt of 
 76.14  any necessary federal approval, whichever date is later. 
 76.15     Sections 1 and 2 are effective for requests for proposals 
 76.16  issued on or after July 1, 1996. 
 76.17                             ARTICLE 3
 76.18                       ACCESS TO HEALTH CARE 
 76.19     Section 1.  [256J.01] [IN GENERAL.] 
 76.20     Subdivision 1.  [PURPOSE.] There is established in the 
 76.21  state of Minnesota one system to purchase health care and 
 76.22  related services for residents who meet the criteria set forth 
 76.23  in this chapter.  This new system, at full implementation, will 
 76.24  replace the medical assistance and the general assistance 
 76.25  medical care programs, and the MinnesotaCare health plan, 
 76.26  established under chapters 256, 256B, and 256D.  This system is 
 76.27  established to provide quality health care services to families 
 76.28  and individuals who do not have access to or cannot pay for 
 76.29  health care coverage. 
 76.30     Subd. 2.  [OBJECTIVES.] This system is intended to and 
 76.31  shall be developed and administered in a manner that encourages 
 76.32  individuals to obtain health care and maintain health; 
 76.33  emphasizes the provision of primary and preventive care; is 
 76.34  easily accessed by those who require it; promotes competition 
 76.35  and cost-efficiency and reduces incentives among providers and 
 76.36  payers to shift costs; provides incentives for care management 
 77.1   and coordination; provides incentives to maintain individuals in 
 77.2   family and community settings; and can be adjusted to 
 77.3   accommodate changes in available funding and to facilitate the 
 77.4   development of new strategies in the purchasing and delivery of 
 77.5   health care services. 
 77.6      Subd. 3.  [FEDERAL AUTHORITY.] The commissioner shall 
 77.7   request any authority that is necessary from the United States 
 77.8   Department of Health and Human Services in order to implement 
 77.9   this system, while making full use of available federal funding, 
 77.10  and shall implement those provisions that are permissible or 
 77.11  specifically authorized under federal law no earlier than 
 77.12  January 1, 1998. 
 77.13     Subd. 4.  [RELATIONSHIP TO OTHER PROGRAMS.] Beginning 
 77.14  January 1, 1998, no individual who is enrolled under this 
 77.15  chapter may remain enrolled in the medical assistance, general 
 77.16  assistance medical care, or MinnesotaCare programs established 
 77.17  under chapters 256, 256B, and 256D. 
 77.18     Sec. 2.  [256J.02] [ELIGIBILITY FOR FAMILIES AND CHILDREN; 
 77.19  AS DISTINGUISHED FROM ELIGIBILITY FOR INDIVIDUALS WITH 
 77.20  DISABILITIES AND INDIVIDUALS AGE 65 AND OLDER.] 
 77.21     Sections 256J.03 to 256J.12 apply to the administration and 
 77.22  certification of eligibility for families and individuals who 
 77.23  request coverage for the standard benefit set as defined in 
 77.24  section 256J.09.  The commissioner shall make recommendations to 
 77.25  the 1997 legislature regarding the administration and 
 77.26  certification of eligibility under this chapter for a standard 
 77.27  benefit set and continuing care services for persons who are 
 77.28  disabled and for persons who are age 65 and older, as required 
 77.29  in section 256J.13.  Nothing in this chapter shall affect 
 77.30  eligibility under chapter 256B for individuals who are disabled 
 77.31  and individuals who are age 65 and older prior to the enactment 
 77.32  of eligibility standards and standards for coverage under this 
 77.33  chapter. 
 77.34     Sec. 3.  [256J.03] [DEFINITIONS.] 
 77.35     Subdivision 1.  [SCOPE.] For purposes of this chapter, the 
 77.36  following terms shall have the meanings given them, unless 
 78.1   otherwise provided. 
 78.2      Subd. 2.  [COMMISSIONER.] "Commissioner" means the 
 78.3   commissioner of human services or a designee. 
