1st Engrossment - 84th Legislature (2005 - 2006) Posted on 12/15/2009 12:00am
1.1 A bill for an act 1.2 relating to health care; modifying premium rate 1.3 restrictions; establishing expenditure limits; 1.4 modifying cost containment provisions; modifying 1.5 certain loan forgiveness programs; modifying medical 1.6 assistance, general assistance medical care, and 1.7 MinnesotaCare programs; requiring reports; 1.8 appropriating money; amending Minnesota Statutes 2004, 1.9 sections 62A.65, subdivision 3; 62D.12, subdivision 1.10 19; 62J.04, subdivision 3, by adding a subdivision; 1.11 62J.041; 62J.301, subdivision 3; 62J.38; 62J.692, 1.12 subdivision 3; 62L.08, subdivision 8; 144.1501, 1.13 subdivisions 2, 4; 256.045, subdivision 3a; 256.9693; 1.14 256B.0625, subdivision 3b, by adding a subdivision; 1.15 256B.0627, subdivisions 1, 4, 9; 256B.0631, by adding 1.16 a subdivision; 256D.03, subdivision 4; 256L.07, 1.17 subdivision 1; proposing coding for new law in 1.18 Minnesota Statutes, chapters 62J; 62Q; 256; 256B; 256L. 1.19 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MINNESOTA: 1.20 Section 1. Minnesota Statutes 2004, section 62A.65, 1.21 subdivision 3, is amended to read: 1.22 Subd. 3. [PREMIUM RATE RESTRICTIONS.] No individual health 1.23 plan may be offered, sold, issued, or renewed to a Minnesota 1.24 resident unless the premium rate charged is determined in 1.25 accordance with the following requirements: 1.26 (a) Premium rates must be no more than 25 percent above and 1.27 no more than 25 percent below the index rate charged to 1.28 individuals for the same or similar coverage, adjusted pro rata 1.29 for rating periods of less than one year. The premium 1.30 variations permitted by this paragraph must be based only upon 1.31 health status, claims experience, and occupation. For purposes 1.32 of this paragraph, health status includes refraining from 2.1 tobacco use or other actuarially valid lifestyle factors 2.2 associated with good health, provided that the lifestyle factor 2.3 and its effect upon premium rates have been determined by the 2.4 commissioner to be actuarially valid and have been approved by 2.5 the commissioner. Variations permitted under this paragraph 2.6 must not be based upon age or applied differently at different 2.7 ages. This paragraph does not prohibit use of a constant 2.8 percentage adjustment for factors permitted to be used under 2.9 this paragraph. 2.10 (b) Premium rates may vary based upon the ages of covered 2.11 persons only as provided in this paragraph. In addition to the 2.12 variation permitted under paragraph (a), each health carrier may 2.13 use an additional premium variation based upon age of up to plus 2.14 or minus 50 percent of the index rate. 2.15 (c) A health carrier may request approval by the 2.16 commissioner to establish no more than three geographic regions 2.17 and to establish separate index rates for each region, provided 2.18 that the index rates do not vary between any two regions by more 2.19 than 20 percent. Health carriers that do not do business in the 2.20 Minneapolis/St. Paul metropolitan area may request approval for 2.21 no more than two geographic regions, and clauses (2) and (3) do 2.22 not apply to approval of requests made by those health 2.23 carriers. The commissioner may grant approval if the following 2.24 conditions are met: 2.25 (1) the geographic regions must be applied uniformly by the 2.26 health carrier; 2.27 (2) one geographic region must be based on the 2.28 Minneapolis/St. Paul metropolitan area; 2.29 (3) for each geographic region that is rural, the index 2.30 rate for that region must not exceed the index rate for the 2.31 Minneapolis/St. Paul metropolitan area; and 2.32 (4) the health carrier provides actuarial justification 2.33 acceptable to the commissioner for the proposed geographic 2.34 variations in index rates, establishing that the variations are 2.35 based upon differences in the cost to the health carrier of 2.36 providing coverage. 3.1 (d) Health carriers may use rate cells and must file with 3.2 the commissioner the rate cells they use. Rate cells must be 3.3 based upon the number of adults or children covered under the 3.4 policy and may reflect the availability of Medicare coverage. 3.5 The rates for different rate cells must not in any way reflect 3.6 generalized differences in expected costs between principal 3.7 insureds and their spouses. 3.8 (e) In developing its index rates and premiums for a health 3.9 plan, a health carrier shall take into account only the 3.10 following factors: 3.11 (1) actuarially valid differences in rating factors 3.12 permitted under paragraphs (a) and (b); and 3.13 (2) actuarially valid geographic variations if approved by 3.14 the commissioner as provided in paragraph (c). 3.15 (f) All premium variations must be justified in initial 3.16 rate filings and upon request of the commissioner in rate 3.17 revision filings. All rate variations are subject to approval 3.18 by the commissioner. 3.19 (g) The loss ratio must comply with the section 62A.021 3.20 requirements for individual health plans. 3.21 (h) Notwithstanding paragraphs (a) to (g), the rates must 3.22 not be approved,unless the commissioner has determined that the 3.23 rates are reasonable. In determining reasonableness, the 3.24 commissioner shallconsider the growth rates applied under3.25section 62J.04, subdivision 1, paragraph (b)apply the premium 3.26 growth limits established under section 62J.04, subdivision 1b, 3.27 to the calendar year or years that the proposed premium rate 3.28 would be in effect, and shall consider actuarially valid changes 3.29 in risks associated with the enrollee populations,and 3.30 actuarially valid changes as a result of statutory changes in 3.31 Laws 1992, chapter 549. 3.32 Sec. 2. Minnesota Statutes 2004, section 62D.12, 3.33 subdivision 19, is amended to read: 3.34 Subd. 19. [COVERAGE OF SERVICE.] A health maintenance 3.35 organization may not deny or limit coverage of a service which 3.36 the enrollee has already received solely on the basis of lack of 4.1 prior authorization or second opinion, to the extent that the 4.2 service would otherwise have been covered under the member's 4.3 contract by the health maintenance organization had prior 4.4 authorization or second opinion been obtained. This subdivision 4.5 does not apply to prior authorization under chapter 256B, 256D, 4.6 or 256L. 4.7 Sec. 3. Minnesota Statutes 2004, section 62J.04, is 4.8 amended by adding a subdivision to read: 4.9 Subd. 1b. [PREMIUM GROWTH LIMITS.] (a) For calendar year 4.10 2005 and each year thereafter, the commissioner shall set annual 4.11 premium growth limits for health plan companies. The premium 4.12 limits set by the commissioner for calendar years 2005 to 2010 4.13 shall not exceed the regional Consumer Price Index for urban 4.14 consumers for the preceding calendar year plus two percentage 4.15 points and an additional one percentage point to be used to 4.16 finance the implementation of the electronic medical record 4.17 system described under section 62J.565. The commissioner shall 4.18 ensure that the additional percentage point is being used to 4.19 provide financial assistance to health care providers to 4.20 implement electronic medical record systems either directly or 4.21 through an increase in reimbursement. 4.22 (b) For the calendar years beyond 2010, the rate of premium 4.23 growth shall be limited to the change in the Consumer Price 4.24 Index for urban consumers for the previous calendar year plus 4.25 two percentage points. The commissioners of health and commerce 4.26 shall make a recommendation to the legislature by January 15, 4.27 2009, regarding the continuation of the additional percentage 4.28 point to the growth limit described in paragraph (a). The 4.29 recommendation shall be based on the progress made by health 4.30 care providers in instituting an electronic medical record 4.31 system and in creating a statewide interactive electronic health 4.32 record system. 4.33 (c) The commissioner may add additional percentage points 4.34 as needed to the premium limit for a calendar year if a major 4.35 disaster, bioterrorism, or a public health emergency occurs that 4.36 results in higher health care costs. Any additional percentage 5.1 points must reflect the additional cost to the health care 5.2 system directly attributed to the disaster or emergency. 5.3 (d) The commissioner shall publish the annual premium 5.4 growth limits in the State Register by January 31 of the year 5.5 that the limits are to be in effect. 5.6 (e) For the purpose of this subdivision, premium growth is 5.7 measured as the percentage change in per member, per month 5.8 premium revenue from the current year to the previous year. 5.9 Premium growth rates shall be calculated for the following lines 5.10 of business: individual, small group, and large group. Data 5.11 used for premium growth rate calculations shall be submitted as 5.12 part of the cost containment filing under section 62J.38. 5.13 (f) For purposes of this subdivision, "health plan company" 5.14 has the meaning given in section 62J.041. 5.15 (g) For coverage that is provided by a health plan company 5.16 under the terms of a contract with the Department of Employee 5.17 Relations, the commissioner of employee relations shall direct 5.18 the contracting health plan companies to reduce reimbursement to 5.19 providers in order to meet the premium growth limitations 5.20 required by this section. 5.21 Sec. 4. Minnesota Statutes 2004, section 62J.04, 5.22 subdivision 3, is amended to read: 5.23 Subd. 3. [COST CONTAINMENT DUTIES.] The commissioner shall: 5.24 (1) establish statewide and regional cost containment goals 5.25 for total health care spending under this section and collect 5.26 data as described in sections 62J.38 to 62J.41 to monitor 5.27 statewide achievement of the cost containment goals and premium 5.28 growth limits; 5.29 (2) divide the state into no fewer than four regions, with 5.30 one of those regions being the Minneapolis/St. Paul metropolitan 5.31 statistical area but excluding Chisago, Isanti, Wright, and 5.32 Sherburne Counties, for purposes of fostering the development of 5.33 regional health planning and coordination of health care 5.34 delivery among regional health care systems and working to 5.35 achieve the cost containment goals; 5.36 (3) monitor the quality of health care throughout the state 6.1 and take action as necessary to ensure an appropriate level of 6.2 quality; 6.3 (4) issue recommendations regarding uniform billing forms, 6.4 uniform electronic billing procedures and data interchanges, 6.5 patient identification cards, and other uniform claims and 6.6 administrative procedures for health care providers and private 6.7 and public sector payers. In developing the recommendations, 6.8 the commissioner shall review the work of the work group on 6.9 electronic data interchange (WEDI) and the American National 6.10 Standards Institute (ANSI) at the national level, and the work 6.11 being done at the state and local level. The commissioner may 6.12 adopt rules requiring the use of the Uniform Bill 82/92 form, 6.13 the National Council of Prescription Drug Providers (NCPDP) 3.2 6.14 electronic version, the Centers for Medicare and Medicaid 6.15 Services 1500 form, or other standardized forms or procedures; 6.16 (5) undertake health planning responsibilities; 6.17 (6) authorize, fund, or promote research and 6.18 experimentation on new technologies and health care procedures; 6.19 (7) within the limits of appropriations for these purposes, 6.20 administer or contract for statewide consumer education and 6.21 wellness programs that will improve the health of Minnesotans 6.22 and increase individual responsibility relating to personal 6.23 health and the delivery of health care services, undertake 6.24 prevention programs including initiatives to improve birth 6.25 outcomes, expand childhood immunization efforts, and provide 6.26 start-up grants for worksite wellness programs; 6.27 (8) undertake other activities to monitor and oversee the 6.28 delivery of health care services in Minnesota with the goal of 6.29 improving affordability, quality, and accessibility of health 6.30 care for all Minnesotans; and 6.31 (9) make the cost containment goal and premium growth limit 6.32 data available to the public in a consumer-oriented manner. 6.33 Sec. 5. Minnesota Statutes 2004, section 62J.041, is 6.34 amended to read: 6.35 62J.041 [INTERIMHEALTH PLAN COMPANYCOST CONTAINMENT GOALS6.36 HEALTH CARE EXPENDITURE LIMITS.] 7.1 Subdivision 1. [DEFINITIONS.] (a) For purposes of this 7.2 section, the following definitions apply. 7.3 (b) "Health plan company" has the definition provided in 7.4 section 62Q.01 and also includes employee health plans offered 7.5 by self-insured employers. 7.6 (c) "TotalHealth care expenditures" means incurred claims 7.7 or expenditures on health care services, administrative7.8expenses, charitable contributions, and all other paymentsmade 7.9 by health plan companiesout of premium revenues. 7.10 (d)"Net expenditures" means total expenditures minus7.11exempted taxes and assessments and payments or allocations made7.12to establish or maintain reserves.7.13(e) "Exempted taxes and assessments" means direct payments7.14for taxes to government agencies, contributions to the Minnesota7.15Comprehensive Health Association, the medical assistance7.16provider's surcharge under section 256.9657, the MinnesotaCare7.17provider tax under section 295.52, assessments by the Health7.18Coverage Reinsurance Association, assessments by the Minnesota7.19Life and Health Insurance Guaranty Association, assessments by7.20the Minnesota Risk Adjustment Association, and any new7.21assessments imposed by federal or state law.7.22(f)"Consumer cost-sharing or subscriber liability" means 7.23 enrollee coinsurance, co-payment, deductible payments, and 7.24 amounts in excess of benefit plan maximums. 