2002 Minnesota Statutes

CHAPTER 256B. Medical assistance for needy persons

     256B.01 Policy.  

    Medical assistance for needy persons whose resources are 
 not adequate to meet the cost of such care is hereby declared to 
 be a matter of state concern.  To provide such care, a statewide 
 program of medical assistance, with free choice of vendor, is 
 hereby established.  

    HIST: Ex1967 c 16 s 1 

     256B.011 Policy for childbirth and abortion funding. 

    Between normal childbirth and abortion it is the policy of 
 the state of Minnesota that normal childbirth is to be given 
 preference, encouragement and support by law and by state 
 action, it being in the best interests of the well being and 
 common good of Minnesota citizens. 

    HIST: 1978 c 508 s 1 

     256B.02 Definitions. 

    Subdivision 1. Repealed, 1987 c 363 s 14 

    Subd. 2. Repealed, 1987 c 363 s 14 

    Subd. 3. Repealed, 1987 c 363 s 14 

    Subd. 4.  "Medical institution" means any licensed medical 
 facility that receives a license from the Minnesota health 
 department or department of human services or appropriate 
 licensing authority of this state, any other state, or a 
 Canadian province. 

    Subd. 5.  "State agency" means the commissioner of human 
 services. 

    Subd. 6.  "County agency" means a local social service 
 agency operating under and pursuant to the provisions of chapter 
 393. 

    Subd. 7.    Vendor of medical care.  (a) "Vendor of 
 medical care" means any person or persons furnishing, within the 
 scope of the vendor's respective license, any or all of the 
 following goods or services:  medical, surgical, hospital, 
 optical, visual, dental and nursing services; drugs and medical 
 supplies; appliances; laboratory, diagnostic, and therapeutic 
 services; nursing home and convalescent care; screening and 
 health assessment services provided by public health nurses as 
 defined in section 145A.02, subdivision 18; health care services 
 provided at the residence of the patient if the services are 
 performed by a public health nurse and the nurse indicates in a 
 statement submitted under oath that the services were actually 
 provided; and such other medical services or supplies provided 
 or prescribed by persons authorized by state law to give such 
 services and supplies.  The term includes, but is not limited 
 to, directors and officers of corporations or members of 
 partnerships who, either individually or jointly with another or 
 others, have the legal control, supervision, or responsibility 
 of submitting claims for reimbursement to the medical assistance 
 program.  The term only includes directors and officers of 
 corporations who personally receive a portion of the distributed 
 assets upon liquidation or dissolution, and their liability is 
 limited to the portion of the claim that bears the same 
 proportion to the total claim as their share of the distributed 
 assets bears to the total distributed assets.  

    (b) "Vendor of medical care" also includes any person who 
 is credentialed as a health professional under standards set by 
 the governing body of a federally recognized Indian tribe 
 authorized under an agreement with the federal government 
 according to United States Code, title 25, section 450f, to 
 provide health services to its members, and who through a tribal 
 facility provides covered services to American Indian people 
 within a contract health service delivery area of a Minnesota 
 reservation, as defined under Code of Federal Regulations, title 
 42, section 36.22. 

    (c) A federally recognized Indian tribe that intends to 
 implement standards for credentialing health professionals must 
 submit the standards to the commissioner of human services, 
 along with evidence of meeting, exceeding, or being exempt from 
 corresponding state standards.  The commissioner shall maintain 
 a copy of the standards and supporting evidence, and shall use 
 those standards to enroll tribal-approved health professionals 
 as medical assistance providers.  For purposes of this section, 
 "Indian" and "Indian tribe" mean persons or entities that meet 
 the definition in United States Code, title 25, section 450b. 

    Subd. 8.    Medical assistance; medical care.  "Medical 
 assistance" or "medical care" means payment of part or all of 
 the cost of the care and services identified in section 
 256B.0625, for eligible individuals whose income and resources 
 are insufficient to meet all of this cost.  

    Subd. 8a. Renumbered 256B.0625, subdivision 1 

    Subd. 8b. Renumbered 256B.0625, subd 2 

    Subd. 8c. Renumbered 256B.0625, subd 3 

    Subd. 8d. Renumbered 256B.0625, subd 4 

    Subd. 8e. Renumbered 256B.0625, subd 5 

    Subd. 8f. Renumbered 256B.0625, subd 6 

    Subd. 8g. Renumbered 256B.0625, subd 7 

    Subd. 8h. Renumbered 256B.0625, subd 8 

    Subd. 8i. Renumbered 256B.0625, subd 9 

    Subd. 8j. Renumbered 256B.0625, subd 10 

    Subd. 8k. Renumbered 256B.0625, subd 11 

    Subd. 8l. Renumbered 256B.0625, subd 12 

    Subd. 8m. Renumbered 256B.0625, subd 13 

    Subd. 8n. Renumbered 256B.0625, subd 14 

    Subd. 8o. Renumbered 256B.0625, subd 15 

    Subd. 8p. Renumbered 256B.0625, subd 16 

    Subd. 8q. Renumbered 256B.0625, subd 17 

    Subd. 8r. Renumbered 256B.0625, subd 18 

    Subd. 8s. Renumbered 256B.0625, subd 19 

    Subd. 8t. Renumbered 256B.0625, subd 20 

    Subd. 8u. Renumbered 256B.0625, subd 21 

    Subd. 8v. Renumbered 256B.0625, subd 22 

    Subd. 8w. Renumbered 256B.0625, subd 23 

    Subd. 8x. Renumbered 256B.0625, subd 24 

    Subd. 8y. Renumbered 256B.0625, subd 25 

    Subd. 9.  "Private health care coverage" means any plan 
 regulated by chapter 62A, 62C or 64B.  Private health care 
 coverage also includes any self-insurance plan providing health 
 care benefits. 

    Subd. 10.  "Automobile accident coverage" means any plan, 
 or that portion of a plan, regulated under chapter 65B, which 
 provides benefits for medical expenses incurred in an automobile 
 accident. 

    Subd. 11.  "Related condition" means that condition defined 
 in section 252.27, subdivision 1a. 

    Subd. 12.  "Third party payer" means a person, entity, or 
 agency or government program that has a probable obligation to 
 pay all or part of the costs of a medical assistance recipient's 
 health services. 

    Subd. 13.    Prepaid health plan.  "Prepaid health plan" 
 means a vendor who receives a capitation payment and assumes 
 financial risk for the provision of medical assistance services 
 under a contract with the commissioner. 

    Subd. 14.    Group health plan.  "Group health plan" 
 means any plan of, or contributed to by, an employer, including 
 a self-insured plan, to provide health care directly or 
 otherwise to the employer's employees, former employees, or the 
 families of the employees or former employees, and includes 
 continuation coverage pursuant to title XXII of the Public 
 Health Service Act, section 4980B of the Internal Revenue Code 
 of 1986, or title VI of the Employee Retirement Income Security 
 Act of 1974. 

    Subd. 15.    Cost-effective.  "Cost-effective" means 
 that the amount paid by the state for premiums, coinsurance, 
 deductibles, other cost-sharing obligations under a health 
 insurance plan, and other administrative costs is likely to be 
 less than the amount paid for an equivalent set of services paid 
 by medical assistance. 

    HIST: Ex1967 c 16 s 2; 1969 c 395 s 1; 1973 c 717 s 17; 1975 c 
 247 s 9; 1975 c 384 s 1; 1975 c 437 art 2 s 3; 1976 c 173 s 56; 
 1976 c 236 s 1; 1976 c 312 s 1; 1978 c 508 s 2; 1978 c 560 s 10; 
 1981 c 360 art 2 s 26,54; 1Sp1981 c 2 s 12; 1Sp1981 c 4 art 4 s 
 22; 3Sp1981 c 2 art 1 s 31; 1982 c 562 s 2; 1983 c 151 s 1,2; 
 1983 c 312 art 1 s 27; art 5 s 10; art 9 s 4; 1984 c 654 art 5 s 
 58; 1985 c 21 s 52-54; 1985 c 49 s 41; 1985 c 252 s 19,20; 
 1Sp1985 c 3 s 19; 1986 c 394 s 17; 1986 c 444; 1987 c 370 art 1 
 s 3; art 2 s 4; 1987 c 374 s 1; 1987 c 309 s 24; 1987 c 403 art 
 2 s 73,74; art 5 s 16; 1988 c 689 art 2 s 141,268; 1992 c 464 
 art 1 s 55; 1992 c 513 art 7 s 31,32; 1994 c 631 s 31; 2002 c 
 275 s 2 

     256B.03 Payments to vendors. 

    Subdivision 1.    General limit.  All payments for 
 medical assistance hereunder must be made to the vendor.  The 
 maximum payment for new vendors enrolled in the medical 
 assistance program after the base year shall be determined from 
 the average usual and customary charge of the same vendor type 
 enrolled in the base year. 

    Subd. 2. Repealed, 2000 c 449 s 15 

    Subd. 3.    Tribal purchasing model.  (a) 
 Notwithstanding subdivision 1 and sections 256B.0625 and 
 256D.03, subdivision 4, paragraph (i), the commissioner may make 
 payments to federally recognized Indian tribes with a 
 reservation in the state to provide medical assistance and 
 general assistance medical care to Indians, as defined under 
 federal law, who reside on or near the reservation.  The 
 payments may be made in the form of a block grant or other 
 payment mechanism determined in consultation with the tribe.  
 Any alternative payment mechanism agreed upon by the tribes and 
 the commissioner under this subdivision is not dependent upon 
 county or health plan agreement but is intended to create a 
 direct payment mechanism between the state and the tribe for the 
 administration of the medical assistance and general assistance 
 medical care programs, and for covered services.  

    (b) A tribe that implements a purchasing model under this 
 subdivision shall report to the commissioner at least annually 
 on the operation of the model.  The commissioner and the tribe 
 shall cooperatively determine the data elements, format, and 
 timetable for the report. 

    (c) For purposes of this subdivision, "Indian tribe" means 
 a tribe, band, or nation, or other organized group or community 
 of Indians that is recognized as eligible for the special 
 programs and services provided by the United States to Indians 
 because of their status as Indians and for which a reservation 
 exists as is consistent with Public Law Number 100-485, as 
 amended. 

    (d) Payments under this subdivision may not result in an 
 increase in expenditures that would not otherwise occur in the 
 medical assistance program under this chapter or the general 
 assistance medical care program under chapter 256D. 