 78.4      Subd. 3.  [FAMILY.] "Family" means a parent and the 
 78.5   parent's biological or adoptive children under age 21, 
 78.6   stepparents and their stepchildren under age 21, or guardians 
 78.7   and their wards who are children under age 21, residing in the 
 78.8   same household.  It also includes children under age 18 who are 
 78.9   out of the parental home in settings such as schools, camps, 
 78.10  visitation with the noncustodial parent, foster care, or 
 78.11  institutions.  Family also means spouses in households without 
 78.12  children and single individuals in a one-person household. 
 78.13     Subd. 4.  [GROSS FAMILY INCOME.] "Gross family income" 
 78.14  means all earned and unearned income of a family as defined in 
 78.15  subdivision 6.  Gross family income for farm and nonfarm 
 78.16  self-employed means income calculated using as the baseline the 
 78.17  adjusted gross income reported on the applicant's federal income 
 78.18  tax form for the previous year and adding back in reported 
 78.19  depreciation and carryover loss amounts that apply to the 
 78.20  business in which the family is currently engaged.  Applicants 
 78.21  shall report the current financial situation of the family if it 
 78.22  has changed significantly from the period of time covered by the 
 78.23  federal income tax form. 
 78.24     Subd. 5.  [HEALTH CARE SERVICE DELIVERY NETWORK.] "Health 
 78.25  care service delivery network" includes public and private 
 78.26  entities, including counties and federally recognized Indian 
 78.27  tribes, that contract with the state on a capitation basis for a 
 78.28  defined benefit set to serve designated individuals who are 
 78.29  eligible under this chapter. 
 78.30     Sec. 4.  [256J.04] [ADMINISTRATION OF ELIGIBILITY FOR 
 78.31  INDIVIDUALS AND FAMILIES.] 
 78.32     Subdivision 1.  [APPLICATION AND AVAILABILITY OF 
 78.33  INFORMATION.] The commissioner shall conduct marketing efforts 
 78.34  to encourage families and individuals to receive information 
 78.35  about the coverage under this chapter.  The commissioner shall 
 78.36  develop an application form which applicants may mail to a 
 79.1   designated processing site.  The commissioner shall develop a 
 79.2   plan to expand access to multiple sites, which may include but 
 79.3   are not limited to county human service agencies, offices of the 
 79.4   department of human services, public health offices, community 
 79.5   action programs, senior citizen centers, local public health 
 79.6   offices, and others. 
 79.7      Subd. 2.  [DOCUMENTATION.] Social security numbers shall be 
 79.8   reported and used as identifiers for purposes of administering 
 79.9   this chapter.  Data matches will be used to verify income.  
 79.10  Applicants may be required to submit evidence of family income, 
 79.11  earned and unearned, including the most recent income tax 
 79.12  return, wage slips, or other documentation that is necessary to 
 79.13  verify income eligibility.  The commissioner shall perform 
 79.14  random audits to verify reported income and eligibility.  The 
 79.15  commissioner will form an interagency work group to develop 
 79.16  additional automated means of sharing data with other 
 79.17  governmental agencies in order to perform income verification 
 79.18  related to eligibility and premium payment under this chapter. 
 79.19     Subd. 3.  [FRAUD AND ABUSE.] The commissioner shall make 
 79.20  recommendations to the 1997 legislature regarding penalties for 
 79.21  individuals who fail to accurately report income. 
 79.22     Subd. 4.  [EFFECTIVE DATE OF COVERAGE.] The effective date 
 79.23  of coverage is the first day of the month following the month in 
 79.24  which eligibility is approved and the first premium payment has 
 79.25  been received.  The first premium must be received within two 
 79.26  calendar months of certification of eligibility.  The effective 
 79.27  date of coverage for eligible newborns or eligible newly 
 79.28  adoptive children added to a family receiving covered health 
 79.29  services is the date of entry into the family.  The effective 
 79.30  date of coverage for other new recipients added to the family 
 79.31  receiving covered health services is the first day of the month 
 79.32  following the month in which eligibility is approved and the 
 79.33  first premium payment has been received. 
 79.34     Subd. 5.  [APPLICATION PROCESSING.] Eligibility for 
 79.35  families and individuals under this chapter shall be determined 
 79.36  no more than 30 days from the date that a complete application 
 80.1   is received by a designated enrollment site. 
