Office of the Revisor of Statutes
Minnesota Session Laws - 2000, Regular Session
Key: (1) language to be deleted (2) new language
CHAPTER 474-H.F.No. 3409
An act relating to human services; modifying
provisions in continuing care services for persons
with disabilities; amending Minnesota Statutes 1998,
sections 62D.09, subdivision 8; 252.28, by adding a
subdivision; and 256B.0625, subdivision 19a; Minnesota
Statutes 1999 Supplement, sections 62Q.73, subdivision
2; 245.462, subdivision 4; 245.4871, subdivision 4;
256B.0625, subdivision 19c; 256B.0627, subdivisions 1,
5, 8, and 11; 256B.501, subdivision 8a; 256B.5011,
subdivision 2; 256B.5013, subdivision 1, and by adding
subdivisions; and 256B.77, subdivision 8.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MINNESOTA:
Section 1. Minnesota Statutes 1998, section 62D.09,
subdivision 8, is amended to read:
Subd. 8. Each health maintenance organization shall issue
a membership card to its enrollees. The membership card must:
(1) identify the health maintenance organization;
(2) include the name, address, and telephone number to call
if the enrollee has a complaint;
(3) include the telephone number to call or the instruction
on how to receive authorization for emergency care; and
(4) include one of the following:
(i) the telephone number to call to appeal to or file a
complaint with the commissioner of health; or
(ii) for persons enrolled under section 256B.69, 256B.77,
256D.03, or 256L.12, the telephone number to call to file a
complaint with the ombudsperson designated by the commissioner
of human services under section 256B.69 or the office of the
ombudsman for mental health and mental retardation under section
256B.77 and the address to appeal to the commissioner of human
services. The ombudsperson shall annually provide the
commissioner of health with a summary of complaints and actions
taken.
Sec. 2. Minnesota Statutes 1999 Supplement, section
62Q.73, subdivision 2, is amended to read:
Subd. 2. [EXCEPTION.] (a) This section does not apply to
governmental programs except as permitted under paragraph (b).
For purposes of this subdivision, "governmental programs" means
the prepaid medical assistance program, the MinnesotaCare
program, the prepaid general assistance medical care
program, the demonstration project for people with disabilities,
and the federal Medicare program.
(b) In the course of a recipient's appeal of a medical
determination to the commissioner of human services under
section 256.045, the recipient may request an expert medical
opinion be arranged by the external review entity under contract
to provide independent external reviews under this section. If
such a request is made, the cost of the review shall be paid by
the commissioner of human services. Any medical opinion
obtained under this paragraph shall only be used by a state
human services referee as evidence in the recipient's appeal to
the commissioner of human services under section 256.045.
(c) Nothing in this subdivision shall be construed to limit
or restrict the appeal rights provided in section 256.045 for
governmental program recipients.
Sec. 3. Minnesota Statutes 1999 Supplement, section
245.462, subdivision 4, is amended to read:
Subd. 4. [CASE MANAGEMENT SERVICE PROVIDER.] (a) "Case
management service provider" means a case manager or case
manager associate employed by the county or other entity
authorized by the county board to provide case management
services specified in section 245.4711.
(b) A case manager must:
(1) be skilled in the process of identifying and assessing
a wide range of client needs;
(2) be knowledgeable about local community resources and
how to use those resources for the benefit of the client;
(3) have a bachelor's degree in one of the behavioral
sciences or related fields including, but not limited to, social
work, psychology, or nursing from an accredited college or
university. A case manager must have at least 2,000 hours of
supervised experience in the delivery of services to adults with
mental illness, must be skilled in the process of identifying
and assessing a wide range of client needs, and must be
knowledgeable about local community resources and how to use
those resources for the benefit of the client or meet the
requirements of paragraph (c); and
(4) meet the supervision and continuing education
requirements described in paragraphs (d), (e), and (f), as
applicable.
(b) Supervision for a case manager during the first year of
service providing case management services shall be one hour per
week of clinical supervision from a case management supervisor.
After the first year, the case manager shall receive regular
ongoing supervision totaling 38 hours per year, of which at
least one hour per month must be clinical supervision regarding
individual service delivery with a case management supervisor.
The remainder may be provided by a case manager with two years
of experience. Group supervision may not constitute more than
one-half of the required supervision hours. Clinical
supervision must be documented in the client record.
(c) A case manager with a bachelor's degree who is not
licensed, registered, or certified by a health-related licensing
board must receive 30 hours of continuing education and training
in mental illness and mental health services annually.
(d) A case manager with a bachelor's degree but without
2,000 hours of supervised experience described in paragraph (a),
must complete 40 hours of training approved by the commissioner
covering case management skills and the characteristics and
needs of adults with serious and persistent mental illness.
(e) (c) Case managers without a bachelor's degree must meet
one of the requirements in clauses (1) to (3):
(1) have three or four years of experience as a case
manager associate as defined in this section;
(2) be a registered nurse without a bachelor's degree and
have a combination of specialized training in psychiatry and
work experience consisting of community interaction and
involvement or community discharge planning in a mental health
setting totaling three years; or
(3) be a person who qualified as a case manager under the
1998 department of human service federal waiver provision and
meet the continuing education and mentoring requirements in this
section.
(d) A case manager with at least 2,000 hours of supervised
experience in the delivery of services to adults with mental
illness must receive regular ongoing supervision and clinical
supervision totaling 38 hours per year of which at least one
hour per month must be clinical supervision regarding individual
service delivery with a case management supervisor. The
remaining 26 hours of supervision may be provided by a case
manager with two years of experience. Group supervision may not
constitute more than one-half of the required supervision
hours. Clinical supervision must be documented in the client
record.
(e) A case manager without 2,000 hours of supervised
experience in the delivery of services to adults with mental
illness must:
(1) receive clinical supervision regarding individual
service delivery from a mental health professional at least one
hour per week until the requirement of 2,000 hours of experience
is met; and
(2) complete 40 hours of training approved by the
commissioner in case management skills and the characteristics
and needs of adults with serious and persistent mental illness.
(f) A case manager who is not licensed, registered, or
certified by a health-related licensing board must receive 30
hours of continuing education and training in mental illness and
mental health services annually.
(g) A case manager associate (CMA) must:
(1) work under the direction of a case manager or case
management supervisor and must;
(2) be at least 21 years of age. A case manager associate
must also;
(3) have at least a high school diploma or its equivalent;
and
(4) meet one of the following criteria:
(1) (i) have an associate of arts degree in one of the
behavioral sciences or human services;
(2) (ii) be a registered nurse without a bachelor's degree;
(3) (iii) within the previous ten years, have three years
of life experience with serious and persistent mental illness as
defined in section 245.462, subdivision 20; or as a child had
severe emotional disturbance as defined in section 245.4871,
subdivision 6; or have three years life experience as a primary
caregiver to an adult with serious and persistent mental illness
within the previous ten years;
(4) (iv) have 6,000 hours work experience as a nondegreed
state hospital technician; or
(5) (v) be a mental health practitioner as defined in
section 245.462, subdivision 17, clause (2).
Individuals meeting one of the criteria in clauses (1) to
(4) items (i) to (iv), may qualify as a case manager after four
years of supervised work experience as a case manager
associate. Individuals meeting the criteria in clause (5) item
(v), may qualify as a case manager after three years of
supervised experience as a case manager associate.
(h) A case management associates associate must meet the
following supervision, mentoring, and continuing education
requirements:
(1) have 40 hours of preservice training described under
paragraph (d) and (e), clause (2);
(2) receive at least 40 hours of continuing education in
mental illness and mental health services annually. Case
manager associates shall; and
(3) receive at least five hours of mentoring per week from
a case management mentor.
