Minnesota Administrative Rules

CHAPTER 4688, ESSENTIAL COMMUNITY PROVIDERS

DEPARTMENT OF HEALTH

4688.0001 STATUTORY AUTHORITY.

Parts 4688.0001 to 4688.0160 are authorized by Minnesota Statutes, section 62Q.19. Parts 4688.0001 to 4688.0160 must be read in conjunction with all applicable federal and state, constitutional, treaty, statutory, and rule provisions which govern the Indian Health Service, service units and facilities, and Indian tribal governments. Nothing in parts 4688.0001 to 4688.0160 is intended to interfere with the sovereignty of Indian tribal governments, including the manner in which they provide, pay for, or charge for health care services.

Statutory Authority:

MS s 62Q.19

History:

21 SR 6

Published Electronically:

September 26, 1997

4688.0005 INCORPORATION BY REFERENCE.

The CPT 95 codes referenced in parts 4688.0020, item C, 4688.0040, subpart 6, and 4688.0160, item G, are incorporated by reference and are contained in the Physicians' Current Procedural Terminology, (CPT 95) 4th edition, 1994. It is subject to frequent change. It is published by and may be purchased from the American Medical Association, Order Department: SPO54195NW, OPO54195NQ, LPO54195NW, P.O. Box 10950, Chicago, Illinois 60610. It is available through the Minitex interlibrary loan system.

Statutory Authority:

MS s 62Q.19

History:

21 SR 6

Published Electronically:

September 26, 1997

4688.0010 DEFINITIONS.

Subpart 1.

Scope.

For the purposes of this chapter, the terms defined in Minnesota Statutes, section 62Q.01, and this part have the meanings given them.

Subp. 2.

Child care.

"Child care" means those services or facilities that are appropriate to care for, supervise, or otherwise safely accommodate children.

Subp. 3.

Culturally sensitive and competent services.

"Culturally sensitive and competent services" means the ability to provide services that are receptive and sensitive to cultural differences as well as the awareness of behavior particular to a specific culture and the ability to carry out professional activities consistent with this awareness.

Subp. 4.

Essential community provider or ECP.

"Essential community provider" or "ECP" means an entity that has demonstrated the ability to integrate appropriate supportive and stabilizing services with medical services for uninsured persons, high risk and special needs populations, and underserved and other special needs populations.

Subp. 5.

High risk and special needs populations.

"High risk and special needs populations" has the meaning given in Minnesota Statutes, section 62Q.07, subdivision 2, paragraph (e).

Subp. 6.

Linguistic services.

"Linguistic services" means translation services and interpreter services that are appropriate to facilitate communication.

Subp. 7.

Local government unit.

"Local government unit" has the meaning given in Minnesota Statutes, section 62D.02, subdivision 11.

Subp. 8.

Sliding fee schedule.

"Sliding fee schedule" means a schedule of fee reductions designed to provide assistance to low income clients based on federal poverty guidelines and family size.

Subp. 9.

Transportation services.

"Transportation services" means those services that are appropriate to enable an ECP's clients to access health care from it.

Statutory Authority:

MS s 62Q.19

History:

21 SR 6

Published Electronically:

September 26, 1997

4688.0020 APPLICATION.

An application for ECP designation shall be made on forms provided by the commissioner. The applicant shall provide all of the information described in items A to G.

A.

The name of the applicant's contact person and that person's address and telephone number.

B.

The applicant's status as either:

(1)

a local government unit, an Indian tribal government, the Indian Health Service, a service unit or facility, or a community health board; or

(2)

evidence of Minnesota Statutes, chapter 317A, nonprofit status, Internal Revenue Code, section 501(c)(3), tax exempt status, a copy of the applicant's current sliding fee schedule, and evidence that the applicant does not restrict access or services because of the client's financial limitation.

C.

A list of medical services provided, by Current Procedural Terminology 95 (CPT 95) codes or categories of Current Procedural Terminology 95 (CPT 95) codes.

D.