7.25 Subd. 2. [ESTABLISHMENT.] The commissioner of health shall 7.26 establishcost containment goalshealth care expenditure limits 7.27 forthe increase in netcalendar year 2006, and each year 7.28 thereafter, for health care expenditures by each health plan 7.29 companyfor calendar years 1994, 1995, 1996, and 1997. The cost7.30containment goals must be the same as the annual cost7.31containment goals for health care spending established under7.32section 62J.04, subdivision 1, paragraph (b). Health plan 7.33 companies that are affiliates may elect to meet one 7.34 combinedcost containment goalhealth care expenditure limit. 7.35 The limits set by the commissioner shall not exceed the premium 7.36 limits established in section 62J.04, subdivision 1b. 8.1 Subd. 3. [DETERMINATION OF EXPENDITURES.] Health plan 8.2 companies shall submit to the commissioner of health, by April 8.31, 1994, for calendar year 1993; April 1, 1995, for calendar8.4year 1994; April 1, 1996, for calendar year 1995; April 1, 1997,8.5for calendar year 1996; and April 1, 1998, for calendar year8.61997of each year beginning 2006, all information the 8.7 commissioner determines to be necessary to implement this 8.8 section. The information must be submitted in the form 8.9 specified by the commissioner. The information must include, 8.10 but is not limited to, health care expenditures per member per 8.11 month or cost per employee per month, and detailed information 8.12 on revenues and reserves. The commissioner, to the extent 8.13 possible, shall coordinate the submittal of the information 8.14 required under this section with the submittal of the financial 8.15 data required under chapter 62J, to minimize the administrative 8.16 burden on health plan companies. The commissioner may adjust 8.17 final expenditure figures for demographic changes, risk 8.18 selection, changes in basic benefits, and legislative 8.19 initiatives that materially change health care costs, as long as 8.20 these adjustments are consistent with the methodology submitted 8.21 by the health plan company to the commissioner, and approved by 8.22 the commissioner as actuarially justified.The methodology to8.23be used for adjustments and the election to meet one cost8.24containment goal for affiliated health plan companies must be8.25submitted to the commissioner by September 1, 1994. Community8.26integrated service networks may submit the information with8.27their application for licensure. The commissioner shall also8.28accept changes to methodologies already submitted. The8.29adjustment methodology submitted and approved by the8.30commissioner must apply to the data submitted for calendar years8.311994 and 1995. The commissioner may allow changes to accepted8.32adjustment methodologies for data submitted for calendar years8.331996 and 1997. Changes to the adjustment methodology must be8.34received by September 1, 1996, and must be approved by the8.35commissioner.8.36 Subd. 4. [MONITORING OF RESERVES.] (a) The commissioners 9.1 of health and commerce shall monitor health plan company 9.2 reserves and net worth as established under chapters 60A, 62C, 9.3 62D, 62H, and 64B, with respect to the health plan companies 9.4 that each commissioner respectively regulates to assess the 9.5 degree to which savings resulting from the establishment of cost 9.6 containment goals are passed on to consumers in the form of 9.7 lower premium rates. 9.8 (b) Health plan companies shall fully reflect in the 9.9 premium rates the savings generated by the cost containment 9.10 goals. No premium rate, currently reviewed by the Department of 9.11 Health or Commerce, may be approved for those health plan 9.12 companies unless the health plan company establishes to the 9.13 satisfaction of the commissioner of commerce or the commissioner 9.14 of health, as appropriate, that the proposed new rate would 9.15 comply with this paragraph. 9.16 (c) Health plan companies, except those licensed under 9.17 chapter 60A to sell accident and sickness insurance under 9.18 chapter 62A, shall annually before the end of the fourth fiscal 9.19 quarter provide to the commissioner of health or commerce, as 9.20 applicable, a projection of the level of reserves the company 9.21 expects to attain during each quarter of the following fiscal 9.22 year. These health plan companies shall submit with required 9.23 quarterly financial statements a calculation of the actual 9.24 reserve level attained by the company at the end of each quarter 9.25 including identification of the sources of any significant 9.26 changes in the reserve level and an updated projection of the 9.27 level of reserves the health plan company expects to attain by 9.28 the end of the fiscal year. In cases where the health plan 9.29 company has been given a certificate to operate a new health 9.30 maintenance organization under chapter 62D, or been licensed as 9.31 a community integrated service network under chapter 62N, or 9.32 formed an affiliation with one of these organizations, the 9.33 health plan company shall also submit with its quarterly 9.34 financial statement, total enrollment at the beginning and end 9.35 of the quarter and enrollment changes within each service area 9.36 of the new organization. The reserve calculations shall be 10.1 maintained by the commissioners as trade secret information, 10.2 except to the extent that such information is also required to 10.3 be filed by another provision of state law and is not treated as 10.4 trade secret information under such other provisions. 10.5 (d) Health plan companies in paragraph (c) whose reserves 10.6 are less than the required minimum or more than the required 10.7 maximum at the end of the fiscal year shall submit a plan of 10.8 corrective action to the commissioner of health or commerce 10.9 under subdivision 7. 10.10 (e) The commissioner of commerce, in consultation with the 10.11 commissioner of health, shall report to the legislature no later 10.12 than January 15, 1995, as to whether the concept of a reserve 10.13 corridor or other mechanism for purposes of monitoring reserves 10.14 is adaptable for use with indemnity health insurers that do 10.15 business in multiple states and that must comply with their 10.16 domiciliary state's reserves requirements. 10.17 Subd. 5. [NOTICE.] The commissioner of health shall 10.18 publish in the State Register and make available to the public 10.19 by July 1,19952007, and each year thereafter, a list of all 10.20 health plan companies that exceeded theircost containment goal10.21 health care expenditure limit for the1994previous calendar 10.22 year.The commissioner shall publish in the State Register and10.23make available to the public by July 1, 1996, a list of all10.24health plan companies that exceeded their combined cost10.25containment goal for calendar years 1994 and 1995.The 10.26 commissioner shall notify each health plan company that the 10.27 commissioner has determined that the health plan company 10.28 exceeded itscost containment goal,health care expenditure 10.29 limit at least 30 days before publishing the list, and shall 10.30 provide each health plan companywithten days to provide an 10.31 explanation for exceeding thecost containment goalhealth care 10.32 expenditure limit. The commissioner shall review the 10.33 explanation and may change a determination if the commissioner 10.34 determines the explanation to be valid. 10.35 Subd. 6. [ASSISTANCE BY THE COMMISSIONER OF COMMERCE.] The 10.36 commissioner of commerce shall provide assistance to the 11.1 commissioner of health in monitoring health plan companies 11.2 regulated by the commissioner of commerce. 11.3 Sec. 6. [62J.255] [HEALTH RISK INFORMATION SHEET.] 11.4 (a) A health plan company shall provide to each enrollee on 11.5 an annual basis information on the increased personal health 11.6 risks and the additional costs to the health care system due to 11.7 obesity and to the use of tobacco. 11.8 (b) The commissioner, in consultation with the Minnesota 11.9 Medical Association, shall develop an information sheet on the 11.10 personal health risks of obesity and smoking and on the 11.11 additional costs to the health care system due to obesity and 11.12 due to smoking. The information sheet shall be posted on the 11.13 Minnesota Department of Health's Web site. 11.14 (c) When providing the information required in paragraph 11.15 (a), the health plan company must also provide each enrollee 11.16 with information on the best practices care guidelines and 11.17 quality of care measurement criteria identified in section 11.18 62J.43 as well as the availability of this information on the 11.19 department's Web site. 11.20 Sec. 7. Minnesota Statutes 2004, section 62J.301, 11.21 subdivision 3, is amended to read: 11.22 Subd. 3. [GENERAL DUTIES.] The commissioner shall: 11.23 (1) collect and maintain data which enable population-based 11.24 monitoring and trending of the access, utilization, quality, and 11.25 cost of health care services within Minnesota; 11.26 (2) collect and maintain data for the purpose of estimating 11.27 total Minnesota health care expenditures and trends; 11.28 (3) collect and maintain data for the purposes of setting 11.29 cost containment goals and premium growth limits under section 11.30 62J.04, and measuring cost containment goal and premium growth 11.31 limit compliance; 11.32 (4) conduct applied research using existing and new data 11.33 and promote applications based on existing research; 11.34 (5) develop and implement data collection procedures to 11.35 ensure a high level of cooperation from health care providers 11.36 and health plan companies, as defined in section 62Q.01, 12.1 subdivision 4; 12.2 (6) work closely with health plan companies and health care 12.3 providers to promote improvements in health care efficiency and 12.4 effectiveness; and 12.5 (7) participate as a partner or sponsor of private sector 12.6 initiatives that promote publicly disseminated applied research 12.7 on health care delivery, outcomes, costs, quality, and 12.8 management. 12.9 Sec. 8. Minnesota Statutes 2004, section 62J.38, is 12.10 amended to read: 12.11 62J.38 [COST CONTAINMENT DATA FROM GROUP PURCHASERS.] 12.12 (a) The commissioner shall require group purchasers to 12.13 submit detailed data on total health care spending for each 12.14 calendar year. Group purchasers shall submit data for the 1993 12.15 calendar year by April 1, 1994, and each April 1 thereafter 12.16 shall submit data for the preceding calendar year. 12.17 (b) The commissioner shall require each group purchaser to 12.18 submit data on revenue, expenses, and member months, as 12.19 applicable. Revenue data must distinguish between premium 12.20 revenue and revenue from other sources and must also include 12.21 information on the amount of revenue in reserves and changes in 12.22 reserves. Premium revenue data, information on aggregate 12.23 enrollment, and data on member months must be broken down to 12.24 distinguish between individual market, small group market, and 12.25 large group market. Filings under this section for calendar 12.26 year 2005 must also include information broken down by 12.27 individual market, small group market, and large group market 12.28 for calendar year 2004. Expenditure data must distinguish 12.29 between costs incurred for patient care and administrative 12.30 costs. Patient care and administrative costs must include only 12.31 expenses incurred on behalf of health plan members and must not 12.32 include the cost of providing health care services for 12.33 nonmembers at facilities owned by the group purchaser or 12.34 affiliate. Expenditure data must be provided separately for the 12.35 following categories and for other categories required by the 12.36 commissioner: physician services, dental services, other 13.1 professional services, inpatient hospital services, outpatient 13.2 hospital services, emergency, pharmacy services and other 13.3 nondurable medical goods, mental health, and chemical dependency 13.4 services, other expenditures, subscriber liability, and 13.5 administrative costs. Administrative costs must include costs 13.6 for marketing; advertising; overhead; salaries and benefits of 13.7 central office staff who do not provide direct patient care; 13.8 underwriting; lobbying; claims processing; provider contracting 13.9 and credentialing; detection and prevention of payment for 13.10 fraudulent or unjustified requests for reimbursement or 13.11 services; clinical quality assurance and other types of medical 13.12 care quality improvement efforts; concurrent or prospective 13.13 utilization review as defined in section 62M.02; costs incurred 13.14 to acquire a hospital, clinic, or health care facility, or the 13.15 assets thereof; capital costs incurred on behalf of a hospital 13.16 or clinic; lease payments; or any other costs incurred pursuant 13.17 to a partnership, joint venture, integration, or affiliation 13.18 agreement with a hospital, clinic, or other health care 13.19 provider. Capital costs and costs incurred must be recorded 13.20 according to standard accounting principles. The reports of 13.21 this data must also separately identify expenses for local, 13.22 state, and federal taxes, fees, and assessments. The 13.23 commissioner may require each group purchaser to submit any 13.24 other data, including data in unaggregated form, for the 13.25 purposes of developing spending estimates, setting spending 13.26 limits, and monitoring actual spending and costs. In addition 13.27 to reporting administrative costs incurred to acquire a 13.28 hospital, clinic, or health care facility, or the assets 13.29 thereof; or any other costs incurred pursuant to a partnership, 13.30 joint venture, integration, or affiliation agreement with a 13.31 hospital, clinic, or other health care provider; reports 13.32 submitted under this section also must include the payments made 13.33 during the calendar year for these purposes. The commissioner 13.34 shall make public, by group purchaser data collected under this 13.35 paragraph in accordance with section 62J.321, subdivision 5. 