A "case management mentor" means a qualified, practicing case
manager or case management supervisor who teaches or advises and
provides intensive training and clinical supervision to one or
more case manager associates. Mentoring may occur while
providing direct services to consumers in the office or in the
field and may be provided to individuals or groups of case
manager associates. At least two mentoring hours per week must
be individual and face-to-face.
(g) (i) A case management supervisor must meet the criteria
for mental health professionals, as specified in section
245.462, subdivision 18.
(h) (j) An immigrant who does not have the qualifications
specified in this subdivision may provide case management
services to adult immigrants with serious and persistent mental
illness who are members of the same ethnic group as the case
manager if the person:
(1) is currently enrolled in and is actively pursuing
credits toward the completion of a bachelor's degree in one of
the behavioral sciences or a related field including, but not
limited to, social work, psychology, or nursing from an
accredited college or university;
(2) completes 40 hours of training as specified in this
subdivision; and
(3) receives clinical supervision at least once a week
until the requirements of this subdivision are met.
Sec. 4. Minnesota Statutes 1999 Supplement, section
245.4871, subdivision 4, is amended to read:
Subd. 4. [CASE MANAGEMENT SERVICE PROVIDER.] (a) "Case
management service provider" means a case manager or case
manager associate employed by the county or other entity
authorized by the county board to provide case management
services specified in subdivision 3 for the child with severe
emotional disturbance and the child's family. A case manager
must have experience and training in working with children.
(b) A case manager must:
(1) have experience and training in working with children;
(2) have at least a bachelor's degree in one of the
behavioral sciences or a related field including, but not
limited to, social work, psychology, or nursing from an
accredited college or university or meet the requirements of
paragraph (d);
(2) have at least 2,000 hours of supervised experience in
the delivery of mental health services to children;
(3) have experience and training in identifying and
assessing a wide range of children's needs; and
(4) be knowledgeable about local community resources and
how to use those resources for the benefit of children and their
families; and
(5) meets the supervision and continuing education
requirements of paragraphs (e), (f), and (g), as applicable.
(c) The A case manager may be a member of any professional
discipline that is part of the local system of care for children
established by the county board.
(d) A case manager without a bachelor's degree must meet
one of the requirements in clauses (1) to (3):
(1) have three or four years of experience as a case
manager associate;
(2) be a registered nurse without a bachelor's degree who
has a combination of specialized training in psychiatry and work
experience consisting of community interaction and involvement
or community discharge planning in a mental health setting
totaling three years; or
(3) be a person who qualified as a case manager under the
1998 department of human services waiver provision and meets the
continuing education, supervision, and mentoring requirements in
this section.
(e) The A case manager shall with at least 2,000 hours of
supervised experience in the delivery of mental health services
to children must receive regular ongoing supervision and
clinical supervision totaling 38 hours per year, of which at
least one hour per month must be clinical supervision regarding
individual service delivery with a case management supervisor.
The remainder other 26 hours of supervision may be provided by a
case manager with two years of experience. Group supervision
may not constitute more than one-half of the required
supervision hours.
(e) (f) A case managers with a bachelor's degree
but manager without 2,000 hours of supervised experience in the
delivery of mental health services to children with emotional
disturbance must:
(1) begin 40 hours of training approved by the commissioner
of human services in case management skills and in the
characteristics and needs of children with severe emotional
disturbance before beginning to provide case management
services; and
(2) receive clinical supervision regarding individual
service delivery from a mental health professional at least one
hour each week until the requirement of 2,000 hours of
experience is met.
(g) A case manager who is not licensed, registered, or
certified by a health-related licensing board must receive 30
hours of continuing education and training in severe emotional
disturbance and mental health services annually.
(f) (h) Clinical supervision must be documented in the
child's record. When the case manager is not a mental health
professional, the county board must provide or contract for
needed clinical supervision.
(g) (i) The county board must ensure that the case manager
has the freedom to access and coordinate the services within the
local system of care that are needed by the child.
(h) Case managers who have a bachelor's degree but are not
licensed, registered, or certified by a health-related licensing
board must receive 30 hours of continuing education and training
in severe emotional disturbance and mental health services
annually.
(i) Case managers without a bachelor's degree must meet one
of the requirements in clauses (1) to (3):
(1) have three or four years of experience as a case
manager associate;
(2) be a registered nurse without a bachelor's degree who
has a combination of specialized training in psychiatry and work
experience consisting of community interaction and involvement
or community discharge planning in a mental health setting
totaling three years; or
(3) be a person who qualified as a case manager under the
1998 department of human service federal waiver provision and
meets the continuing education and mentoring requirements in
this section.
(j) A case manager associate (CMA) must:
(1) work under the direction of a case manager or case
management supervisor and must;
(2) be at least 21 years of age. A case manager associate
must also;
(3) have at least a high school diploma or its equivalent;
and
(4) meet one of the following criteria:
(1) (i) have an associate of arts degree in one of the
behavioral sciences or human services;
(2) (ii) be a registered nurse without a bachelor's degree;
(3) (iii) have three years of life experience as a primary
caregiver to a child with serious emotional disturbance as
defined in section 245.4871, subdivision 6, within the previous
ten years;
(4) (iv) have 6,000 hours work experience as a nondegreed
state hospital technician; or
(5) (v) be a mental health practitioner as defined in
section 245.462, subdivision 17 26, clause (2).
Individuals meeting one of the criteria in clauses
(1) items (i) to (4) (iv) may qualify as a case manager after
four years of supervised work experience as a case manager
associate. Individuals meeting the criteria in clause (5) item
(v) may qualify as a case manager after three years of
supervised experience as a case manager associate.
(k) Case manager associates must meet the following
supervision, mentoring, and continuing education requirements;
(1) have 40 hours of preservice training described under
paragraph (e) (f), clause (1), and;
(2) receive at least 40 hours of continuing education in
severe emotional disturbance and mental health service
annually. Case manager associates shall; and
(3) receive at least five hours of mentoring per week from
a case management mentor. A "case management mentor" means a
qualified, practicing case manager or case management supervisor
who teaches or advises and provides intensive training and
clinical supervision to one or more case manager associates.
Mentoring may occur while providing direct services to consumers
in the office or in the field and may be provided to individuals
or groups of case manager associates. At least two mentoring
hours per week must be individual and face-to-face.
(k) (l) A case management supervisor must meet the criteria
for a mental health professional as specified in section
245.4871, subdivision 27.
(l) (m) An immigrant who does not have the qualifications
specified in this subdivision may provide case management
services to child immigrants with severe emotional disturbance
of the same ethnic group as the immigrant if the person:
(1) is currently enrolled in and is actively pursuing
credits toward the completion of a bachelor's degree in one of
the behavioral sciences or related fields at an accredited
college or university;
(2) completes 40 hours of training as specified in this
subdivision; and
(3) receives clinical supervision at least once a week
until the requirements of obtaining a bachelor's degree and
2,000 hours of supervised experience are met.
Sec. 5. Minnesota Statutes 1998, section 252.28, is
amended by adding a subdivision to read:
Subd. 3b. [OLMSTED COUNTY LICENSING EXEMPTION.] (a)
Notwithstanding subdivision 3, the commissioner may license
service sites each accommodating up to five residents moving
from a 43-bed intermediate care facility for persons with mental
retardation or related conditions located in Olmsted county that
is closing under section 252.292.
(b) Notwithstanding the provisions of any other state law
or administrative rule, the rate provisions of section 256I.05,
subdivision 1, apply to the exception in this subdivision.
