SF 3613

as introduced - 92nd Legislature (2021 - 2022) Posted on 04/05/2022 09:11am

A bill for an act
relating to human services; establishing pediatric home-based enteral nutrition
services as a covered service under medical assistance; amending Minnesota
Statutes 2020, sections 256B.0625, subdivision 32, by adding a subdivision;
256B.0651, subdivisions 1, 2; 256B.0652, subdivisions 2, 11, by adding a
subdivision; 256B.766; Minnesota Statutes 2021 Supplement, section 256B.0625,
subdivision 31; proposing coding for new law in Minnesota Statutes, chapter 256B.

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MINNESOTA:

Section 1.

Minnesota Statutes 2021 Supplement, section 256B.0625, subdivision 31, is
amended to read:

Subd. 31.

Medical supplies and equipment.

(a) Medical assistance covers medical
supplies and equipment. Separate payment outside of the facility's payment rate shall be
made for wheelchairs and wheelchair accessories for recipients who are residents of
intermediate care facilities for the developmentally disabled. Reimbursement for wheelchairs
and wheelchair accessories for ICF/DD recipients shall be subject to the same conditions
and limitations as coverage for recipients who do not reside in institutions. A wheelchair
purchased outside of the facility's payment rate is the property of the recipient.

(b) Vendors of durable medical equipment, prosthetics, orthotics, or medical supplies
must enroll as a Medicare provider.

(c) When necessary to ensure access to durable medical equipment, prosthetics, orthotics,
or medical supplies, the commissioner may exempt a vendor from the Medicare enrollment
requirement if:

(1) the vendor supplies only one type of durable medical equipment, prosthetic, orthotic,
or medical supply;

(2) the vendor serves ten or fewer medical assistance recipients per year;

(3) the commissioner finds that other vendors are not available to provide same or similar
durable medical equipment, prosthetics, orthotics, or medical supplies; and

(4) the vendor complies with all screening requirements in this chapter and Code of
Federal Regulations, title 42, part 455. The commissioner may also exempt a vendor from
the Medicare enrollment requirement if the vendor is accredited by a Centers for Medicare
and Medicaid Services approved national accreditation organization as complying with the
Medicare program's supplier and quality standards and the vendor serves primarily pediatric
patients.

(d) Durable medical equipment means a device or equipment that:

(1) can withstand repeated use;

(2) is generally not useful in the absence of an illness, injury, or disability; and

(3) is provided to correct or accommodate a physiological disorder or physical condition
or is generally used primarily for a medical purpose.

(e) Electronic tablets may be considered durable medical equipment if the electronic
tablet will be used as an augmentative and alternative communication system as defined
under subdivision 31a, paragraph (a). To be covered by medical assistance, the device must
be locked in order to prevent use not related to communication.

(f) Notwithstanding the requirement in paragraph (e) that an electronic tablet must be
locked to prevent use not as an augmentative communication device, a recipient of waiver
services may use an electronic tablet for a use not related to communication when the
recipient has been authorized under the waiver to receive one or more additional applications
that can be loaded onto the electronic tablet, such that allowing the additional use prevents
the purchase of a separate electronic tablet with waiver funds.

(g) An order or prescription for medical supplies, equipment, or appliances must meet
the requirements in Code of Federal Regulations, title 42, part 440.70.

(h) Allergen-reducing products provided according to subdivision 67, paragraph (c) or
(d), shall be considered durable medical equipment.

new text begin (i) Enteral nutrition and supplies provided according to subdivision 31d must not be
considered medical supplies and equipment under this subdivision.
new text end

Sec. 2.

Minnesota Statutes 2020, section 256B.0625, is amended by adding a subdivision
to read:

new text begin Subd. 31d. new text end

new text begin Pediatric home-based enteral nutrition services. new text end

new text begin Medical assistance covers
enteral nutrition, supplies, equipment, and services provided to patients 21 years of age or
younger receiving enteral nutrition in the patient's home residence and who are dependent
on a feeding tube for at least 75 percent of their nutritional needs. Pediatric home-based
enteral nutrition services must be provided according to the applicable requirements under
sections 256B.0651, 256B.0652, and 256B.066.
new text end

Sec. 3.