 80.2      Subd. 6.  [ANNUAL DETERMINATIONS.] Determination of 
 80.3   eligibility under this chapter shall be made annually.  This 
 80.4   determination must include a full report of changes in income, 
 80.5   family composition, availability of other insurance, and all 
 80.6   other factors affecting the enrollee's continued eligibility.  
 80.7   Sliding scale premium payments must be adjusted at annual 
 80.8   determination based upon changes in enrollee income or other 
 80.9   factors.  Enrollment will be terminated for enrollees who fail 
 80.10  to file the required annual report or who no longer meet the 
 80.11  eligibility requirements of this chapter. 
 80.12     Subd. 7.  [ADJUSTMENTS BETWEEN ANNUAL DETERMINATIONS.] 
 80.13  Adjustments to enrollment and sliding scale premium payments 
 80.14  shall be made between annual determinations when the enrollment 
 80.15  authority receives a report of any of the following: 
 80.16     (1) an enrollee requests termination; 
 80.17     (2) an enrollee acquires other health insurance which 
 80.18  precludes eligibility under this chapter; 
 80.19     (3) an enrollee fails to make the required sliding scale 
 80.20  premium payment; 
 80.21     (4) an enrollee is no longer a resident of Minnesota; 
 80.22     (5) a family member leaves the household and is no longer 
 80.23  considered part of the family as defined in section 256J.03; 
 80.24     (6) a person who is considered part of the family as 
 80.25  defined in section 256J.03 enters the household. 
 80.26     Sec. 5.  [256J.05] [ELIGIBILITY REQUIREMENTS FOR FAMILIES 
 80.27  AND INDIVIDUALS.] 
 80.28     Subdivision 1.  [CHILDREN.] "Eligible enrollees" means 
 80.29  children who are less than 21 years of age who have gross family 
 80.30  incomes that are equal to or less than 275 percent of the 
 80.31  federal poverty guidelines and who meet other eligibility 
 80.32  requirements of this chapter. 
 80.33     Subd. 2.  [PREGNANT WOMEN.] "Eligible enrollees" means 
 80.34  pregnant women with gross family incomes that are equal to or 
 80.35  less than 275 percent of the federal poverty guideline and who 
 80.36  meet other eligibility requirements of this chapter.  A woman 
 81.1   whose pregnancy is medically verified will be considered as two 
 81.2   people in determining eligibility and the amount of the sliding 
 81.3   scale premium payment. 
 81.4      Subd. 3.  [ADULTS WITH CHILDREN.] "Eligible enrollees" 
 81.5   means parents, stepparents, and legal guardians with children 
 81.6   considered part of the family as defined in section 256J.03, who 
 81.7   have gross family incomes equal to or less than 275 percent of 
 81.8   the federal poverty guidelines and who meet other eligibility 
 81.9   requirements of this chapter. 
 81.10     Subd. 4.  [SINGLE ADULTS AND HOUSEHOLDS WITHOUT 
 81.11  CHILDREN.] "Eligible enrollees" means all individuals in 
 81.12  households with no children, who are not eligible for Medicare, 
 81.13  and who have gross family incomes that are equal to or less than 
 81.14  125 percent of the federal poverty guidelines and who meet other 
 81.15  eligibility requirements of this chapter. 
 81.16     Subd. 5.  [FAMILY ENROLLMENT.] Families cannot choose to 
 81.17  enroll only certain uninsured members.  Parents, stepparents, 
 81.18  and legal guardians who enroll under this chapter must also 
 81.19  enroll their children, stepchildren, or wards, if children, 
 81.20  stepchildren, or wards are eligible.  If one parent in the 
 81.21  household enrolls, both parents must enroll, if parents are 
 81.22  eligible.  If one child from a family is enrolled, all children, 
 81.23  parents, stepparents, and legal guardians as must be enrolled if 
 81.24  those family members are eligible.  If one spouse in a household 
 81.25  enrolls, the other spouse in the household must also enroll, if 
 81.26  the spouse is eligible. 