Sec. 6. Minnesota Statutes 1998, section 256B.0625,
subdivision 19a, is amended to read:
Subd. 19a. [PERSONAL CARE SERVICES.] Medical assistance
covers personal care services in a recipient's home. To qualify
for personal care services, recipients or responsible parties
must be able to identify the recipient's needs, direct and
evaluate task accomplishment, and provide for health and
safety. Approved hours may be used outside the home when normal
life activities take them outside the home and when, without the
provision of personal care, their health and safety would be
jeopardized. To use personal care services at school, the
recipient or responsible party must provide written
authorization in the care plan identifying the chosen provider
and the daily amount of services to be used at school. Total
hours for services, whether actually performed inside or outside
the recipient's home, cannot exceed that which is otherwise
allowed for personal care services in an in-home setting
according to section 256B.0627. Medical assistance does not
cover personal care services for residents of a hospital,
nursing facility, intermediate care facility, health care
facility licensed by the commissioner of health, or unless a
resident who is otherwise eligible is on leave from the facility
and the facility either pays for the personal care services or
forgoes the facility per diem for the leave days that personal
care services are used. All personal care services must be
provided according to section 256B.0627. Personal care services
may not be reimbursed if the personal care assistant is the
spouse or legal guardian of the recipient or the parent of a
recipient under age 18, or the responsible party or the foster
care provider of a recipient who cannot direct the recipient's
own care unless, in the case of a foster care provider, a county
or state case manager visits the recipient as needed, but not
less than every six months, to monitor the health and safety of
the recipient and to ensure the goals of the care plan are met.
Parents of adult recipients, adult children of the recipient or
adult siblings of the recipient may be reimbursed for personal
care services if they are not the recipient's legal guardian and
are granted a waiver under section 256B.0627. Until July 1,
2001, and notwithstanding the provisions of section 256B.0627,
subdivision 4, paragraph (b), clause (4), the noncorporate legal
guardian or conservator of an adult, who is not the responsible
party and not the personal care provider organization, may be
granted a hardship waiver under section 256B.0627, to be
reimbursed to provide personal care assistant services to the
recipient, and shall not be considered to have a service
provider interest for purposes of participation on the screening
team under section 256B.092, subdivision 7.
Sec. 7. Minnesota Statutes 1999 Supplement, section
256B.0625, subdivision 19c, is amended to read:
Subd. 19c. [PERSONAL CARE.] Medical assistance covers
personal care services provided by an individual who is
qualified to provide the services according to subdivision 19a
and section 256B.0627, where the services are prescribed by a
physician in accordance with a plan of treatment and are
supervised by the recipient under the fiscal agent option
according to section 256B.0627, subdivision 10, or a qualified
professional. "Qualified professional" means a mental health
professional as defined in section 245.462, subdivision 18, or
245.4871, subdivision 26 27; or a registered nurse as defined in
sections 148.171 to 148.285. As part of the assessment, the
county public health nurse will consult with the recipient or
responsible party and identify the most appropriate person to
provide supervision of the personal care assistant. The
qualified professional shall perform the duties described in
Minnesota Rules, part 9505.0335, subpart 4.
Sec. 8. Minnesota Statutes 1999 Supplement, section
256B.0627, subdivision 1, is amended to read:
Subdivision 1. [DEFINITION.] (a) "Assessment" means a
review and evaluation of a recipient's need for home care
services conducted in person. Assessments for private duty
nursing shall be conducted by a registered private duty nurse.
Assessments for home health agency services shall be conducted
by a home health agency nurse. Assessments for personal care
assistant services shall be conducted by the county public
health nurse or a certified public health nurse under contract
with the county. A face-to-face assessment must include: a
documentation of health status assessment and, determination of
need, evaluation of service outcomes, collection of case data
effectiveness, identification of appropriate services and,
service plan development or modification, coordination of
services, referrals and follow-up to appropriate payers and
community resources, completion of required reports, obtaining
recommendation of service authorization, and consumer
education. Once the need for personal care assistant services
is determined under this section, the county public health nurse
or certified public health nurse under contract with the county
is responsible for communicating this recommendation to the
commissioner and the recipient. A face-to-face assessment for
personal care services is conducted on those recipients who have
never had a county public health nurse assessment. A
face-to-face assessment must occur at least annually or when
there is a significant change in the recipient's condition or
when there is a change in the need for personal care assistant
services. A service update may substitute for the annual
face-to-face assessment when there is not a significant change
in recipient condition or a change in the need for personal care
assistant service. A service update or review for temporary
increase includes a review of initial baseline data, evaluation
of service outcomes effectiveness, redetermination of service
need, modification of service plan and appropriate referrals,
update of initial forms, obtaining service authorization, and on
going consumer education. Assessments for medical assistance
home care services for mental retardation or related conditions
and alternative care services for developmentally disabled home
and community-based waivered recipients may be conducted by the
county public health nurse to ensure coordination and avoid
duplication. Assessments must be completed on forms provided by
the commissioner within 30 days of a request for home care
services by a recipient or responsible party.
(b) "Care plan" means a written description of personal
care assistant services developed by the qualified professional
with the recipient or responsible party to be used by the
personal care assistant with a copy provided to the recipient or
responsible party.
(c) "Home care services" means a health service, determined
by the commissioner as medically necessary, that is ordered by a
physician and documented in a service plan that is reviewed by
the physician at least once every 62 days for the provision of
home health services, or private duty nursing, or at least once
every 365 days for personal care. Home care services are
provided to the recipient at the recipient's residence that is a
place other than a hospital or long-term care facility or as
specified in section 256B.0625.
(d) "Medically necessary" has the meaning given in
Minnesota Rules, parts 9505.0170 to 9505.0475.
(e) "Personal care assistant" means a person who: (1) is
at least 18 years old, except for persons 16 to 18 years of age
who participated in a related school-based job training program
or have completed a certified home health aide competency
evaluation; (2) is able to effectively communicate with the
recipient and personal care provider organization; (3) effective
July 1, 1996, has completed one of the training requirements as
specified in Minnesota Rules, part 9505.0335, subpart 3, items A
to D; (4) has the ability to, and provides covered personal care
services according to the recipient's care plan, responds
appropriately to recipient needs, and reports changes in the
recipient's condition to the supervising qualified professional;
(5) is not a consumer of personal care services; and (6) is
subject to criminal background checks and procedures specified
in section 245A.04.
(f) "Personal care provider organization" means an
organization enrolled to provide personal care services under
the medical assistance program that complies with the
following: (1) owners who have a five percent interest or more,
and managerial officials are subject to a background study as
provided in section 245A.04. This applies to currently enrolled
personal care provider organizations and those agencies seeking
enrollment as a personal care provider organization. An
organization will be barred from enrollment if an owner or
managerial official of the organization has been convicted of a
crime specified in section 245A.04, or a comparable crime in
another jurisdiction, unless the owner or managerial official
meets the reconsideration criteria specified in section 245A.04;
(2) the organization must maintain a surety bond and liability
insurance throughout the duration of enrollment and provides
proof thereof. The insurer must notify the department of human
services of the cancellation or lapse of policy; and (3) the
organization must maintain documentation of services as
specified in Minnesota Rules, part 9505.2175, subpart 7, as well
as evidence of compliance with personal care assistant training
requirements.
(g) "Responsible party" means an individual residing with a
recipient of personal care services who is capable of providing
the supportive care necessary to assist the recipient to live in
the community, is at least 18 years old, and is not a personal
care assistant. Responsible parties who are parents of minors
or guardians of minors or incapacitated persons may delegate the
responsibility to another adult during a temporary absence of at
least 24 hours but not more than six months. The person
delegated as a responsible party must be able to meet the
definition of responsible party, except that the delegated
responsible party is required to reside with the recipient only
while serving as the responsible party. Foster care license
holders may be designated the responsible party for residents of
the foster care home if case management is provided as required
in section 256B.0625, subdivision 19a. For persons who, as of
April 1, 1992, are sharing personal care services in order to
obtain the availability of 24-hour coverage, an employee of the
personal care provider organization may be designated as the
responsible party if case management is provided as required in
section 256B.0625, subdivision 19a.