Minnesota Statutes 2020, section 256B.0625, subdivision 32, is amended to read:

Subd. 32.

Nutritional products.

new text begin (a) new text end Medical assistance covers nutritional products
needed for nutritional supplementation because solid food or nutrients thereof cannot be
properly absorbed by the body or needed for treatment of phenylketonuria, hyperlysinemia,
maple syrup urine disease, a combined allergy to human milk, cow's milk, and soy formula,
or any other childhood or adult diseases, conditions, or disorders identified by the
commissioner as requiring a similarly necessary nutritional product. Nutritional products
needed for the treatment of a combined allergy to human milk, cow's milk, and soy formula
require prior authorization.

new text begin (b) new text end Separate payment deleted text begin shall deleted text end new text begin must new text end not be made for nutritional products for residents of
long-term care facilities. Payment for dietary requirements is a component of the per diem
rate paid to these facilities.

new text begin (c) Separate payment must not be made for nutritional products included in the payment
rate for pediatric home-based enteral nutrition services.
new text end

Sec. 4.

Minnesota Statutes 2020, section 256B.0651, subdivision 1, is amended to read:

Subdivision 1.

Definitions.

(a) For the purposes of sections 256B.0651 to 256B.0654
and 256B.0659 new text begin to 256B.066 new text end , the terms in paragraphs (b) to (g) have the meanings given.

(b) "Activities of daily living" has the meaning given in section 256B.0659, subdivision
1, paragraph (b).

(c) "Assessment" means a review and evaluation of a recipient's need for home care
services conducted in person.

(d) "Home care services" means medical assistance covered services that are home health
agency services, including skilled nurse visits; home health aide visits; physical therapy,
occupational therapy, respiratory therapy, and language-speech pathology therapy; home
care nursing; deleted text begin and deleted text end personal care assistance new text begin ; and pediatric home-based enteral nutrition
services new text end .

(e) "Home residence," effective January 1, 2010, means a residence owned or rented by
the recipient either alone, with roommates of the recipient's choosing, or with an unpaid
responsible party or legal representative; or a family foster home where the license holder
lives with the recipient and is not paid to provide home care services for the recipient except
as allowed under sections 256B.0652, subdivision 10, and 256B.0654, subdivision 4.

(f) "Medically necessary" has the meaning given in Minnesota Rules, parts 9505.0170
to 9505.0475.

(g) "Ventilator-dependent" means an individual who receives mechanical ventilation
for life support at least six hours per day and is expected to be or has been dependent on a
ventilator for at least 30 consecutive days.

Sec. 5.

Minnesota Statutes 2020, section 256B.0651, subdivision 2, is amended to read:

Subd. 2.

Services covered.

Home care services covered under this section and sections
256B.0652 to 256B.0654 and 256B.0659 new text begin to 256B.066 new text end include:

(1) nursing services under sections 256B.0625, subdivision 6a, and 256B.0653;

(2) home care nursing services under sections 256B.0625, subdivision 7, and 256B.0654;

(3) home health services under sections 256B.0625, subdivision 6a, and 256B.0653;

(4) personal care assistance services under sections 256B.0625, subdivision 19a, and
256B.0659;

(5) supervision of personal care assistance services provided by a qualified professional
under sections 256B.0625, subdivision 19a, and 256B.0659;

(6) face-to-face assessments by county public health nurses for services under sections
256B.0625, subdivision 19a, and 256B.0659; deleted text begin and
deleted text end

(7) service updates and review of temporary increases for personal care assistance
services by the county public health nurse for services under sections 256B.0625, subdivision
19a, and 256B.0659 deleted text begin . deleted text end new text begin ; and
new text end

new text begin (8) pediatric home-based enteral nutrition services under sections 256B.0625, subdivision
31d, and 256B.066.
new text end

Sec. 6.

