1999 Minnesota Statutes

     256B.69 Prepayment demonstration project. 

    Subdivision 1.    Purpose.  The commissioner of human 
 services shall establish a medical assistance demonstration 
 project to determine whether prepayment combined with better 
 management of health care services is an effective mechanism to 
 ensure that all eligible individuals receive necessary health 
 care in a coordinated fashion while containing costs.  For the 
 purposes of this project, waiver of certain statutory provisions 
 is necessary in accordance with this section.  

    Subd. 2.    Definitions.  For the purposes of this 
 section, the following terms have the meanings given.  

    (a) "Commissioner" means the commissioner of human services.
 For the remainder of this section, the commissioner's 
 responsibilities for methods and policies for implementing the 
 project will be proposed by the project advisory committees and 
 approved by the commissioner.  

    (b) "Demonstration provider" means a health maintenance 
 organization, community integrated service network, or 
 accountable provider network authorized and operating under 
 chapter 62D, 62N, or 62T that participates in the demonstration 
 project according to criteria, standards, methods, and other 
 requirements established for the project and approved by the 
 commissioner.  Notwithstanding the above, Itasca county may 
 continue to participate as a demonstration provider until July 
 1, 2000. 

    (c) "Eligible individuals" means those persons eligible for 
 medical assistance benefits as defined in sections 256B.055, 
 256B.056, and 256B.06. 

    (d) "Limitation of choice" means suspending freedom of 
 choice while allowing eligible individuals to choose among the 
 demonstration providers.  

    (e) This paragraph supersedes paragraph (c) as long as the 
 Minnesota health care reform waiver remains in effect.  When the 
 waiver expires, this paragraph expires and the commissioner of 
 human services shall publish a notice in the State Register and 
 notify the revisor of statutes.  "Eligible individuals" means 
 those persons eligible for medical assistance benefits as 
 defined in sections 256B.055, 256B.056, and 256B.06.  
 Notwithstanding sections 256B.055, 256B.056, and 256B.06, an 
 individual who becomes ineligible for the program because of 
 failure to submit income reports or recertification forms in a 
 timely manner, shall remain enrolled in the prepaid health plan 
 and shall remain eligible to receive medical assistance coverage 
 through the last day of the month following the month in which 
 the enrollee became ineligible for the medical assistance 
 program. 

    Subd. 3.    Geographic area.  The commissioner shall 
 designate the geographic areas in which eligible individuals may 
 be included in the medical assistance prepayment programs. 

    Subd. 3a.    County authority.  (a) The commissioner, 
 when implementing the general assistance medical care, or 
 medical assistance prepayment program within a county, must 
 include the county board in the process of development, 
 approval, and issuance of the request for proposals to provide 
 services to eligible individuals within the proposed county.  
 County boards must be given reasonable opportunity to make 
 recommendations regarding the development, issuance, review of 
 responses, and changes needed in the request for proposals.  The 
 commissioner must provide county boards the opportunity to 
 review each proposal based on the identification of community 
 needs under chapters 145A and 256E and county advocacy 
 activities.  If a county board finds that a proposal does not 
 address certain community needs, the county board and 
 commissioner shall continue efforts for improving the proposal 
 and network prior to the approval of the contract.  The county 
 board shall make recommendations regarding the approval of local 
 networks and their operations to ensure adequate availability 
 and access to covered services.  The provider or health plan 
 must respond directly to county advocates and the state prepaid 
 medical assistance ombudsperson regarding service delivery and 
 must be accountable to the state regarding contracts with 
 medical assistance and general assistance medical care funds.  
 The county board may recommend a maximum number of participating 
 health plans after considering the size of the enrolling 
 population; ensuring adequate access and capacity; considering 
 the client and county administrative complexity; and considering 
 the need to promote the viability of locally developed health 
 plans.  The county board or a single entity representing a group 
 of county boards and the commissioner shall mutually select 
 health plans for participation at the time of initial 
 implementation of the prepaid medical assistance program in that 
 county or group of counties and at the time of contract renewal. 
 The commissioner shall also seek input for contract requirements 
 from the county or single entity representing a group of county 
 boards at each contract renewal and incorporate those 
 recommendations into the contract negotiation process.  The 
 commissioner, in conjunction with the county board, shall 
 actively seek to develop a mutually agreeable timetable prior to 
 the development of the request for proposal, but counties must 
 agree to initial enrollment beginning on or before January 1, 
 1999, in either the prepaid medical assistance and general 
 assistance medical care programs or county-based purchasing 
 under section 256B.692.  At least 90 days before enrollment in 
 the medical assistance and general assistance medical care 
 prepaid programs begins in a county in which the prepaid 
 programs have not been established, the commissioner shall 
 provide a report to the chairs of senate and house committees 
 having jurisdiction over state health care programs which 
 verifies that the commissioner complied with the requirements 
 for county involvement that are specified in this subdivision. 