Evidence of the applicant's capacity to provide medical services in a timely manner consistent with community norms, including the number and type of health professionals available and the applicant's appointment scheduling guidelines and procedures.

E.

A list of which of the following populations the applicant serves: uninsured persons, high risk and special needs populations, and underserved and other special needs populations. In addition, the applicant must provide:

(1)

the total number of clients falling within the populations served annually; and

(2)

what percent of the applicant's total patient population falls within those populations.

F.

A list of supportive and stabilizing services available including an explanation of how the need for services is assessed, how clients access the services, how these services are made available to clients in need of such services, and to what extent these services are used by clients. If specific supportive and stabilizing services are not available, an explanation of why the following services are unavailable or inappropriate for the specific populations served by the applicant:

(1)

transportation;

(2)

child care;

(3)

linguistic services;

(4)

culturally sensitive and competent services; and

(5)

other supportive and stabilizing services.

G.

Any other information requested by the commissioner that is reasonably necessary to determine whether the application should be granted or denied.

Statutory Authority:

MS s 62Q.19

History:

21 SR 6

Published Electronically:

September 26, 1997

4688.0030 APPLICATION FEE.

A nonrefundable application fee of $46 is required for each ECP application.

Statutory Authority:

MS s 62Q.19

History:

21 SR 6

Published Electronically:

September 26, 1997

4688.0040 CRITERIA FOR ECP DESIGNATION BY COMMISSIONER.

Subpart 1.

Generally.

Upon receipt of a completed application for ECP designation, the commissioner of health shall determine whether the applicant satisfies all of the criteria in this part.

Subp. 2.

Medical care.

The applicant must provide medical care to uninsured persons, high risk and special needs populations, and underserved and other special needs populations as follows:

A.

the applicant must have sufficient personnel and facilities to provide timely medical care to its clients, consistent with community norms;

B.

the applicant must have appointment scheduling guidelines that fall within community norms;

C.

average waiting times must fall within community norms; and

D.

the applicant must monitor appointment scheduling and waiting times and takes corrective action if times do not fall within community norms.

Subp. 3.

Supportive and stabilizing services.

The applicant must provide or coordinate the provision of supportive and stabilizing services for uninsured persons, high risk and special needs populations, and underserved and other special needs populations in a manner that is appropriate to the populations served by the applicant as identified in the application and to the geographic area served by the applicant and must include the criteria in items A to D. If the applicant provides related services other than those listed, or if the service is not appropriate for the applicant to provide, the applicant shall report this, and provide an explanation, to the commissioner.

A.

The applicant must provide at least one of the following transportation services:

(1)

coordination with community transportation services;

(2)

operation of bus or van service;

(3)

payment for public transportation services;

(4)

coordination with volunteer drivers; or

(5)

contracting with a licensed transportation vendor.

B.

The applicant must provide at least one of the following child care services:

(1)

coordination with a licensed day care provider;

(2)

coordination with an unlicensed day care provider who is exempt from the licensing requirements of applicable state law, including Minnesota Statutes, section 245A.03, subdivision 2;

(3)

provision of child care on site;

(4)

coordination with community child care services; or

(5)

permitting children to accompany parents during medical visits.

C.

The applicant must provide at least one of the following linguistic services:

(1)

coordination with community linguistic services;

(2)

coordination with certified interpreters;

(3)

coordination with qualified translators; or

(4)

professional and support staff who provide translation and interpretation services.

D.

The applicant must provide at least one of the following culturally sensitive and competent services options:

(1)

some professional staff are familiar with the cultural background of clients; or

(2)

provision of preservice and in-service training for all professional and support staff on cultural awareness and health issues affecting high risk and special needs clients.

Subp. 4.

Integration of supportive and stabilizing services with medical care.

The applicant must have developed and implemented a plan to identify the need for supportive and stabilizing services and to enable clients to access these services as available and appropriate in a timely manner.

Subp. 5.

Fees.

Only nonprofit entities are required to utilize a sliding fee schedule. The applicant's sliding fee schedule must meet all of the following criteria:

A.

it has been adopted by the applicant's governing body;

B.

it is based on current federal poverty level guidelines and family size;

C.

the applicant informs its clients of the availability of the sliding fee schedule; and

D.

free care is available as needed in specific instances.