    HIST: Ex1967 c 16 s 3; 1981 c 360 art 2 s 27,54; 1Sp1981 c 2 s 
 13; 1Sp1981 c 4 art 4 s 22; 3Sp1982 c 1 art 2 s 4; 1983 c 312 
 art 1 s 27; 1987 c 384 art 2 s 63; 1987 c 403 art 2 s 75; 1996 c 
 451 art 5 s 14; 1998 c 407 art 4 s 11 

*   NOTE:  Subdivision 3, as added by Laws 1996, chapter 451, 
*article 5, section 14, is effective October 1, 1996, or upon 
*receipt of any necessary federal approval, whichever date is 
*later.  Laws 1996, chapter 451, article 5, section 40.

     256B.031 Prepaid health plans. 

    Subdivision 1.    Contracts.  The commissioner may 
 contract with health insurers licensed and operating under 
 chapters 60A and 62A, nonprofit health service plans licensed 
 and operating under chapter 62C, health maintenance 
 organizations licensed and operating under chapter 62D, and 
 vendors of medical care and organizations participating in 
 prepaid programs under section 256D.03, subdivision 4, clause 
 (b), to provide medical services to medical assistance 
 recipients.  Notwithstanding any other law, health insurers may 
 enter into contracts with the commissioner under this section.  
 As a condition of the contract, health insurers and health 
 service plan corporations must agree to comply with the 
 requirements of section 62D.04, subdivision 1, clauses (a), (b), 
 (c), (d), and (f), and provide a complaint procedure that 
 satisfies the requirements of section 62D.11.  Nothing in this 
 section permits health insurers not licensed as health 
 maintenance organizations under chapter 62D to offer a prepaid 
 health plan as defined in section 256B.02, subdivision 12, to 
 persons other than those receiving medical assistance or general 
 assistance medical care under this section.  Contracts between 
 the commissioner and a prepaid health plan are exempt from the 
 set-aside and preference provisions of section 16C.16, 
 subdivisions 6, paragraph (a), and 7.  Contracts must specify 
 the services that are included in the per capita rate.  
 Contracts must specify those services that are to be eligible 
 for risk sharing between the prepaid health plan and the state.  
 Contracts must also state that payment must be made within 60 
 days after the month of coverage. 

    Subd. 2.    Services.  State contracts for these 
 services must assure recipients of at least the comprehensive 
 health services defined in sections 256B.02, subdivision 8, and 
 256B.0625, except services defined in section 256B.0625, 
 subdivisions 2, 5, 18, and 19a, and except services defined as 
 chemical dependency services and mental health services. 

    Contracts under this section must include provision for 
 assessing pregnant women to determine their risk of poor 
 pregnancy outcome.  Contracts must also include provision for 
 treatment of women found to be at risk of poor pregnancy outcome.

    Subd. 3.    Information required.  Prepaid health plans 
 under contract must provide information to the commissioner 
 according to the contract specifications.  The information must 
 include, at a minimum, the number of people receiving services, 
 the number of encounters, the types of services received, 
 evidence of an operating quality assurance program, and 
 information about the use of and actual recoveries of available 
 third-party resources.  A plan under contract to provide 
 services in a county must provide the county agency with the 
 most current listing of the health care providers whose services 
 are covered by the plan. 

    Subd. 4.    Prepaid health plan rates.  For payments 
 made during calendar year 1988, the monthly maximum allowable 
 rate established by the commissioner of human services for 
 payment to prepaid health plans must not exceed 90 percent of 
 the projected average monthly per capita fee-for-service medical 
 assistance costs for state fiscal year 1988 for recipients of 
 the aid to families with dependent children program formerly 
 codified in sections 256.72 to 256.87.  The base year for 
 projecting the average monthly per capita fee-for-service 
 medical assistance costs is state fiscal year 1986.  A maximum 
 allowable per capita rate must be established collectively for 
 Anoka, Carver, Dakota, Hennepin, Ramsey, St. Louis, Scott, and 
 Washington counties.  A separate maximum allowable per capita 
 rate must be established collectively for all other counties.  
 The maximum allowable per capita rate may be adjusted to reflect 
 utilization differences among eligible classes of recipients.  
 For payments made during calendar year 1989, the maximum 
 allowable rate must be calculated in the same way as 1988 rates, 
 except the base year is state fiscal year 1987.  For payments 
 made during calendar year 1990 and later years, the commissioner 
 shall consult with an independent actuary in establishing 
 prepayment rates, but shall retain final control over the rate 
 methodology.  Rates established for prepaid health plans must be 
 based on the services that the prepaid health plan provides 
 under contract with the commissioner.  

    Subd. 5.    Free choice limited.  (a) The commissioner 
 may require recipients of the Minnesota family investment 
 program to enroll in a prepaid health plan and receive services 
 from or through the prepaid health plan, with the following 
 exceptions: 

    (1) recipients who are refugees and whose health services 
 are reimbursed 100 percent by the federal government; and 

    (2) recipients who are placed in a foster home or 
 facility.  If placement occurs before the seventh day prior to 
 the end of any month, the recipient will be disenrolled from the 
 recipient's prepaid health plan effective the first day of the 
 following month.  If placement occurs after the seventh day 
 before the end of any month, that recipient will be disenrolled 
 from the prepaid health plan on the first day of the second 
 month following placement.  The prepaid health plan must provide 
 all services set forth in subdivision 2 during the interim 
 period. 

    Enrollment in a prepaid health plan is mandatory only when 
 recipients have a choice of at least two prepaid health plans.  

    (b) Recipients who become eligible on or after December 1, 
 1987, must choose a health plan within 30 days of the date 
 eligibility is determined.  At the time of application, the 
 local agency shall ask the recipient whether the recipient has a 
 primary health care provider.  If the recipient has not chosen a 
 health plan within 30 days but has provided the local agency 
 with the name of a primary health care provider, the local 
 agency shall determine whether the provider participates in a 
 prepaid health plan available to the recipient and, if so, the 
 local agency shall select that plan on the recipient's behalf.  
 If the recipient has not provided the name of a primary health 
 care provider who participates in an available prepaid health 
 plan, commissioner shall randomly assign the recipient to a 
 health plan.  

    (c) If possible, the local agency shall ask whether the 
 recipient has a primary health care provider and the procedures 
 under paragraph (b) shall apply.  If a recipient does not choose 
 a prepaid health plan by this date, the commissioner shall 
 randomly assign the recipient to a health plan.  

    (d) The commissioner shall request a waiver from the 
 federal Centers for Medicare and Medicaid Services to limit a 
 recipient's ability to change health plans to once every six or 
 12 months.  If such a waiver is obtained, each recipient must be 
 enrolled in the health plan for a minimum of six or 12 months.  
 A recipient may change health plans once within the first 60 
 days after initial enrollment. 

    (e) Women who are receiving medical assistance due to 
 pregnancy and later become eligible for the Minnesota family 
 investment program are not required to choose a prepaid health 
 plan until 60 days postpartum.  An infant born as a result of 
 that pregnancy must be enrolled in a prepaid health plan at the 
 same time as the mother. 

    (f) If third-party coverage is available to a recipient 
 through enrollment in a prepaid health plan through employment, 
 through coverage by the former spouse, or if a duty of support 
 has been imposed by law, order, decree, or judgment of a court 
 under section 518.551, the obligee or recipient shall 
 participate in the prepaid health plan in which the obligee has 
 enrolled provided that the commissioner has contracted with the 
 plan. 

    Subd. 6.    Ombudsman.  The commissioner shall designate 
 an ombudsman to advocate for persons required to enroll in 
 prepaid health plans under this section.  The ombudsman 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 ombudsman 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. 7.    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. 8.    Case management.  The commissioner shall 
 prepare a report to the legislature by January 1988, that 
 describes the issues involved in successfully implementing a 
 case management system in counties where the commissioner has 
 fewer than two prepaid health plans under contract to provide 
 health care services to eligible classes of recipients.  In the 
 report the commissioner shall address which health care 
 providers could be case managers, the responsibilities of the 
 case manager, the assumption of risk by the case manager, the 
 services to be provided either directly or by referral, 
 reimbursement concerns, federal waivers that may be required, 
 and other issues that may affect the quality and cost of care 
 under such a system. 

    Subd. 9.    Prepayment coordinator.  The local agency 
 shall designate a prepayment coordinator to assist the state 
 agency in implementing this section, section 256B.69, 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 6. 

    Subd. 10.    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. 

    Subd. 11.    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. 

    HIST: 1987 c 403 art 2 s 76; 1988 c 689 art 2 s 142,268; 1989 
 c 282 art 3 s 40; 1991 c 292 art 4 s 31,32; 1998 c 386 art 2 s 
 77; 1999 c 159 s 51,52; 2000 c 260 s 30; 2002 c 277 s 32 

     256B.035 Managed care. 

    The commissioner of human services may contract with public 
 or private entities or operate a preferred provider program to 
 deliver health care services to medical assistance, general 
 assistance medical care, and MinnesotaCare program recipients.  
 The commissioner may enter into risk-based and non-risk-based 
 contracts.  Contracts may be for the full range of health 
 services, or a portion thereof, for medical assistance and 
 general assistance medical care populations to determine the 
 effectiveness of various provider reimbursement and care 
 delivery mechanisms.  The commissioner may seek necessary 
 federal waivers and implement projects when approval of the 
 waivers is obtained from the Centers for Medicare and Medicaid 
 Services of the United States Department of Health and Human 
 Services. 

    HIST: 1990 c 568 art 3 s 20; 1992 c 513 art 7 s 33; 1995 c 234 
 art 8 s 56; 2002 c 277 s 32 

     256B.037 Prospective payment of dental services. 

    Subdivision 1.    Contract for dental services.  The 
 commissioner may conduct a demonstration project to contract, on 
 a prospective per capita payment basis, with an organization or 
 organizations licensed under chapter 62C, 62D, or 62N for the 
 provision of all dental care services beginning July 1, 1994, 
 under the medical assistance, general assistance medical care, 
 and MinnesotaCare programs, or when necessary waivers are 
 granted by the secretary of health and human services, whichever 
 occurs later.  The commissioner shall identify a geographic area 
 or areas, including both urban and rural areas, where access to 
 dental services has been inadequate, in which to conduct 
 demonstration projects.  The commissioner shall seek any federal 
 waivers or approvals necessary to implement this section from 
 the secretary of health and human services. 