 81.27     Sec. 6.  [256J.06] [PREMIUM PAYMENTS; FAMILIES AND 
 81.28  INDIVIDUALS.] 
 81.29     Subdivision 1.  [PREMIUM PAYMENTS.] Eligible enrollees 
 81.30  shall be required to pay a premium based on a sliding scale, as 
 81.31  established under subdivision 2.  Premiums are calculated on a 
 81.32  calendar month basis and may be paid on a monthly, quarterly, or 
 81.33  annual basis.  The initial premium payment is due upon notice of 
 81.34  the premium amount required, but may be submitted no later than 
 81.35  two calendar months after the month in which the premium notice 
 81.36  was issued.  Ongoing premiums are due by the processing date 
 82.1   specified in the monthly premium notice.  Nonpayment of the 
 82.2   initial premium by two calendar months after the month in which 
 82.3   the premium notice was issued will result in the termination of 
 82.4   the application.  Reapplication will be required to be 
 82.5   considered under this chapter.  Nonpayment of the ongoing 
 82.6   premium will result in disenrollment under this chapter within 
 82.7   one calendar month after the due date.  Persons disenrolled for 
 82.8   nonpayment may not reenroll until one calendar month has 
 82.9   elapsed.  The following individuals are not required to pay 
 82.10  premiums: 
 82.11     (1) individuals who receive assistance under the aid to 
 82.12  families with dependent children, Minnesota family investment 
 82.13  plan, refugee cash assistance, general assistance, Minnesota 
 82.14  supplemental aid, and any successors to these programs; 
 82.15     (2) children, pregnant women, and adults with children who 
 82.16  do not receive cash assistance but whose gross family income is 
 82.17  equal to or less than 100 percent of the federal poverty 
 82.18  guidelines; 
 82.19     (3) single adults without children who do not receive cash 
 82.20  assistance but whose gross family income is equal to or less 
 82.21  than the current income standard for an individual in a 
 82.22  nonshared household under the supplemental security income for 
 82.23  aged, blind, and disabled under United States Code, title 42, 
 82.24  chapter 7, subchapter XVI; 
 82.25     (4) married couples without children who do not receive 
 82.26  cash assistance but whose gross family income is equal to or 
 82.27  less than the current income standard for a couple in a 
 82.28  nonshared household under the supplemental security income for 
 82.29  aged, blind, and disabled under United States Code, title 42, 
 82.30  chapter 7, subchapter XVI. 
 82.31     Subd. 2.  [SLIDING SCALES TO DETERMINE PERCENTAGE OF GROSS 
 82.32  FAMILY INCOME.] Enrollees who are not exempt from premium 
 82.33  payment under subdivision 1 shall pay a premium determined 
 82.34  according to a sliding fee based on the cost of coverage as a 
 82.35  percentage of the family's gross income.  A sliding scale shall 
 82.36  be established to determine the percentage of gross family 
 83.1   income that households at different income levels must pay to 
 83.2   obtain coverage under this chapter.  The sliding scale must be 
 83.3   based on the enrollee's current gross family income, as defined 
 83.4   in section 256J.03, for a 12-month period beginning with the 
 83.5   month of application.  The sliding scale must provide separate 
 83.6   sliding scales for individuals, two-person households, and 
 83.7   households of three or more.  The sliding fee scales begin with 
 83.8   a premium of 1.5 percent of gross family income for children, 
 83.9   pregnant women, and adults with children with gross family 
 83.10  incomes above 100 percent of the federal poverty guideline and 
 83.11  proceed through the following evenly spaced steps:  1.8, 2.3, 
 83.12  3.1, 3.8, 4.8, 5.9, 7.4, and 8.8.  These percentages are matched 
 83.13  to evenly spaced income steps ranging from 100 percent of the 
 83.14  federal poverty guideline to 275 percent of the federal poverty 
 83.15  guidelines for the applicable family size.  The sliding fee 
 83.16  scales begin with a premium of 1.8 percent of gross family 
 83.17  income for individuals and couples without children with gross 
 83.18  family incomes above the applicable income standard described in 
 83.19  subdivision 1 and increase to 2.3 percent of gross family income 
 83.20  for individuals and couples with incomes between 100 percent and 
 83.21  125 percent of the federal poverty guideline. 