Minnesota Statutes 2020, section 256B.0652, subdivision 2, is amended to read:

Subd. 2.

Duties.

(a) The commissioner may contract with or employ necessary staff, or
contract with qualified agencies, to provide home care authorization and review services
for medical assistance recipients who are receiving home care services.

(b) Reimbursement for the authorization function shall be made through the medical
assistance administrative authority. The state shall pay the nonfederal share. The functions
will be to:

(1) assess the recipient's individual need for services required to be cared for safely in
the community;

(2) ensure that a care plan that meets the recipient's needs is developed by the appropriate
agency or individual;

(3) ensure cost-effectiveness and nonduplication of medical assistance home care services;

(4) recommend the approval or denial of the use of medical assistance funds to pay for
home care services;

(5) reassess the recipient's need for and level of home care services at a frequency
determined by the commissioner;

(6) conduct on-site assessments when determined necessary by the commissioner and
recommend changes to care plans that will provide more efficient and appropriate home
care; and

(7) on the department's website:

(i) provide a link to MinnesotaHelp.info for a list of enrolled home care agencies with
the following information: main office address, contact information for the agency, counties
in which services are provided, type of home care services provided, whether the personal
care assistance choice option is offered, types of qualified professionals employed, number
of personal care assistants employed, and data on staff turnover; and

(ii) post data on home care services including information from both fee-for-service and
managed care plans on recipients as available.

(c) In addition, the commissioner or the commissioner's designee may:

(1) review care plans, service plans, and reimbursement data for utilization of services
that exceed community-based standards for home care, inappropriate home care services,
medical necessity, home care services that do not meet quality of care standards, or
unauthorized services and make appropriate referrals within the department or to other
appropriate entities based on the findings;

(2) assist the recipient in obtaining services necessary to allow the recipient to remain
safely in or return to the community;

(3) coordinate home care services with other medical assistance services under section
256B.0625;

(4) assist the recipient with problems related to the provision of home care services;

(5) assure the quality of home care services; and

(6) assure that all liable third-party payers including, but not limited to, Medicare have
been used prior to medical assistance for home care services.

(d) For the purposes of this section, "home care services" means medical assistance
services defined under section 256B.0625, subdivisions 6a, 7, deleted text begin and deleted text end 19a new text begin , and 31d new text end .

Sec. 7.

Minnesota Statutes 2020, section 256B.0652, is amended by adding a subdivision
to read:

new text begin Subd. 6a. new text end

new text begin Authorization; pediatric home-based enteral nutrition services. new text end

new text begin All pediatric
home-based enteral nutrition services must be authorized by the commissioner or the
commissioner's designee. Authorization for pediatric home-based enteral nutrition services
must be based on medical necessity and cost-effectiveness when compared with alternative
care options. The commissioner must receive the request for authorization of pediatric
home-based enteral nutrition services within 20 working days of the start of service. The
commissioner may authorize medically necessary pediatric home-based enteral nutrition
services in monthly units. When authorizing pediatric home-based enteral nutrition services,
the commissioner or the commissioner's designee must determine to which tier the patient
should be assigned according to the definitions under section 256B.066. If the commissioner
or the commissioner's designee lacks sufficient information to determine to which tier a
patient should be assigned, the patient must be assigned to the lowest tier. Upon receipt of
information sufficient to reassign a patient to a higher tier, the commissioner or the
commissioner's designee must reassign the patient and within 30 days the commissioner
must modify the payment rates accordingly.
new text end

Sec. 8.

Minnesota Statutes 2020, section 256B.0652, subdivision 11, is amended to read:

Subd. 11.

Limits on services without authorization.