(h) "Service plan" means a written description of the
services needed based on the assessment developed by the nurse
who conducts the assessment together with the recipient or
responsible party. The service plan shall include a description
of the covered home care services, frequency and duration of
services, and expected outcomes and goals. The recipient and
the provider chosen by the recipient or responsible party must
be given a copy of the completed service plan within 30 calendar
days of the request for home care services by the recipient or
responsible party.
(i) "Skilled nurse visits" are provided in a recipient's
residence under a plan of care or service plan that specifies a
level of care which the nurse is qualified to provide. These
services are:
(1) nursing services according to the written plan of care
or service plan and accepted standards of medical and nursing
practice in accordance with chapter 148;
(2) services which due to the recipient's medical condition
may only be safely and effectively provided by a registered
nurse or a licensed practical nurse;
(3) assessments performed only by a registered nurse; and
(4) teaching and training the recipient, the recipient's
family, or other caregivers requiring the skills of a registered
nurse or licensed practical nurse.
Sec. 9. Minnesota Statutes 1999 Supplement, section
256B.0627, subdivision 5, is amended to read:
Subd. 5. [LIMITATION ON PAYMENTS.] Medical assistance
payments for home care services shall be limited according to
this subdivision.
(a) [LIMITS ON SERVICES WITHOUT PRIOR AUTHORIZATION.] A
recipient may receive the following home care services during a
calendar year:
(1) up to two face-to-face assessments to determine a
recipient's need for personal care assistant services;
(2) one service update done to determine a recipient's need
for personal care services; and
(3) up to five skilled nurse visits.
(b) [PRIOR AUTHORIZATION; EXCEPTIONS.] All home care
services above the limits in paragraph (a) must receive the
commissioner's prior authorization, except when:
(1) the home care services were required to treat an
emergency medical condition that if not immediately treated
could cause a recipient serious physical or mental disability,
continuation of severe pain, or death. The provider must
request retroactive authorization no later than five working
days after giving the initial service. The provider must be
able to substantiate the emergency by documentation such as
reports, notes, and admission or discharge histories;
(2) the home care services were provided on or after the
date on which the recipient's eligibility began, but before the
date on which the recipient was notified that the case was
opened. Authorization will be considered if the request is
submitted by the provider within 20 working days of the date the
recipient was notified that the case was opened;
(3) a third-party payor for home care services has denied
or adjusted a payment. Authorization requests must be submitted
by the provider within 20 working days of the notice of denial
or adjustment. A copy of the notice must be included with the
request;
(4) the commissioner has determined that a county or state
human services agency has made an error; or
(5) the professional nurse determines an immediate need for
up to 40 skilled nursing or home health aide visits per calendar
year and submits a request for authorization within 20 working
days of the initial service date, and medical assistance is
determined to be the appropriate payer.
(c) [RETROACTIVE AUTHORIZATION.] A request for retroactive
authorization will be evaluated according to the same criteria
applied to prior authorization requests.
(d) [ASSESSMENT AND SERVICE PLAN.] Assessments under
section 256B.0627, subdivision 1, paragraph (a), shall be
conducted initially, and at least annually thereafter, in person
with the recipient and result in a completed service plan using
forms specified by the commissioner. Within 30 days of
recipient or responsible party request for home care services,
the assessment, the service plan, and other information
necessary to determine medical necessity such as diagnostic or
testing information, social or medical histories, and hospital
or facility discharge summaries shall be submitted to the
commissioner. For personal care services:
(1) The amount and type of service authorized based upon
the assessment and service plan will follow the recipient if the
recipient chooses to change providers.
(2) If the recipient's medical need changes, the
recipient's provider may assess the need for a change in service
authorization and request the change from the county public
health nurse. Within 30 days of the request, the public health
nurse will determine whether to request the change in services
based upon the provider assessment, or conduct a home visit to
assess the need and determine whether the change is appropriate.
(3) To continue to receive personal care services after the
first year, the recipient or the responsible party, in
conjunction with the public health nurse, may complete a service
update on forms developed by the commissioner according to
criteria and procedures in subdivision 1.
(e) [PRIOR AUTHORIZATION.] The commissioner, or the
commissioner's designee, shall review the assessment, service
update, request for temporary services, service plan, and any
additional information that is submitted. The commissioner
shall, within 30 days after receiving a complete request,
assessment, and service plan, authorize home care services as
follows:
(1) [HOME HEALTH SERVICES.] All home health services
provided by a licensed nurse or a home health aide must be prior
authorized by the commissioner or the commissioner's designee.
Prior authorization must be based on medical necessity and
cost-effectiveness when compared with other care options. When
home health services are used in combination with personal care
and private duty nursing, the cost of all home care services
shall be considered for cost-effectiveness. The commissioner
shall limit nurse and home health aide visits to no more than
one visit each per day.
(2) [PERSONAL CARE SERVICES.] (i) All personal care
services and supervision by a qualified professional must be
prior authorized by the commissioner or the commissioner's
designee except for the assessments established in paragraph
(a). The amount of personal care services authorized must be
based on the recipient's home care rating. A child may not be
found to be dependent in an activity of daily living if because
of the child's age an adult would either perform the activity
for the child or assist the child with the activity and the
amount of assistance needed is similar to the assistance
appropriate for a typical child of the same age. Based on
medical necessity, the commissioner may authorize:
(A) up to two times the average number of direct care hours
provided in nursing facilities for the recipient's comparable
case mix level; or
(B) up to three times the average number of direct care
hours provided in nursing facilities for recipients who have
complex medical needs or are dependent in at least seven
activities of daily living and need physical assistance with
eating or have a neurological diagnosis; or
(C) up to 60 percent of the average reimbursement rate, as
of July 1, 1991, for care provided in a regional treatment
center for recipients who have Level I behavior, plus any
inflation adjustment as provided by the legislature for personal
care service; or
(D) up to the amount the commissioner would pay, as of July
1, 1991, plus any inflation adjustment provided for home care
services, for care provided in a regional treatment center for
recipients referred to the commissioner by a regional treatment
center preadmission evaluation team. For purposes of this
clause, home care services means all services provided in the
home or community that would be included in the payment to a
regional treatment center; or
(E) up to the amount medical assistance would reimburse for
facility care for recipients referred to the commissioner by a
preadmission screening team established under section 256B.0911
or 256B.092; and
(F) a reasonable amount of time for the provision of
supervision by a qualified professional of personal care
services.
(ii) The number of direct care hours shall be determined
according to the annual cost report submitted to the department
by nursing facilities. The average number of direct care hours,
as established by May 1, 1992, shall be calculated and
incorporated into the home care limits on July 1, 1992. These
limits shall be calculated to the nearest quarter hour.
(iii) The home care rating shall be determined by the
commissioner or the commissioner's designee based on information
submitted to the commissioner by the county public health nurse
on forms specified by the commissioner. The home care rating
shall be a combination of current assessment tools developed
under sections 256B.0911 and 256B.501 with an addition for
seizure activity that will assess the frequency and severity of
seizure activity and with adjustments, additions, and
clarifications that are necessary to reflect the needs and
conditions of recipients who need home care including children
and adults under 65 years of age. The commissioner shall
establish these forms and protocols under this section and shall
use an advisory group, including representatives of recipients,
providers, and counties, for consultation in establishing and
revising the forms and protocols.