    (b) The commissioner shall seek a federal waiver to allow a 
 fee-for-service plan option to MinnesotaCare enrollees.  The 
 commissioner shall develop an increase of the premium fees 
 required under section 256L.06 up to 20 percent of the premium 
 fees for the enrollees who elect the fee-for-service option.  
 Prior to implementation, the commissioner shall submit this fee 
 schedule to the chair and ranking minority member of the senate 
 health care committee, the senate health care and family 
 services funding division, the house of representatives health 
 and human services committee, and the house of representatives 
 health and human services finance division. 

    (c) At the option of the county board, the board may 
 develop contract requirements related to the achievement of 
 local public health goals to meet the health needs of medical 
 assistance and general assistance medical care enrollees.  These 
 requirements must be reasonably related to the performance of 
 health plan functions and within the scope of the medical 
 assistance and general assistance medical care benefit sets.  If 
 the county board and the commissioner mutually agree to such 
 requirements, the department shall include such requirements in 
 all health plan contracts governing the prepaid medical 
 assistance and general assistance medical care programs in that 
 county at initial implementation of the program in that county 
 and at the time of contract renewal.  The county board may 
 participate in the enforcement of the contract provisions 
 related to local public health goals. 

    (d) For counties in which prepaid medical assistance and 
 general assistance medical care programs have not been 
 established, the commissioner shall not implement those programs 
 if a county board submits acceptable and timely preliminary and 
 final proposals under section 256B.692, until county-based 
 purchasing is no longer operational in that county.  For 
 counties in which prepaid medical assistance and general 
 assistance medical care programs are in existence on or after 
 September 1, 1997, the commissioner must terminate contracts 
 with health plans according to section 256B.692, subdivision 5, 
 if the county board submits and the commissioner accepts 
 preliminary and final proposals according to that subdivision.  
 The commissioner is not required to terminate contracts that 
 begin on or after September 1, 1997, according to section 
 256B.692 until two years have elapsed from the date of initial 
 enrollment. 

    (e) In the event that a county board or a single entity 
 representing a group of county boards and the commissioner 
 cannot reach agreement regarding:  (i) the selection of 
 participating health plans in that county; (ii) contract 
 requirements; or (iii) implementation and enforcement of county 
 requirements including provisions regarding local public health 
 goals, the commissioner shall resolve all disputes after taking 
 into account the recommendations of a three-person mediation 
 panel.  The panel shall be composed of one designee of the 
 president of the association of Minnesota counties, one designee 
 of the commissioner of human services, and one designee of the 
 commissioner of health. 

    (f) If a county which elects to implement county-based 
 purchasing ceases to implement county-based purchasing, it is 
 prohibited from assuming the responsibility of county-based 
 purchasing for a period of five years from the date it 
 discontinues purchasing. 

    (g) Notwithstanding the requirement in this subdivision 
 that a county must agree to initial enrollment on or before 
 January 1, 1999, the commissioner shall grant a delay in the 
 implementation of the county-based purchasing authorized in 
 section 256B.692 until federal waiver authority and approval has 
 been granted, if the county or group of counties has submitted a 
 preliminary proposal for county-based purchasing by September 1, 
 1997, has not already implemented the prepaid medical assistance 
 program before January 1, 1998, and has submitted a written 
 request for the delay to the commissioner by July 1, 1998.  In 
 order for the delay to be continued, the county or group of 
 counties must also submit to the commissioner the following 
 information by December 1, 1998.  The information must: 

    (1) identify the proposed date of implementation, as 
 determined under section 256B.692, subdivision 5; 

    (2) include copies of the county board resolutions which 
 demonstrate the continued commitment to the implementation of 
 county-based purchasing by the proposed date.  County board 
 authorization may remain contingent on the submission of a final 
 proposal which meets the requirements of section 256B.692, 
 subdivision 5, paragraph (b); 

    (3) demonstrate actions taken for the establishment of a 
 governance structure between the participating counties and 
 describe how the fiduciary responsibilities of county-based 
 purchasing will be allocated between the counties, if more than 
 one county is involved in the proposal; 