A recipient may receive the
following home care services during a calendar year:

(1) up to two face-to-face assessments to determine a recipient's need for personal care
assistance services;

(2) one service update done to determine a recipient's need for personal care assistance
services; deleted text begin and
deleted text end

(3) up to nine face-to-face skilled nurse visits deleted text begin . deleted text end new text begin ; and
new text end

new text begin (4) up to two months of pediatric home-based enteral nutrition services.
new text end

Sec. 9.

new text begin [256B.066] PEDIATRIC HOME-BASED ENTERAL NUTRITION SERVICES.
new text end

new text begin Subdivision 1. new text end

new text begin Definitions. new text end

new text begin (a) For the purposes of this section, the following terms have
the meanings given.
new text end

new text begin (b) "Base care rate" means the case rate for a patient ten years of age or younger.
new text end

new text begin (c) "Case rate" means the monthly bundled payment rate paid to a pediatric home-based
enteral nutrition services provider as reimbursement for all nutritional products, medical
supplies and equipment, and covered services provided to a patient receiving pediatric
home-based enteral nutrition services.
new text end

new text begin (d) "Pediatric patient" means a patient 21 years of age or younger.
new text end

new text begin (e) "Rate year" means January 1 to December 31.
new text end

new text begin (f) "Tier one patient" means a pediatric patient who is dependent on a feeding tube for
at least 75 percent of the patient's nutritional needs.
new text end

new text begin (g) "Tier two patient" means a pediatric patient who is dependent on a feeding tube for
at least 75 percent of the patient's nutritional needs and who has multiple diagnoses or
significantly higher needs than a tier one patient or is at risk of infections or complications.
new text end

new text begin Subd. 2. new text end

new text begin Pediatric home-based enteral nutrition services. new text end

new text begin (a) Pediatric home-based
enteral nutrition services include the provision of the following nutritional products and
medical supplies and equipment for tier one and tier two patients: formula, feeding tubes,
extension sets, dressings, tape, syringes, feeding sets, gravity bags, venting systems,
declogging agents, securement devices, food pumps, IV poles, and backpacks.
new text end

new text begin (b) Pediatric home-based enteral nutrition services include the provision of the following
services for tier one patients: patient intake, ordering, clinical set-up, clinical troubleshooting,
ongoing shipment or delivery of nutritional products and medical supplies and equipment,
equipment maintenance and management, and interpreter use.
new text end

new text begin (c) Pediatric home-based enteral nutrition services include the provision of the following
services for tier two patients: the services described in paragraph (b), clinical dietitian
assessments, clinical dietitian reassessments, clinical dietitian follow-up, and skilled nursing
for the purposes of supporting achievement of quality metrics under subdivision 4.
new text end

new text begin Subd. 3. new text end

new text begin Noncovered services. new text end

new text begin The following enteral nutrition, supplies, equipment,
and services are not eligible for payment under medical assistance as pediatric home-based
enteral nutrition services:
new text end

new text begin (1) those provided to patients 22 years of age or older; and
new text end

new text begin (2) those provided to a pediatric patient who does not meet the definition of a tier one
or tier two patient.
new text end

new text begin Subd. 4. new text end

new text begin Quality metrics. new text end

new text begin For the purposes of developing incentive programs under
subdivisions 7 and 8, in consultation with stakeholders, the commissioner must develop
methods to measure and report the following:
new text end

new text begin (1) care plan completion;
new text end

new text begin (2) clinical follow-up and assessments;
new text end

new text begin (3) tier two patients meeting their weight goals;
new text end

new text begin (4) triage prior to avoidable complications;
new text end

new text begin (5) avoidable emergency room visits;
new text end

new text begin (6) feeding tube site management and skin integrity;
new text end

new text begin (7) care coordination; and
new text end

new text begin (8) patient and caregiver satisfaction.
new text end

new text begin Subd. 5. new text end

new text begin Base case rates for pediatric home-based enteral nutrition services. new text end

new text begin (a) The
base case rate for tier one patients is $862 per patient per month.
new text end