13.36 Workers' compensation insurance plans and automobile insurance 14.1 plans are exempt from complying with this paragraph as it 14.2 relates to the submission of administrative costs. 14.3 (c) The commissioner may collect information on: 14.4 (1) premiums, benefit levels, managed care procedures, and 14.5 other features of health plan companies; 14.6 (2) prices, provider experience, and other information for 14.7 services less commonly covered by insurance or for which 14.8 patients commonly face significant out-of-pocket expenses; and 14.9 (3) information on health care services not provided 14.10 through health plan companies, including information on prices, 14.11 costs, expenditures, and utilization. 14.12 (d) All group purchasers shall provide the required data 14.13 using a uniform format and uniform definitions, as prescribed by 14.14 the commissioner. 14.15 Sec. 9. Minnesota Statutes 2004, section 62J.692, 14.16 subdivision 3, is amended to read: 14.17 Subd. 3. [APPLICATION PROCESS.] (a) A clinical medical 14.18 education program conducted in Minnesota by a teaching 14.19 institution to train physicians, doctor of pharmacy 14.20 practitioners, dentists, chiropractors, or physician assistants 14.21 is eligible for funds under subdivision 4 if the program: 14.22 (1) is funded, in part, by patient care revenues; 14.23 (2) occurs in patient care settings that face increased 14.24 financial pressure as a result of competition with nonteaching 14.25 patient care entities; and 14.26 (3) emphasizes primary care or specialties that are in 14.27 undersupply in Minnesota. 14.28 A clinical medical education program that trains 14.29 pediatricians is requested to include in its program curriculum 14.30 training in case management and medication management for 14.31 children suffering from mental illness to be eligible for funds 14.32 under subdivision 4. 14.33 (b) A clinical medical education program for advanced 14.34 practice nursing is eligible for funds under subdivision 4 if 14.35 the program meets the eligibility requirements in paragraph (a), 14.36 clauses (1) to (3), and is sponsored by the University of 15.1 Minnesota Academic Health Center, the Mayo Foundation, or 15.2 institutions that are part of the Minnesota State Colleges and 15.3 Universities system or members of the Minnesota Private College 15.4 Council. 15.5 (c) Applications must be submitted to the commissioner by a 15.6 sponsoring institution on behalf of an eligible clinical medical 15.7 education program and must be received by October 31 of each 15.8 year for distribution in the following year. An application for 15.9 funds must contain the following information: 15.10 (1) the official name and address of the sponsoring 15.11 institution and the official name and site address of the 15.12 clinical medical education programs on whose behalf the 15.13 sponsoring institution is applying; 15.14 (2) the name, title, and business address of those persons 15.15 responsible for administering the funds; 15.16 (3) for each clinical medical education program for which 15.17 funds are being sought; the type and specialty orientation of 15.18 trainees in the program; the name, site address, and medical 15.19 assistance provider number of each training site used in the 15.20 program; the total number of trainees at each training site; and 15.21 the total number of eligible trainee FTEs at each site. Only 15.22 those training sites that host 0.5 FTE or more eligible trainees 15.23 for a program may be included in the program's application; and 15.24 (4) other supporting information the commissioner deems 15.25 necessary to determine program eligibility based on the criteria 15.26 in paragraphs (a) and (b) and to ensure the equitable 15.27 distribution of funds. 15.28 (d) An application must include the information specified 15.29 in clauses (1) to (3) for each clinical medical education 15.30 program on an annual basis for three consecutive years. After 15.31 that time, an application must include the information specified 15.32 in clauses (1) to (3) in the first year of each biennium: 15.33 (1) audited clinical training costs per trainee for each 15.34 clinical medical education program when available or estimates 15.35 of clinical training costs based on audited financial data; 15.36 (2) a description of current sources of funding for 16.1 clinical medical education costs, including a description and 16.2 dollar amount of all state and federal financial support, 16.3 including Medicare direct and indirect payments; and 16.4 (3) other revenue received for the purposes of clinical 16.5 training. 16.6 (e) An applicant that does not provide information 16.7 requested by the commissioner shall not be eligible for funds 16.8 for the current funding cycle. 16.9 Sec. 10. Minnesota Statutes 2004, section 62L.08, 16.10 subdivision 8, is amended to read: 16.11 Subd. 8. [FILING REQUIREMENT.] (a) No later than July 1, 16.12 1993, and each year thereafter, a health carrier that offers, 16.13 sells, issues, or renews a health benefit plan for small 16.14 employers shall file with the commissioner the index rates and 16.15 must demonstrate that all rates shall be within the rating 16.16 restrictions defined in this chapter. Such demonstration must 16.17 include the allowable range of rates from the index rates and a 16.18 description of how the health carrier intends to use demographic 16.19 factors including case characteristics in calculating the 16.20 premium rates. 16.21 (b) Notwithstanding paragraph (a), the rates shall not be 16.22 approved,unless the commissioner has determined that the rates 16.23 are reasonable. In determining reasonableness, the commissioner 16.24 shallconsider the growth rates applied under section 62J.04,16.25subdivision 1, paragraph (b)apply the premium growth limits 16.26 established under section 62J.04, subdivision 1b, to the 16.27 calendar year or years that the proposed premium rate would be 16.28 in effect, and shall consider actuarially valid changes in risk 16.29 associated with the enrollee population, and actuarially valid 16.30 changes as a result of statutory changes in Laws 1992, chapter 16.31 549.For premium rates proposed to go into effect between July16.321, 1993 and December 31, 1993, the pertinent growth rate is the16.33growth rate applied under section 62J.04, subdivision 1,16.34paragraph (b), to calendar year 1994.16.35 Sec. 11. [62Q.175] [COVERAGE EXEMPTIONS.] 16.36 Notwithstanding any law to the contrary, no health plan 17.1 company is required to provide coverage for any health care 17.2 service included on the list established under section 17.3 256B.0625, subdivision 46. 17.4 Sec. 12. Minnesota Statutes 2004, section 144.1501, 17.5 subdivision 2, is amended to read: 17.6 Subd. 2. [CREATION OF ACCOUNT.] (a) A health professional 17.7 education loan forgiveness program account is established. The 17.8 commissioner of health shall use money from the account to 17.9 establish a loan forgiveness program: 17.10 (1) for medical residents agreeing to practice in 17.11 designated rural areas or underserved urban communities,or 17.12 specializing in the area of pediatric psychiatry; 17.13 (2) for midlevel practitioners agreeing to practice in 17.14 designated rural areas,; and 17.15 (3) for nurses who agree to practice in a Minnesota nursing 17.16 home or intermediate care facility for persons with mental 17.17 retardation or related conditions. 17.18 (b) Appropriations made to the account do not cancel and 17.19 are available until expended, except that at the end of each 17.20 biennium, any remaining balance in the account that is not 17.21 committed by contract and not needed to fulfill existing 17.22 commitments shall cancel to the fund. 17.23 Sec. 13. Minnesota Statutes 2004, section 144.1501, 17.24 subdivision 4, is amended to read: 17.25 Subd. 4. [LOAN FORGIVENESS.] The commissioner of health 17.26 may select applicants each year for participation in the loan 17.27 forgiveness program, within the limits of available funding. The 17.28 commissioner shall distribute available funds for loan 17.29 forgiveness proportionally among the eligible professions 17.30 according to the vacancy rate for each profession in the 17.31 required geographic areaor, facility type, or specialty area 17.32 specified in subdivision 2. The commissioner shall allocate 17.33 funds for physician loan forgiveness so that7550 percent of 17.34 the funds available are used for rural physician loan 17.35 forgivenessand, 25 percent of the funds available are used for 17.36 underserved urban communities loan forgiveness, and 25 percent 18.1 of the funds available are used for pediatric psychiatry loan 18.2 forgiveness. If the commissioner does not receive enough 18.3 qualified applicants each year to use the entire allocation of 18.4 funds for urban underserved communities, the remaining funds may 18.5 be allocated for rural physician loan forgiveness. Applicants 18.6 are responsible for securing their own qualified educational 18.7 loans. The commissioner shall select participants based on 18.8 their suitability for practice serving the required geographic 18.9 areaor, facility type, or specialty area specified in 18.10 subdivision 2, as indicated by experience or training. The 18.11 commissioner shall give preference to applicants closest to 18.12 completing their training. For each year that a participant 18.13 meets the service obligation required under subdivision 3, up to 18.14 a maximum of four years, the commissioner shall make annual 18.15 disbursements directly to the participant equivalent to 15 18.16 percent of the average educational debt for indebted graduates 18.17 in their profession in the year closest to the applicant's 18.18 selection for which information is available, not to exceed the 18.19 balance of the participant's qualifying educational loans. 18.20 Before receiving loan repayment disbursements and as requested, 18.21 the participant must complete and return to the commissioner an 18.22 affidavit of practice form provided by the commissioner 18.23 verifying that the participant is practicing as required under 18.24 subdivisions 2 and 3. The participant must provide the 18.25 commissioner with verification that the full amount of loan 18.26 repayment disbursement received by the participant has been 18.27 applied toward the designated loans. After each disbursement, 18.28 verification must be received by the commissioner and approved 18.29 before the next loan repayment disbursement is made. 18.30 Participants who move their practice remain eligible for loan 18.31 repayment as long as they practice as required under subdivision 18.32 2. 18.33 Sec. 14. Minnesota Statutes 2004, section 256.045, 18.34 subdivision 3a, is amended to read: 18.35 Subd. 3a. [PREPAID HEALTH PLAN APPEALS.] (a) All prepaid 18.36 health plans under contract to the commissioner under chapter 19.1 256B or 256D must provide for a complaint system according to 19.2 section 62D.11. When a prepaid health plan denies, reduces, or 19.3 terminates a health service or denies a request to authorize a 19.4 previously authorized health service, the prepaid health plan 19.5 must notify the recipient of the right to file a complaint or an 19.6 appeal. The notice must include the name and telephone number 19.7 of the ombudsman and notice of the recipient's right to request 19.8 a hearing under paragraph (b). When a complaint is filed, the 19.9 prepaid health plan must notify the ombudsman within three 19.10 working days. Recipients may request the assistance of the 19.11 ombudsman in the complaint system process. The prepaid health 19.12 plan must issue a written resolution of the complaint to the 19.13 recipient within 30 days after the complaint is filed with the 19.14 prepaid health plan. A recipient is not required to exhaust the 19.15 complaint system procedures in order to request a hearing under 19.16 paragraph (b). 19.17 (b) Recipients enrolled in a prepaid health plan under 19.18 chapter 256B or 256D may contest a prepaid health plan's denial, 19.19 reduction, or termination of health services, a prepaid health 19.20 plan's denial of a request to authorize a previously authorized 19.21 health service, or the prepaid health plan's written resolution 19.22 of a complaint by submitting a written request for a hearing 19.23 according to subdivision 3. A state human services referee 19.24 shall conduct a hearing on the matter and shall recommend an 19.25 order to the commissioner of human services. The referee may 19.26 not overturn a decision on prior authorization for services 19.27 covered under section 28, if the prepaid health plan has 19.28 appropriately used evidence-based criteria or guidelines in 19.29 making the determination. The commissioner need not grant a 19.30 hearing if the sole issue raised by a recipient is the 19.31 commissioner's authority to require mandatory enrollment in a 19.32 prepaid health plan in a county where prepaid health plans are 19.33 under contract with the commissioner. The state human services 19.34 referee may order a second medical opinion from the prepaid 19.35 health plan or may order a second medical opinion from a 19.36 nonprepaid health plan provider at the expense of the prepaid 20.1 health plan. Recipients may request the assistance of the 20.2 ombudsman in the appeal process. 