    (4) describe how the risk of a deficit will be managed in 
 the event expenditures are greater than total capitation 
 payments.  This description must identify how any of the 
 following strategies will be used: 

    (i) risk contracts with licensed health plans; 

    (ii) risk arrangements with providers who are not licensed 
 health plans; 

    (iii) risk arrangements with other licensed insurance 
 entities; and 

    (iv) funding from other county resources; 

    (5) include, if county-based purchasing will not contract 
 with licensed health plans or provider networks, letters of 
 interest from local providers in at least the categories of 
 hospital, physician, mental health, and pharmacy which express 
 interest in contracting for services.  These letters must 
 recognize any risk transfer identified in clause (4), item (ii); 
 and 

    (6) describe the options being considered to obtain the 
 administrative services required in section 256B.692, 
 subdivision 3, clauses (3) and (5). 

    (h) For counties which receive a delay under this 
 subdivision, the final proposals required under section 
 256B.692, subdivision 5, paragraph (b), must be submitted at 
 least six months prior to the requested implementation date.  
 Authority to implement county-based purchasing remains 
 contingent on approval of the final proposal as required under 
 section 256B.692. 

    (i) If the commissioner is unable to provide 
 county-specific, individual-level fee-for-service claims to 
 counties by June 4, 1998, the commissioner shall grant a delay 
 under paragraph (g) of up to 12 months in the implementation of 
 county-based purchasing, and shall require implementation not 
 later than January 1, 2000.  In order to receive an extension of 
 the proposed date of implementation under this paragraph, a 
 county or group of counties must submit a written request for 
 the extension to the commissioner by August 1, 1998, must submit 
 the information required under paragraph (g) by December 1, 
 1998, and must submit a final proposal as provided under 
 paragraph (h). 

    (j) Notwithstanding other requirements of this subdivision, 
 the commissioner shall not require the implementation of the 
 county-based purchasing authorized in section 256B.692 until six 
 months after federal waiver approval has been obtained for 
 county-based purchasing, if the county or counties have 
 submitted the final plan as required in section 256B.692, 
 subdivision 5.  The commissioner shall allow the county or 
 counties which submitted information under section 256B.692, 
 subdivision 5, to submit supplemental or additional information 
 which was not possible to submit by April 1, 1999.  A county or 
 counties shall continue to submit the required information and 
 substantive detail necessary to obtain a prompt response and 
 waiver approval.  If amendments to the final plan are necessary 
 due to the terms and conditions of the waiver approval, the 
 commissioner shall allow the county or group of counties 60 days 
 to make the necessary amendments to the final plan and shall not 
 require implementation of the county-based purchasing until six 
 months after the revised final plan has been submitted. 

    Subd. 3b.    Provision of data to county boards.  The 
 commissioner, in consultation with representatives of county 
 boards of commissioners shall identify program information and 
 data necessary on an ongoing basis for county boards to:  (1) 
 make recommendations to the commissioner related to state 
 purchasing under the prepaid medical assistance program; and (2) 
 effectively administer county-based purchasing.  This 
 information and data must include, but is not limited to, 
 county-specific, individual-level fee-for-service and prepaid 
 health plan claims information. 