    The commissioner may exclude from participation in the 
 demonstration project any or all groups currently excluded from 
 participation in the prepaid medical assistance program under 
 section 256B.69.  Except for persons excluded from participation 
 in the demonstration project, all persons who have been 
 determined eligible for medical assistance, general assistance 
 medical care and, if applicable, MinnesotaCare and reside in the 
 designated geographic areas are required to enroll in a dental 
 plan to receive their dental care services.  Except for 
 emergency services or out-of-plan services authorized by the 
 dental plan, recipients must receive their dental services from 
 dental care providers who are part of the dental plan provider 
 network.  

    The commissioner shall select either multiple dental plans 
 or a single dental plan in a designated area.  A dental plan 
 under contract with the department must serve both medical 
 assistance recipients and general assistance medical care 
 recipients in a designated geographic area and may serve 
 MinnesotaCare recipients.  The commissioner may limit the number 
 of dental plans with which the department contracts within a 
 designated geographic area, taking into consideration the number 
 of recipients within the designated geographic area; the number 
 of potential dental plan contractors; the size of the provider 
 network offered by dental plans; the dental care services 
 offered by a dental plan; qualifications of dental plan 
 personnel; accessibility of services to recipients; dental plan 
 assurances of recipient confidentiality; dental plan marketing 
 and enrollment activities; dental plan compliance with this 
 section; dental plan performance under other contracts with the 
 department to serve medical assistance, general assistance 
 medical care, or MinnesotaCare recipients; or any other factors 
 necessary to provide the most economical care consistent with 
 high standards of dental care.  

    For purposes of this section, "dental plan" means an 
 organization licensed under chapter 62C, 62D, or 62N that 
 contracts with the department to provide covered dental care 
 services to recipients on a prepaid capitation basis.  
 "Emergency services" has the meaning given in section 256B.0625, 
 subdivision 4.  "Multiple dental plan area" means a designated 
 area in which more than one dental plan is offered.  
 "Participating provider" means a dentist or dental clinic who is 
 employed by or under contract with a dental plan to provide 
 dental care services to recipients.  "Single dental plan area" 
 means a designated area in which only one dental plan is 
 available. 

    Subd. 1a.    Multiple dental plan areas.  After the 
 department has executed contracts with dental plans to provide 
 covered dental care services in a multiple dental plan area, the 
 department shall:  

    (1) inform applicants and recipients, in writing, of 
 available dental plans, when written notice of dental plan 
 selection must be submitted to the department, and when dental 
 plan participation begins; 

    (2) assign to a dental plan recipients who fail to notify 
 the department in writing of their dental plan choice; and 

    (3) notify recipients, in writing, of their assigned dental 
 plan before the effective date of the recipient's dental plan 
 participation.  

    Subd. 1b.    Single dental plan areas.  After the 
 department has executed a contract with a dental plan to provide 
 covered dental care services as the sole dental plan in a 
 geographic area, the provisions in paragraphs (a) to (c) apply.  

    (a) The department shall assure that applicants and 
 recipients are informed, in writing, of participating providers 
 in the dental plan and when dental plan participation begins.  

    (b) The dental plan may require the recipient to select a 
 specific dentist or dental clinic and may assign to a specific 
 dentist or dental clinic recipients who fail to notify the 
 dental plan of their selection.  

    (c) The dental plan shall notify recipients in writing of 
 their assigned providers before the effective date of dental 
 plan participation.  

    Subd. 1c.    Dental choice.  (a) In multiple dental plan 
 areas, recipients may change dental plans once within the first 
 year the recipient participates in a dental plan.  After the 
 first year of dental plan participation, recipients may change 
 dental plans during the annual 30-day open enrollment period.  

    (b) In single dental plan areas, recipients may change 
 their specific dentist or clinic at least once during the first 
 year of dental plan participation.  After the first year of 
 dental plan participation, recipients may change their specific 
 dentist or clinic at least once annually.  The dental plan shall 
 notify recipients of this change option.  

    (c) If a dental plan's contract with the department is 
 terminated for any reason, recipients in that dental plan shall 
 select a new dental plan and may change dental plans or a 
 specific dentist or clinic within the first 60 days of 
 participation in the second dental plan.  

    (d) Recipients may change dental plans or a specific 
 dentist or clinic at any time as follows:  

    (1) in multiple dental plan areas, if the travel time from 
 the recipient's residence to a general practice dentist is over 
 30 minutes, the recipient may change dental plans; 

    (2) in single dental plan areas, if the travel time from 
 the recipient's residence to the recipient's specific dentist or 
 clinic is over 30 minutes, the recipient may change providers; 
 or 

    (3) if the recipient's dental plan or specific dentist or 
 clinic was incorrectly designated due to department or dental 
 plan error.  

    (e) Requests for change under this subdivision must be 
 submitted to the department or dental plan in writing.  The 
 department or dental plan shall notify recipients whether the 
 request is approved or denied within 30 days after receipt of 
 the written request. 

    Subd. 2.    Establishment of prepayment rates.  The 
 commissioner shall consult with an independent actuary to 
 establish prepayment rates, but shall retain final authority 
 over the methodology used to establish the rates.  The 
 prepayment rates shall not result in payments that exceed the 
 per capita expenditures that would have been made for dental 
 services by the programs under a fee-for-service reimbursement 
 system.  The package of dental benefits provided to individuals 
 under this subdivision shall not be less than the package of 
 benefits provided under the medical assistance fee-for-service 
 reimbursement system for dental services. 

    Subd. 3.    Appeals.  All recipients of services under 
 this section have the right to appeal to the commissioner under 
 section 256.045.  A recipient participating in a dental plan may 
 utilize the dental plan's internal complaint procedure but is 
 not required to exhaust the internal complaint procedure before 
 appealing to the commissioner.  The appeal rights and procedures 
 in Minnesota Rules, part 9500.1463, apply to recipients who 
 enroll in dental plans. 

    Subd. 4.    Information required by commissioner.  A 
 contractor shall submit encounter-specific information as 
 required by the commissioner, including, but not limited to, 
 information required for assessing client satisfaction, quality 
 of care, and cost and utilization of services.  Dental plans and 
 participating providers must provide the commissioner access to 
 recipient dental records to monitor compliance with the 
 requirements of this section.  

    Subd. 5.    Other contracts permitted.  Nothing in this 
 section prohibits the commissioner from contracting with an 
 organization for comprehensive health services, including dental 
 services, under section 256B.031, 256B.035, 256B.69, or 256D.03, 
 subdivision 4, paragraph (c). 

    Subd. 6.    Recipient costs.  A dental plan and its 
 participating providers or nonparticipating providers who 
 provide emergency services or services authorized by the dental 
 plan shall not charge recipients for any costs for covered 
 services.  

    Subd. 7.    Financial accountability.  A dental plan is 
 accountable to the commissioner for the fiscal management of 
 covered dental care services.  The state of Minnesota and 
 recipients shall be held harmless for the payment of obligations 
 incurred by a dental plan if the dental plan or a participating 
 provider becomes insolvent and the department has made the 
 payments due to the dental plan under the contract. 

    Subd. 8.    Quality improvement.  A dental plan shall 
 have an internal quality improvement system.  A dental plan 
 shall permit the commissioner or the commissioner's agents to 
 evaluate the quality, appropriateness, and timeliness of covered 
 dental care services through inspections, site visits, and 
 review of dental records.  

    Subd. 9.    Third-party liability.  To the extent 
 required under section 62A.046 and Minnesota Rules, part 
 9506.0080, a dental plan shall coordinate benefits for or 
 recover the cost of dental care services provided recipients who 
 have other dental care coverage.  Coordination of benefits 
 includes the dental plan paying applicable copayments or 
 deductibles on behalf of a recipient.  

    Subd. 10.    Financial capacity.  A dental plan shall 
 demonstrate that its financial risk capacity is acceptable to 
 its participating providers; except, an organization licensed as 
 a health maintenance organization under chapter 62D, a nonprofit 
 health service plan under chapter 62C, or a community integrated 
 service network under chapter 62N, is not required to 
 demonstrate financial risk capacity beyond the requirements in 
 those chapters for licensure or a certificate of authority.  

    Subd. 11.    Data privacy.  The contract between the 
 commissioner and the dental plan must specify that the dental 
 plan is an agent of the welfare system and shall have access to 
 welfare data on recipients to the extent necessary to carry out 
 the dental plan's responsibilities under the contract.  The 
 dental plan shall comply with chapter 13, the Minnesota 
 Government Data Practices Act. 

    HIST: 1Sp1993 c 1 art 5 s 27; 1995 c 234 art 6 s 22-33; 1997 c 
 203 art 9 s 9; 1997 c 225 art 2 s 62 

     256B.038 Provider rate increases after June 30, 1999. 

    (a) For fiscal years beginning on or after July 1, 1999, 
 the commissioner of finance shall include an annual inflationary 
 adjustment in payment rates for the services listed in paragraph 
 (b) as a budget change request in each biennial detailed 
 expenditure budget submitted to the legislature under section 
 16A.11.  The adjustment shall be accomplished by indexing the 
 rates in effect for inflation based on the change in the 
 Consumer Price Index-All Items (United States city 
 average)(CPI-U) as forecasted by Data Resources, Inc., in the 
 fourth quarter of the prior year for the calendar year during 
 which the rate increase occurs. 

    (b) Within the limits of appropriations specifically for 
 this purpose, the commissioner shall apply the rate increases in 
 paragraph (a) to home and community-based waiver services for 
 persons with mental retardation or related conditions under 
 section 256B.501; home and community-based waiver services for 
 the elderly under section 256B.0915; waivered services under 
 community alternatives for disabled individuals under section 
 256B.49; community alternative care waivered services under 
 section 256B.49; traumatic brain injury waivered services under 
 section 256B.49; nursing services and home health services under 
 section 256B.0625, subdivision 6a; personal care services and 
 nursing supervision of personal care services under section 
 256B.0625, subdivision 19a; private duty nursing services under 
 section 256B.0625, subdivision 7; day training and habilitation 
 services for adults with mental retardation or related 
 conditions under sections 252.40 to 252.46; physical therapy 
 services under sections 256B.0625, subdivision 8, and 256D.03, 
 subdivision 4; occupational therapy services under sections 
 256B.0625, subdivision 8a, and 256D.03, subdivision 4; 
 speech-language therapy services under section 256D.03, 
 subdivision 4, and Minnesota Rules, part 9505.0390; respiratory 
 therapy services under section 256D.03, subdivision 4, and 
 Minnesota Rules, part 9505.0295; physician services under 
 section 256B.0625, subdivision 3; dental services under sections 
 256B.0625, subdivision 9, and 256D.03, subdivision 4; 
 alternative care services under section 256B.0913; adult 
 residential program grants under Minnesota Rules, parts 
 9535.2000 to 9535.3000; adult and family community support 
 grants under Minnesota Rules, parts 9535.1700 to 9535.1760; and 
 semi-independent living services under section 252.275, 
 including SILS funding under county social services grants 
 formerly funded under chapter 256I. 