20.3 (c) In the written request for a hearing to appeal from a 20.4 prepaid health plan's denial, reduction, or termination of a 20.5 health service, a prepaid health plan's denial of a request to 20.6 authorize a previously authorized service, or the prepaid health 20.7 plan's written resolution to a complaint, a recipient may 20.8 request an expedited hearing. If an expedited appeal is 20.9 warranted, the state human services referee shall hear the 20.10 appeal and render a decision within a time commensurate with the 20.11 level of urgency involved, based on the individual circumstances 20.12 of the case. 20.13 Sec. 15. [256.9545] [PRESCRIPTION DRUG DISCOUNT PROGRAM.] 20.14 Subdivision 1. [ESTABLISHMENT; ADMINISTRATION.] The 20.15 commissioner shall establish and administer the prescription 20.16 drug discount program, effective July 1, 2005. 20.17 Subd. 2. [COMMISSIONER'S AUTHORITY.] The commissioner 20.18 shall administer a drug rebate program for drugs purchased 20.19 according to the prescription drug discount program. The 20.20 commissioner shall require a rebate agreement from all 20.21 manufacturers of covered drugs as defined in section 256B.0625, 20.22 subdivision 13. For each drug, the amount of the rebate shall 20.23 be equal to the rebate as defined for purposes of the federal 20.24 rebate program in United States Code, title 42, section 20.25 1396r-8. The rebate program shall utilize the terms and 20.26 conditions used for the federal rebate program established 20.27 according to section 1927 of title XIX of the federal Social 20.28 Security Act. 20.29 Subd. 3. [DEFINITIONS.] For the purpose of this section, 20.30 the following terms have the meanings given them. 20.31 (a) "Commissioner" means the commissioner of human services. 20.32 (b) "Manufacturer" means a manufacturer as defined in 20.33 section 151.44, paragraph (c). 20.34 (c) "Covered prescription drug" means a prescription drug 20.35 as defined in section 151.44, paragraph (d), that is covered 20.36 under medical assistance as described in section 256B.0625, 21.1 subdivision 13, and that is provided by a manufacturer that has 21.2 a fully executed rebate agreement with the commissioner under 21.3 this section and complies with that agreement. 21.4 (d) "Health carrier" means an insurance company licensed 21.5 under chapter 60A to offer, sell, or issue an individual or 21.6 group policy of accident and sickness insurance as defined in 21.7 section 62A.01; a nonprofit health service plan corporation 21.8 operating under chapter 62C; a health maintenance organization 21.9 operating under chapter 62D; a joint self-insurance employee 21.10 health plan operating under chapter 62H; a community integrated 21.11 systems network licensed under chapter 62N; a fraternal benefit 21.12 society operating under chapter 64B; a city, county, school 21.13 district, or other political subdivision providing self-insured 21.14 health coverage under section 471.617 or sections 471.98 to 21.15 471.982; and a self-funded health plan under the Employee 21.16 Retirement Income Security Act of 1974, as amended. 21.17 (e) "Participating pharmacy" means a pharmacy as defined in 21.18 section 151.01, subdivision 2, that agrees to participate in the 21.19 prescription drug discount program. 21.20 (f) "Enrolled individual" means a person who is eligible 21.21 for the program under subdivision 4 and has enrolled in the 21.22 program according to subdivision 5. 21.23 Subd. 4. [ELIGIBLE PERSONS.] To be eligible for the 21.24 program, an applicant must: 21.25 (1) be a permanent resident of Minnesota as defined in 21.26 section 256L.09, subdivision 4; 21.27 (2) not be enrolled in Medicare, medical assistance, 21.28 general assistance medical care, or MinnesotaCare; 21.29 (3) not be enrolled in and have currently available 21.30 prescription drug coverage under a health plan offered by a 21.31 health carrier or employer or under a pharmacy benefit program 21.32 offered by a pharmaceutical manufacturer; and 21.33 (4) not be enrolled in and have currently available 21.34 prescription drug coverage under a Medicare supplement plan, as 21.35 defined in sections 62A.31 to 62A.44, or policies, contracts, or 21.36 certificates that supplement Medicare issued by health 22.1 maintenance organizations or those policies, contracts, or 22.2 certificates governed by section 1833 or 1876 of the federal 22.3 Social Security Act, United States Code, title 42, section 1395, 22.4 et seq., as amended. 22.5 Subd. 5. [APPLICATION PROCEDURE.] (a) Applications and 22.6 information on the program must be made available at county 22.7 social services agencies, health care provider offices, and 22.8 agencies and organizations serving senior citizens. Individuals 22.9 shall submit applications and any information specified by the 22.10 commissioner as being necessary to verify eligibility directly 22.11 to the commissioner. The commissioner shall determine an 22.12 applicant's eligibility for the program within 30 days from the 22.13 date the application is received. Upon notice of approval, the 22.14 applicant must submit to the commissioner the enrollment fee 22.15 specified in subdivision 10. Eligibility begins the month after 22.16 the enrollment fee is received by the commissioner. 22.17 (b) An enrollee's eligibility must be renewed every 12 22.18 months with the 12-month period beginning in the month after the 22.19 application is approved. 22.20 (c) The commissioner shall develop an application form that 22.21 does not exceed one page in length and requires information 22.22 necessary to determine eligibility for the program. 22.23 Subd. 6. [PARTICIPATING PHARMACY.] According to a valid 22.24 prescription, a participating pharmacy must sell a covered 22.25 prescription drug to an enrolled individual at the pharmacy's 22.26 usual and customary retail price, minus an amount that is equal 22.27 to the rebate amount described in subdivision 8, plus the amount 22.28 of any switch fee established by the commissioner under 22.29 subdivision 10. Each participating pharmacy shall provide the 22.30 commissioner with all information necessary to administer the 22.31 program, including, but not limited to, information on 22.32 prescription drug sales to enrolled individuals and usual and 22.33 customary retail prices. 22.34 Subd. 7. [NOTIFICATION OF REBATE AMOUNT.] The commissioner 22.35 shall notify each drug manufacturer, each calendar quarter or 22.36 according to a schedule to be established by the commissioner, 23.1 of the amount of the rebate owed on the prescription drugs sold 23.2 by participating pharmacies to enrolled individuals. 23.3 Subd. 8. [PROVISION OF REBATE.] To the extent that a 23.4 manufacturer's prescription drugs are prescribed to a resident 23.5 of this state, the manufacturer must provide a rebate equal to 23.6 the rebate provided under the medical assistance program for any 23.7 prescription drug distributed by the manufacturer that is 23.8 purchased by an enrolled individual at a participating 23.9 pharmacy. The manufacturer must provide full payment within 30 23.10 days of receipt of the state invoice for the rebate, or 23.11 according to a schedule to be established by the commissioner. 23.12 The commissioner shall deposit all rebates received into the 23.13 Minnesota prescription drug dedicated fund established under 23.14 subdivision 11. The manufacturer must provide the commissioner 23.15 with any information necessary to verify the rebate determined 23.16 per drug. 23.17 Subd. 9. [PAYMENT TO PHARMACIES.] The commissioner shall 23.18 distribute on a biweekly basis an amount that is equal to an 23.19 amount collected under subdivision 8 to each participating 23.20 pharmacy based on the prescription drugs sold by that pharmacy 23.21 to enrolled individuals. 23.22 Subd. 10. [ENROLLMENT FEE; SWITCH FEE.] (a) The 23.23 commissioner shall establish an annual enrollment fee that 23.24 covers the commissioner's expenses for enrollment, processing 23.25 claims, and distributing rebates under this program. 23.26 (b) The commissioner shall establish a reasonable switch 23.27 fee that covers expenses incurred by pharmacies in formatting 23.28 for electronic submission claims for prescription drugs sold to 23.29 enrolled individuals. 23.30 Subd. 11. [DEDICATED FUND; CREATION; USE OF FUND.] (a) The 23.31 Minnesota prescription drug dedicated fund is established as an 23.32 account in the state treasury. The commissioner of finance 23.33 shall credit to the dedicated fund all rebates paid under 23.34 subdivision 8, any federal funds received for the program, all 23.35 enrollment fees paid by the enrollees, and any appropriations or 23.36 allocations designated for the fund. The commissioner of 24.1 finance shall ensure that fund money is invested under section 24.2 11A.25. All money earned by the fund must be credited to the 24.3 fund. The fund shall earn a proportionate share of the total 24.4 state annual investment income. 24.5 (b) Money in the fund is appropriated to the commissioner 24.6 to reimburse participating pharmacies for prescription drug 24.7 discounts provided to enrolled individuals under this section; 24.8 to reimburse the commissioner for costs related to enrollment, 24.9 processing claims, and distributing rebates and for other 24.10 reasonable administrative costs related to administration of the 24.11 prescription drug discount program; and to repay the 24.12 appropriation provided for this section. The commissioner must 24.13 administer the program so that the costs total no more than 24.14 funds appropriated plus the drug rebate proceeds. 24.15 Sec. 16. Minnesota Statutes 2004, section 256.9693, is 24.16 amended to read: 24.17 256.9693 [CONTINUING CARE PROGRAM FOR PERSONS WITH MENTAL 24.18 ILLNESS.] 24.19 The commissioner shall establish a continuing care benefit 24.20 program for persons with mental illness in which persons with 24.21 mental illness may obtain acute care hospital inpatient 24.22 treatment for mental illness for up to 45 days beyond that 24.23 allowed by section 256.969. Persons with mental illness who are 24.24 eligible for medical assistance or general assistance medical 24.25 care may obtain inpatient treatment under this program in 24.26 hospital beds for which the commissioner contracts under this 24.27 section. The commissioner may selectively contract with 24.28 hospitals to provide this benefit through competitive bidding 24.29 when reasonable geographic access by recipients can be assured. 24.30 Payments under this section shall not affect payments under 24.31 section 256.969. The commissioner may contract externally with 24.32 a utilization review organization to authorize persons with 24.33 mental illness to access the continuing care benefit program. 24.34 The commissioner, as part of the contracts with hospitals, shall 24.35 establish admission criteria to allow persons with mental 24.36 illness to access the continuing care benefit program. If a 25.1 court orders acute care hospital inpatient treatment for mental 25.2 illness for a person, the person may obtain the treatment under 25.3 the continuing care benefit program. The commissioner shall not 25.4 require, as part of the admission criteria, any commitment or 25.5 petition under chapter 253B as a condition of accessing the 25.6 program. This benefit is not available for people who are also 25.7 eligible for Medicare and who have not exhausted their annual or 25.8 lifetime inpatient psychiatric benefit under Medicare. If a 25.9 recipient is enrolled in a prepaid plan, this program is 25.10 included in the plan's coverage. 25.11 Sec. 17. Minnesota Statutes 2004, section 256B.0625, 25.12 subdivision 3b, is amended to read: 25.13 Subd. 3b. [TELEMEDICINE CONSULTATIONS.] Medical assistance 25.14 covers telemedicine consultations. Telemedicine consultations 25.15 must be made via two-way, interactive video or store-and-forward 25.16 technology. Store-and-forward technology includes telemedicine 25.17 consultations that do not occur in real time via synchronous 25.18 transmissions, and that do not require a face-to-face encounter 25.19 with the patient for all or any part of any such telemedicine 25.20 consultation. The patient record must include a written opinion 25.21 from the consulting physician providing the telemedicine 25.22 consultation. A communication between two physicians that 25.23 consists solely of a telephone conversation is not a 25.24 telemedicine consultation, unless the communication is between a 25.25 pediatrician and psychiatrist for the purpose of managing the 25.26 medications of a child with mental health needs. Coverage is 25.27 limited to three telemedicine consultations per recipient per 25.28 calendar week. Telemedicine consultations shall be paid at the 25.29 full allowable rate. 25.30 Sec. 18. Minnesota Statutes 2004, section 256B.0625, is 25.31 amended by adding a subdivision to read: 25.32 Subd. 46. [LIST OF HEALTH CARE SERVICES NOT ELIGIBLE FOR 25.33 COVERAGE.] (a) The commissioner of human services, in 25.34 consultation with the commissioner of health, shall biennially 25.35 establish a list of diagnosis/treatment pairings that are not 25.36 eligible for reimbursement under this chapter and chapters 256D 26.1 and 256L, effective for services provided on or after July 1, 26.2 2007. The commissioner shall review the list in effect for the 26.3 prior biennium and shall make any additions or deletions from 26.4 the list as appropriate, taking into consideration the following: 26.5 (1) scientific and medical information; 26.6 (2) clinical assessment; 26.7 (3) cost-effectiveness of treatment; 26.8 (4) prevention of future costs; and 26.9 (5) medical ineffectiveness. 26.10 (b) The commissioner may appoint an ad hoc advisory panel 26.11 made up of physicians, consumers, nurses, dentists, 26.12 chiropractors, and other experts to assist the commissioner in 26.13 reviewing and establishing the list. The commissioner shall 26.14 solicit comments and recommendations from any interested persons 26.15 and organizations and shall schedule at least one public hearing. 