 83.22     Subd. 3.  [INCOME INELIGIBILITY.] Children, pregnant women, 
 83.23  and adults with children whose gross monthly income is above 275 
 83.24  percent of the federal poverty guideline are not eligible under 
 83.25  this chapter.  Individuals or couples without children whose 
 83.26  gross monthly income is greater than 125 percent of the federal 
 83.27  poverty guidelines are not eligible under this chapter. 
 83.28     Subd. 4.  [PREMIUM COLLECTION THROUGH WAGE 
 83.29  WITHHOLDING.] The premium for coverage under this chapter may be 
 83.30  collected through wage withholding with the consent of the 
 83.31  employer and the employee. 
 83.32     Subd. 5.  [EXCLUSION FROM CHAPTER 14.] The sliding fee 
 83.33  scale and percentages are not subject to the provisions of 
 83.34  chapter 14. 
 83.35     Subd. 6.  [MINIMUM PREMIUM PAYMENT.] The commissioner may 
 83.36  establish a minimum premium amount to ensure that the premium 
 84.1   amount is sufficient to cover the administrative cost of premium 
 84.2   collection. 
 84.3      Sec. 7.  [256J.07] [ACCESS TO OTHER INSURANCE COVERAGE; 
 84.4   FAMILIES AND INDIVIDUALS.] 
 84.5      Subdivision 1.  [GENERAL REQUIREMENTS.] Eligible enrollees 
 84.6   are eligible for subsidized premium payments under section 
 84.7   256J.04 only if the family or individual meets the requirements 
 84.8   in subdivisions 2 and 3.  Enrollees with gross family income 
 84.9   equal to or less than 100 percent of the federal poverty 
 84.10  guideline are eligible for subsidized premium payments without 
 84.11  meeting these requirements. 
 84.12     Subd. 2.  [EMPLOYER-SUBSIDIZED COVERAGE.] (a) To be 
 84.13  eligible for subsidized premium payments based on a sliding 
 84.14  scale, a family or individual must not have access to subsidized 
 84.15  health coverage through an employer, and must not have had 
 84.16  access to subsidized health coverage through an employer for the 
 84.17  12 months prior to application for subsidized coverage under 
 84.18  this chapter.  This requirement applies to situations in which 
 84.19  employer-subsidized coverage is lost due to an employer 
 84.20  terminating health care coverage as an employee benefit.  The 
 84.21  requirement that the family or individual must not have had 
 84.22  access to employer-subsidized coverage during the previous 12 
 84.23  months does not apply if: 
 84.24     (1) employer-subsidized coverage was lost because family 
 84.25  members no longer qualify as dependents for family coverage; or 
 84.26     (2) the family member who had access to employer-based 
 84.27  coverage is receiving unemployment compensation. 
 84.28     (b) For purposes of this requirement, subsidized health 
 84.29  coverage means health coverage for which the employer pays at 
 84.30  least 50 percent of the cost of coverage for the employee, 
 84.31  excluding dependent coverage.  For children, this requirement 
 84.32  applies to employer-subsidized coverage available through either 
 84.33  parent, including the noncustodial parent.  For purposes of this 
 84.34  subdivision, employer contributions to Internal Revenue Code 
 84.35  section 125 plans qualify as employer subsidies toward the cost 
 84.36  of health coverage for employees. 
 85.1      Subd. 3.  [PERIOD UNINSURED.] To be eligible for subsidized 
 85.2   premium payments based on a sliding scale, eligible enrollees 
 85.3   must have had no health coverage for at least four months prior 
 85.4   to application.  The requirement of at least four months of no 
 85.5   health coverage prior to application does not apply to: 
 85.6      (1) individuals currently serving or who have served in the 
 85.7   military reserves, and dependents of these individuals, if these 
 85.8   individuals: 
 85.9      (i) reapply for coverage under this chapter after a period 
 85.10  of active military service during which they had been covered by 
 85.11  the Civilian Health and Medical Program of the Uniformed 
 85.12  Services (CHAMPUS); 
 85.13     (ii) were covered under this chapter immediately prior to 
 85.14  obtaining coverage under CHAMPUS; and 
 85.15     (iii) have maintained continuous coverage; 
 85.16     (2) newborns born to a parent enrolled under this chapter. 