    (c) The commissioner shall increase prepaid medical 
 assistance program capitation rates as appropriate to reflect 
 the rate increases in this section. 

    (d) In implementing this section, the commissioner shall 
 consider proposing a schedule to equalize rates paid by 
 different programs for the same service. 

    HIST: 1998 c 407 art 4 s 12 

     256B.039 Reporting of supplemental nursing services 
  agency use. 

    Beginning March 1, 2002, the commissioner shall report to 
 the legislature annually on the use of supplemental nursing 
 services, including the number of hours worked by supplemental 
 nursing services agency personnel and payments to supplemental 
 nursing services agencies. 

    HIST: 1Sp2001 c 9 art 7 s 7; 2002 c 379 art 1 s 113 

     256B.04 Duties of state agency. 

    Subdivision 1.    General.  The state agency shall:  
 Supervise the administration of medical assistance for eligible 
 recipients by the county agencies hereunder. 

    Subd. 1a.    Comprehensive health services system.  The 
 commissioner shall carry out the duties in this section with the 
 participation of the boards of county commissioners, and with 
 full consideration for the interests of counties, to plan and 
 implement a unified, accountable, comprehensive health services 
 system that: 

    (1) promotes accessible and quality health care for all 
 Minnesotans; 

    (2) assures provision of adequate health care within 
 limited state and county resources; 

    (3) avoids shifting funding burdens to county tax 
 resources; 

    (4) provides statewide eligibility, benefit, and service 
 expectations; 

    (5) manages care, develops risk management strategies, and 
 contains cost in all health and human services; and 

    (6) supports effective implementation of publicly funded 
 health and human services for all areas of the state. 

    Subd. 1b.    Contract for administrative services for 
 American Indian children.  Notwithstanding subdivision 1, the 
 commissioner may contract with federally recognized Indian 
 tribes with a reservation in Minnesota for the provision of 
 early and periodic screening, diagnosis, and treatment 
 administrative services for American Indian children, according 
 to Code of Federal Regulations, title 42, section 441, subpart 
 B, and Minnesota Rules, part 9505.1693 et seq., when the tribe 
 chooses to provide such services.  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.  Notwithstanding Minnesota 
 Rules, part 9505.1748, subpart 1, the commissioner, the local 
 agency, and the tribe may contract with any entity for the 
 provision of early and periodic screening, diagnosis, and 
 treatment administrative services. 

    Subd. 2.    Rulemaking authority.  Make uniform rules, 
 not inconsistent with law, for carrying out and enforcing the 
 provisions hereof in an efficient, economical, and impartial 
 manner, and to the end that the medical assistance system may be 
 administered uniformly throughout the state, having regard for 
 varying costs of medical care in different parts of the state 
 and the conditions in each case, and in all things to carry out 
 the spirit and purpose of this program, which rules shall be 
 furnished immediately to all county agencies, and shall be 
 binding on such county agencies. 

    Subd. 3.    Required forms.  Prescribe the form of, 
 print, and supply to the county agencies, blanks for 
 applications, reports, affidavits, and such other forms as it 
 may deem necessary or advisable. 

    Subd. 4.    Cooperation with federal agency.  Cooperate 
 with the federal Centers for Medicare and Medicaid Services in 
 any reasonable manner as may be necessary to qualify for federal 
 aid in connection with the medical assistance program, including 
 the making of such reports in such form and containing such 
 information as the department of health, education, and welfare 
 may, from time to time, require, and comply with such provisions 
 as such department may, from time to time, find necessary to 
 assure the correctness and verifications of such reports. 

    Subd. 5.    Annual report required.  The state agency 
 within 60 days after the close of each fiscal year, shall 
 prepare and print for the fiscal year a report that includes a 
 full account of the operations and expenditure of funds under 
 this chapter, a full account of the activities undertaken in 
 accordance with subdivision 10, adequate and complete statistics 
 divided by counties about all medical assistance provided in 
 accordance with this chapter, and any other information it may 
 deem advisable. 

    Subd. 6.    Monthly statement.  Prepare and release a 
 summary statement monthly showing by counties the amount paid 
 hereunder and the total number of persons assisted. 

    Subd. 7.    Program safeguards.  Establish and enforce 
 safeguards to prevent unauthorized disclosure or improper use of 
 the information contained in applications, reports of 
 investigations and medical examinations, and correspondence in 
 the individual case records of recipients of medical assistance. 

    Subd. 8.    Information.  Furnish information to 
 acquaint needy persons and the public generally with the plan 
 for medical assistance of this state. 

    Subd. 9.    Reciprocal agreements.  Cooperate with 
 agencies in other states in establishing reciprocal agreements 
 to provide for payment of medical assistance to recipients who 
 have moved to another state, consistent with the provisions 
 hereof and of Title XIX of the Social Security Act of the United 
 States of America. 

    Subd. 10.    Investigation of certain claims.  Establish 
 by rule general criteria and procedures for the identification 
 and prompt investigation of suspected medical assistance fraud, 
 theft, abuse, presentment of false or duplicate claims, 
 presentment of claims for services not medically necessary, or 
 false statement or representation of material facts by a vendor 
 of medical care, and for the imposition of sanctions against a 
 vendor of medical care.  If it appears to the state agency that 
 a vendor of medical care may have acted in a manner warranting 
 civil or criminal proceedings, it shall so inform the attorney 
 general in writing. 

    Subd. 11. Repealed, 1997 c 7 art 2 s 67 

    Subd. 12.    Limitation on services.  Place limits on 
 the types of services covered by medical assistance, the 
 frequency with which the same or similar services may be covered 
 by medical assistance for an individual recipient, and the 
 amount paid for each covered service.  The state agency shall 
 promulgate rules establishing maximum reimbursement rates for 
 emergency and nonemergency transportation.  

    The rules shall provide:  

    (a) An opportunity for all recognized transportation 
 providers to be reimbursed for nonemergency transportation 
 consistent with the maximum rates established by the agency; 

    (b) Reimbursement of public and private nonprofit providers 
 serving the handicapped population generally at reasonable 
 maximum rates that reflect the cost of providing the service 
 regardless of the fare that might be charged by the provider for 
 similar services to individuals other than those receiving 
 medical assistance or medical care under this chapter; and 

    (c) Reimbursement for each additional passenger carried on 
 a single trip at a substantially lower rate than the first 
 passenger carried on that trip.  

    The commissioner shall encourage providers reimbursed under 
 this chapter to coordinate their operation with similar services 
 that are operating in the same community.  To the extent 
 practicable, the commissioner shall encourage eligible 
 individuals to utilize less expensive providers capable of 
 serving their needs.  

    For the purpose of this subdivision and section 256B.02, 
 subdivision 8, and effective on January 1, 1981, "recognized 
 provider of transportation services" means an operator of 
 special transportation service as defined in section 174.29 that 
 has been issued a current certificate of compliance with 
 operating standards of the commissioner of transportation or, if 
 those standards do not apply to the operator, that the agency 
 finds is able to provide the required transportation in a safe 
 and reliable manner.  Until January 1, 1981, "recognized 
 transportation provider" includes an operator of special 
 transportation service that the agency finds is able to provide 
 the required transportation in a safe and reliable manner.  

    Subd. 13.    Medical necessity review.  Each person 
 appointed by the commissioner to participate in decisions 
 whether medical care to be provided to eligible recipients is 
 medically necessary shall abstain from participation in those 
 cases in which the appointee(a) has issued treatment orders in 
 the care of the patient or participated in the formulation or 
 execution of the patient's treatment plan or (b) has, or a 
 member of the appointee's family has, an ownership interest of 
 five percent or more in the institution that provided or 
 proposed to provide the services being reviewed.  

    Subd. 14.    Competitive bidding.  When determined to be 
 effective, economical, and feasible, the commissioner may 
 utilize volume purchase through competitive bidding and 
 negotiation under the provisions of chapter 16C, to provide 
 items under the medical assistance program including but not 
 limited to the following: 

    (1) eyeglasses; 

    (2) oxygen.  The commissioner shall provide for oxygen 
 needed in an emergency situation on a short-term basis, until 
 the vendor can obtain the necessary supply from the contract 
 dealer; 

    (3) hearing aids and supplies; and 

    (4) durable medical equipment, including but not limited to:

    (a) hospital beds; 

    (b) commodes; 

    (c) glide-about chairs; 

    (d) patient lift apparatus; 

    (e) wheelchairs and accessories; 

    (f) oxygen administration equipment; 

    (g) respiratory therapy equipment; 

    (h) electronic diagnostic, therapeutic and life support 
 systems; 

    (5) special transportation services; and 

    (6) drugs. 

    Subd. 15.    Utilization review.  (1) Establish on a 
 statewide basis a new program to safeguard against unnecessary 
 or inappropriate use of medical assistance services, against 
 excess payments, against unnecessary or inappropriate hospital 
 admissions or lengths of stay, and against underutilization of 
 services in prepaid health plans, long-term care facilities or 
 any health care delivery system subject to fixed rate 
 reimbursement.  In implementing the program, the state agency 
 shall utilize both prepayment and postpayment review systems to 
 determine if utilization is reasonable and necessary.  The 
 determination of whether services are reasonable and necessary 
 shall be made by the commissioner in consultation with a 
 professional services advisory group or health care consultant 
 appointed by the commissioner.  

    (2) Contracts entered into for purposes of meeting the 
 requirements of this subdivision shall not be subject to the 
 set-aside provisions of chapter 16C. 

    (3) A recipient aggrieved by the commissioner's termination 
 of services or denial of future services may appeal pursuant to 
 section 256.045.  A vendor aggrieved by the commissioner's 
 determination that services provided were not reasonable or 
 necessary may appeal pursuant to the contested case procedures 
 of chapter 14.  To appeal, the vendor shall notify the 
 commissioner in writing within 30 days of receiving the 
 commissioner's notice.  The appeal request shall specify each 
 disputed item, the reason for the dispute, an estimate of the 
 dollar amount involved for each disputed item, the computation 
 that the vendor believes is correct, the authority in statute or 
 rule upon which the vendor relies for each disputed item, the 
 name and address of the person or firm with whom contacts may be 
 made regarding the appeal, and other information required by the 
 commissioner. 