26.16 (c) The list must be established by January 15, 2007, for 26.17 the list effective July 1, 2007, and by October 1 of the 26.18 even-numbered years beginning October 1, 2008, for the lists 26.19 effective the following July 1. The commissioner shall publish 26.20 the list in the State Register by November 1 of the 26.21 even-numbered years beginning November 1, 2008. The list shall 26.22 be submitted to the legislature by January 15 of the 26.23 odd-numbered years beginning January 15, 2007. 26.24 Sec. 19. Minnesota Statutes 2004, section 256B.0627, 26.25 subdivision 1, is amended to read: 26.26 Subdivision 1. [DEFINITION.] (a) "Activities of daily 26.27 living" includes eating, toileting, grooming, dressing, bathing, 26.28 transferring, mobility, and positioning. 26.29 (b) "Assessment" means a review and evaluation of a 26.30 recipient's need for home care services conducted in person. 26.31 Assessments for private duty nursing shall be conducted by a 26.32 registered private duty nurse. Assessments for home health 26.33 agency services shall be conducted by a home health agency 26.34 nurse. Assessments for personal care assistant services shall 26.35 be conducted by the county public health nurse or a certified 26.36 public health nurse under contract with the county. A 27.1 face-to-face assessment must include: documentation of health 27.2 status, determination of need, evaluation of service 27.3 effectiveness, identification of appropriate services, service 27.4 plan development or modification, coordination of services, 27.5 referrals and follow-up to appropriate payers and community 27.6 resources, completion of required reports, recommendation of 27.7 service authorization, and consumer education. Once the need 27.8 for personal care assistant services is determined under this 27.9 section, the county public health nurse or certified public 27.10 health nurse under contract with the county is responsible for 27.11 communicating this recommendation to the commissioner and the 27.12 recipient. A face-to-face assessment for personal care 27.13 assistant services is conducted on those recipients who have 27.14 never had a county public health nurse assessment. A 27.15 face-to-face assessment must occur at least annually or when 27.16 there is a significant change in the recipient's condition or 27.17 when there is a change in the need for personal care assistant 27.18 services. A service update may substitute for the annual 27.19 face-to-face assessment when there is not a significant change 27.20 in recipient condition or a change in the need for personal care 27.21 assistant service. A service update or review for temporary 27.22 increase includes a review of initial baseline data, evaluation 27.23 of service effectiveness, redetermination of service need, 27.24 modification of service plan and appropriate referrals, update 27.25 of initial forms, obtaining service authorization, and on going 27.26 consumer education. Assessments for medical assistance home 27.27 care services for mental retardation or related conditions and 27.28 alternative care services for developmentally disabled home and 27.29 community-based waivered recipients may be conducted by the 27.30 county public health nurse to ensure coordination and avoid 27.31 duplication. Assessments must be completed on forms provided by 27.32 the commissioner within 30 days of a request for home care 27.33 services by a recipient or responsible party. Assessments shall 27.34 not be conducted by the same agency, individual, or organization 27.35 providing the care services. 27.36 (c) "Care plan" means a written description of personal 28.1 care assistant services developed by the qualified professional 28.2 or the recipient's physician with the recipient or responsible 28.3 party to be used by the personal care assistant with a copy 28.4 provided to the recipient or responsible party. 28.5 (d) "Complex and regular private duty nursing care" means: 28.6 (1) complex care is private duty nursing provided to 28.7 recipients who are ventilator dependent or for whom a physician 28.8 has certified that were it not for private duty nursing the 28.9 recipient would meet the criteria for inpatient hospital 28.10 intensive care unit (ICU) level of care; and 28.11 (2) regular care is private duty nursing provided to all 28.12 other recipients. 28.13 (e) "Health-related functions" means functions that can be 28.14 delegated or assigned by a licensed health care professional 28.15 under state law to be performed by a personal care attendant. 28.16 (f) "Home care services" means a health service, determined 28.17 by the commissioner as medically necessary, that is ordered by a 28.18 physician and documented in a service plan that is reviewed by 28.19 the physician at least once every 60 days for the provision of 28.20 home health services, or private duty nursing, or at least once 28.21 every 365 days for personal care. Home care services are 28.22 provided to the recipient at the recipient's residence that is a 28.23 place other than a hospital or long-term care facility or as 28.24 specified in section 256B.0625. 28.25 (g) "Instrumental activities of daily living" includes meal 28.26 planning and preparation, managing finances, shopping for food, 28.27 clothing, and other essential items, performing essential 28.28 household chores, communication by telephone and other media, 28.29 and getting around and participating in the community. 28.30 (h) "Medically necessary" has the meaning given in 28.31 Minnesota Rules, parts 9505.0170 to 9505.0475. 28.32 (i) "Personal care assistant" means a person who: 28.33 (1) is at least 18 years old, except for persons 16 to 18 28.34 years of age who participated in a related school-based job 28.35 training program or have completed a certified home health aide 28.36 competency evaluation; 29.1 (2) is able to effectively communicate with the recipient 29.2 and personal care provider organization; 29.3 (3) effective July 1, 1996, has completed one of the 29.4 training requirements as specified in Minnesota Rules, part 29.5 9505.0335, subpart 3, items A to D; 29.6 (4) has the ability to, and provides covered personal care 29.7 assistant services according to the recipient's care plan, 29.8 responds appropriately to recipient needs, and reports changes 29.9 in the recipient's condition to the supervising qualified 29.10 professional or physician; 29.11 (5) is not a consumer of personal care assistant services; 29.12 and 29.13 (6) is subject to criminal background checks and procedures 29.14 specified in chapter 245C. 29.15 (j) "Personal care provider organization" means an 29.16 organization enrolled to provide personal care assistant 29.17 services under the medical assistance program that complies with 29.18 the following: (1) owners who have a five percent interest or 29.19 more, and managerial officials are subject to a background study 29.20 as provided in chapter 245C. This applies to currently enrolled 29.21 personal care provider organizations and those agencies seeking 29.22 enrollment as a personal care provider organization. An 29.23 organization will be barred from enrollment if an owner or 29.24 managerial official of the organization has been convicted of a 29.25 crime specified in chapter 245C, or a comparable crime in 29.26 another jurisdiction, unless the owner or managerial official 29.27 meets the reconsideration criteria specified in chapter 245C; 29.28 (2) the organization must maintain a surety bond and liability 29.29 insurance throughout the duration of enrollment and provides 29.30 proof thereof. The insurer must notify the Department of Human 29.31 Services of the cancellation or lapse of policy; and (3) the 29.32 organization must maintain documentation of services as 29.33 specified in Minnesota Rules, part 9505.2175, subpart 7, as well 29.34 as evidence of compliance with personal care assistant training 29.35 requirements. 29.36 (k) "Responsible party" means an individual who is capable 30.1 of providing the support necessary to assist the recipient to 30.2 live in the community, is at least 18 years old, actively 30.3 participates in planning and directing of personal care 30.4 assistant services, and is not the personal care assistant. The 30.5 responsible party must be accessible to the recipient and the 30.6 personal care assistant when personal care services are being 30.7 provided and monitor the services at least weekly according to 30.8 the plan of care. The responsible party must be identified at 30.9 the time of assessment and listed on the recipient's service 30.10 agreement and care plan. Responsible parties who are parents of 30.11 minors or guardians of minors or incapacitated persons may 30.12 delegate the responsibility to another adultwho is not the30.13personal care assistantduring a temporary absence of at least 30.14 24 hours but not more than six months. The person delegated as 30.15 a responsible party must be able to meet the definition of 30.16 responsible party, except that the delegated responsible party 30.17 is required to reside with the recipient only while serving as 30.18 the responsible party. The responsible party must assure that 30.19 the delegate performs the functions of the responsible party, is 30.20 identified at the time of the assessment, and is listed on the 30.21 service agreement and the care plan. Foster care license 30.22 holders may be designated the responsible party for residents of 30.23 the foster care home if case management is provided as required 30.24 in section 256B.0625, subdivision 19a. For persons who, as of 30.25 April 1, 1992, are sharing personal care assistant services in 30.26 order to obtain the availability of 24-hour coverage, an 30.27 employee of the personal care provider organization may be 30.28 designated as the responsible party if case management is 30.29 provided as required in section 256B.0625, subdivision 19a. 30.30 (l) "Service plan" means a written description of the 30.31 services needed based on the assessment developed by the nurse 30.32 who conducts the assessment together with the recipient or 30.33 responsible party. The service plan shall include a description 30.34 of the covered home care services, frequency and duration of 30.35 services, and expected outcomes and goals. The recipient and 30.36 the provider chosen by the recipient or responsible party must 31.1 be given a copy of the completed service plan within 30 calendar 31.2 days of the request for home care services by the recipient or 31.3 responsible party. 31.4 (m) "Skilled nurse visits" are provided in a recipient's 31.5 residence under a plan of care or service plan that specifies a 31.6 level of care which the nurse is qualified to provide. These 31.7 services are: 31.8 (1) nursing services according to the written plan of care 31.9 or service plan and accepted standards of medical and nursing 31.10 practice in accordance with chapter 148; 31.11 (2) services which due to the recipient's medical condition 31.12 may only be safely and effectively provided by a registered 31.13 nurse or a licensed practical nurse; 31.14 (3) assessments performed only by a registered nurse; and 31.15 (4) teaching and training the recipient, the recipient's 31.16 family, or other caregivers requiring the skills of a registered 31.17 nurse or licensed practical nurse. 31.18 (n) "Telehomecare" means the use of telecommunications 31.19 technology by a home health care professional to deliver home 31.20 health care services, within the professional's scope of 31.21 practice, to a patient located at a site other than the site 31.22 where the practitioner is located. 31.23 Sec. 20. Minnesota Statutes 2004, section 256B.0627, 31.24 subdivision 4, is amended to read: 31.25 Subd. 4. [PERSONAL CARE ASSISTANT SERVICES.] (a) The 31.26 personal care assistant services that are eligible for payment 31.27 are services and supports furnished to an individual, as needed, 31.28 to assist in accomplishing activities of daily living; 31.29 instrumental activities of daily living; health-related 31.30 functions through hands-on assistance, supervision, and cuing; 31.31 and redirection and intervention for behavior including 31.32 observation and monitoring. 31.33 (b) Payment for services will be made within the limits 31.34 approved using the prior authorized process established in 31.35 subdivision 5. 31.36 (c) The amount and type of services authorized shall be 32.1 based on an assessment of the recipient's needs in these areas: 32.2 (1) bowel and bladder care; 32.3 (2) skin care to maintain the health of the skin; 32.4 (3) repetitive maintenance range of motion, muscle 32.5 strengthening exercises, and other tasks specific to maintaining 32.6 a recipient's optimal level of function; 32.7 (4) respiratory assistance; 32.8 (5) transfers and ambulation; 32.9 (6) bathing, grooming, and hairwashing necessary for 32.10 personal hygiene; 32.11 (7) turning and positioning; 32.12 (8) assistance with furnishing medication that is 32.13 self-administered; 32.14 (9) application and maintenance of prosthetics and 32.15 orthotics; 32.16 (10) cleaning medical equipment; 32.17 (11) dressing or undressing; 32.18 (12) assistance with eating and meal preparation and 32.19 necessary grocery shopping; 32.20 (13) accompanying a recipient to obtain medical diagnosis 32.21 or treatment; 32.22 (14) assisting, monitoring, or prompting the recipient to 32.23 complete the services in clauses (1) to (13); 32.24 (15) redirection, monitoring, and observation that are 32.25 medically necessary and an integral part of completing the 32.26 personal care assistant services described in clauses (1) to 32.27 (14); 32.28 (16) redirection and intervention for behavior, including 32.29 observation and monitoring; 32.30 (17) interventions for seizure disorders, including 32.31 monitoring and observation if the recipient has had a seizure 32.32 that requires intervention within the past three months; 32.33 (18) tracheostomy suctioning using a clean procedure if the 32.34 procedure is properly delegated by a registered nurse. Before 32.35 this procedure can be delegated to a personal care assistant, a 32.36 registered nurse must determine that the tracheostomy suctioning 33.1 can be accomplished utilizing a clean rather than a sterile 33.2 procedure and must ensure that the personal care assistant has 33.3 been taught the proper procedure; and 33.4 (19) incidental household services that are an integral 33.5 part of a personal care service described in clauses (1) to (18). 