    Subd. 4.    Limitation of choice.  The commissioner 
 shall develop criteria to determine when limitation of choice 
 may be implemented in the experimental counties.  The criteria 
 shall ensure that all eligible individuals in the county have 
 continuing access to the full range of medical assistance 
 services as specified in subdivision 6.  The commissioner shall 
 exempt the following persons from participation in the project, 
 in addition to those who do not meet the criteria for limitation 
 of choice:  (1) persons eligible for medical assistance 
 according to section 256B.055, subdivision 1; (2) persons 
 eligible for medical assistance due to blindness or disability 
 as determined by the social security administration or the state 
 medical review team, unless:  (i) they are 65 years of age or 
 older, or (ii) they reside in Itasca county or they reside in a 
 county in which the commissioner conducts a pilot project under 
 a waiver granted pursuant to section 1115 of the Social Security 
 Act; (3) recipients who currently have private coverage through 
 a health maintenance organization; (4) recipients who are 
 eligible for medical assistance by spending down excess income 
 for medical expenses other than the nursing facility per diem 
 expense; (5) recipients who receive benefits under the Refugee 
 Assistance Program, established under United States Code, title 
 8, section 1522(e); (6) children who are both determined to be 
 severely emotionally disturbed and receiving case management 
 services according to section 256B.0625, subdivision 20; and (7) 
 adults who are both determined to be seriously and persistently 
 mentally ill and received case management services according to 
 section 256B.0625, subdivision 20.  Children under age 21 who 
 are in foster placement may enroll in the project on an elective 
 basis.  Individuals excluded under clauses (6) and (7) may 
 choose to enroll on an elective basis.  The commissioner may 
 allow persons with a one-month spenddown who are otherwise 
 eligible to enroll to voluntarily enroll or remain enrolled, if 
 they elect to prepay their monthly spenddown to the state.  
 Beginning on or after July 1, 1997, the commissioner may require 
 those individuals to enroll in the prepaid medical assistance 
 program who otherwise would have been excluded under clauses (1) 
 and (3) and under Minnesota Rules, part 9500.1452, subpart 2, 
 items H, K, and L.  Before limitation of choice is implemented, 
 eligible individuals shall be notified and after notification, 
 shall be allowed to choose only among demonstration providers.  
 The commissioner may assign an individual with private coverage 
 through a health maintenance organization, to the same health 
 maintenance organization for medical assistance coverage, if the 
 health maintenance organization is under contract for medical 
 assistance in the individual's county of residence.  After 
 initially choosing a provider, the recipient is allowed to 
 change that choice only at specified times as allowed by the 
 commissioner.  If a demonstration provider ends participation in 
 the project for any reason, a recipient enrolled with that 
 provider must select a new provider but may change providers 
 without cause once more within the first 60 days after 
 enrollment with the second provider. 

    Subd. 4a. Repealed, 1996 c 451 art 5 s 39 

    Subd. 4b.    Individual education plan and individualized 
 family service plan services.  The commissioner shall amend 
 the federal waiver allowing the state to separate out individual 
 education plan and individualized family service plan services 
 for children enrolled in the prepaid medical assistance program 
 and the MinnesotaCare program.  Effective July 1, 1999, or upon 
 federal approval, medical assistance coverage of eligible 
 individual education plan and individualized family service plan 
 services shall not be included in the capitated services for 
 children enrolled in health plans through the prepaid medical 
 assistance program and the MinnesotaCare program.  Upon federal 
 approval, local school districts shall bill the commissioner for 
 these services, and claims shall be paid on a fee-for-service 
 basis. 

    Subd. 5.    Prospective per capita payment.  The 
 commissioner shall establish the method and amount of payments 
 for services.  The commissioner shall annually contract with 
 demonstration providers to provide services consistent with 
 these established methods and amounts for payment.  

    If allowed by the commissioner, a demonstration provider 
 may contract with an insurer, health care provider, nonprofit 
 health service plan corporation, or the commissioner, to provide 
 insurance or similar protection against the cost of care 
 provided by the demonstration provider or to provide coverage 
 against the risks incurred by demonstration providers under this 
 section.  The recipients enrolled with a demonstration provider 
 are a permissible group under group insurance laws and chapter 
 62C, the Nonprofit Health Service Plan Corporations Act.  Under 
 this type of contract, the insurer or corporation may make 
 benefit payments to a demonstration provider for services 
 rendered or to be rendered to a recipient.  Any insurer or 
 nonprofit health service plan corporation licensed to do 
 business in this state is authorized to provide this insurance 
 or similar protection.  

    Payments to providers participating in the project are 
 exempt from the requirements of sections 256.966 and 256B.03, 
 subdivision 2.  The commissioner shall complete development of 
 capitation rates for payments before delivery of services under 
 this section is begun.  For payments made during calendar year 
 1990 and later years, the commissioner shall contract with an 
 independent actuary to establish prepayment rates. 

    By January 15, 1996, the commissioner shall report to the 
 legislature on the methodology used to allocate to participating 
 counties available administrative reimbursement for advocacy and 
 enrollment costs.  The report shall reflect the commissioner's 
 judgment as to the adequacy of the funds made available and of 
 the methodology for equitable distribution of the funds.  The 
 commissioner must involve participating counties in the 
 development of the report. 

    Subd. 5a.    Managed care contracts.  Managed care 
 contracts under this section and sections 256L.12 and 256D.03, 
 shall be entered into or renewed on a calendar year basis 
 beginning January 1, 1996.  Managed care contracts which were in 
 effect on June 30, 1995, and set to renew on July 1, 1995, shall 
 be renewed for the period July 1, 1995 through December 31, 1995 
 at the same terms that were in effect on June 30, 1995. 