 85.17     Subd. 4.  [POST-SECONDARY STUDENTS.] Post-secondary 
 85.18  students who have health coverage or health services available 
 85.19  to them through an educational program or institution will be 
 85.20  considered to have access to other insurance coverage. 
 85.21     Sec. 8.  [256J.08] [COOPERATION IN ESTABLISHING PATERNITY, 
 85.22  CHILD SUPPORT, AND MEDICAL SUPPORT; FAMILIES AND INDIVIDUALS.] 
 85.23     Caretakers or children enrolled under this chapter must 
 85.24  assign to the state any rights to medical support or payments 
 85.25  for medical expenses from any other person or entity on their 
 85.26  own or their dependent's behalf.  Eligible enrollees must 
 85.27  cooperate with the state in establishing paternity of an 
 85.28  enrolled child and in obtaining child and medical support for 
 85.29  the child and any other person for whom the person can legally 
 85.30  assign rights, in accordance with applicable laws and rules 
 85.31  governing the child and medical support enforcement program.  If 
 85.32  an enrollee fails to cooperate without a finding of good cause 
 85.33  as defined by the commissioner, the enrollee and all members of 
 85.34  his or her family shall be ineligible under this chapter. 
 85.35     Sec. 9.  [256J.09] [THIRD PARTY LIABILITY.] 
 85.36     Subdivision 1.  [OTHER HEALTH COVERAGE.] Notwithstanding 
 86.1   any other law to the contrary, benefits under this chapter are 
 86.2   secondary to a plan of insurance or benefit program under which 
 86.3   an eligible person may have coverage. 
 86.4      Subd. 2.  [COOPERATION.] To be eligible under this chapter, 
 86.5   applicants and enrollees must cooperate with the state and local 
 86.6   agency or representative of the state, to identify potentially 
 86.7   liable third-party payers and assist the state in obtaining 
 86.8   third-party payments, unless good cause for noncooperation is 
 86.9   determined according to Code of Federal Regulations, title 42, 
 86.10  part 433.147.  "Cooperation" includes the following:  
 86.11  identifying any third party who may be liable for card and 
 86.12  services provided under this chapter to the applicant, enrollee, 
 86.13  or any other family member for whom application is made; 
 86.14  providing relevant information to assist the state in pursuing a 
 86.15  potentially liable third party; completing forms necessary to 
 86.16  recover third party payments; and paying to the agency any 
 86.17  support or medical care funds received that are covered by the 
 86.18  assignment of benefits.  Cooperation also includes providing 
 86.19  information about a group health plan for which the person may 
 86.20  be eligible and if there is no cost to the enrollee, they must 
 86.21  enroll or remain enrolled with the group.  Cost-effective 
 86.22  insurance premiums approved for payment by the state agency and 
 86.23  paid by the local agency are eligible for reimbursement 
 86.24  according to section 256B.19. 
 86.25     Sec. 10.  [256J.10] [PENDING ENROLLMENT.] 
 86.26     The commissioner shall develop a plan and present 
 86.27  recommendations to the 1997 legislature to address coverage of 
 86.28  and payment for services to eligible people for unexpected, 
 86.29  catastrophic events for a specified period prior to enrollment 
 86.30  under this chapter.  The plan will consider requiring health 
 86.31  delivery networks under contract to deliver other services under 
 86.32  this chapter to participate and may be based on payment of 
 86.33  either a fixed aggregate amount or a rate per person to the 
 86.34  networks. 
 86.35     Sec. 11.  [256J.11] [COVERAGE FOR INDIVIDUALS AND 
 86.36  FAMILIES.] 
 87.1      The commissioner shall purchase a package of health care 
 87.2   services on behalf of individuals and families who are eligible 
 87.3   under this chapter.  The package of health care services shall 
 87.4   be similar to health coverage offered to state employees.  The 
 87.5   package must cover the following services:  physician services, 
 87.6   including preventive services; inpatient services; outpatient 
 87.7   hospital and surgical center; emergency room; pharmacy; lab and 
 87.8   diagnostics; therapies, including physical therapy, occupational 
 87.9   therapy, speech and respiratory therapy; home health care; 
 87.10  emergency transportation; chiropractic care; mental health; 
 87.11  chemical dependency; durable medical equipment; vision care; 
 87.12  hearing aids and batteries; preventive dental services for 
 87.13  adults limited to oral exams, cleaning, fluoride, and x-rays, 
 87.14  and comprehensive dental services for children, except that 
 87.15  orthodontia is not covered. 