new text begin (b) The base case rate for tier two patients is $1,083 per patient per month.
new text end

new text begin Subd. 6. new text end

new text begin Age-based case rate modifiers. new text end

new text begin (a) The age-based case rate modifier for patients
who are 11 or 12 years of age is $233 per patient per month.
new text end

new text begin (b) The age-based case rate modifier for patients who are 13 years of age or older is
$429 per patient per month.
new text end

new text begin Subd. 7. new text end

new text begin Quality metric reporting incentives. new text end

new text begin The commissioner must develop a quality
metric reporting incentive program in consultation with stakeholders. The annual funding
pool available for quality metric reporting incentive payments must be equal to three percent
of the estimated state expenditures during rate year 2023 for pediatric home-based enteral
nutrition services exclusive of any incentive payments. For services provided between
January 1, 2023, and December 31, 2025, providers of pediatric home-based enteral nutrition
services are eligible for quality metric reporting payments for meeting quality metric reporting
standards established by the commissioner.
new text end

new text begin Subd. 8. new text end

new text begin Quality improvement incentives. new text end

new text begin The commissioner must develop a quality
improvement incentive program in consultation with stakeholders. The annual funding pool
available for quality improvement incentive payments must be equal to three percent of the
estimated state expenditures during rate year 2026 for pediatric home-based enteral nutrition
services exclusive of any incentive payments. For services provided after January 1, 2026,
providers of pediatric home-based enteral nutrition services are eligible for quality
improvement payments for meeting quality improvement goals established by the
commissioner.
new text end

new text begin Subd. 9. new text end

new text begin Total payment rate. new text end

new text begin The total per-patient, per-month payment for pediatric
home-based enteral nutrition services is the sum of the base care rate, the age-based case
rate modifier, and any applicable incentive payment under subdivision 7 or 8.
new text end

Sec. 10.

Minnesota Statutes 2020, section 256B.766, is amended to read:

256B.766 REIMBURSEMENT FOR BASIC CARE SERVICES.

(a) Effective for services provided on or after July 1, 2009, total payments for basic care
services, shall be reduced by three percent, except that for the period July 1, 2009, through
June 30, 2011, total payments shall be reduced by 4.5 percent for the medical assistance
and general assistance medical care programs, prior to third-party liability and spenddown
calculation. Effective July 1, 2010, the commissioner shall classify physical therapy services,
occupational therapy services, and speech-language pathology and related services as basic
care services. The reduction in this paragraph shall apply to physical therapy services,
occupational therapy services, and speech-language pathology and related services provided
on or after July 1, 2010.

(b) Payments made to managed care plans and county-based purchasing plans shall be
reduced for services provided on or after October 1, 2009, to reflect the reduction effective
July 1, 2009, and payments made to the plans shall be reduced effective October 1, 2010,
to reflect the reduction effective July 1, 2010.

(c) Effective for services provided on or after September 1, 2011, through June 30, 2013,
total payments for outpatient hospital facility fees shall be reduced by five percent from the
rates in effect on August 31, 2011.

(d) Effective for services provided on or after September 1, 2011, through June 30, 2013,
total payments for ambulatory surgery centers facility fees, medical supplies and durable
medical equipment not subject to a volume purchase contract, prosthetics and orthotics,
renal dialysis services, laboratory services, public health nursing services, physical therapy
services, occupational therapy services, speech therapy services, eyeglasses not subject to
a volume purchase contract, hearing aids not subject to a volume purchase contract, and
anesthesia services shall be reduced by three percent from the rates in effect on August 31,
2011.

(e) Effective for services provided on or after September 1, 2014, payments for
ambulatory surgery centers facility fees, hospice services, renal dialysis services, laboratory
services, public health nursing services, eyeglasses not subject to a volume purchase contract,
and hearing aids not subject to a volume purchase contract shall be increased by three percent
and payments for outpatient hospital facility fees shall be increased by three percent.
Payments made to managed care plans and county-based purchasing plans shall not be
adjusted to reflect payments under this paragraph.