33.6 For purposes of this subdivision, monitoring and observation 33.7 means watching for outward visible signs that are likely to 33.8 occur and for which there is a covered personal care service or 33.9 an appropriate personal care intervention. For purposes of this 33.10 subdivision, a clean procedure refers to a procedure that 33.11 reduces the numbers of microorganisms or prevents or reduces the 33.12 transmission of microorganisms from one person or place to 33.13 another. A clean procedure may be used beginning 14 days after 33.14 insertion. 33.15 (d) The personal care assistant services that are not 33.16 eligible for payment are the following: 33.17 (1) services not ordered by the physician; 33.18 (2) assessments by personal care assistant provider 33.19 organizations or by independently enrolled registered nurses; 33.20 (3) services that are not in the service plan; 33.21 (4) services provided by the recipient's spouse, legal 33.22 guardian for an adult or child recipient, or parent of a 33.23 recipient under age 18; 33.24 (5) services provided by a foster care provider of a 33.25 recipient who cannot direct the recipient's own care, unless 33.26 monitored by a county or state case manager under section 33.27 256B.0625, subdivision 19a; 33.28 (6) services provided by the residential or program license 33.29 holder in a residence for more than four persons; 33.30 (7) services that are the responsibility of a residential 33.31 or program license holder under the terms of a service agreement 33.32 and administrative rules; 33.33 (8) sterile procedures; 33.34 (9) injections of fluids into veins, muscles, or skin; 33.35 (10) services provided by parents of adult recipients, 33.36 adult children, or siblings of the recipient, unless these 34.1 relatives meet one of the following hardship criteria and the 34.2 commissioner waives this requirement: 34.3 (i) the relative resigns from a part-time or full-time job 34.4 to provide personal care for the recipient; 34.5 (ii) the relative goes from a full-time to a part-time job 34.6 with less compensation to provide personal care for the 34.7 recipient; 34.8 (iii) the relative takes a leave of absence without pay to 34.9 provide personal care for the recipient; 34.10 (iv) the relative incurs substantial expenses by providing 34.11 personal care for the recipient; or 34.12 (v) because of labor conditions, special language needs, or 34.13 intermittent hours of care needed, the relative is needed in 34.14 order to provide an adequate number of qualified personal care 34.15 assistants to meet the medical needs of the recipient; 34.16 (11) homemaker services that are not an integral part of a 34.17 personal care assistant services; 34.18(11)(12) home maintenance or chore services; 34.19(12)(13) services not specified under paragraph (a); and 34.20(13)(14) services not authorized by the commissioner or 34.21 the commissioner's designee. 34.22 (e) The recipient or responsible party may choose to 34.23 supervise the personal care assistant or to have a qualified 34.24 professional, as defined in section 256B.0625, subdivision 19c, 34.25 provide the supervision. As required under section 256B.0625, 34.26 subdivision 19c, the county public health nurse, as a part of 34.27 the assessment, will assist the recipient or responsible party 34.28 to identify the most appropriate person to provide supervision 34.29 of the personal care assistant. Health-related delegated tasks 34.30 performed by the personal care assistant will be under the 34.31 supervision of a qualified professional or the direction of the 34.32 recipient's physician. If the recipient has a qualified 34.33 professional, Minnesota Rules, part 9505.0335, subpart 4, 34.34 applies. 34.35 (f) The commissioner shall establish an ongoing audit 34.36 process for potential fraud and abuse for personal care 35.1 assistant services. 35.2 Sec. 21. Minnesota Statutes 2004, section 256B.0627, 35.3 subdivision 9, is amended to read: 35.4 Subd. 9. [FLEXIBLE USE OF PERSONAL CARE ASSISTANT HOURS.] 35.5 (a) The commissioner may allow for the flexible use of personal 35.6 care assistant hours. "Flexible use" means the scheduled use of 35.7 authorized hours of personal care assistant services, which vary 35.8 within the length of the service authorization in order to more 35.9 effectively meet the needs and schedule of the recipient. 35.10 Recipients may use their approved hours flexibly within the 35.11 service authorization period for medically necessary covered 35.12 services specified in the assessment required in subdivision 1. 35.13 The flexible use of authorized hours does not increase the total 35.14 amount of authorized hours available to a recipient as 35.15 determined under subdivision 5. The commissioner shall not 35.16 authorize additional personal care assistant services to 35.17 supplement a service authorization that is exhausted before the 35.18 end date under a flexible service use plan, unless the county 35.19 public health nurse determines a change in condition and a need 35.20 for increased services is established. 35.21 (b) The recipient or responsible party, together with the 35.22 county public health nurse, shall determine whether flexible use 35.23 is an appropriate option based on the needs and preferences of 35.24 the recipient or responsible party, and, if appropriate, must 35.25 ensure that the allocation of hours covers the ongoing needs of 35.26 the recipient over the entire service authorization period. As 35.27 part of the assessment and service planning process, the 35.28 recipient or responsible party must work with the county public 35.29 health nurse to develop a written month-to-month plan of the 35.30 projected use of personal care assistant services that is part 35.31 of the service plan and ensures: 35.32 (1) that the health and safety needs of the recipient will 35.33 be met; 35.34 (2) that the total annual authorization will not exceed 35.35 before the end date; and 35.36 (3) how actual use of hours will be monitored. 36.1 (c) If the actual use of personal care assistant service 36.2 varies significantly from the use projected in the plan, the 36.3 written plan must be promptly updated by the recipient or 36.4 responsible party and the county public health nurse. 36.5 (d) The recipient or responsible party, together with the 36.6 provider, must work to monitor and document the use of 36.7 authorized hours and ensure that a recipient is able to manage 36.8 services effectively throughout the authorized period. The 36.9 provider must ensure that the month-to-month plan is 36.10 incorporated into the care plan. Upon request of the recipient 36.11 or responsible party, the provider must furnish regular updates 36.12 to the recipient or responsible party on the amount of personal 36.13 care assistant services used. 36.14 (e) The recipient or responsible party may revoke the 36.15 authorization for flexible use of hours by notifying the 36.16 provider and county public health nurse in writing. 36.17 (f) If the requirements in paragraphs (a) to (e) have not 36.18 substantially been met, the commissioner shall deny, revoke, or 36.19 suspend the authorization to use authorized hours flexibly. The 36.20 recipient or responsible party may appeal the commissioner's 36.21 action according to section 256.045. The denial, revocation, or 36.22 suspension to use the flexible hours option shall not affect the 36.23 recipient's authorized level of personal care assistant services 36.24 as determined under subdivision 5. 36.25 Sec. 22. Minnesota Statutes 2004, section 256B.0631, is 36.26 amended by adding a subdivision to read: 36.27 Subd. 5. [HEALTHY LIFESTYLE WAIVER.] The co-payments 36.28 described in subdivision 1 shall be waived by the provider if 36.29 the recipient is practicing a healthy lifestyle by refraining 36.30 from tobacco use or is participating in a smoking cessation 36.31 program. To obtain the waiver, the recipient must sign a 36.32 statement stating that the recipient does not use tobacco 36.33 products or is currently participating in a smoking cessation 36.34 program. The provider shall keep the signed statement on file. 36.35 Sec. 23. [256B.072] [PERFORMANCE REPORTING AND QUALITY 36.36 IMPROVEMENT PAYMENT SYSTEM.] 37.1 (a) The commissioner of human services shall establish a 37.2 performance reporting and payment system for health care 37.3 providers who provide health care services to public program 37.4 recipients covered under chapters 256B, 256D, and 256L. 37.5 (b) The measures used for the performance reporting and 37.6 payment system for medical groups or single-physician practices 37.7 shall include, but are not limited to, measures of care for 37.8 asthma, diabetes, hypertension, and coronary artery disease and 37.9 measures of preventive care services. The measures used for the 37.10 performance reporting and payment system for inpatient hospitals 37.11 shall include, but are not limited to, measures of care for 37.12 acute myocardial infarction, heart failure, and pneumonia, and 37.13 measures of care and prevention of surgical infections. In the 37.14 case of a medical group or single-physician practice, the 37.15 measures used shall be consistent with measures published by 37.16 nonprofit Minnesota or national organizations that produce and 37.17 disseminate health care quality measures or evidence-based 37.18 health care guidelines. In the case of inpatient hospital 37.19 measures, the commissioner shall appoint the Minnesota Hospital 37.20 Association and Stratis Health to develop the performance 37.21 measures to be used for hospital reporting. To enable a 37.22 consistent measurement process across the community, the 37.23 commissioner may use measures of care provided for patients in 37.24 addition to those identified in paragraph (a). The commissioner 37.25 shall ensure collaboration with other health care reporting 37.26 organizations so that the measures described in this section are 37.27 consistent with those reported by those organizations and used 37.28 by other purchasers in Minnesota. 37.29 (c) For recipients seen on or after January 1, 2007, the 37.30 commissioner shall provide a performance bonus payment to 37.31 providers who have achieved certain levels of performance 37.32 established by the commissioner with respect to the measures or 37.33 who have achieved certain rates of improvement established by 37.34 the commissioner with respect to the measures or whose rates of 37.35 achievement have increased over a previous period, as 37.36 established by the commissioner. The performance bonus payment 38.1 may be a fixed dollar amount per patient, paid quarterly or 38.2 annually, or alternatively payment may be made as a percentage 38.3 increase over payments allowed elsewhere in statute for the 38.4 recipients identified in paragraph (a). In order for providers 38.5 to be eligible for a performance bonus payment under this 38.6 section, the commissioner may require the providers to submit 38.7 information in a required format to a health care reporting 38.8 organization or to cooperate with the information collection 38.9 procedures of that organization. The commissioner may contract 38.10 with a reporting organization to assist with the collection of 38.11 reporting information and to prevent duplication of reporting. 38.12 The commissioner may limit application of the performance bonus 38.13 payment system to providers that provide a sufficiently large 38.14 volume of care to permit adequate statistical precision in the 38.15 measurement of that care, as established by the commissioner, 38.16 after consulting with other health care quality reporting 38.17 organizations. 38.18 (d) The performance bonus payments shall be funded with the 38.19 projected savings in the program costs due to improved results 38.20 of these measures with the eligible providers. 38.21 (e) The commissioner shall publish a description of the 38.22 proposed performance reporting and payment system for the 38.23 calendar year beginning January 1, 2007, and each subsequent 38.24 calendar year, at least three months prior to the beginning of 38.25 that calendar year. 38.26 (f) By April 1, 2007, and annually thereafter, the 38.27 commissioner shall report through a public Web site the results 38.28 by medical group, single-physician practice, and hospital of the 38.29 measures and the performance payments under this section, and 38.30 shall compare the results by medical group, single-physician 38.31 practice, and hospital for patients enrolled in public programs 38.32 to patients enrolled in private health plans. To achieve this 38.33 reporting, the commissioner may contract with a health care 38.34 reporting organization that operates a Web site suitable for 38.35 this purpose. 38.36 Sec. 24. [256B.0918] [EMPLOYEE SCHOLARSHIP COSTS AND 39.1 TRAINING IN ENGLISH AS A SECOND LANGUAGE.] 