(iv) A recipient shall qualify as having complex medical
needs if the care required is difficult to perform and because
of recipient's medical condition requires more time than
community-based standards allow or requires more skill than
would ordinarily be required and the recipient needs or has one
or more of the following:
(A) daily tube feedings;
(B) daily parenteral therapy;
(C) wound or decubiti care;
(D) postural drainage, percussion, nebulizer treatments,
suctioning, tracheotomy care, oxygen, mechanical ventilation;
(E) catheterization;
(F) ostomy care;
(G) quadriplegia; or
(H) other comparable medical conditions or treatments the
commissioner determines would otherwise require institutional
care.
(v) A recipient shall qualify as having Level I behavior if
there is reasonable supporting evidence that the recipient
exhibits, or that without supervision, observation, or
redirection would exhibit, one or more of the following
behaviors that cause, or have the potential to cause:
(A) injury to the recipient's own body;
(B) physical injury to other people; or
(C) destruction of property.
(vi) Time authorized for personal care relating to Level I
behavior in subclause (v), items (A) to (C), shall be based on
the predictability, frequency, and amount of intervention
required.
(vii) A recipient shall qualify as having Level II behavior
if the recipient exhibits on a daily basis one or more of the
following behaviors that interfere with the completion of
personal care services under subdivision 4, paragraph (a):
(A) unusual or repetitive habits;
(B) withdrawn behavior; or
(C) offensive behavior.
(viii) A recipient with a home care rating of Level II
behavior in subclause (vii), items (A) to (C), shall be rated as
comparable to a recipient with complex medical needs under
subclause (iv). If a recipient has both complex medical needs
and Level II behavior, the home care rating shall be the next
complex category up to the maximum rating under subclause (i),
item (B).
(3) [PRIVATE DUTY NURSING SERVICES.] All private duty
nursing services shall be prior authorized by the commissioner
or the commissioner's designee. Prior authorization for private
duty nursing services shall be based on medical necessity and
cost-effectiveness when compared with alternative care options.
The commissioner may authorize medically necessary private duty
nursing services in quarter-hour units when:
(i) the recipient requires more individual and continuous
care than can be provided during a nurse visit; or
(ii) the cares are outside of the scope of services that
can be provided by a home health aide or personal care assistant.
The commissioner may authorize:
(A) up to two times the average amount of direct care hours
provided in nursing facilities statewide for case mix
classification "K" as established by the annual cost report
submitted to the department by nursing facilities in May 1992;
(B) private duty nursing in combination with other home
care services up to the total cost allowed under clause (2);
(C) up to 16 hours per day if the recipient requires more
nursing than the maximum number of direct care hours as
established in item (A) and the recipient meets the hospital
admission criteria established under Minnesota Rules, parts
9505.0500 to 9505.0540.
The commissioner may authorize up to 16 hours per day of
medically necessary private duty nursing services or up to 24
hours per day of medically necessary private duty nursing
services until such time as the commissioner is able to make a
determination of eligibility for recipients who are
cooperatively applying for home care services under the
community alternative care program developed under section
256B.49, or until it is determined by the appropriate regulatory
agency that a health benefit plan is or is not required to pay
for appropriate medically necessary health care services.
Recipients or their representatives must cooperatively assist
the commissioner in obtaining this determination. Recipients
who are eligible for the community alternative care program may
not receive more hours of nursing under this section than would
otherwise be authorized under section 256B.49.
(4) [VENTILATOR-DEPENDENT RECIPIENTS.] If the recipient is
ventilator-dependent, the monthly medical assistance
authorization for home care services shall not exceed what the
commissioner would pay for care at the highest cost hospital
designated as a long-term hospital under the Medicare program.
For purposes of this clause, home care services means all
services provided in the home that would be included in the
payment for care at the long-term hospital.
"Ventilator-dependent" means an individual who receives
mechanical ventilation for life support at least six hours per
day and is expected to be or has been dependent for at least 30
consecutive days.
(f) [PRIOR AUTHORIZATION; TIME LIMITS.] The commissioner
or the commissioner's designee shall determine the time period
for which a prior authorization shall be effective. If the
recipient continues to require home care services beyond the
duration of the prior authorization, the home care provider must
request a new prior authorization. Under no circumstances,
other than the exceptions in paragraph (b), shall a prior
authorization be valid prior to the date the commissioner
receives the request or for more than 12 months. A recipient
who appeals a reduction in previously authorized home care
services may continue previously authorized services, other than
temporary services under paragraph (h), pending an appeal under
section 256.045. The commissioner must provide a detailed
explanation of why the authorized services are reduced in amount
from those requested by the home care provider.
(g) [APPROVAL OF HOME CARE SERVICES.] The commissioner or
the commissioner's designee shall determine the medical
necessity of home care services, the level of caregiver
according to subdivision 2, and the institutional comparison
according to this subdivision, the cost-effectiveness of
services, and the amount, scope, and duration of home care
services reimbursable by medical assistance, based on the
assessment, primary payer coverage determination information as
required, the service plan, the recipient's age, the cost of
services, the recipient's medical condition, and diagnosis or
disability. The commissioner may publish additional criteria
for determining medical necessity according to section 256B.04.
(h) [PRIOR AUTHORIZATION REQUESTS; TEMPORARY SERVICES.]
The agency nurse, the independently enrolled private duty nurse,
or county public health nurse may request a temporary
authorization for home care services by telephone. The
commissioner may approve a temporary level of home care services
based on the assessment, and service or care plan information,
and primary payer coverage determination information as required.
Authorization for a temporary level of home care services
including nurse supervision is limited to the time specified by
the commissioner, but shall not exceed 45 days, unless extended
because the county public health nurse has not completed the
required assessment and service plan, or the commissioner's
determination has not been made. The level of services
authorized under this provision shall have no bearing on a
future prior authorization.
(i) [PRIOR AUTHORIZATION REQUIRED IN FOSTER CARE SETTING.]
Home care services provided in an adult or child foster care
setting must receive prior authorization by the department
according to the limits established in paragraph (a).
The commissioner may not authorize:
(1) home care services that are the responsibility of the
foster care provider under the terms of the foster care
placement agreement and administrative rules. Requests for home
care services for recipients residing in a foster care setting
must include the foster care placement agreement and
determination of difficulty of care;
(2) personal care services when the foster care license
holder is also the personal care provider or personal care
assistant unless the recipient can direct the recipient's own
care, or case management is provided as required in section
256B.0625, subdivision 19a;
(3) personal care services when the responsible party is an
employee of, or under contract with, or has any direct or
indirect financial relationship with the personal care provider
or personal care assistant, unless case management is provided
as required in section 256B.0625, subdivision 19a; or
(4) home personal care assistant and private duty nursing
services when the number of foster care residents is greater
than four unless the county responsible for the recipient's
foster placement made the placement prior to April 1, 1992,
requests that home personal care assistant and private duty
nursing services be provided, and case management is provided as
required in section 256B.0625, subdivision 19a; or.
(5) home care services when combined with foster care
payments, other than room and board payments that exceed the
total amount that public funds would pay for the recipient's
care in a medical institution.
Sec. 10. Minnesota Statutes 1999 Supplement, section
256B.0627, subdivision 8, is amended to read:
Subd. 8. [SHARED PERSONAL CARE ASSISTANT SERVICES.] (a)
Medical assistance payments for shared personal care assistance
services shall be limited according to this subdivision.
(b) Recipients of personal care assistant services may
share staff and the commissioner shall provide a rate system for
shared personal care assistant services. For two persons
sharing services, the rate paid to a provider shall not exceed
1-1/2 times the rate paid for serving a single individual, and
for three persons sharing services, the rate paid to a provider
shall not exceed twice the rate paid for serving a single
individual. These rates apply only to situations in which all
recipients were present and received shared services on the date
for which the service is billed. No more than three persons may
receive shared services from a personal care assistant in a
single setting.