    (4) The commissioner may select providers to provide case 
 management services to recipients who use health care services 
 inappropriately or to recipients who are eligible for other 
 managed care projects.  The providers shall be selected based 
 upon criteria that may include a comparison with a peer group of 
 providers related to the quality, quantity, or cost of health 
 care services delivered or a review of sanctions previously 
 imposed by health care services programs or the provider's 
 professional licensing board. 

    Subd. 16.    Personal care services.  (a) 
 Notwithstanding any contrary language in this paragraph, the 
 commissioner of human services and the commissioner of health 
 shall jointly promulgate rules to be applied to the licensure of 
 personal care services provided under the medical assistance 
 program.  The rules shall consider standards for personal care 
 services that are based on the World Institute on Disability's 
 recommendations regarding personal care services.  These rules 
 shall at a minimum consider the standards and requirements 
 adopted by the commissioner of health under section 144A.45, 
 which the commissioner of human services determines are 
 applicable to the provision of personal care services, in 
 addition to other standards or modifications which the 
 commissioner of human services determines are appropriate. 

    The commissioner of human services shall establish an 
 advisory group including personal care consumers and providers 
 to provide advice regarding which standards or modifications 
 should be adopted.  The advisory group membership must include 
 not less than 15 members, of which at least 60 percent must be 
 consumers of personal care services and representatives of 
 recipients with various disabilities and diagnoses and ages.  At 
 least 51 percent of the members of the advisory group must be 
 recipients of personal care. 

    The commissioner of human services may contract with the 
 commissioner of health to enforce the jointly promulgated 
 licensure rules for personal care service providers. 

    Prior to final promulgation of the joint rule the 
 commissioner of human services shall report preliminary findings 
 along with any comments of the advisory group and a plan for 
 monitoring and enforcement by the department of health to the 
 legislature by February 15, 1992. 

    Limits on the extent of personal care services that may be 
 provided to an individual must be based on the 
 cost-effectiveness of the services in relation to the costs of 
 inpatient hospital care, nursing home care, and other available 
 types of care.  The rules must provide, at a minimum:  

    (1) that agencies be selected to contract with or employ 
 and train staff to provide and supervise the provision of 
 personal care services; 

    (2) that agencies employ or contract with a qualified 
 applicant that a qualified recipient proposes to the agency as 
 the recipient's choice of assistant; 

    (3) that agencies bill the medical assistance program for a 
 personal care service by a personal care assistant and 
 supervision by a qualified professional supervising the personal 
 care assistant unless the recipient selects the fiscal agent 
 option under section 256B.0627, subdivision 10; 

    (4) that agencies establish a grievance mechanism; and 

    (5) that agencies have a quality assurance program.  

    (b) The commissioner may waive the requirement for the 
 provision of personal care services through an agency in a 
 particular county, when there are less than two agencies 
 providing services in that county and shall waive the 
 requirement for personal care assistants required to join an 
 agency for the first time during 1993 when personal care 
 services are provided under a relative hardship waiver under 
 section 256B.0627, subdivision 4, paragraph (b), clause (7), and 
 at least two agencies providing personal care services have 
 refused to employ or contract with the independent personal care 
 assistant. 

    Subd. 17.    Prenatal care outreach.  (a) The 
 commissioner of human services shall award a grant to an 
 eligible organization to conduct a statewide media campaign 
 promoting early prenatal care.  The goals of the campaign are to 
 increase public awareness of the importance of early and 
 continuous prenatal care and to inform the public about public 
 and private funds available for prenatal care. 

    (b) In order to receive a grant under this section, an 
 applicant must: 

    (1) have experience conducting prenatal care outreach; 

    (2) have an established statewide constituency or service 
 area; and 

    (3) demonstrate an ability to accomplish the purposes in 
 this subdivision. 

    (c) Money received under this subdivision may be used for 
 purchase of materials and supplies, staff fees and salaries, 
 consulting fees, and other goods and services necessary to 
 accomplish the goals of the campaign.  Money may not be used for 
 capital expenditures. 

    Subd. 18.    Applications for medical assistance.  The 
 state agency may take applications for medical assistance and 
 conduct eligibility determinations for MinnesotaCare enrollees. 

    Subd. 19.    Performance data reporting unit.  The 
 commissioner of human services shall establish a performance 
 data reporting unit that serves counties and the state.  The 
 department shall support this unit and provide technical 
 assistance and access to the data warehouse.  The performance 
 data reporting unit, which will operate within the department's 
 central office and consist of both county and department staff, 
 shall provide performance data reports to individual counties, 
 share expertise from counties and the department perspective, 
 and participate in joint planning to link with county databases 
 and other county data sources in order to provide information on 
 services provided to public clients from state, federal, and 
 county funding sources.  The performance data reporting unit 
 shall provide counties both individual and group summary level 
 standard or unique reports on health care eligibility and 
 services provided to clients for whom they have financial 
 responsibility. 

    HIST: Ex1967 c 16 s 4; 1976 c 273 s 1-3; 1977 c 185 s 1; 1977 
 c 347 s 39,40; 1978 c 560 s 11; Ex1979 c 1 s 46; 1980 c 349 s 
 3,4; 1982 c 640 s 3; 1983 c 312 art 5 s 11,12; 1984 c 640 s 32; 
 1985 c 248 s 70; 1Sp1985 c 9 art 2 s 37; 1986 c 444; 1987 c 378 
 s 15; 1987 c 403 art 2 s 77,78; 1988 c 532 s 13; 1989 c 282 art 
 3 s 41,42; 1990 c 568 art 3 s 21,22; 1991 c 292 art 7 s 8; 
 1Sp1993 c 1 art 5 s 28; 1995 c 233 art 2 s 56; 1995 c 234 art 6 
 s 34; 1997 c 7 art 1 s 101; 1997 c 203 art 4 s 18; 1998 c 386 
 art 2 s 78,79; 1998 c 407 art 5 s 2; 1999 c 245 art 4 s 26,27; 
 1Sp2001 c 9 art 2 s 14; 2002 c 277 s 32; 2002 c 379 art 1 s 113 

     256B.041 Centralized disbursement of medical assistance 
  payments. 

    Subdivision 1.    Statewide disbursement system.  The 
 state agency shall establish on a statewide basis a system for 
 the centralized disbursement of medical assistance payments to 
 vendors. 

    Subd. 2.    Account.  An account is established in the 
 state treasury from which medical assistance payments to vendors 
 shall be made.  Into this account there shall be deposited 
 federal funds, state funds, county funds, and other moneys which 
 are available and which may be paid to the state agency for 
 medical assistance payments and reimbursements from counties or 
 others for their share of such payments. 

    Subd. 3.    Vendor forms.  The state agency shall 
 prescribe and furnish vendors suitable forms for submitting 
 claims under the medical assistance program. 

    Subd. 4.    Comply with federal requirements.  The state 
 agency in establishing a statewide system of centralized 
 disbursement of medical assistance payments shall comply with 
 federal requirements in order to receive the maximum amount of 
 federal funds which are available for the purpose, together with 
 such additional federal funds which may be made available for 
 the operation of a centralized system of disbursement of medical 
 assistance payments to vendors. 

    Subd. 5.    Payment by county to state treasurer.  If 
 required by federal law or rules promulgated thereunder, or by 
 authorized rule of the state agency, each county shall pay to 
 the state treasurer the portion of medical assistance paid by 
 the state for which it is responsible.  

    The county shall advance medical assistance costs not met 
 by federal funds, based upon estimates submitted by the state 
 agency to the county agency, stating the estimated expenditures 
 for the succeeding month.  Upon the direction of the county 
 agency, payment shall be made monthly by the county to the state 
 for the estimated expenditures for each month.  Adjustment of 
 any overestimate or underestimate based on actual expenditures 
 shall be made by the state agency by adjusting the estimate for 
 any succeeding month. 

    Payment to counties under this subdivision is subject to 
 the provisions of section 256.017. 

    Subd. 6.    Contracted services.  The commissioners of 
 human services and administration may contract with any agency 
 of government or any corporation for providing all or a portion 
 of the services for carrying out the provisions of this 
 section.  Local welfare agencies may pay vendors of 
 transportation for nonemergency medical care when so authorized 
 by rule of the commissioner of human services. 

    Subd. 7.    Disbursement of federal funds.  Federal 
 funds available for administrative purposes shall be distributed 
 between the state and the county on the same basis that 
 reimbursements are earned, except as provided for under section 
 256.017. 

    HIST: 1973 c 717 s 2; 1975 c 437 art 2 s 4; 1978 c 560 s 12; 
 1983 c 312 art 5 s 13,14; 1984 c 654 art 5 s 58; 1985 c 248 s 
 70; 1988 c 719 art 8 s 11,12; 1989 c 277 art 2 s 7; 1Sp1989 c 1 
 art 16 s 6; 2002 c 277 s 9 

     256B.042 Third party liability. 

    Subdivision 1.    Lien for cost of care.  When the state 
 agency provides, pays for, or becomes liable for medical care, 
 it shall have a lien for the cost of the care upon any and all 
 causes of action or recovery rights under any policy, plan, or 
 contract providing benefits for health care or injury, which 
 accrue to the person to whom the care was furnished, or to the 
 person's legal representatives, as a result of the illness or 
 injuries which necessitated the medical care.  For purposes of 
 this section, "state agency" includes prepaid health plans under 
 contract with the commissioner according to sections 256B.69, 
 256D.03, subdivision 4, paragraph (d), and 256L.12; children's 
 mental health collaboratives under section 245.493; 
 demonstration projects for persons with disabilities under 
 section 256B.77; nursing facilities under the alternative 
 payment demonstration project under section 256B.434; and 
 county-based purchasing entities under section 256B.692.  

    Subd. 2.    Lien enforcement.  (a) The state agency may 
 perfect and enforce its lien by following the procedures set 
 forth in sections 514.69, 514.70 and 514.71, and its verified 
 lien statement shall be filed with the appropriate court 
 administrator in the county of financial responsibility.  The 
 verified lien statement shall contain the following:  the name 
 and address of the person to whom medical care was furnished, 
 the date of injury, the name and address of the vendor or 
 vendors furnishing medical care, the dates of the service, the 
 amount claimed to be due for the care, and, to the best of the 
 state agency's knowledge, the names and addresses of all 
 persons, firms, or corporations claimed to be liable for damages 
 arising from the injuries.  This section shall not affect the 
 priority of any attorney's lien.  