    A prepaid health plan providing covered health services for 
 eligible persons pursuant to chapters 256B, 256D, and 256L, is 
 responsible for complying with the terms of its contract with 
 the commissioner.  Requirements applicable to managed care 
 programs under chapters 256B, 256D, and 256L, established after 
 the effective date of a contract with the commissioner take 
 effect when the contract is next issued or renewed. 

    Subd. 5b.    Prospective reimbursement rates.  (a) For 
 prepaid medical assistance and general assistance medical care 
 program contract rates set by the commissioner under subdivision 
 5 and effective on or after January 1, 1998, capitation rates 
 for nonmetropolitan counties shall on a weighted average be no 
 less than 88 percent of the capitation rates for metropolitan 
 counties, excluding Hennepin county.  The commissioner shall 
 make a pro rata adjustment in capitation rates paid to counties 
 other than nonmetropolitan counties in order to make this 
 provision budget neutral.  

    (b) For prepaid medical assistance program contract rates 
 set by the commissioner under subdivision 5 and effective on or 
 after January 1, 2001, capitation rates for nonmetropolitan 
 counties shall, on a weighted average, be no less than 89 
 percent of the capitation rates for metropolitan counties, 
 excluding Hennepin county. 

    Subd. 5c.    Medical education and research fund.  (a) 
 Beginning in January 1999 and each year thereafter: 

    (1) the commissioner of human services shall transfer an 
 amount equal to the reduction in the prepaid medical assistance 
 and prepaid general assistance medical care payments resulting 
 from clause (2), excluding nursing facility and elderly waiver 
 payments, to the medical education and research fund established 
 under section 62J.692; 

    (2) the county medical assistance and general assistance 
 medical care capitation base rate prior to plan specific 
 adjustments shall be reduced 6.3 percent for Hennepin county, 
 two percent for the remaining metropolitan counties, and 1.6 
 percent for nonmetropolitan Minnesota counties; and 

    (3) the amount calculated under clause (1) shall not be 
 adjusted for subsequent changes to the capitation payments for 
 periods already paid.  

    (b) This subdivision shall be effective upon approval of a 
 federal waiver which allows federal financial participation in 
 the medical education and research fund.  

    Subd. 5d.    Modification of payment dates effective 
 January 1, 2001.  Effective for services rendered on or after 
 January 1, 2001, capitation payments under this section and 
 under section 256D.03 shall be made no earlier than the first 
 day after the month of service. 

    Subd. 5e.    Medical education and research payments.  
 For the calendar years 1999, 2000, and 2001, a hospital that 
 participates in funding the federal share of the medical 
 education and research trust fund payment under Laws 1998, 
 chapter 407, article 1, section 3, shall not be held liable for 
 any amounts attributable to this payment above the charge limit 
 of section 256.969, subdivision 3a.  The commissioner of human 
 services shall assume liability for any corresponding federal 
 share of the payments above the charge limit. 

    Subd. 6.    Service delivery.  (a) Each demonstration 
 provider shall be responsible for the health care coordination 
 for eligible individuals.  Demonstration providers:  

    (1) shall authorize and arrange for the provision of all 
 needed health services including but not limited to the full 
 range of services listed in sections 256B.02, subdivision 8, and 
 256B.0625 in order to ensure appropriate health care is 
 delivered to enrollees; 

    (2) shall accept the prospective, per capita payment from 
 the commissioner in return for the provision of comprehensive 
 and coordinated health care services for eligible individuals 
 enrolled in the program; 

    (3) may contract with other health care and social service 
 practitioners to provide services to enrollees; and 

    (4) shall institute recipient grievance procedures 
 according to the method established by the project, utilizing 
 applicable requirements of chapter 62D.  Disputes not resolved 
 through this process shall be appealable to the commissioner as 
 provided in subdivision 11.  

    (b) Demonstration providers must comply with the standards 
 for claims settlement under section 72A.201, subdivisions 4, 5, 
 7, and 8, when contracting with other health care and social 
 service practitioners to provide services to enrollees.  A 
 demonstration provider must pay a clean claim, as defined in 
 Code of Federal Regulations, title 42, section 447.45(b), within 
 30 business days of the date of acceptance of the claim.  

    Subd. 6a.    Nursing home services.  (a) Notwithstanding 
 Minnesota Rules, part 9500.1457, subpart 1, item B, up to 90 
 days of nursing facility services as defined in section 
 256B.0625, subdivision 2, which are provided in a nursing 
 facility certified by the Minnesota department of health for 
 services provided and eligible for payment under Medicaid, shall 
 be covered under the prepaid medical assistance program for 
 individuals who are not residing in a nursing facility at the 
 time of enrollment in the prepaid medical assistance program.  