39.2 (a) For the fiscal year beginning July 1, 2005, the 39.3 commissioner shall provide to each provider listed in paragraph 39.4 (c) a scholarship reimbursement increase of two-tenths percent 39.5 of the reimbursement rate for that provider to be used: 39.6 (1) for employee scholarships that satisfy the following 39.7 requirements: 39.8 (i) scholarships are available to all employees who work an 39.9 average of at least 20 hours per week for the provider, except 39.10 administrators, department supervisors, and registered nurses; 39.11 and 39.12 (ii) the course of study is expected to lead to career 39.13 advancement with the provider or in long-term care, including 39.14 home care or care of persons with disabilities, including 39.15 medical care interpreter services and social work; and 39.16 (2) to provide job-related training in English as a second 39.17 language. 39.18 (b) A provider receiving a rate adjustment under this 39.19 subdivision with an annualized value of at least $1,000 shall 39.20 maintain documentation to be submitted to the commissioner on a 39.21 schedule determined by the commissioner and on a form supplied 39.22 by the commissioner of the scholarship rate increase received, 39.23 including: 39.24 (1) the amount received from this reimbursement increase; 39.25 (2) the amount used for training in English as a second 39.26 language; 39.27 (3) the number of persons receiving the training; 39.28 (4) the name of the person or entity providing the 39.29 training; and 39.30 (5) for each scholarship recipient, the name of the 39.31 recipient, the amount awarded, the educational institution 39.32 attended, the nature of the educational program, the program 39.33 completion date, and a determination of the amount spent as a 39.34 percentage of the provider's reimbursement. 39.35 The commissioner shall report to the legislature annually, 39.36 beginning January 15, 2006, with information on the use of these 40.1 funds. 40.2 (c) The rate increases described in this section shall be 40.3 provided to home and community-based waivered services for 40.4 persons with mental retardation or related conditions under 40.5 section 256B.501; home and community-based waivered services for 40.6 the elderly under section 256B.0915; waivered services under 40.7 community alternatives for disabled individuals under section 40.8 256B.49; community alternative care waivered services under 40.9 section 256B.49; traumatic brain injury waivered services under 40.10 section 256B.49; nursing services and home health services under 40.11 section 256B.0625, subdivision 6a; personal care services and 40.12 nursing supervision of personal care services under section 40.13 256B.0625, subdivision 19a; private duty nursing services under 40.14 section 256B.0625, subdivision 7; day training and habilitation 40.15 services for adults with mental retardation or related 40.16 conditions under sections 252.40 to 252.46; alternative care 40.17 services under section 256B.0913; adult residential program 40.18 grants under Minnesota Rules, parts 9535.2000 to 9535.3000; 40.19 semi-independent living services (SILS) under section 252.275, 40.20 including SILS funding under county social services grants 40.21 formerly funded under chapter 256I; community support services 40.22 for deaf and hard-of-hearing adults with mental illness who use 40.23 or wish to use sign language as their primary means of 40.24 communication; the group residential housing supplementary 40.25 service rate under section 256I.05, subdivision 1a; chemical 40.26 dependency residential and nonresidential service providers 40.27 under section 254B.03; and intermediate care facilities for 40.28 persons with mental retardation under section 256B.5012. 40.29 (d) These increases shall be included in the provider's 40.30 reimbursement rate for the purpose of determining future rates 40.31 for the provider. 40.32 Sec. 25. Minnesota Statutes 2004, section 256D.03, 40.33 subdivision 4, is amended to read: 40.34 Subd. 4. [GENERAL ASSISTANCE MEDICAL CARE; SERVICES.] 40.35 (a)(i) For a person who is eligible under subdivision 3, 40.36 paragraph (a), clause (2), item (i), general assistance medical 41.1 care covers, except as provided in paragraph (c): 41.2 (1) inpatient hospital services; 41.3 (2) outpatient hospital services; 41.4 (3) services provided by Medicare certified rehabilitation 41.5 agencies; 41.6 (4) prescription drugs and other products recommended 41.7 through the process established in section 256B.0625, 41.8 subdivision 13; 41.9 (5) equipment necessary to administer insulin and 41.10 diagnostic supplies and equipment for diabetics to monitor blood 41.11 sugar level; 41.12 (6) eyeglasses and eye examinations provided by a physician 41.13 or optometrist; 41.14 (7) hearing aids; 41.15 (8) prosthetic devices; 41.16 (9) laboratory and X-ray services; 41.17 (10) physician's services; 41.18 (11) medical transportation except special transportation; 41.19 (12) chiropractic services as covered under the medical 41.20 assistance program; 41.21 (13) podiatric services; 41.22 (14) dental services and dentures, subject to the 41.23 limitations specified in section 256B.0625, subdivision 9; 41.24 (15) outpatient services provided by a mental health center 41.25 or clinic that is under contract with the county board and is 41.26 established under section 245.62; 41.27 (16) day treatment services for mental illness provided 41.28 under contract with the county board; 41.29 (17) prescribed medications for persons who have been 41.30 diagnosed as mentally ill as necessary to prevent more 41.31 restrictive institutionalization; 41.32 (18) psychological services, medical supplies and 41.33 equipment, and Medicare premiums, coinsurance and deductible 41.34 payments; 41.35 (19) medical equipment not specifically listed in this 41.36 paragraph when the use of the equipment will prevent the need 42.1 for costlier services that are reimbursable under this 42.2 subdivision; 42.3 (20) services performed by a certified pediatric nurse 42.4 practitioner, a certified family nurse practitioner, a certified 42.5 adult nurse practitioner, a certified obstetric/gynecological 42.6 nurse practitioner, a certified neonatal nurse practitioner, or 42.7 a certified geriatric nurse practitioner in independent 42.8 practice, if (1) the service is otherwise covered under this 42.9 chapter as a physician service, (2) the service provided on an 42.10 inpatient basis is not included as part of the cost for 42.11 inpatient services included in the operating payment rate, and 42.12 (3) the service is within the scope of practice of the nurse 42.13 practitioner's license as a registered nurse, as defined in 42.14 section 148.171; 42.15 (21) services of a certified public health nurse or a 42.16 registered nurse practicing in a public health nursing clinic 42.17 that is a department of, or that operates under the direct 42.18 authority of, a unit of government, if the service is within the 42.19 scope of practice of the public health nurse's license as a 42.20 registered nurse, as defined in section 148.171; and 42.21 (22) telemedicine consultations, to the extent they are 42.22 covered under section 256B.0625, subdivision 3b. 42.23 (ii) Effective October 1, 2003, for a person who is 42.24 eligible under subdivision 3, paragraph (a), clause (2), item 42.25 (ii), general assistance medical care coverage is limited to 42.26 inpatient hospital services, including physician services 42.27 provided during the inpatient hospital stay. A $1,000 42.28 deductible is required for each inpatient hospitalization. 42.29 (b) Gender reassignment surgery and related services are 42.30 not covered services under this subdivision unless the 42.31 individual began receiving gender reassignment services prior to 42.32 July 1, 1995. 42.33 (c) In order to contain costs, the commissioner of human 42.34 services shall select vendors of medical care who can provide 42.35 the most economical care consistent with high medical standards 42.36 and shall where possible contract with organizations on a 43.1 prepaid capitation basis to provide these services. The 43.2 commissioner shall consider proposals by counties and vendors 43.3 for prepaid health plans, competitive bidding programs, block 43.4 grants, or other vendor payment mechanisms designed to provide 43.5 services in an economical manner or to control utilization, with 43.6 safeguards to ensure that necessary services are provided. 43.7 Before implementing prepaid programs in counties with a county 43.8 operated or affiliated public teaching hospital or a hospital or 43.9 clinic operated by the University of Minnesota, the commissioner 43.10 shall consider the risks the prepaid program creates for the 43.11 hospital and allow the county or hospital the opportunity to 43.12 participate in the program in a manner that reflects the risk of 43.13 adverse selection and the nature of the patients served by the 43.14 hospital, provided the terms of participation in the program are 43.15 competitive with the terms of other participants considering the 43.16 nature of the population served. Payment for services provided 43.17 pursuant to this subdivision shall be as provided to medical 43.18 assistance vendors of these services under sections 256B.02, 43.19 subdivision 8, and 256B.0625. For payments made during fiscal 43.20 year 1990 and later years, the commissioner shall consult with 43.21 an independent actuary in establishing prepayment rates, but 43.22 shall retain final control over the rate methodology. 43.23 (d) Recipients eligible under subdivision 3, paragraph (a), 43.24 clause (2), item (i), shall pay the following co-payments for 43.25 services provided on or after October 1, 2003: 43.26 (1) $3 per nonpreventive visit. For purposes of this 43.27 subdivision, a visit means an episode of service which is 43.28 required because of a recipient's symptoms, diagnosis, or 43.29 established illness, and which is delivered in an ambulatory 43.30 setting by a physician or physician ancillary, chiropractor, 43.31 podiatrist, nurse midwife, advanced practice nurse, audiologist, 43.32 optician, or optometrist; 43.33 (2) $25 for eyeglasses; 43.34 (3) $25 for nonemergency visits to a hospital-based 43.35 emergency room; 43.36 (4) $3 per brand-name drug prescription and $1 per generic 44.1 drug prescription, subject to a $20 per month maximum for 44.2 prescription drug co-payments. No co-payments shall apply to 44.3 antipsychotic drugs when used for the treatment of mental 44.4 illness; and 44.5 (5) 50 percent coinsurance on restorative dental services. 44.6 (e) Co-payments shall be limited to one per day per 44.7 provider for nonpreventive visits, eyeglasses, and nonemergency 44.8 visits to a hospital-based emergency room. Recipients of 44.9 general assistance medical care are responsible for all 44.10 co-payments in this subdivision. The general assistance medical 44.11 care reimbursement to the provider shall be reduced by the 44.12 amount of the co-payment, except that reimbursement for 44.13 prescription drugs shall not be reduced once a recipient has 44.14 reached the $20 per month maximum for prescription drug 44.15 co-payments. The provider collects the co-payment from the 44.16 recipient. Providers may not deny services to recipients who 44.17 are unable to pay the co-payment, except as provided in 44.18 paragraph (f). 44.19 (f) If it is the routine business practice of a provider to 44.20 refuse service to an individual with uncollected debt, the 44.21 provider may include uncollected co-payments under this 44.22 section. A provider must give advance notice to a recipient 44.23 with uncollected debt before services can be denied. 44.24 (g) The co-payments described in paragraph (d) shall be 44.25 waived by the provider if the recipient practices a healthy 44.26 lifestyle by refraining from tobacco use or is participating in 44.27 a smoking cessation program. To obtain the waiver, the 44.28 recipient must sign a statement stating that the recipient does 44.29 not use tobacco products or is currently participating in a 44.30 smoking cessation program. The provider shall keep the signed 44.31 statement on file. 44.32(g)(h) Any county may, from its own resources, provide 44.33 medical payments for which state payments are not made. 44.34(h)(i) Chemical dependency services that are reimbursed 44.35 under chapter 254B must not be reimbursed under general 44.36 assistance medical care. 45.1(i)(j) The maximum payment for new vendors enrolled in the 45.2 general assistance medical care program after the base year 45.3 shall be determined from the average usual and customary charge 45.4 of the same vendor type enrolled in the base year. 45.5(j)(k) The conditions of payment for services under this 45.6 subdivision are the same as the conditions specified in rules 45.7 adopted under chapter 256B governing the medical assistance 45.8 program, unless otherwise provided by statute or rule. 45.9(k)(l) Inpatient and outpatient payments shall be reduced 45.10 by five percent, effective July 1, 2003. This reduction is in 45.11 addition to the five percent reduction effective July 1, 2003, 45.12 and incorporated by reference in paragraph (i). 45.13(l)(m) Payments for all other health services except 45.14 inpatient, outpatient, and pharmacy services shall be reduced by 45.15 five percent, effective July 1, 2003. 45.16(m)(n) Payments to managed care plans shall be reduced by 45.17 five percent for services provided on or after October 1, 2003. 45.18(n)(o) A hospital receiving a reduced payment as a result 45.19 of this section may apply the unpaid balance toward satisfaction 45.20 of the hospital's bad debts. 