(f) Payments for medical supplies and durable medical equipment not subject to a volume
purchase contract, and prosthetics and orthotics, provided on or after July 1, 2014, through
June 30, 2015, shall be decreased by .33 percent. Payments for medical supplies and durable
medical equipment not subject to a volume purchase contract, and prosthetics and orthotics,
provided on or after July 1, 2015, shall be increased by three percent from the rates as
determined under paragraphs (i) and (j).

(g) Effective for services provided on or after July 1, 2015, payments for outpatient
hospital facility fees, medical supplies and durable medical equipment not subject to a
volume purchase contract, prosthetics, and orthotics to a hospital meeting the criteria specified
in section 62Q.19, subdivision 1, paragraph (a), clause (4), shall be increased by 90 percent
from the rates in effect on June 30, 2015. Payments made to managed care plans and
county-based purchasing plans shall not be adjusted to reflect payments under this paragraph.

(h) This section does not apply to physician and professional services, inpatient hospital
services, family planning services, mental health services, dental services, prescription
drugs, medical transportation, federally qualified health centers, rural health centers, Indian
health services, and Medicare cost-sharing.

(i) Effective for services provided on or after July 1, 2015, the following categories of
medical supplies and durable medical equipment shall be individually priced items: enteral
nutrition and supplies new text begin not included in the payment rate for pediatric home-based enteral
nutrition services under section 256B.0625, subdivision 31d new text end , customized and other specialized
tracheostomy tubes and supplies, electric patient lifts, and durable medical equipment repair
and service. This paragraph does not apply to medical supplies and durable medical
equipment subject to a volume purchase contract, products subject to the preferred diabetic
testing supply program, and items provided to dually eligible recipients when Medicare is
the primary payer for the item. The commissioner shall not apply any medical assistance
rate reductions to durable medical equipment as a result of Medicare competitive bidding.

(j) Effective for services provided on or after July 1, 2015, medical assistance payment
rates for durable medical equipment, prosthetics, orthotics, or supplies shall be increased
as follows:

(1) payment rates for durable medical equipment, prosthetics, orthotics, or supplies that
were subject to the Medicare competitive bid that took effect in January of 2009 shall be
increased by 9.5 percent; and

(2) payment rates for durable medical equipment, prosthetics, orthotics, or supplies on
the medical assistance fee schedule, whether or not subject to the Medicare competitive bid
that took effect in January of 2009, shall be increased by 2.94 percent, with this increase
being applied after calculation of any increased payment rate under clause (1).

This paragraph does not apply to medical supplies and durable medical equipment subject
to a volume purchase contract, products subject to the preferred diabetic testing supply
program, items provided to dually eligible recipients when Medicare is the primary payer
for the item, and individually priced items identified in paragraph (i). Payments made to
managed care plans and county-based purchasing plans shall not be adjusted to reflect the
rate increases in this paragraph.

(k) Effective for nonpressure support ventilators provided on or after January 1, 2016,
the rate shall be the lower of the submitted charge or the Medicare fee schedule rate. Effective
for pressure support ventilators provided on or after January 1, 2016, the rate shall be the
lower of the submitted charge or 47 percent above the Medicare fee schedule rate. For
payments made in accordance with this paragraph, if, and to the extent that, the commissioner
identifies that the state has received federal financial participation for ventilators in excess
of the amount allowed effective January 1, 2018, under United States Code, title 42, section
1396b(i)(27), the state shall repay the excess amount to the Centers for Medicare and
Medicaid Services with state funds and maintain the full payment rate under this paragraph.

(l) Payment rates for durable medical equipment, prosthetics, orthotics or supplies, that
are subject to the upper payment limit in accordance with section 1903(i)(27) of the Social
Security Act, shall be paid the Medicare rate. Rate increases provided in this chapter shall
not be applied to the items listed in this paragraph.