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9506.0080 COVERED HEALTH SERVICES.

Subpart 1.

Covered health services.

Health services covered by MinnesotaCare include the services listed in Minnesota Statutes, section 256L.03.

Subp. 2.

Inpatient hospital services.

A.

Enrollees are covered for medically necessary inpatient hospital services including acute care services, mental health services, and chemical dependency services.

B.

MinnesotaCare benefits for inpatient hospital services for adult enrollees are limited to $10,000 per calendar year. No benefit limit for inpatient hospital services applies to children.

C.

To be reimbursed under MinnesotaCare for inpatient hospital services provided to enrollees, eligible providers must comply with:

(1)

parts 9500.1090 to 9500.1140 and Minnesota Statutes, sections 256.9685, 256.9686, 256.969, and 256.9695, governing inpatient hospital payment rates for medical assistance;

(2)

parts 9505.0170 and 9505.0475 and Minnesota Statutes, section 256L.03, subdivisions 1 to 5, establishing standards for services covered by medical assistance;

(3)

parts 9505.5000 to 9505.5030 and Minnesota Statutes, section 256B.0625, subdivision 25, requiring prior authorization for certain services; and

(4)

parts 9505.0540 and 9505.5035 to 9505.5105, governing second surgical opinions.

Subp. 3.

Hospital admission certification.

Inpatient hospital admissions of enrollees, including admission of a pregnant woman that results in the delivery of a newborn or a stillbirth or an admission where the principal diagnosis or procedure is an inpatient dental procedure, must be certified in accordance with the medical assistance certification criteria in parts 9505.0501 to 9505.0540, except for admissions:

A.

approved under Medicare; or

B.

authorized under parts 9530.6600 to 9530.6655.

Subp. 4.

Cost avoidance.

The commissioner shall use cost avoidance techniques to ensure benefit coordination for enrollees, including items A to C.

A.

MinnesotaCare coverage for covered health services is secondary to other health coverage for which enrollees are eligible, except for coverage under the consolidated chemical dependency treatment fund.

B.

Coverage by all potential third-party payers must be exhausted before MinnesotaCare payment for covered health services will be made. An eligible provider must attempt to collect payment from potential third-party payers before billing the department for a covered health service.

C.

Private accident and health care coverage must be used according to the rules of the specific health plan. MinnesotaCare shall not pay for services that would have been covered by the primary health coverage if the applicable rules of that health coverage had been followed.

Subp. 5.

Lien.

When the department provides, pays for, or becomes liable for covered health services, the department has a lien for the cost of care upon any and all causes of action accruing to the enrollee, or to the enrollee's legal representatives, as a result of the occurrence necessitating payment for covered health services. All liens under this subpart are governed by Minnesota Statutes, section 256.015.

Statutory Authority:

MS s 256.9352; 256L.02

History:

19 SR 1286

Published Electronically:

January 14, 2010