    (b) For individuals enrolled in the Minnesota senior health 
 options project authorized under subdivision 23, nursing 
 facility services shall be covered according to the terms and 
 conditions of the federal agreement governing that demonstration 
 project. 

    Subd. 6b.    Home and community-based waiver services.  
 (a) For individuals enrolled in the Minnesota senior health 
 options project authorized under subdivision 23, elderly waiver 
 services shall be covered according to the terms and conditions 
 of the federal agreement governing that demonstration project. 

    (b) For individuals under age 65 with physical disabilities 
 but without a primary diagnosis of mental illness or 
 developmental disabilities, except for related conditions, 
 enrolled in the Minnesota senior health options project 
 authorized under subdivision 23, home and community-based waiver 
 services shall be covered according to the terms and conditions 
 of the federal agreement governing that demonstration project. 

    Subd. 7.    Enrollee benefits.  All eligible individuals 
 enrolled by demonstration providers shall receive all needed 
 health care services as defined in subdivision 6.  

    All enrolled individuals have the right to appeal if 
 necessary services are not being authorized as defined in 
 subdivision 11.  

    Subd. 8.    Preadmission screening waiver.  Except as 
 applicable to the project's operation, the provisions of section 
 256B.0911 are waived for the purposes of this section for 
 recipients enrolled with demonstration providers.  

    Subd. 9.    Reporting.  Each demonstration provider 
 shall submit information as required by the commissioner, 
 including data required for assessing client satisfaction, 
 quality of care, cost, and utilization of services for purposes 
 of project evaluation.  The commissioner shall also develop 
 methods of data collection from county advocacy activities in 
 order to provide aggregate enrollee information on encounters 
 and outcomes to determine access and quality assurance.  
 Required information shall be specified before the commissioner 
 contracts with a demonstration provider. 

    Subd. 10.    Information.  Notwithstanding any law or 
 rule to the contrary, the commissioner may allow disclosure of 
 the recipient's identity solely for the purposes of (a) allowing 
 demonstration providers to provide the information to the 
 recipient regarding services, access to services, and other 
 provider characteristics, and (b) facilitating monitoring of 
 recipient satisfaction and quality of care.  The commissioner 
 shall develop and implement measures to protect recipients from 
 invasions of privacy and from harassment.  

    Subd. 11.    Appeals.  A recipient may appeal to the 
 commissioner a demonstration provider's delay or refusal to 
 provide services, according to section 256.045.  

    Subd. 12. Repealed, 1989 c 282 art 3 s 98 

    Subd. 13. Repealed, 1989 c 282 art 3 s 98 

    Subd. 14. Repealed, 1989 c 282 art 3 s 98 

    Subd. 15. Repealed, 1989 c 282 art 3 s 98 

    Subd. 16.    Project extension.  Minnesota Rules, parts 
 9500.1450; 9500.1451; 9500.1452; 9500.1453; 9500.1454; 
 9500.1455; 9500.1456; 9500.1457; 9500.1458; 9500.1459; 
 9500.1460; 9500.1461; 9500.1462; 9500.1463; and 9500.1464 are 
 extended.  

    Subd. 17.    Continuation of prepaid medical assistance. 
  The commissioner may continue the provisions of this section 
 after June 30, 1990, in any or all of the participating counties 
 if necessary federal authority is granted.  The commissioner may 
 adopt permanent rules to continue prepaid medical assistance in 
 these areas. 

    Subd. 18.    Services pending appeal.  If the recipient 
 appeals in writing to the state agency on or before the tenth 
 day after the decision of the prepaid health plan to reduce, 
 suspend, or terminate services which the recipient had been 
 receiving, and the treating physician or another plan physician 
 orders the services to be continued at the previous level, the 
 prepaid health plan must continue to provide services at a level 
 equal to the level ordered by the plan's physician until the 
 state agency renders its decision. 

    Subd. 19.    Limitation on reimbursement to providers not 
 affiliated with a prepaid health plan.  A prepaid health plan 
 may limit any reimbursement it may be required to pay to 
 providers not employed by or under contract with the prepaid 
 health plan to the medical assistance rates for medical 
 assistance enrollees, and the general assistance medical care 
 rates for general assistance medical care enrollees, paid by the 
 commissioner of human services to providers for services to 
 recipients not enrolled in a prepaid health plan. 