    (b) The state agency is not subject to any limitations 
 period referred to in section 514.69 or 514.71 and has one year 
 from the date notice is first received by it under subdivision 
 4, paragraph (c), even if the notice is untimely, or one year 
 from the date medical bills are first paid by the state agency, 
 whichever is later, to file its verified lien statement.  The 
 state agency may commence an action to enforce the lien within 
 one year of (1) the date the notice required by subdivision 4, 
 paragraph (c), is received or (2) the date the recipient's cause 
 of action is concluded by judgment, award, settlement, or 
 otherwise, whichever is later.  

    (c) If the notice required in subdivision 4 is not provided 
 by any of the parties to the claim at any stage of the claim, 
 the state agency will have one year from the date the state 
 agency learns of the lack of notice to commence an action.  If 
 amounts on the claim or cause of action are paid and the amount 
 required to be paid to the state agency under subdivision 5, is 
 not paid to the state agency, the state agency may commence an 
 action to recover on the lien against any or all of the parties 
 or entities which have either paid or received the payments. 

    Subd. 3.    Attorney general representation.  The 
 attorney general shall represent the commissioner to enforce the 
 lien created under this section or, if no action has been 
 brought, may initiate and prosecute an independent action on 
 behalf of the commissioner against a person, firm, or 
 corporation that may be liable to the person to whom the care 
 was furnished. 

    Any prepaid health plan providing services under sections 
 256B.69, 256D.03, subdivision 4, paragraph (d), and 256L.12; 
 children's mental health collaboratives under section 245.493; 
 demonstration projects for persons with disabilities under 
 section 256B.77; nursing homes under the alternative payment 
 demonstration project under section 256B.434; or the 
 county-based purchasing entity providing services under section 
 256B.692 may retain legal representation to enforce their lien 
 created under this section or, if no action has been brought, 
 may initiate and prosecute an independent action on their behalf 
 against a person, firm, or corporation that may be liable to the 
 person to whom the care or payment was furnished.  

    Subd. 4.    Notice.  The state agency must be given 
 notice of monetary claims against a person, firm, or corporation 
 that may be liable to pay part or all of the cost of medical 
 care when the state agency has paid or become liable for the 
 cost of that care.  Notice must be given as follows:  

    (a) Applicants for medical assistance shall notify the 
 state or local agency of any possible claims when they submit 
 the application.  Recipients of medical assistance shall notify 
 the state or local agency of any possible claims when those 
 claims arise. 

    (b) A person providing medical care services to a recipient 
 of medical assistance shall notify the state agency when the 
 person has reason to believe that a third party may be liable 
 for payment of the cost of medical care.  

    (c) A party to a claim upon which the state agency may be 
 entitled to a lien under this section shall notify the state 
 agency of its potential lien claim at each of the following 
 stages of a claim:  

    (1) when a claim is filed; 

    (2) when an action is commenced; and 

    (3) when a claim is concluded by payment, award, judgment, 
 settlement, or otherwise.  

 Every party involved in any stage of a claim under this 
 subdivision is required to provide notice to the state agency at 
 that stage of the claim.  However, when one of the parties to 
 the claim provides notice at that stage, every other party to 
 the claim is deemed to have provided the required notice at that 
 stage of the claim.  If the required notice under this paragraph 
 is not provided to the state agency, all parties to the claim 
 are deemed to have failed to provide the required notice.  A 
 party to a claim includes the injured person or the person's 
 legal representative, the plaintiff, the defendants, or persons 
 alleged to be responsible for compensating the injured person or 
 plaintiff, and any other party to the cause of action or claim, 
 regardless of whether the party knows the state agency has a 
 potential or actual lien claim. 

    Notice given to the local agency is not sufficient to meet 
 the requirements of paragraphs (b) and (c). 

    Subd. 5.    Costs deducted.  Upon any judgment, award, 
 or settlement of a cause of action, or any part of it, upon 
 which the state agency has filed its lien, including 
 compensation for liquidated, unliquidated, or other damages, 
 reasonable costs of collection, including attorney fees, must be 
 deducted first.  The full amount of medical assistance paid to 
 or on behalf of the person as a result of the injury must be 
 deducted next, and paid to the state agency.  The rest must be 
 paid to the medical assistance recipient or other plaintiff.  
 The plaintiff, however, must receive at least one-third of the 
 net recovery after attorney fees and other collection costs. 

    HIST: 1975 c 247 s 6; 1976 c 236 s 2; 1986 c 444; 1Sp1986 c 3 
 art 1 s 82; 1987 c 370 art 2 s 5-8; 1988 c 689 art 2 s 143; 
 1Sp1993 c 1 art 5 s 29; 1995 c 207 art 6 s 26; 1997 c 217 art 2 
 s 5-7; 1999 c 245 art 4 s 28-30 

     256B.05 Administration by county agencies. 

    Subdivision 1.    Administration of medical assistance.  
 The county agencies shall administer medical assistance in their 
 respective counties under the supervision of the state agency 
 and the commissioner of human services as specified in section 
 256.01, and shall make such reports, prepare such statistics, 
 and keep such records and accounts in relation to medical 
 assistance as the state agency may require under section 256.01, 
 subdivision 2, paragraph (17). 

    Subd. 2.    Fee or charges.  In administering the 
 medical assistance program, no local social services agency 
 shall pay a fee or charge for medical, dental, surgical, 
 hospital, nursing, licensed nursing home care, medicine, or 
 medical supplies in excess of the schedules of maximum fees and 
 charges as established by the state agency.  

    Subd. 3.    Maximum allowances.  Notwithstanding the 
 provisions of subdivision 2, the commissioner of human services 
 shall establish a schedule of maximum allowances to be paid by 
 the state on behalf of recipients of medical assistance toward 
 fees charged for services rendered such medical assistance 
 recipients.  

    Subd. 4. Repealed, 1987 c 403 art 2 s 164 

    HIST: Ex1967 c 16 s 5; 1971 c 961 s 28; 1982 c 640 s 4; 1984 c 
 580 s 3; 1984 c 654 art 5 s 58; 1988 c 719 art 8 s 13; 1989 c 89 
 s 10; 1994 c 631 s 31 

     256B.055 Eligibility categories. 

    Subdivision 1.    Children eligible for subsidized 
 adoption assistance.  Medical assistance may be paid for a 
 child eligible for or receiving adoption assistance payments 
 under title IV-E of the Social Security Act, United States Code, 
 title 42, sections 670 to 676, and to any child who is not title 
 IV-E eligible but who was determined eligible for adoption 
 assistance under Minnesota Statutes, section 259.67, subdivision 
 4, clauses (a) to (c), and has a special need for medical or 
 rehabilitative care. 

    Subd. 2.    Subsidized foster children.  Medical 
 assistance may be paid for a child eligible for or receiving 
 foster care maintenance payments under Title IV-E of the Social 
 Security Act, United States Code, title 42, sections 670 to 676. 

    Subd. 3.    AFDC families.  Until March 31, 1998, 
 medical assistance may be paid for a person who is eligible for 
 or receiving, or who would be eligible for, except for excess 
 income or assets, public assistance under the aid to families 
 with dependent children program in effect as of July 16, 1996, 
 as required by the Personal Responsibility and Work Opportunity 
 Reconciliation Act of 1996 (PRWORA), Public Law Number 104-193.  

    Subd. 3a.    Families with children.  Beginning July 1, 
 2002, medical assistance may be paid for a person who is a child 
 under the age of 18, or age 18 if a full-time student in a 
 secondary school, or in the equivalent level of vocational or 
 technical training, and reasonably expected to complete the 
 program before reaching age 19; the parent of a dependent child, 
 including a pregnant woman; or a caretaker relative of a 
 dependent child.  

    Subd. 4.    Recipients of Minnesota supplemental aid.  
 Medical assistance may be paid for a person who is receiving 
 public assistance under the Minnesota supplemental aid program. 

    Subd. 5.    Pregnant women; dependent unborn child.  
 Medical assistance may be paid for a pregnant woman who has 
 written verification of a positive pregnancy test from a 
 physician or licensed registered nurse, who meets the other 
 eligibility criteria of this section and who would be 
 categorically eligible for assistance under the state's AFDC 
 plan in effect as of July 16, 1996, as required by the Personal 
 Responsibility and Work Opportunity Reconciliation Act of 1996 
 (PRWORA), Public Law Number 104-193, if the child had been born 
 and was living with the woman.  For purposes of this 
 subdivision, a woman is considered pregnant for 60 days 
 postpartum. 

    Subd. 6.    Pregnant women; needy unborn child.  Medical 
 assistance may be paid for a pregnant woman who has written 
 verification of a positive pregnancy test from a physician or 
 licensed registered nurse, who meets the other eligibility 
 criteria of this section and whose unborn child would be 
 eligible as a needy child under subdivision 10 if born and 
 living with the woman.  For purposes of this subdivision, a 
 woman is considered pregnant for 60 days postpartum.  

    Subd. 7.    Aged, blind, or disabled persons.  Medical 
 assistance may be paid for a person who meets the categorical 
 eligibility requirements of the supplemental security income 
 program or, who would meet those requirements except for excess 
 income or assets, and who meets the other eligibility 
 requirements of this section.  

    Subd. 7a.    Special category for disabled children.  
 Medical assistance may be paid for a person who is under age 18 
 and who meets income and asset eligibility requirements of the 
 Supplemental Security Income program if the person was receiving 
 Supplemental Security Income payments on the date of enactment 
 of section 211(a) of Public Law Number 104-193, the Personal 
 Responsibility and Work Opportunity Act of 1996, and the person 
 would have continued to receive the payments except for the 
 change in the childhood disability criteria in section 211(a) of 
 Public Law Number 104-193. 

    Subd. 8. Repealed, 1990 c 568 art 3 s 104 

    Subd. 9.    Children.  Medical assistance may be paid 
 for a person who is under 21 years of age and in need of medical 
 care that neither the person nor the person's relatives 
 responsible under sections 256B.01 to 256B.26 are financially 
 able to provide. 

    Subd. 10.    Infants.  Medical assistance may be paid 
 for an infant less than one year of age, whose mother was 
 eligible for and receiving medical assistance at the time of 
 birth and who remains in the mother's household or who is in a 
 family with countable income that is equal to or less than the 
 income standard established under section 256B.057, subdivision 
 1.  

