Minnesota Administrative Rules

9506.0200 PREPAID MINNESOTACARE PROGRAM; GENERAL.

Subpart 1.

Designation of geographic area.

The commissioner shall designate geographic areas in which enrollees must receive covered health services through a managed care health plan.

A.

In designating geographic areas, the commissioner shall consider area size, size of the population to be served, accessibility of health services, the availability of health plans, and any other factors necessary to provide the most economical care consistent with high medical standards.

B.

The commissioner shall implement either a multiple health plan model or a single health plan model in a designated geographic area.

(1)

A multiple health plan model is a health services delivery system in which more than one managed care health plan is offered to enrollees in the geographic area.

(2)

A single health plan model is a health services delivery system in which only one health plan is available to enrollees in the geographic area.

C.

The commissioner may limit the number of health plans with which the department contracts within a designated geographic area, taking into consideration:

(1)

the number of enrollees within the designated geographic area;

(2)

the number of potential health plan contractors;

(3)

the size of the provider network offered by health plans;

(4)

the health services offered by a health plan;

(5)

qualifications of health plan personnel;

(6)

accessibility of services to enrollees;

(7)

health plan assurances of enrollee confidentiality;

(8)

health plan marketing and enrollment activities;

(9)

health plan compliance with parts 9506.0010 to 9506.0400;

(10)

health plan performance under other contracts with the department to serve MinnesotaCare enrollees and medical assistance or general assistance medical care recipients; or

(11)

any other factors necessary to provide the most economical care consistent with high medical standards.

Subp. 2.

Contracts.

Contracts between the department and a health plan to provide covered services to enrollees must:

A.

require the health plan to serve medical assistance recipients and general assistance medical care recipients;

B.

comply with the requirements of United States Code, title 42, section 1396a(a)(23)(B), prohibiting the health plan from restricting enrollee access to family planning services, and Minnesota Statutes, section 62Q.14; and

C.

permit the commissioner to terminate the contract upon 90 days notice to the health plan.

Subp. 3.

Multiple health plan model areas.

After the department has executed contracts with health plans to provide covered health services in a multiple health plan model area, the department or an entity under contract with the department shall:

A.

inform applicants and enrollees, in writing, of available health plans, when written notice of health plan selection must be submitted to the department, and when health plan participation begins;

B.

randomly assign to a health plan enrollees who fail to notify the department in writing of their health plan choice; and

C.

notify enrollees, in writing, of their assigned health plan before the effective date of the enrollee's health plan participation.

Subp. 4.

Single health plan model areas.

After the department has executed a contract with a health plan to provide covered health services as the sole health plan in a geographic area:

A.

the department shall assure that applicants and enrollees are informed, in writing, of participating providers in the health plan and when health plan participation begins;

B.

the health plan may require the enrollee to select a primary care provider and may assign to a primary care provider enrollees who fail to notify the health plan of their selection; and

C.

the health plan shall notify enrollees, in writing, of their assigned providers before the effective date of health plan participation.

Subp. 5.

Changing health plans or primary care providers.

A.

In multiple health plan model areas, enrollees may change health plans once within the first year the enrollee participates in a health plan. After the first year of health plan participation, enrollees may change health plans during the annual 30-day open enrollment period. The department or entity under contract with the department shall notify enrollees when the annual open enrollment period will occur.

B.

In single health plan model areas, enrollees may change primary care providers at least once during the first year of health plan participation. After the first year of health plan participation, enrollees may change primary care providers at least annually. The health plan shall notify enrollees of this change option.

C.

If a health plan's contract with the department is terminated for any reason, enrollees in that health plan shall select a new health plan and may change health plans or primary care providers within the first 60 days of participation in the second health plan.

D.

Enrollees may change health plans or primary care providers for cause as determined through an appeal under part 9506.0070 and as provided in subitems (1) and (2).

(1)

In multiple health plan model areas, enrollees may change health plans without a hearing if the travel time from the enrollee's residence to the enrollee's primary care provider is over 30 minutes or the enrollee's health plan was incorrectly designated due to department error. Requests for change under this subitem must be submitted to the department in writing. The department shall notify enrollees whether the request is approved or denied within 30 days after receipt of the written request.

(2)

In single health plan model areas, enrollees may change primary care provider without a hearing if the travel time from the enrollee's residence to the enrollee's primary care provider is over 30 minutes or the enrollee's primary care provider was incorrectly designated due to health plan error. Requests for change under this subitem must be submitted to the health plan in writing. The health plan shall notify enrollees whether the request is approved or denied within 30 days after receipt of the written request.

Subp. 6.

Family participation in a health plan.

All family members enrolled in MinnesotaCare must receive health services from the same health plan.

Statutory Authority:

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

History:

20 SR 495

Published Electronically:

February 2, 2005