    Subd. 20.    Ombudsperson.  The commissioner shall 
 designate an ombudsperson to advocate for persons required to 
 enroll in prepaid health plans under this section.  The 
 ombudsperson shall advocate for recipients enrolled in prepaid 
 health plans through complaint and appeal procedures and ensure 
 that necessary medical services are provided either by the 
 prepaid health plan directly or by referral to appropriate 
 social services.  At the time of enrollment in a prepaid health 
 plan, the local agency shall inform recipients about the 
 ombudsperson program and their right to a resolution of a 
 complaint by the prepaid health plan if they experience a 
 problem with the plan or its providers. 

    Subd. 21.    Prepayment coordinator.  The county board 
 shall designate a prepayment coordinator to assist the state 
 agency in implementing this section and section 256D.03, 
 subdivision 4.  Assistance must include educating recipients 
 about available health care options, enrolling recipients under 
 subdivision 5, providing necessary eligibility and enrollment 
 information to health plans and the state agency, and 
 coordinating complaints and appeals with the ombudsman 
 established in subdivision 18. 

    Subd. 22.    Impact on public or teaching hospitals and 
 community clinics.  (a) Before implementing prepaid programs 
 in counties with a county operated or affiliated public teaching 
 hospital or a hospital or clinic operated by the University of 
 Minnesota, the commissioner shall consider the risks the prepaid 
 program creates for the hospital and allow the county or 
 hospital the opportunity to participate in the program, provided 
 the terms of participation in the program are competitive with 
 the terms of other participants. 

    (b) Prepaid health plans serving counties with a nonprofit 
 community clinic or community health services agency must 
 contract with the clinic or agency to provide services to 
 clients who choose to receive services from the clinic or 
 agency, if the clinic or agency agrees to payment rates that are 
 competitive with rates paid to other health plan providers for 
 the same or similar services. 

    (c) For purposes of this subdivision, "nonprofit community 
 clinic" includes, but is not limited to, a community mental 
 health center as defined in sections 245.62 and 256B.0625, 
 subdivision 5. 

    Subd. 23.    Alternative integrated long-term care 
 services; elderly and disabled persons.  (a) The commissioner 
 may implement demonstration projects to create alternative 
 integrated delivery systems for acute and long-term care 
 services to elderly and disabled persons that provide increased 
 coordination, improve access to quality services, and mitigate 
 future cost increases.  The commissioner may seek federal 
 authority to combine Medicare and Medicaid capitation payments 
 for the purpose of such demonstrations.  Medicare funds and 
 services shall be administered according to the terms and 
 conditions of the federal waiver and demonstration provisions.  
 For the purpose of administering medical assistance funds, 
 demonstrations under this subdivision are subject to 
 subdivisions 1 to 17.  The provisions of Minnesota Rules, parts 
 9500.1450 to 9500.1464, apply to these demonstrations, with the 
 exceptions of parts 9500.1452, subpart 2, item B; and 9500.1457, 
 subpart 1, items B and C, which do not apply to elderly persons 
 enrolling in demonstrations under this section.  An initial open 
 enrollment period may be provided.  Persons who disenroll from 
 demonstrations under this subdivision remain subject to 
 Minnesota Rules, parts 9500.1450 to 9500.1464.  When a person is 
 enrolled in a health plan under these demonstrations and the 
 health plan's participation is subsequently terminated for any 
 reason, the person shall be provided an opportunity to select a 
 new health plan and shall have the right to change health plans 
 within the first 60 days of enrollment in the second health 
 plan.  Persons required to participate in health plans under 
 this section who fail to make a choice of health plan shall not 
 be randomly assigned to health plans under these demonstrations. 
 Notwithstanding section 256L.12, subdivision 5, and Minnesota 
 Rules, part 9505.5220, subpart 1, item A, if adopted, for the 
 purpose of demonstrations under this subdivision, the 
 commissioner may contract with managed care organizations to 
 serve only elderly persons eligible for medical assistance, 
 elderly and disabled persons, or disabled persons only. 

    Before implementation of a demonstration project for 
 disabled persons, the commissioner must provide information to 
 appropriate committees of the house of representatives and 
 senate and must involve representatives of affected disability 
 groups in the design of the demonstration projects. 

    (b) A nursing facility reimbursed under the alternative 
 reimbursement methodology in section 256B.434 may, in 
 collaboration with a hospital, clinic, or other health care 
 entity provide services under paragraph (a).  The commissioner 
 shall amend the state plan and seek any federal waivers 
 necessary to implement this paragraph. 