(c) Shared service is the provision of personal care
services by a personal care assistant to two or three recipients
at the same time and in the same setting. For the purposes of
this subdivision, "setting" means:
(1) the home or foster care home of one of the individual
recipients; or
(2) a child care program in which all recipients served by
one personal care assistant are participating, which is licensed
under chapter 245A or operated by a local school district or
private school.; or
(3) outside the home or foster care home of one of the
recipients when normal life activities take the recipients
outside the home.
The provisions of this subdivision do not apply when a
personal care assistant is caring for multiple recipients in
more than one setting.
(d) The recipient or the recipient's responsible party, in
conjunction with the county public health nurse, shall determine:
(1) whether shared personal care assistant services is an
appropriate option based on the individual needs and preferences
of the recipient; and
(2) the amount of shared services allocated as part of the
overall authorization of personal care services.
The recipient or the responsible party, in conjunction with
the supervising qualified professional, shall arrange the
setting and grouping of shared services based on the individual
needs and preferences of the recipients. Decisions on the
selection of recipients to share services must be based on the
ages of the recipients, compatibility, and coordination of their
care needs.
(e) The following items must be considered by the recipient
or the responsible party and the supervising qualified
professional, and documented in the recipient's health service
record:
(1) the additional qualifications needed by the personal
care assistant to provide care to several recipients in the same
setting;
(2) the additional training and supervision needed by the
personal care assistant to ensure that the needs of the
recipient are met appropriately and safely. The provider must
provide on-site supervision by a qualified professional within
the first 14 days of shared services, and monthly thereafter;
(3) the setting in which the shared services will be
provided;
(4) the ongoing monitoring and evaluation of the
effectiveness and appropriateness of the service and process
used to make changes in service or setting; and
(5) a contingency plan which accounts for absence of the
recipient in a shared services setting due to illness or other
circumstances and staffing contingencies.
(f) The provider must offer the recipient or the
responsible party the option of shared or one-on-one personal
care assistant services. The recipient or the responsible party
can withdraw from participating in a shared services arrangement
at any time.
(g) In addition to documentation requirements under
Minnesota Rules, part 9505.2175, a personal care provider must
meet documentation requirements for shared personal care
assistant services and must document the following in the health
service record for each individual recipient sharing services:
(1) permission by the recipient or the recipient's
responsible party, if any, for the maximum number of shared
services hours per week chosen by the recipient;
(2) permission by the recipient or the recipient's
responsible party, if any, for personal care assistant services
provided outside the recipient's residence;
(3) permission by the recipient or the recipient's
responsible party, if any, for others to receive shared services
in the recipient's residence;
(4) revocation by the recipient or the recipient's
responsible party, if any, of the shared service authorization,
or the shared service to be provided to others in the
recipient's residence, or the shared service to be provided
outside the recipient's residence;
(5) supervision of the shared personal care assistant
services by the qualified professional, including the date, time
of day, number of hours spent supervising the provision of
shared services, whether the supervision was face-to-face or
another method of supervision, changes in the recipient's
condition, shared services scheduling issues and
recommendations;
(6) documentation by the qualified professional of
telephone calls or other discussions with the personal care
assistant regarding services being provided to the recipient;
and
(7) daily documentation of the shared services provided by
each identified personal care assistant including:
(i) the names of each recipient receiving shared services
together;
(ii) the setting for the shared services, including the
starting and ending times that the recipient received shared
services; and
(iii) notes by the personal care assistant regarding
changes in the recipient's condition, problems that may arise
from the sharing of services, scheduling issues, care issues,
and other notes as required by the qualified professional.
(h) Unless otherwise provided in this subdivision, all
other statutory and regulatory provisions relating to personal
care services apply to shared services.
Nothing in this subdivision shall be construed to reduce
the total number of hours authorized for an individual recipient.
Sec. 11. Minnesota Statutes 1999 Supplement, section
256B.0627, subdivision 11, is amended to read:
Subd. 11. [SHARED PRIVATE DUTY NURSING CARE OPTION.] (a)
Medical assistance payments for shared private duty nursing
services by a private duty nurse shall be limited according to
this subdivision. For the purposes of this section, "private
duty nursing agency" means an agency licensed under chapter 144A
to provide private duty nursing services.
(b) Recipients of private duty nursing services may share
nursing staff and the commissioner shall provide a rate
methodology for shared private duty nursing. For two persons
sharing nursing care, the rate paid to a provider shall not
exceed 1.5 times the nonwaivered private duty nursing rates paid
for serving a single individual who is not ventilator dependent,
by a registered nurse or licensed practical nurse. These rates
apply only to situations in which both recipients are present
and receive shared private duty nursing care on the date for
which the service is billed. No more than two persons may
receive shared private duty nursing services from a private duty
nurse in a single setting.
(c) Shared private duty nursing care is the provision of
nursing services by a private duty nurse to two recipients at
the same time and in the same setting. For the purposes of this
subdivision, "setting" means:
(1) the home or foster care home of one of the individual
recipients; or
(2) a child care program licensed under chapter 245A or
operated by a local school district or private school; or
(3) an adult day care service licensed under chapter 245A.;
or
(4) outside the home or foster care home of one of the
recipients when normal life activities take the recipients
outside the home.
This subdivision does not apply when a private duty nurse
is caring for multiple recipients in more than one setting.
(d) The recipient or the recipient's legal representative,
and the recipient's physician, in conjunction with the home
health care agency, shall determine:
(1) whether shared private duty nursing care is an
appropriate option based on the individual needs and preferences
of the recipient; and
(2) the amount of shared private duty nursing services
authorized as part of the overall authorization of nursing
services.
(e) The recipient or the recipient's legal representative,
in conjunction with the private duty nursing agency, shall
approve the setting, grouping, and arrangement of shared private
duty nursing care based on the individual needs and preferences
of the recipients. Decisions on the selection of recipients to
share services must be based on the ages of the recipients,
compatibility, and coordination of their care needs.
(f) The following items must be considered by the recipient
or the recipient's legal representative and the private duty
nursing agency, and documented in the recipient's health service
record:
(1) the additional training needed by the private duty
nurse to provide care to several two recipients in the same
setting and to ensure that the needs of the recipients are met
appropriately and safely;
(2) the setting in which the shared private duty nursing
care will be provided;
(3) the ongoing monitoring and evaluation of the
effectiveness and appropriateness of the service and process
used to make changes in service or setting;
(4) a contingency plan which accounts for absence of the
recipient in a shared private duty nursing setting due to
illness or other circumstances;
(5) staffing backup contingencies in the event of employee
illness or absence; and
(6) arrangements for additional assistance to respond to
urgent or emergency care needs of the recipients.
(g) The provider must offer the recipient or responsible
party the option of shared or one-on-one private duty nursing
services. The recipient or responsible party can withdraw from
participating in a shared service arrangement at any time.
(h) The private duty nursing agency must document the
following in the health service record for each individual
recipient sharing private duty nursing care:
(1) permission by the recipient or the recipient's legal
representative for the maximum number of shared nursing care
hours per week chosen by the recipient;
(2) permission by the recipient or the recipient's legal
representative for shared private duty nursing services provided
outside the recipient's residence;
(3) permission by the recipient or the recipient's legal
representative for others to receive shared private duty nursing
services in the recipient's residence;
(4) revocation by the recipient or the recipient's legal
representative of the shared private duty nursing care
authorization, or the shared care to be provided to others in
the recipient's residence, or the shared private duty nursing
services to be provided outside the recipient's residence; and
(5) daily documentation of the shared private duty nursing
services provided by each identified private duty nurse,
including:
(i) the names of each recipient receiving shared private
duty nursing services together;
(ii) the setting for the shared services, including the
starting and ending times that the recipient received shared
private duty nursing care; and
(iii) notes by the private duty nurse regarding changes in
the recipient's condition, problems that may arise from the
sharing of private duty nursing services, and scheduling and
care issues.