 87.16     Sec. 12.  [256J.12] [PURCHASING COVERAGE FOR FAMILIES AND 
 87.17  INDIVIDUALS.] 
 87.18     Subdivision 1.  [IN GENERAL.] The commissioner may request 
 87.19  proposals from public and private entities to deliver health 
 87.20  care services to individuals and families who are eligible under 
 87.21  this chapter.  The commissioner may contract, on a capitation 
 87.22  basis, with any or all responsible bidders to provide services 
 87.23  in a designated geographic area.  The bidding process may 
 87.24  include incentives for health care service delivery networks and 
 87.25  enrollees to minimize state costs.  Capitation payments may 
 87.26  incorporate a risk adjustment mechanism that adjusts payment for 
 87.27  the relative cost of enrollees based on the research required by 
 87.28  section 62Q.03, subdivision 5.  The commissioner may also 
 87.29  participate in public or private pools to provide coverage under 
 87.30  this chapter. 
 87.31     Subd. 2.  [REQUIREMENTS; ENROLLEES.] Individuals and 
 87.32  families who are eligible under this chapter must enroll in a 
 87.33  health care services delivery network and receive those services 
 87.34  through providers participating in their selected network, 
 87.35  except in the case of emergencies, when authorized by the 
 87.36  network, or otherwise required by law or contract.  If more than 
 88.1   one health care service delivery network is under contract in a 
 88.2   designated geographic area, enrollees shall have the right to 
 88.3   change to another network once within the first year of initial 
 88.4   enrollment and each year during an open enrollment period. 
 88.5      Subd. 3.  [REQUIREMENTS; HEALTH CARE SERVICE DELIVERY 
 88.6   NETWORKS.] The following requirements apply to all health care 
 88.7   service delivery networks.  Networks: 
 88.8      (1) shall accept, authorize, and arrange for the provision 
 88.9   of all medically necessary services listed in section 256J.09 
 88.10  according to the terms of the contract with the commissioner; 
 88.11     (2) shall accept the prospective, per capita payment from 
 88.12  the commissioner in return for the provision and coordination of 
 88.13  health care services for individuals and families enrolled in 
 88.14  the network; 
 88.15     (3) shall accept all eligible enrollees, without regard to 
 88.16  health status or previous utilization of health services; 
 88.17     (4) shall demonstrate capacity to accept financial risk 
 88.18  according to requirements specified in the contract with the 
 88.19  department; 
 88.20     (5) shall submit information as required by the contract, 
 88.21  including data required for the purpose of assessing consumer 
 88.22  satisfaction, quality of care, utilization, and cost of 
 88.23  services; 
 88.24     (6) shall demonstrate that its network is sufficient to 
 88.25  provide reasonable access to care within the designated 
 88.26  geographic area; and 
 88.27     (7) shall describe how it will provide culturally competent 
 88.28  services to enrollees who are members of minority groups. 
 88.29     Sec. 13.  [256J.13] [COVERAGE FOR INDIVIDUALS WITH 
 88.30  DISABILITIES AND FOR INDIVIDUALS AGE 65 AND OLDER.] 
 88.31     Subdivision 1.  [RECOMMENDATIONS.] The commissioner, in 
 88.32  collaboration with the commissioner of health, and with input 
 88.33  from counties, consumers, providers and payers of health and 
 88.34  continuing care services, shall develop recommendations for the 
 88.35  1997 legislature regarding the certification of eligibility and 
 88.36  the purchase of health and continuing care services for 
 89.1   individuals who are age 65 or older and for individuals who are 
 89.2   considered as disabled according to the supplemental security 
 89.3   income for aged, blind, and disabled under United States Code, 
 89.4   title 42, chapter 7, subchapter XVI. 
