256B.071 Medicare maximization program.
Subdivision 1. Definition. (a) "Dual entitlees" means recipients eligible for either the medical assistance program or the alternative care program who are also eligible for the federal Medicare program.
(b) For purposes of this section, "home care services" means home health agency services, private duty nursing services, personal care assistant services, waivered services, alternative care program services, hospice services, rehabilitation therapy services, and suppliers of medical supplies and equipment.
Subd. 2. Technical assistance to providers. (a) The commissioner shall establish a technical assistance program to require providers of services and equipment under this section to maximize collections from the federal Medicare program. The technical assistance may include the provision of materials to help providers determine those services and equipment likely to be reimbursed by Medicare. The technical assistance may also include the provision of computer software to providers to assist in this process. The commissioner may expand the technical assistance program to include providers of other services under this chapter.
(b) Any provider of home care services enrolled in the medical assistance program, or county public health nursing agency responsible for personal care assessments, or county case managers for alternative care or medical assistance waiver programs, is required to use the method developed and supplied by the department of human services for determining Medicare coverage for home care equipment and services provided to dual entitlees to ensure appropriate billing of Medicare. The method will be developed in two phases; the first phase is a manual system effective July 1, 1996, and the second phase will automate the manual procedure by expanding the current Medicaid Management Information System (MMIS) effective January 1, 1997. Both methods will determine Medicare coverage for the dates of service and Medicare coverage for home care services, and create an audit trail including reports. Both methods will be linked to prior authorization, therefore, either method must be used before home care services are authorized and when there is a change of condition affecting medical assistance authorization. The department will conduct periodic reviews of participant performance with the method and upon demonstrating appropriate referral and billing of Medicare, participants may be determined exempt from regular performance audits.
Subd. 3. Referrals to Medicare providers required. Non-Medicare certified home care providers and medical suppliers that do not participate or accept Medicare assignment must refer and document the referral of dual eligible recipients to Medicare providers when Medicare is determined to be the appropriate payer for services and supplies and equipment. Providers will be terminated from participation in the medical assistance program for failure to make such referrals.
Subd. 4. Medicare certification requirement. Medicare certification is required of all medical assistance enrolled home care service providers as required under Title XIX of the Social Security Act.
Subd. 5. Advisory committee. The commissioner shall establish an advisory committee comprised of home care services recipients, providers, county public health nurses, home care and county nursing associations, and department of human services staff to make recommendations to the Medicare maximization program. The recommendations shall include: nursing practice issues as they relate to home care services funded by Medicare and medical assistance; and streamlining assessment, prior authorization, and up-front payer determination processes to achieve administrative efficiencies.
* NOTE: Subdivision 3, as added by Laws 1996, chapter 451, *article 2, section 22, is effective upon federal approval. Laws *1996, chapter 451, article 2, section 62.