    Subd. 24.  MS 1997 SUPP [Repealed, 1999 c 245 art 3 s 51] 

    Subd. 24.    Social service and public health costs.  
 The commissioner shall report on recommendations to the 
 legislature by January 15, 1997, identifying county social 
 services and public health administrative costs for each target 
 population that should be excluded from the overall capitation 
 rate. 

    Subd. 25.    Continuation of payments through discharge. 
  In the event a medical assistance recipient or beneficiary 
 enrolled in a health plan under this section is denied nursing 
 facility services after residing in the facility for more than 
 180 days, any denial of medical assistance payment to a provider 
 under this section shall be prospective only and payments to the 
 provider shall continue until the resident is discharged or 30 
 days after the effective date of the service denial, whichever 
 is sooner. 

    Subd. 26.    American Indian recipients.  (a) Beginning 
 on or after January 1, 1999, for American Indian recipients of 
 medical assistance who are required to enroll with a 
 demonstration provider under subdivision 4 or in a county-based 
 purchasing entity, if applicable, under section 256B.692, 
 medical assistance shall cover health care services provided at 
 Indian health services facilities and facilities operated by a 
 tribe or tribal organization under funding authorized by United 
 States Code, title 25, sections 450f to 450n, or title III of 
 the Indian Self-Determination and Education Assistance Act, 
 Public Law Number 93-638, if those services would otherwise be 
 covered under section 256B.0625.  Payments for services provided 
 under this subdivision shall be made on a fee-for-service basis, 
 and may, at the option of the tribe or tribal organization, be 
 made according to rates authorized under sections 256.969, 
 subdivision 16, and 256B.0625, subdivision 34.  Implementation 
 of this purchasing model is contingent on federal approval. 

    (b) The commissioner of human services, in consultation 
 with the tribal governments, shall develop a plan for tribes to 
 assist in the enrollment process for American Indian recipients 
 enrolled in the prepaid medical assistance program under this 
 section or the prepaid general assistance medical care program 
 under section 256D.03, subdivision 4, paragraph (d).  This plan 
 also shall address how tribes will be included in ensuring the 
 coordination of care for American Indian recipients between 
 Indian health service or tribal providers and other providers. 

    (c) For purposes of this subdivision, "American Indian" has 
 the meaning given to persons to whom services will be provided 
 for in Code of Federal Regulations, title 42, section 36.12. 

    (d) This subdivision also applies to American Indian 
 recipients of general assistance medical care and to the prepaid 
 general assistance medical care program under section 256D.03, 
 subdivision 4, paragraph (d). 

    Subd. 27.    Information for persons with limited 
 English-language proficiency.  Managed care contracts entered 
 into under this section and sections 256D.03, subdivision 4, 
 paragraph (d), and 256L.12 must require demonstration providers 
 to inform enrollees that upon request the enrollee can obtain a 
 certificate of coverage in the following languages:  Spanish, 
 Hmong, Laotian, Russian, Somali, Vietnamese, or Cambodian.  Upon 
 request, the demonstration provider must provide the enrollee 
 with a certificate of coverage in the specified language of 
 preference. 

    HIST: 1983 c 312 art 5 s 27; 1984 c 654 art 5 s 58; 1987 c 403 
 art 2 s 95-101; 1988 c 689 art 2 s 182,183,268; 1989 c 209 art 1 
 s 23; 1989 c 282 art 3 s 87-90; 1990 c 426 art 1 s 29; 1990 c 
 568 art 3 s 83,84; 1991 c 292 art 7 s 25; 1994 c 529 s 11; 1995 
 c 207 art 6 s 90-102; art 7 s 41; 1995 c 234 art 6 s 40,41; 1996 
 c 451 art 2 s 33-37; art 5 s 32; 1997 c 203 art 2 s 26; art 4 s 
 48-55; 1998 c 407 art 3 s 17; art 4 s 44-48; 1999 c 159 s 53; 
 1999 c 245 art 2 s 38; art 3 s 37,38; art 4 s 70-75 

*   NOTE:  The amendment to subdivision 4 by Laws 1996, chapter 
*451, article 2, section 34, is effective the day following final 
*enactment and upon federal approval.  Laws 1996, chapter 451, 
*article 2, section 62, paragraphs (d) and (f). 

*   NOTE:  Subdivision 24, as enacted by Laws 1997, chapter 
*203, article 4, section 55, and repealed by Laws 1999, chapter 
*245, article 3, section 51, was inadvertently omitted from 
*Minnesota Statutes 1998.