(i) Unless otherwise provided in this subdivision, all
other statutory and regulatory provisions relating to private
duty nursing services apply to shared private duty nursing
services.
Nothing in this subdivision shall be construed to reduce
the total number of private duty nursing hours authorized for an
individual recipient under subdivision 5.
Sec. 12. Minnesota Statutes 1999 Supplement, section
256B.501, subdivision 8a, is amended to read:
Subd. 8a. [PAYMENT FOR PERSONS WITH SPECIAL NEEDS FOR
CRISIS INTERVENTION SERVICES.] Community-based crisis services
authorized by the commissioner or the commissioner's designee
for a resident of an intermediate care facility for persons with
mental retardation (ICF/MR) reimbursed under this section shall
be paid by medical assistance in accordance with the paragraphs
(a) to (g).
(a) "Crisis services" means the specialized services listed
in clauses (1) to (3) provided to prevent the recipient from
requiring placement in a more restrictive institutional setting
such as an inpatient hospital or regional treatment center and
to maintain the recipient in the present community setting.
(1) The crisis services provider shall assess the
recipient's behavior and environment to identify factors
contributing to the crisis.
(2) The crisis services provider shall develop a
recipient-specific intervention plan in coordination with the
service planning team and provide recommendations for revisions
to the individual service plan if necessary to prevent or
minimize the likelihood of future crisis situations. The
intervention plan shall include a transition plan to aid the
recipient in returning to the community-based ICF/MR if the
recipient is receiving residential crisis services.
(3) The crisis services provider shall consult with and
provide training and ongoing technical assistance to the
recipient's service providers to aid in the implementation of
the intervention plan and revisions to the individual service
plan.
(b) "Residential crisis services" means crisis services
that are provided to a recipient admitted to an alternative,
state-licensed site approved by the commissioner, because the
ICF/MR receiving reimbursement under this section is not able,
as determined by the commissioner, to provide the intervention
and protection of the recipient and others living with the
recipient that is necessary to prevent the recipient from
requiring placement in a more restrictive institutional setting.
(c) Residential crisis services providers must maintain a
license from the commissioner for the residence when providing
crisis services for short-term crisis intervention, and must not
be located in a private residence.
(d) Payment rates shall be established consistent with
county negotiated crisis intervention services.
(e) Payment for residential crisis services is limited to
21 days, unless an additional period is authorized by the
commissioner or part of an approved regional plan.
(f) Payment for crisis services shall be made only for
services provided while the ICF/MR receiving reimbursement under
this section:
(1) has a shared services agreement with the crisis
services provider in effect under section 246.57; and
(2) has executed a cooperative agreement with the crisis
services provider to implement the intervention plan and
revisions to the individual service plan as necessary to prevent
or minimize the likelihood of future crisis situations, to
maintain the recipient in the present community setting, and to
prevent the recipient from requiring a more restrictive
institutional setting.
(g) Payment to the ICF/MR receiving reimbursement under
this section shall be made for up to 18 therapeutic leave days
during which the recipient is receiving residential crisis
services, if the ICF/MR is otherwise eligible to receive payment
for a therapeutic leave day under Minnesota Rules, part
9505.0415. Payment under this paragraph shall be terminated if
the commissioner determines that the ICF/MR is not meeting the
terms of the shared cooperative service agreement under
paragraph (f) or that the recipient will not return to the
ICF/MR.
Sec. 13. Minnesota Statutes 1999 Supplement, section
256B.5011, subdivision 2, is amended to read:
Subd. 2. [CONTRACT PROVISIONS.] (a) The service contract
with each intermediate care facility must include provisions for:
(1) modifying payments when significant changes occur in
the needs of the consumers;
(2) the establishment and use of continuous a quality
improvement processes using the results attained through service
quality monitoring plan. Using criteria and options for
performance measures developed by the commissioner, each
intermediate care facility must identify a minimum of one
performance measure on which to focus its efforts for quality
improvement during the contract period;
(3) appropriate and necessary statistical information
required by the commissioner;
(4) annual aggregate facility financial information; and
(5) additional requirements for intermediate care
facilities not meeting the standards set forth in the service
contract.
(b) The commissioner shall recommend to the legislature by
January 15, 2000, whether the contract should include service
quality monitoring that may utilize performance indicators that
measure consumer and program outcomes. Performance measurement
shall not increase or duplicate regulatory requirements.
(b) The commissioner of human services and the commissioner
of health, in consultation with representatives from counties,
advocacy organizations, and the provider community, shall review
the consolidated standards under chapter 245B and the supervised
living facility rule under Minnesota Rules, chapter 4665, to
determine what provisions in Minnesota Rules, chapter 4665, may
be waived by the commissioner of health for intermediate care
facilities in order to enable facilities to implement the
performance measures in their contract and provide quality
services to residents without a duplication of or increase in
regulatory requirements.
Sec. 14. Minnesota Statutes 1999 Supplement, section
256B.5013, subdivision 1, is amended to read:
Subdivision 1. [VARIABLE RATE ADJUSTMENTS.] For rate years
beginning on or after October 1, 2000, when there is a
documented increase in the resource needs of a current ICF/MR
recipient or recipients, or a person is admitted to a facility
who requires additional resources, the county of financial
responsibility may approve recommend approval of an enhanced a
variable rate for one or more persons in the to enable the
facility to meet the needs based on the recipient's screening.
Resource needs directly attributable to an individual that may
be considered under the variable rate adjustment include
increased direct staff hours and other specialized services,
equipment, and human resources. The guidelines in paragraphs
(a) to (d) apply for the payment rate adjustments under this
section.
(a) All persons must be screened according to section
256B.092, subdivisions 7 and 8, prior to implementation of the
new payment system, and annually thereafter, and when a variable
rate is being requested due to changes in the needs of the
recipient. Screening data shall be analyzed to develop broad
profiles of the functional characteristics of recipients. Three
components shall Criteria to be used to distinguish recipients
based on the following broad develop these profiles shall
include, but not be limited to:
(1) the functional ability of a recipient to care for and
maintain one's the recipient's own basic needs;
(2) the intensity of any aggressive or destructive
behavior; and
(3) any history of obstructive behavior in combination with
a diagnosis of psychosis or neurosis.;
(4) a need for resources due to a change in resident day
program participation because the resident: (i) has reached the
age of 65 or has a change in health condition that makes it
difficult for the person to participate in day training and
habilitation services over an extended period of time because it
is medically contraindicated; and (ii) has expressed a desire
for change through the developmental disabilities screening
process under section 256B.092; and
(5) a need for additional resources for intensive
short-term training which is necessary prior to a recipient's
discharge to a less restrictive, more integrated setting.
The profile groups recipients' screenings shall be used to
link resource needs to funding. The resource profile shall
determine the level of funding that may be authorized by the
county. The county of financial responsibility may approve a
rate adjustment for an individual. The commissioner shall
recommend to the legislature by January 15, 2000, a methodology
using the profile groups to determine variable rates. The
variable rate must be applied to expenses related to increased
direct staff hours and other specialized services, equipment,
and human resources. This variable rate component plus the
facility's current operating payment rate equals the
individual's total operating payment rate.