45.21 Sec. 26. Minnesota Statutes 2004, section 256L.07, 45.22 subdivision 1, is amended to read: 45.23 Subdivision 1. [GENERAL REQUIREMENTS.] (a) Children 45.24 enrolled in the original children's health plan as of September 45.25 30, 1992, children who enrolled in the MinnesotaCare program 45.26 after September 30, 1992, pursuant to Laws 1992, chapter 549, 45.27 article 4, section 17, and children who have family gross 45.28 incomes that are equal to or less than 150 percent of the 45.29 federal poverty guidelines are eligible without meeting the 45.30 requirements of subdivision 2 and the four-month requirement in 45.31 subdivision 3, as long as they maintain continuous coverage in 45.32 the MinnesotaCare program or medical assistance. Children who 45.33 apply for MinnesotaCare on or after the implementation date of 45.34 the employer-subsidized health coverage program as described in 45.35 Laws 1998, chapter 407, article 5, section 45, who have family 45.36 gross incomes that are equal to or less than 150 percent of the 46.1 federal poverty guidelines, must meet the requirements of 46.2 subdivision 2 to be eligible for MinnesotaCare. 46.3 (b) Families enrolled in MinnesotaCare under section 46.4 256L.04, subdivision 1, whose income increases above 275 percent 46.5 of the federal poverty guidelines, are no longer eligible for 46.6 the program and shall be disenrolled by the commissioner. 46.7 Individuals enrolled in MinnesotaCare under section 256L.04, 46.8 subdivision 7, whose income increases above 175 percent of the 46.9 federal poverty guidelines are no longer eligible for the 46.10 program and shall be disenrolled by the commissioner. For 46.11 persons disenrolled under this subdivision, MinnesotaCare 46.12 coverage terminates the last day of the calendar month following 46.13 the month in which the commissioner determines that the income 46.14 of a family or individual exceeds program income limits. 46.15 (c)(1)Notwithstanding paragraph (b), individuals and 46.16 familiesenrolled in MinnesotaCare under section 256L.04,46.17subdivision 1,may remain enrolled in MinnesotaCare if ten 46.18 percent of their annual income is less than the annual premium 46.19 for a policy with a $500 deductible available through the 46.20 Minnesota Comprehensive Health Association. Individuals and 46.21 families who are no longer eligible for MinnesotaCare under this 46.22 subdivision shall be givenan 18-montha 12-month notice period 46.23 from the date that ineligibility is determined before 46.24 disenrollment.This clause expires February 1, 2004.46.25(2) Effective February 1, 2004, notwithstanding paragraph46.26(b), children may remain enrolled in MinnesotaCare if ten46.27percent of their annual family income is less than the annual46.28premium for a policy with a $500 deductible available through46.29the Minnesota Comprehensive Health Association. Children who46.30are no longer eligible for MinnesotaCare under this clause shall46.31be given a 12-month notice period from the date that46.32ineligibility is determined before disenrollment.The premium 46.33 forchildrenindividuals and families remaining eligible under 46.34 thisclauseparagraph shall be the maximum premium determined 46.35 under section 256L.15, subdivision 2, paragraph (b). 46.36 (d) Effective July 1, 2003, notwithstanding paragraphs (b) 47.1 and (c), parents are no longer eligible for MinnesotaCare if 47.2 gross household income exceeds $50,000. 47.3 Sec. 27. [256L.20] [MINNESOTACARE OPTION FOR SMALL 47.4 EMPLOYERS.] 47.5 Subdivision 1. [DEFINITIONS.] (a) For the purpose of this 47.6 section, the terms used have the meanings given them. 47.7 (b) "Dependent" means an unmarried child under 21 years of 47.8 age. 47.9 (c) "Eligible employer" means a business that employs at 47.10 least two, but not more than 50, eligible employees, the 47.11 majority of whom are employed in the state, and includes a 47.12 municipality that has 50 or fewer employees. 47.13 (d) "Eligible employee" means an employee who works at 47.14 least 20 hours per week for an eligible employer. Eligible 47.15 employee does not include an employee who works on a temporary 47.16 or substitute basis or who does not work more than 26 weeks 47.17 annually. 47.18 (e) "Maximum premium" has the meaning given under section 47.19 256L.15, subdivision 2, paragraph (b), clause (3). 47.20 (f) "Participating employer" means an eligible employer who 47.21 meets the requirements described in subdivision 3 and applies to 47.22 the commissioner to enroll its eligible employees and their 47.23 dependents in the MinnesotaCare program. 47.24 (g) "Program" means the MinnesotaCare program. 47.25 Subd. 2. [OPTION.] Eligible employees and their dependents 47.26 may enroll in MinnesotaCare if the eligible employer meets the 47.27 requirements of subdivision 3. The effective date of coverage 47.28 is according to section 256L.05, subdivision 3. 47.29 Subd. 3. [EMPLOYER REQUIREMENTS.] The commissioner shall 47.30 establish procedures for an eligible employer to apply for 47.31 coverage through the program. In order to participate, an 47.32 eligible employer must meet the following requirements: 47.33 (1) agrees to contribute toward the cost of the premium for 47.34 the employee and the employee's dependents according to 47.35 subdivision 4; 47.36 (2) certifies that at least 75 percent of its eligible 48.1 employees who do not have other creditable health coverage are 48.2 enrolled in the program; 48.3 (3) offers coverage to all eligible employees and the 48.4 dependents of eligible employees; and 48.5 (4) has not provided employer-subsidized health coverage as 48.6 an employee benefit during the previous 12 months, as defined in 48.7 section 256L.07, subdivision 2, paragraph (c). 48.8 Subd. 4. [PREMIUMS.] (a) The premium for MinnesotaCare 48.9 coverage provided under this section is equal to the maximum 48.10 premium regardless of the income of the eligible employee. 48.11 (b) For eligible employees without dependents with income 48.12 equal to or less than 175 percent of the federal poverty 48.13 guidelines and for eligible employees with dependents with 48.14 income equal to or less than 275 percent of the federal poverty 48.15 guidelines, the participating employer shall pay 50 percent of 48.16 the maximum premium for the eligible employee and any 48.17 dependents, if applicable. 48.18 (c) For eligible employees without dependents with income 48.19 over 175 percent of the federal poverty guidelines and for 48.20 eligible employees with dependents with income over 275 percent 48.21 of the federal poverty guidelines, the participating employer 48.22 shall pay the full cost of the maximum premium for the eligible 48.23 employee and any dependents, if applicable. The participating 48.24 employer may require the employee to pay a portion of the cost 48.25 of the premium so long as the employer pays 50 percent of the 48.26 cost. If the employer requires the employee to pay a portion of 48.27 the premium, the employee shall pay the portion of the cost to 48.28 the employer. 48.29 (d) The commissioner shall collect premium payments from 48.30 participating employers for eligible employees and their 48.31 dependents who are covered by the program as provided under this 48.32 section. All premiums collected shall be deposited in the 48.33 health care access fund. 48.34 Subd. 5. [COVERAGE.] The coverage offered to those 48.35 enrolled in the program under this section must include all 48.36 health services described under section 256L.03 and all 49.1 co-payments and coinsurance requirements described under section 49.2 256L.03, subdivision 5, apply. 49.3 Subd. 6. [ENROLLMENT.] Upon payment of the premium, in 49.4 accordance with this section and section 256L.06, eligible 49.5 employees and their dependents shall be enrolled in 49.6 MinnesotaCare. For purposes of enrollment under this section, 49.7 income eligibility limits established under sections 256L.04 and 49.8 256L.07, subdivision 1, and asset limits established under 49.9 section 256L.17 do not apply. The barriers established under 49.10 section 256L.07, subdivision 2 or 3, do not apply to enrollees 49.11 eligible under this section. The commissioner may require 49.12 eligible employees to provide income verification to determine 49.13 premiums. 49.14 Sec. 28. [LIMITING COVERAGE OF HEALTH CARE SERVICES FOR 49.15 MEDICAL ASSISTANCE, GENERAL ASSISTANCE MEDICAL CARE, AND 49.16 MINNESOTACARE PROGRAMS.] 49.17 Subdivision 1. [PRIOR AUTHORIZATION OF SERVICES.] (a) 49.18 Effective July 1, 2005, prior authorization is required for the 49.19 diagnosis/treatment pairings described in subdivision 2 for 49.20 reimbursement under Minnesota Statutes, chapters 256B, 256D, and 49.21 256L. 49.22 (b) This subdivision expires July 1, 2007, or when a list 49.23 is established according to Minnesota Statutes, section 49.24 256B.0625, subdivision 46, whichever is earlier. 49.25 Subd. 2. [SERVICES REQUIRING PRIOR AUTHORIZATION.] The 49.26 following services require prior authorization: 49.27 (1) obstetrical ultrasound; 49.28 (2) positive emission tomography (PET) scans; 49.29 (3) electronic beam computed tomography (EBCT); 49.30 (4) virtual colonoscopy; 49.31 (5) spinal fusion, unless in an emergency situation related 49.32 to trauma; 49.33 (6) bariatric surgery; and 49.34 (7) orthodontia. 49.35 Subd. 3. [SERVICES REQUIRING REVIEW BEFORE ADDITION TO 49.36 PUBLIC PROGRAMS BENEFIT SETS.] No new medical device, brand 50.1 drug, or medical procedure shall be included in the public 50.2 programs benefit sets under Minnesota Statutes, chapter 256B, 50.3 256D, or 256L, until a technology assessment has been completed 50.4 and the potential benefits are proven to outweigh the additional 50.5 costs of the new device, drug, or procedure. Technology 50.6 assessments by independent organizations with no conflict of 50.7 interest should be used in making these determinations. 50.8 Sec. 29. [TASK FORCE ON CHILDHOOD OBESITY.] 50.9 (a) The commissioner of health, in consultation with the 50.10 commissioners of human services and education, shall convene a 50.11 task force to study and make recommendations on reducing the 50.12 rate of obesity among the children in Minnesota. The task force 50.13 shall determine the number of children who are currently obese 50.14 and set a goal, including measurable outcomes for the state in 50.15 terms of reducing the rate of childhood obesity. The task force 50.16 shall make recommendations on how to achieve this goal, 50.17 including, but not limited to, increasing physical activities; 50.18 exploring opportunities to promote physical education and 50.19 healthy eating programs; improving the nutritional offerings 50.20 through breakfast and lunch menus; and evaluating the 50.21 availability and choice of nutritional products offered in 50.22 public schools. The members of the task force shall include 50.23 representatives of the Minnesota Medical Association; the 50.24 Minnesota Nurses Association; the Local Public Health 50.25 Association of Minnesota; the Minnesota Dietetic Association; 50.26 the Minnesota School Food Service Association; the Minnesota 50.27 Association of Health, Physical Education, Recreation, and 50.28 Dance; the Minnesota School Boards Association; the Minnesota 50.29 School Administrators Association; the Minnesota Secondary 50.30 Principals Association; the vending industry; and consumers. 50.31 The terms and compensation of the members of the task force 50.32 shall be in accordance with Minnesota Statutes, section 15.059, 50.33 subdivision 6. 50.34 (b) The commissioner must submit the recommendations of the 50.35 task force to the legislature by January 15, 2007. 50.36 Sec. 30. [IMPLEMENTATION OF AN ELECTRONIC HEALTH RECORDS 51.1 SYSTEM.] 51.2 The commissioner of health, in consultation with the 51.3 electronic health record planning work group established in Laws 51.4 2004, chapter 288, article 7, section 7, shall develop a 51.5 statewide plan for all hospitals and physician group practices 51.6 to have in place an interoperable electronic health records 51.7 system by January 1, 2015. In developing the plan, the 51.8 commissioner shall consider: 51.9 (1) creating financial assistance to hospitals and 51.10 providers for implementing or updating an electronic health 51.11 records system, including, but not limited to, the establishment 51.12 of grants, financial incentives, or low-interest loans; 51.13 (2) addressing specific needs and concerns of safety-net 51.14 hospitals, community health clinics, and other health care 51.15 providers who serve low-income patients in implementing an 51.16 electronic records system within the hospital or practice; and 51.17 (3) providing assistance in the development of possible 51.18 alliances or collaborations among providers. 51.19 The commissioner shall provide preliminary reports to the 51.20 chairs of the senate and house committees with jurisdiction over 51.21 health care policy and finance biennially beginning January 15, 51.22 2007, on the status of reaching the goal for all hospitals and 51.23 physician group practices to have an interoperable electronic 51.24 health records system in place by January 1, 2005. The reports 51.25 shall include recommendations on statutory language necessary to 51.26 implement the plan, including possible financing options. 51.27 Sec. 31. [APPROPRIATION.] 51.28 (a) $....... is appropriated for the biennium beginning 51.29 July 1, 2005, from the general fund to the Board of Trustees of 51.30 the Minnesota State Colleges and Universities for the nursing 51.31 and health care education plan designed to: 51.32 (1) expand the system's enrollment in registered nursing 51.33 education programs; 51.34 (2) support practical nursing programs in regions of high 51.35 need; 51.36 (3) address the shortage of nursing faculty; and 52.1 (4) provide accessible learning opportunities to students 52.2 through distance education and simulation experiences. 52.3 (b) $....... is appropriated for the biennium beginning 52.4 July 1, 2005, from the general fund to the commissioner of 52.5 health for the loan forgiveness program in Minnesota Statutes, 52.6 section 144.1501.