    Subd. 10a.    Children.  This subdivision supersedes 
 subdivision 10, as long as the Minnesota health care reform 
 waiver remains in effect.  When the waiver expires, this 
 subdivision expires and the commissioner of human services shall 
 publish a notice in the State Register and notify the revisor of 
 statutes.  Medical assistance may be paid for a child less than 
 two years of age, whose mother was eligible for and receiving 
 medical assistance at the time of birth and who remains in the 
 mother's household or who is in a family with countable income 
 that is equal to or less than the income standard established 
 under section 256B.057, subdivision 1.  

    Subd. 11.    Elderly hospital inpatients.  Medical 
 assistance may be paid for a person who is residing in a 
 hospital for treatment of mental disease or tuberculosis and is 
 65 years of age or older and without means sufficient to pay the 
 per capita hospital charge.  

    Subd. 12.    Disabled children.  (a) A person is 
 eligible for medical assistance if the person is under age 19 
 and qualifies as a disabled individual under United States Code, 
 title 42, section 1382c(a), and would be eligible for medical 
 assistance under the state plan if residing in a medical 
 institution, and the child requires a level of care provided in 
 a hospital, nursing facility, or intermediate care facility for 
 persons with mental retardation or related conditions, for whom 
 home care is appropriate, provided that the cost to medical 
 assistance under this section is not more than the amount that 
 medical assistance would pay for if the child resides in an 
 institution.  After the child is determined to be eligible under 
 this section, the commissioner shall review the child's 
 disability under United States Code, title 42, section 1382c(a) 
 and level of care defined under this section no more often than 
 annually and may elect, based on the recommendation of health 
 care professionals under contract with the state medical review 
 team, to extend the review of disability and level of care up to 
 a maximum of four years.  The commissioner's decision on the 
 frequency of continuing review of disability and level of care 
 is not subject to administrative appeal under section 256.045.  
 Nothing in this subdivision shall be construed as affecting 
 other redeterminations of medical assistance eligibility under 
 this chapter and annual cost-effective reviews under this 
 section.  

    (b) For purposes of this subdivision, "hospital" means an 
 institution as defined in section 144.696, subdivision 3, 
 144.55, subdivision 3, or Minnesota Rules, part 4640.3600, and 
 licensed pursuant to sections 144.50 to 144.58.  For purposes of 
 this subdivision, a child requires a level of care provided in a 
 hospital if the child is determined by the commissioner to need 
 an extensive array of health services, including mental health 
 services, for an undetermined period of time, whose health 
 condition requires frequent monitoring and treatment by a health 
 care professional or by a person supervised by a health care 
 professional, who would reside in a hospital or require frequent 
 hospitalization if these services were not provided, and the 
 daily care needs are more complex than a nursing facility level 
 of care.  

    A child with serious emotional disturbance requires a level 
 of care provided in a hospital if the commissioner determines 
 that the individual requires 24-hour supervision because the 
 person exhibits recurrent or frequent suicidal or homicidal 
 ideation or behavior, recurrent or frequent psychosomatic 
 disorders or somatopsychic disorders that may become life 
 threatening, recurrent or frequent severe socially unacceptable 
 behavior associated with psychiatric disorder, ongoing and 
 chronic psychosis or severe, ongoing and chronic developmental 
 problems requiring continuous skilled observation, or severe 
 disabling symptoms for which office-centered outpatient 
 treatment is not adequate, and which overall severely impact the 
 individual's ability to function. 

    (c) For purposes of this subdivision, "nursing facility" 
 means a facility which provides nursing care as defined in 
 section 144A.01, subdivision 5, licensed pursuant to sections 
 144A.02 to 144A.10, which is appropriate if a person is in 
 active restorative treatment; is in need of special treatments 
 provided or supervised by a licensed nurse; or has unpredictable 
 episodes of active disease processes requiring immediate 
 judgment by a licensed nurse.  For purposes of this subdivision, 
 a child requires the level of care provided in a nursing 
 facility if the child is determined by the commissioner to meet 
 the requirements of the preadmission screening assessment 
 document under section 256B.0911 and the home care independent 
 rating document under section 256B.0627, subdivision 5, 
 paragraph (f), item (iii), adjusted to address age-appropriate 
 standards for children age 18 and under, pursuant to section 
 256B.0627, subdivision 5, paragraph (d), clause (2). 

    (d) For purposes of this subdivision, "intermediate care 
 facility for persons with mental retardation or related 
 conditions" or "ICF/MR" means a program licensed to provide 
 services to persons with mental retardation under section 
 252.28, and chapter 245A, and a physical plant licensed as a 
 supervised living facility under chapter 144, which together are 
 certified by the Minnesota department of health as meeting the 
 standards in Code of Federal Regulations, title 42, part 483, 
 for an intermediate care facility which provides services for 
 persons with mental retardation or persons with related 
 conditions who require 24-hour supervision and active treatment 
 for medical, behavioral, or habilitation needs.  For purposes of 
 this subdivision, a child requires a level of care provided in 
 an ICF/MR if the commissioner finds that the child has mental 
 retardation or a related condition in accordance with section 
 256B.092, is in need of a 24-hour plan of care and active 
 treatment similar to persons with mental retardation, and there 
 is a reasonable indication that the child will need ICF/MR 
 services. 

    (e) For purposes of this subdivision, a person requires the 
 level of care provided in a nursing facility if the person 
 requires 24-hour monitoring or supervision and a plan of mental 
 health treatment because of specific symptoms or functional 
 impairments associated with a serious mental illness or disorder 
 diagnosis, which meet severity criteria for mental health 
 established by the commissioner and published in March 1997 as 
 the Minnesota Mental Health Level of Care for Children and 
 Adolescents with Severe Emotional Disorders. 

    (f) The determination of the level of care needed by the 
 child shall be made by the commissioner based on information 
 supplied to the commissioner by the parent or guardian, the 
 child's physician or physicians, and other professionals as 
 requested by the commissioner.  The commissioner shall establish 
 a screening team to conduct the level of care determinations 
 according to this subdivision. 

    (g) If a child meets the conditions in paragraph (b), (c), 
 (d), or (e), the commissioner must assess the case to determine 
 whether: 

    (1) the child qualifies as a disabled individual under 
 United States Code, title 42, section 1382c(a), and would be 
 eligible for medical assistance if residing in a medical 
 institution; and 

    (2) the cost of medical assistance services for the child, 
 if eligible under this subdivision, would not be more than the 
 cost to medical assistance if the child resides in a medical 
 institution to be determined as follows: 

    (i) for a child who requires a level of care provided in an 
 ICF/MR, the cost of care for the child in an institution shall 
 be determined using the average payment rate established for the 
 regional treatment centers that are certified as ICFs/MR; 

    (ii) for a child who requires a level of care provided in 
 an inpatient hospital setting according to paragraph (b), 
 cost-effectiveness shall be determined according to Minnesota 
 Rules, part 9505.3520, items F and G; and 

    (iii) for a child who requires a level of care provided in 
 a nursing facility according to paragraph (c) or (e), 
 cost-effectiveness shall be determined according to Minnesota 
 Rules, part 9505.3040, except that the nursing facility average 
 rate shall be adjusted to reflect rates which would be paid for 
 children under age 16.  The commissioner may authorize an amount 
 up to the amount medical assistance would pay for a child 
 referred to the commissioner by the preadmission screening team 
 under section 256B.0911. 

    (h) Children eligible for medical assistance services under 
 section 256B.055, subdivision 12, as of June 30, 1995, must be 
 screened according to the criteria in this subdivision prior to 
 January 1, 1996.  Children found to be ineligible may not be 
 removed from the program until January 1, 1996.  

    HIST: Ex1967 c 16 s 6; 1969 c 841 s 1; 1973 c 717 s 18; 1974 c 
 525 s 1,2; 1975 c 247 s 10; 1976 c 236 s 3; 1977 c 448 s 6; 1978 
 c 760 s 1; 1979 c 309 s 4; 1980 c 509 s 106; 1980 c 527 s 1; 
 1981 c 360 art 2 s 28; 1Sp1981 c 2 s 14; 3Sp1981 c 2 art 1 s 32; 
 3Sp1981 c 3 s 17; 1982 c 553 s 6; 1982 c 640 s 5; 1983 c 312 art 
 5 s 15; 1984 c 422 s 1; 1984 c 534 s 22; 1984 c 654 art 5 s 58; 
 1985 c 248 s 70; 1985 c 252 s 21; 1986 c 444; 1Sp1986 c 1 art 8 
 s 5; 1987 c 403 art 2 s 79,80; 1988 c 689 art 2 s 144,145,268; 
 1989 c 282 art 3 s 43,44; 1990 c 568 art 3 s 23-27; 1991 c 292 
 art 4 s 33,34; 1Sp1993 c 1 art 5 s 30; 1994 c 631 s 31; 1995 c 
 207 art 6 s 27; 1995 c 234 art 6 s 35; 1996 c 451 art 2 s 7; 
 1997 c 85 art 3 s 10-12; 1997 c 203 art 4 s 19; 1998 c 407 art 4 
 s 13,14; 1999 c 245 art 4 s 31; 1Sp2001 c 9 art 2 s 15; 2002 c 
 379 art 1 s 113 

     256B.056 Eligibility; residency; resources; income. 

    Subdivision 1.    Residency.  To be eligible for medical 
 assistance, a person must reside in Minnesota, or, if absent 
 from the state, be deemed to be a resident of Minnesota in 
 accordance with the rules of the state agency. 

    Subd. 1a.    Income and assets generally.  Unless 
 specifically required by state law or rule or federal law or 
 regulation, the methodologies used in counting income and assets 
 to determine eligibility for medical assistance for persons 
 whose eligibility category is based on blindness, disability, or 
 age of 65 or more years, the methodologies for the supplemental 
 security income program shall be used.  Increases in benefits 
 under title II of the Social Security Act shall not be counted 
 as income for purposes of this subdivision until July 1 of each 
 year.  Effective upon federal approval, for children eligible 
 under section 256B.055, subdivision 12, or for home and 
 community-based waiver services whose eligibility for medical 
 assistance is determined without regard to parental income, 
 child support payments, including any payments made by an 
 obligor in satisfaction of or in addition to a temporary or 
 permanent order for child support, and social security payments 
 are not counted as income.  For families and children, which 
 includes all other eligibility categories, the methodologies 
 under the state's AFDC plan in effect as of July 16, 1996, as 
 required by the Personal Responsibility and Work Opportunity 
 Reconciliation Act of 1996 (PRWORA), Public Law Number 104-193, 
 shall be used, except that effective July 1, 2002, the $90 and 
 $30 and one-third earned income disregards shall not apply and 
 the disregard specified in subdivision 1c shall apply.  For 
 these purposes, a "methodology" does not include an asset or 
 income standard, or accounting method, or method of determining 
 effective dates. 