(b) A recipient must be screened by the county of financial
responsibility using the developmental disabilities screening
document completed immediately prior to approval of a variable
rate by the county. A comparison of the updated screening and
the previous screening must demonstrate an increase in resource
needs.
(c) Rate adjustments projected to exceed the authorized
funding level associated with the person's profile must be
submitted to the commissioner.
(d) The new rate approved through this process shall not be
averaged across all persons living at a facility but shall be an
individual rate. The county of financial responsibility must
indicate the projected length of time that the additional
funding may be needed by for the individual. The need to
continue an individual variable rate must be reviewed at the end
of the anticipated duration of need but at least annually
through the completion of the developmental disabilities
screening document.
Sec. 15. Minnesota Statutes 1999 Supplement, section
256B.5013, is amended by adding a subdivision to read:
Subd. 5. [REQUIRED DATA; PAYMENT ADJUSTMENTS.] Facilities
shall maintain and submit monthly bed use data in the form of
resident days and variable rate information. When a variable
rate is reported by a facility, monthly bed use data shall be
used to track the amount and time span of the rate adjustment.
The total payments made to a facility may be adjusted based on
concurrent changes in the needs of recipients that are covered
by a variable rate adjustment. Any adjustment for multiple
resident changes shall not result in a decrease to the facility
base rate.
Sec. 16. Minnesota Statutes 1999 Supplement, section
256B.5013, is amended by adding a subdivision to read:
Subd. 6. [COMMISSIONER REVIEW.] During the initial
contracting period, the commissioner shall review the process of
variable rate adjustments to determine if the variable rate
process is being effectively implemented and whether the
variable rate process minimizes unnecessary detailed
recordkeeping and meets recipient needs.
Sec. 17. Minnesota Statutes 1999 Supplement, section
256B.77, subdivision 8, is amended to read:
Subd. 8. [RESPONSIBILITIES OF THE COUNTY ADMINISTRATIVE
ENTITY.] (a) The county administrative entity shall meet the
requirements of this subdivision, unless the county authority or
the commissioner, with written approval of the county authority,
enters into a service delivery contract with a service delivery
organization for any or all of the requirements contained in
this subdivision.
(b) The county administrative entity shall enroll eligible
individuals regardless of health or disability status.
(c) The county administrative entity shall provide all
enrollees timely access to the medical assistance benefit set.
Alternative services and additional services are available to
enrollees at the option of the county administrative entity and
may be provided if specified in the personal support plan.
County authorities are not required to seek prior authorization
from the department as required by the laws and rules governing
medical assistance.
(d) The county administrative entity shall cover necessary
services as a result of an emergency without prior
authorization, even if the services were rendered outside of the
provider network.
(e) The county administrative entity shall authorize
necessary and appropriate services when needed and requested by
the enrollee or the enrollee's legal representative in response
to an urgent situation. Enrollees shall have 24-hour access to
urgent care services coordinated by experienced disability
providers who have information about enrollees' needs and
conditions.
(f) The county administrative entity shall accept the
capitation payment from the commissioner in return for the
provision of services for enrollees.
(g) The county administrative entity shall maintain
internal grievance and complaint procedures, including an
expedited informal complaint process in which the county
administrative entity must respond to verbal complaints within
ten calendar days, and a formal grievance process, in which the
county administrative entity must respond to written complaints
within 30 calendar days.
(h) The county administrative entity shall provide a
certificate of coverage, upon enrollment, to each enrollee and
the enrollee's legal representative, if any, which describes the
benefits covered by the county administrative entity, any
limitations on those benefits, and information about providers
and the service delivery network. This information must also be
made available to prospective enrollees. This certificate must
be approved by the commissioner.
(i) The county administrative entity shall present evidence
of an expedited process to approve exceptions to benefits,
provider network restrictions, and other plan limitations under
appropriate circumstances.
(j) The county administrative entity shall provide
enrollees or their legal representatives with written notice of
their appeal rights under subdivision 16, and of ombudsman and
advocacy programs under subdivisions 13 and 14, at the following
times: upon enrollment, upon submission of a written complaint,
when a service is reduced, denied, or terminated, or when
renewal of authorization for ongoing service is refused.
(k) The county administrative entity shall determine
immediate needs, including services, support, and assessments,
within 30 calendar days after enrollment, or within a shorter
time frame if specified in the intergovernmental contract.
(l) The county administrative entity shall assess the need
for services of new enrollees within 60 calendar days after
enrollment, or within a shorter time frame if specified in the
intergovernmental contract, and periodically reassess the need
for services for all enrollees.
(m) The county administrative entity shall ensure the
development of a personal support plan for each person within 60
calendar days of enrollment, or within a shorter time frame if
specified in the intergovernmental contract, unless otherwise
agreed to by the enrollee and the enrollee's legal
representative, if any. Until a personal support plan is
developed and agreed to by the enrollee, enrollees must have
access to the same amount, type, setting, duration, and
frequency of covered services that they had at the time of
enrollment unless other covered services are needed. For an
enrollee who is not receiving covered services at the time of
enrollment and for enrollees whose personal support plan is
being revised, access to the medical assistance benefit set must
be assured until a personal support plan is developed or
revised. If an enrollee chooses not to develop a personal
support plan, the enrollee will be subject to the network and
prior authorization requirements of the county administrative
entity or service delivery organization 60 days after
enrollment. An enrollee can choose to have a personal support
plan developed at any time. The personal support plan must be
based on choices, preferences, and assessed needs and strengths
of the enrollee. The service coordinator shall develop the
personal support plan, in consultation with the enrollee or the
enrollee's legal representative and other individuals requested
by the enrollee. The personal support plan must be updated as
needed or as requested by the enrollee. Enrollees may choose
not to have a personal support plan.
(n) The county administrative entity shall ensure timely
authorization, arrangement, and continuity of needed and covered
supports and services.
(o) The county administrative entity shall offer service
coordination that fulfills the responsibilities under
subdivision 12 and is appropriate to the enrollee's needs,
choices, and preferences, including a choice of service
coordinator.
(p) The county administrative entity shall contract with
schools and other agencies as appropriate to provide otherwise
covered medically necessary medical assistance services as
described in an enrollee's individual family support plan, as
described in sections 125A.26 to 125A.48, or individual
education plan, as described in chapter 125A.
(q) The county administrative entity shall develop and
implement strategies, based on consultation with affected
groups, to respect diversity and ensure culturally competent
service delivery in a manner that promotes the physical, social,
psychological, and spiritual well-being of enrollees and
preserves the dignity of individuals, families, and their
communities.
(r) When an enrollee changes county authorities, county
administrative entities shall ensure coordination with the
entity that is assuming responsibility for administering the
medical assistance benefit set to ensure continuity of supports
and services for the enrollee.
(s) The county administrative entity shall comply with
additional requirements as specified in the intergovernmental
contract.
(t) To the extent that alternatives are approved under
subdivision 17, county administrative entities must provide for
the health and safety of enrollees and protect the rights to
privacy and to provide informed consent.
(u) Prepaid health plans serving counties with a nonprofit
community clinic or community health services agency must
contract with the clinic or agency to provide services to
clients who choose to receive services from the clinic or
agency, if the clinic or agency agrees to payment rates that are
competitive with rates paid to other health plan providers for
the same or similar services.
For purposes of this paragraph, "nonprofit community
clinic" includes, but is not limited to, a community mental
health center as defined in sections 245.62 and 256B.0625,
subdivision 5.
Sec. 18. [EFFECTIVE DATE.]
Section 6, amending section 256B.0625, subdivision 19a, is
effective the day following final enactment.
Presented to the governor May 11, 2000
Signed by the governor May 15, 2000, 10:27 a.m.
Official Publication of the State of Minnesota
Revisor of Statutes