Subp. 6.

Services provided.

The applicant must list the medical services it provides by CPT 95 codes or groups of CPT 95 codes.

Subp. 7.

Basis for ECP designation.

The applicant must provide evidence that it satisfies the criteria under Minnesota Statutes, section 62Q.19, subdivision 1.

Subp. 8.

Federal qualification.

An applicant that has been designated a federally qualified health center or a rural health clinic under applicable federal regulations may attach a copy of the information it provided to the federal agency that addresses any of the information required under subparts 2 to 7, and so indicate in the ECP application.

Statutory Authority:

MS s 62Q.19

History:

21 SR 6

Published Electronically:

September 26, 1997

4688.0050 REQUIREMENTS FOR CONTRACTS WITH HEALTH PLAN COMPANIES.

A health plan company that contracts with providers shall offer a provider contract to all designated ECPs located within the health plan company's approved service area. An ECP shall agree to serve, with or without a contract, all health plan companies within whose approved service area the ECP is located. The provider contract shall be the same or substantially similar to those offered to health plan providers who provide the same type or category of services, unless the parties mutually agree to a different contract. The provider contract shall include all of the services designated by the commissioner to the extent the services are covered under any health plan company certificate of coverage. Every provider contract between a designated ECP and a health maintenance organization or community integrated service network shall contain the provisions of Minnesota Statutes, section 62D.123. Designation of an applicant as an ECP shall not directly or indirectly require a health plan company to contract with a related organization that is affiliated with the designated ECP but is neither designated nor eligible for designation as an ECP. For the purposes of parts 4688.0001 to 4688.0160, "related organization" has the meaning given in Minnesota Statutes, section 317A.011, subdivision 18.

Statutory Authority:

MS s 62Q.19

History:

21 SR 6; L 1997 c 225 art 2 s 62

Published Electronically:

September 26, 1997

4688.0060 REFUSAL TO CONTRACT.

A health plan company shall give written notice to the ECP of the basis for refusal to contract. A designated ECP that has been refused a provider contract may use the dispute resolution methods available under Minnesota Statutes, section 62Q.11.

Statutory Authority:

MS s 62Q.19

History:

21 SR 6

Published Electronically:

September 26, 1997

4688.0070 PAYMENT.

The negotiated rate of payment between an ECP and a health plan company may be cost-based, fee-for-service, capitated, or other risk-sharing arrangement, unless the parties mutually agree to a different rate of payment. An ECP may be capitated only to the extent, and in the same manner, as other health plan company providers are capitated for the same or similar services. An ECP may file a complaint with the commissioner according to Minnesota Statutes, section 62Q.19, if it believes that the negotiated rate is not the same rate per unit of services as is paid to other health plan company providers for the same or similar services. An ECP that has been refused a provider contract because of inability to agree on the rate of payment may use the dispute resolution methods available under Minnesota Statutes, section 62Q.11.

Statutory Authority:

MS s 62Q.19

History:

21 SR 6

Published Electronically:

September 26, 1997

4688.0080 INFORMATION TO ENROLLEES.

A health plan company shall inform its enrollees that designated ECPs are available to provide designated services to uninsured persons, high risk and special needs populations, and underserved and other special needs populations. The health plan company shall clearly inform enrollees how to access services at an ECP, including which services require prior authorization, and how to obtain prior authorization. Enrollees shall be provided with a toll-free telephone number to call the member services section of the health plan company with questions about access to ECPs.

Statutory Authority:

MS s 62Q.19

History:

21 SR 6

Published Electronically:

September 26, 1997

4688.0090 PRIOR AUTHORIZATION.

A health plan company may require prior authorization for services provided by an ECP only to the same extent that it requires prior authorization for these services from other health plan providers. A health plan company shall not impose any additional or different prior authorization requirements or standards for services provided by an ECP than it does for the same services if provided by other health plan company providers.