 89.5      Subd. 2.  [ELIGIBILITY.] The commissioner's recommendations 
 89.6   regarding eligibility under this chapter shall include the 
 89.7   following elements: 
 89.8      (1) an individual must be age 65 or older, or must be 
 89.9   considered to be disabled according to the supplemental security 
 89.10  income for aged, blind, and disabled under United States Code, 
 89.11  title 42, chapter 7, subchapter XVI; 
 89.12     (2) an individual must have income and assets under 
 89.13  established limits; and 
 89.14     (3) an individual must pay a premium. 
 89.15     Subd. 3.  [PURCHASING.] The commissioner's recommendations 
 89.16  shall include a plan by which all acute and continuing care 
 89.17  services are purchased comprehensively on a capitated basis, and 
 89.18  provided through health care service delivery networks that meet 
 89.19  the requirements of section 256B.77, subdivision 3.  This plan 
 89.20  will clearly set forth the conditions and requirements for any 
 89.21  contractor from which these comprehensive services can be 
 89.22  purchased.  The plan will attempt to ensure that there is a 
 89.23  reasonable number of competing service vendors to promote 
 89.24  competition, innovation, and choice.  The plan will also: 
 89.25     (1) provide opportunities for the widest possible variety 
 89.26  of public and private vendors of comprehensive services; 
 89.27     (2) provide opportunities for contractors to share 
 89.28  financial risk and reward; 
 89.29     (3) encourage the purchase of services for the broadest 
 89.30  possible groups of the elderly and disabled, based on the 
 89.31  functional and cognitive need, rather than diagnostic grouping; 
 89.32     (4) explicitly direct the purchase of services so as to 
 89.33  provide continuity and integration for enrollees across time and 
 89.34  service settings, and therefore to minimize possibilities for 
 89.35  costs to be inappropriately shifted to counties or other 
 89.36  providers and payers; 
 90.1      (5) require the strong contractual integration between 
 90.2   service providers and counties when the purchase of service 
 90.3   provision is not fully integrated, and when enrollees are 
 90.4   receiving services from multiple sources of public funding; 
 90.5      (6) differentiate clearly the public and private roles and 
 90.6   responsibilities in service delivery and quality improvement; 
 90.7      (7) when appropriate, provide for the regulatory 
 90.8   simplification of services and purchasing structures so as to 
 90.9   maximize flexibility and innovation in the provision of care, 
 90.10  reduce ineffective and onerous requirements for enrollees, 
 90.11  counties, and providers, and ensure clinical and satisfaction 
 90.12  outcomes that are meaningful to enrollees, and affordable within 
 90.13  available resources. 
 90.14     Subd. 4.  [CARE EXPECTATIONS.] The commissioner's 
 90.15  recommendations shall also include a description of care 
 90.16  expectations for individuals age 65 and older, and for 
 90.17  individuals who are certified as disabled.  These care 
 90.18  expectations shall be standards of care by which the 
 90.19  appropriateness of the care plan implemented by the health care 
 90.20  service delivery network may be evaluated.  The commissioner 
 90.21  shall also develop a list of possible services covered under the 
 90.22  contract with the health care service delivery network, but the 
 90.23  proposal shall not allow for entitlement to any particular 
 90.24  service, or any particular amount or frequency of service.  
 90.25  Instead, networks will be required to prepare and implement a 
 90.26  plan of care which utilizes covered services and allows for the 
 90.27  substitution of covered services, and which is reasonably 
 90.28  adequate to meet the care expectation for the client. 
 90.29     The commissioner will consider service utilization patterns 
 90.30  that might be more appropriate and cost-effective for Minnesota 
 90.31  residents, and integration of these assumptions into capitation 
 90.32  payment rates for continuing care services. 
 90.33     Subd. 5.  [LIVING EXPENSES.] The commissioner shall also 
 90.34  develop a proposal that may allow payment for living expenses 
 90.35  that is separate from the capitation payment for other health 
 90.36  care and continuing care services.  This proposal shall be 
 91.1   developed in order to provide appropriate incentives for 
 91.2   networks and enrollees to choose alternatives to institutional 
 91.3   settings.