Minnesota Administrative Rules

9506.0300 HEALTH PLAN SERVICES; PAYMENT.

Subpart 1.

Covered services; additional health services.

Except as provided in subparts 2 and 3, a health plan must provide and pay for all covered health services listed in Minnesota Statutes, section 256L.03. A health plan may offer enrollees additional health services that are not covered by MinnesotaCare.

Subp. 2.

Payment for inpatient hospital services.

The commissioner may contract with a health plan for inpatient hospital services for enrollees on either a risk or a nonrisk basis.

A.

If the commissioner contracts with a health plan for inpatient hospital services on a nonrisk basis:

(1)

except as authorized under subpart 3, the health plan must require enrollees to receive inpatient hospital services from participating providers;

(2)

the health plan must comply with units (a) to (c) when arranging inpatient hospital services for enrollees:

(a)

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;

(b)

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

(c)

part 9506.0080, subpart 3, governing hospital admission certification;

(3)

the department shall pay for inpatient hospital services according to part 9506.0080, subpart 2, and shall make payment to the health plan to pass through to the hospital;

(4)

the hospital shall collect from adult enrollees required MinnesotaCare copayments and costs not covered by MinnesotaCare or medical assistance; and

(5)

the health plan must report enrollee inpatient hospital admissions to the department within 30 days after the admission date, in a form prescribed by the department.

B.

If the commissioner contracts with a health plan for inpatient hospital services on a risk basis:

(1)

except as authorized under subpart 3, the health plan must require enrollees to receive inpatient hospital services from participating providers;

(2)

the health plan shall pay for all inpatient hospital services for children and up to the annual benefit limit established for adult enrollees;

(3)

the hospital shall collect from adult enrollees required MinnesotaCare copayments and costs not covered by MinnesotaCare or medical assistance; and

(4)

the health plan must report enrollee inpatient hospital admissions to the department within 30 days after the admission date, in a form prescribed by the department.

Subp. 3.

Payment for out-of-plan services.

A.

A health plan is not liable for payment for health services provided enrollees by providers not participating in the health plan, except, a health plan must pay for:

(1)

enrollee emergency services, as defined in Minnesota Statutes, section 256B.0625, subdivision 4;

(2)

any other health services required under the contract with the department or by law; and

(3)

out-of-plan services authorized by the health plan or a participating provider; the health plan is not required to pay more than the rate under part 9506.0090, subpart 2, for authorized out-of-plan services unless another payment rate is required by law.

B.

The department is not liable to nonparticipating providers for payment for health services.

Subp. 4.

Enrollee costs.

Except for copayments required under Minnesota Statutes, section 256L.03, subdivision 5, and inpatient hospital charges that exceed the MinnesotaCare benefit limit, enrollees are not liable for any costs for covered services or for authorized out-of-plan services.

Subp. 5.

Payment to health plans.

A.

Payments to health plans for covered health services for enrollees shall be prospective, per capita payments, made on an actuarially sound basis as determined by the commissioner; except, the commissioner may allow health plans to arrange for inpatient hospital services on a risk or nonrisk basis as provided in subpart 2.

B.

By the tenth day of each month, the commissioner shall prepay the health plan the capitation rate specified in the contract.

C.

The department shall make payment rates and contracts with health plans available to the public upon request.

Statutory Authority:

MS s 256.9352; 256.9363; 256L.02; 256L.12

History:

20 SR 495

Published Electronically:

October 16, 2013