Statutory Authority:

MS s 62Q.19

History:

21 SR 6

Published Electronically:

September 26, 1997

4688.0100 OTHER PROVIDERS.

A health plan company may make other providers available to its high risk and special needs populations, and underserved and other special needs populations, for any and all services provided by an ECP. Nothing in this chapter requires that high risk and special needs populations, and underserved and other special needs populations be served exclusively by designated ECPs.

Statutory Authority:

MS s 62Q.19

History:

21 SR 6

Published Electronically:

September 26, 1997

4688.0110 COVERAGE.

Designation of a service included in a contract between an ECP and a health plan company as an ECP service does not require a health plan company to cover that service. Designation of an entity as an ECP does not add benefits to an enrollee's certificate of coverage.

Statutory Authority:

MS s 62Q.19

History:

21 SR 6

Published Electronically:

September 26, 1997

4688.0120 CONFLICT OF INTEREST.

A conflict of interest may arise when a local government unit owns a health plan and also owns and operates an ECP. In these circumstances, if an enrollee files a complaint against the health plan or the ECP, the local government unit shall:

A.

fully disclose in writing to every complainant that the health plan and the ECP are both owned and operated by local government unit;

B.

clearly explain in writing to every complainant that there is the potential for a conflict of interest when local government unit is both the provider and the contractor of the health service; and

C.

offer every complainant the option of filing the complaint with the appropriate state agency rather than with the health plan.

Statutory Authority:

MS s 62Q.19

History:

21 SR 6

Published Electronically:

September 26, 1997

4688.0130 PRIMARY CARE CLINIC.

An ECP may be designated a primary care clinic by a health plan company.

Statutory Authority:

MS s 62Q.19

History:

21 SR 6

Published Electronically:

September 26, 1997

4688.0140 RESTRICTIONS ON SERVICES.

Minnesota Statutes, section 62Q.14, applies to the extent an ECP provides the services designated in that statute.

If a health plan company has a contract with an ECP, it may impose copayments only to the same extent and in the same manner that it imposes copayments for these services from other plan providers.

Statutory Authority:

MS s 62Q.19

History:

21 SR 6

Published Electronically:

September 26, 1997

4688.0150 PENALTIES.

Upon being designated an ECP by the commissioner, the entity must continue to operate in compliance with the standards in this chapter and Minnesota Statutes, section 62Q.19.

Noncompliance may result in the imposition of a fine, or in suspension, modification, or revocation of the ECP designation in accordance with Minnesota Statutes, section 62Q.19.

Statutory Authority:

MS s 62Q.19

History:

21 SR 6

Published Electronically:

September 26, 1997

4688.0160 ANNUAL REPORTS.

Every ECP shall file an annual report with the commissioner on or before April 15. Except as otherwise provided by this part, the report shall be on forms prescribed by the commissioner and shall include all of the following information:

A.

verification of tax exempt status under Internal Revenue Code, section 501(c)(3), and Minnesota Statutes, chapter 317A, if appropriate;

B.

a copy of the sliding fee schedule currently in effect, if appropriate;

C.

transportation options currently available to clients, if appropriate;

D.

child care options currently available to clients, if appropriate;

E.

linguistic service options currently available to clients, if appropriate;

F.

culturally sensitive and competent services currently available to clients, if appropriate;

G.

medical services currently being provided reported by CPT 95 codes or groups of CPT 95 codes;

H.

the number of clients served during the previous 12 months who were uninsured, members of high risk and special needs populations, and members of underserved and other special needs populations; and

I.

any other information requested by the commissioner that is reasonably necessary to determine whether the entity continues to qualify for ECP designation.

An ECP that is a community health board as defined in Minnesota Statutes, chapter 145A, may attach a copy of the documentation provided to the Department of Health in the annual report for community health boards, including the maternal child health report, that provides the information required under one or more of items A to I. The ECP must indicate in the ECP annual report that the community health board annual report is being submitted in full or partial satisfaction of the requirements of this part.

Statutory Authority:

MS s 62Q.19

History:

21 SR 6

Published Electronically:

September 26, 1997