    Subd. 1b.    Aged, blind, and disabled income methodology. 
  The $20 general income disregard allowed under the 
 supplemental security income program is included in the standard 
 and shall not be allowed as a deduction from income for a person 
 eligible under section 256B.055, subdivisions 7, 7a, and 12. 

    Subd. 1c.    Families with children income methodology.  
 (a) For children ages one to five whose eligibility is 
 determined under section 256B.057, subdivision 2, 21 percent of 
 countable earned income shall be disregarded for up to four 
 months.  

    (b) For families with children whose eligibility is 
 determined using the standard specified in section 256B.056, 
 subdivision 4, paragraph (c), 17 percent of countable earned 
 income shall be disregarded for up to four months. 

    (c) If the disregard has been applied to the wage earner's 
 income for four months, the disregard shall not be applied again 
 until the wage earner's income has not been considered in 
 determining medical assistance eligibility for 12 consecutive 
 months.  

    Subd. 2.    Homestead; exclusion for institutionalized 
 persons.  The homestead shall be excluded for the first six 
 calendar months of a person's stay in a long-term care facility 
 and shall continue to be excluded for as long as the recipient 
 can be reasonably expected to return to the homestead.  For 
 purposes of this subdivision, "reasonably expected to return to 
 the homestead" means the recipient's attending physician has 
 certified that the expectation is reasonable, and the recipient 
 can show that the cost of care upon returning home will be met 
 through medical assistance or other sources.  The homestead 
 shall continue to be excluded for persons residing in a 
 long-term care facility if it is used as a primary residence by 
 one of the following individuals:  

    (a) the spouse; 

    (b) a child under age 21; 

    (c) a child of any age who is blind or permanently and 
 totally disabled as defined in the supplemental security income 
 program; 

    (d) a sibling who has equity interest in the home and who 
 resided in the home for at least one year immediately before the 
 date of the person's admission to the facility; or 

    (e) a child of any age, or, subject to federal approval, a 
 grandchild of any age, who resided in the home for at least two 
 years immediately before the date of the person's admission to 
 the facility, and who provided care to the person that permitted 
 the person to reside at home rather than in an institution.  

    Subd. 3.    Asset limitations for elderly and disabled 
 individuals.  To be eligible for medical assistance, a person 
 must not individually own more than $3,000 in assets, or if a 
 member of a household with two family members, husband and wife, 
 or parent and child, the household must not own more than $6,000 
 in assets, plus $200 for each additional legal dependent.  In 
 addition to these maximum amounts, an eligible individual or 
 family may accrue interest on these amounts, but they must be 
 reduced to the maximum at the time of an eligibility 
 redetermination.  The accumulation of the clothing and personal 
 needs allowance according to section 256B.35 must also be 
 reduced to the maximum at the time of the eligibility 
 redetermination.  The value of assets that are not considered in 
 determining eligibility for medical assistance is the value of 
 those assets excluded under the supplemental security income 
 program for aged, blind, and disabled persons, with the 
 following exceptions: 

    (a) Household goods and personal effects are not considered.

    (b) Capital and operating assets of a trade or business 
 that the local agency determines are necessary to the person's 
 ability to earn an income are not considered. 

    (c) Motor vehicles are excluded to the same extent excluded 
 by the supplemental security income program. 

    (d) Assets designated as burial expenses are excluded to 
 the same extent excluded by the supplemental security income 
 program.  Burial expenses funded by annuity contracts or life 
 insurance policies must irrevocably designate the individual's 
 estate as contingent beneficiary to the extent proceeds are not 
 used for payment of selected burial expenses. 

    (e) Effective upon federal approval, for a person who no 
 longer qualifies as an employed person with a disability due to 
 loss of earnings, assets allowed while eligible for medical 
 assistance under section 256B.057, subdivision 9, are not 
 considered for 12 months, beginning with the first month of 
 ineligibility as an employed person with a disability, to the 
 extent that the person's total assets remain within the allowed 
 limits of section 256B.057, subdivision 9, paragraph (b). 

    Subd. 3a. Repealed, 1992 c 513 art 7 s 135 

    Subd. 3b.    Treatment of trusts.  (a) A "medical 
 assistance qualifying trust" is a revocable or irrevocable 
 trust, or similar legal device, established on or before August 
 10, 1993, by a person or the person's spouse under the terms of 
 which the person receives or could receive payments from the 
 trust principal or income and the trustee has discretion in 
 making payments to the person from the trust principal or income.
 Notwithstanding that definition, a medical assistance qualifying 
 trust does not include:  (1) a trust set up by will; (2) a trust 
 set up before April 7, 1986, solely to benefit a person with 
 mental retardation living in an intermediate care facility for 
 persons with mental retardation; or (3) a trust set up by a 
 person with payments made by the Social Security Administration 
 pursuant to the United States Supreme Court decision in Sullivan 
 v. Zebley, 110 S. Ct. 885 (1990).  The maximum amount of 
 payments that a trustee of a medical assistance qualifying trust 
 may make to a person under the terms of the trust is considered 
 to be available assets to the person, without regard to whether 
 the trustee actually makes the maximum payments to the person 
 and without regard to the purpose for which the medical 
 assistance qualifying trust was established. 

    (b) Trusts established after August 10, 1993, are treated 
 according to section 13611(b) of the Omnibus Budget 
 Reconciliation Act of 1993 (OBRA), Public Law Number 103-66. 

    Subd. 3c.    Asset limitations for families and children. 
  A household of two or more persons must not own more than 
 $30,000 in total net assets, and a household of one person must 
 not own more than $15,000 in total net assets.  In addition to 
 these maximum amounts, an eligible individual or family may 
 accrue interest on these amounts, but they must be reduced to 
 the maximum at the time of an eligibility redetermination.  The 
 value of assets that are not considered in determining 
 eligibility for medical assistance for families and children is 
 the value of those assets excluded under the AFDC state plan as 
 of July 16, 1996, as required by the Personal Responsibility and 
 Work Opportunity Reconciliation Act of 1996 (PRWORA), Public Law 
 Number 104-193, with the following exceptions: 

    (1) household goods and personal effects are not 
 considered; 

    (2) capital and operating assets of a trade or business up 
 to $200,000 are not considered; 

    (3) one motor vehicle is excluded for each person of legal 
 driving age who is employed or seeking employment; 

    (4) one burial plot and all other burial expenses equal to 
 the supplemental security income program asset limit are not 
 considered for each individual; 

    (5) court-ordered settlements up to $10,000 are not 
 considered; 

    (6) individual retirement accounts and funds are not 
 considered; and 

    (7) assets owned by children are not considered.  

    Subd. 4.    Income.  (a) To be eligible for medical 
 assistance, a person eligible under section 256B.055, 
 subdivisions 7, 7a, and 12, may have income up to 100 percent of 
 the federal poverty guidelines.  Effective January 1, 2000, and 
 each successive January, recipients of supplemental security 
 income may have an income up to the supplemental security income 
 standard in effect on that date.  

    (b) To be eligible for medical assistance, families and 
 children may have an income up to 133-1/3 percent of the AFDC 
 income standard in effect under the July 16, 1996, AFDC state 
 plan.  Effective July 1, 2000, the base AFDC standard in effect 
 on July 16, 1996, shall be increased by three percent.  

    (c) Effective July 1, 2002, to be eligible for medical 
 assistance, families and children may have an income up to 100 
 percent of the federal poverty guidelines for the family size.  

    (d) In computing income to determine eligibility of persons 
 under paragraphs (a) to (c) who are not residents of long-term 
 care facilities, the commissioner shall disregard increases in 
 income as required by Public Law Numbers 94-566, section 503; 
 99-272; and 99-509.  Veterans aid and attendance benefits and 
 Veterans Administration unusual medical expense payments are 
 considered income to the recipient. 

    Subd. 4a.    Asset verification.  For purposes of 
 verification, the value of a life estate shall be considered not 
 salable unless the owner of the remainder interest intends to 
 purchase the life estate, or the owner of the life estate and 
 the owner of the remainder sell the entire property. 

    Subd. 4b.    Income verification.  The local agency 
 shall not require a monthly income verification form for a 
 recipient who is a resident of a long-term care facility and who 
 has monthly earned income of $80 or less.  The commissioner or 
 county agency shall use electronic verification as the primary 
 method of income verification.  If there is a discrepancy 
 between reported income and electronically verified income, an 
 individual may be required to submit additional verification.  

    Subd. 5.    Excess income.  A person who has excess 
 income is eligible for medical assistance if the person has 
 expenses for medical care that are more than the amount of the 
 person's excess income, computed by deducting incurred medical 
 expenses from the excess income to reduce the excess to the 
 income standard specified in subdivision 5c.  The person shall 
 elect to have the medical expenses deducted at the beginning of 
 a one-month budget period or at the beginning of a six-month 
 budget period.  The commissioner shall allow persons eligible 
 for assistance on a one-month spenddown basis under this 
 subdivision to elect to pay the monthly spenddown amount in 
 advance of the month of eligibility to the state agency in order 
 to maintain eligibility on a continuous basis.  If the recipient 
 does not pay the spenddown amount on or before the 20th of the 
 month, the recipient is ineligible for this option for the 
 following month.  The local agency shall code the Medicaid 
 Management Information System (MMIS) to indicate that the 
 recipient has elected this option.  The state agency shall 
 convey recipient eligibility information relative to the 
 collection of the spenddown to providers through the Electronic 
 Verification System (EVS).  A recipient electing advance payment 
 must pay the state agency the monthly spenddown amount on or 
 before the 20th of the month in order to be eligible for this 
 option in the following month.  

    Subd. 5a.    Individuals on fixed or excluded income.  
 Recipients of medical assistance who receive only fixed unearned 
 or excluded income, when that income is excluded from 
 consideration as income or unvarying in amount and timing of 
 receipt throughout the year, shall report and verify their 
 income annually. 

    Subd. 5b.    Individuals with low income.  Recipients of 
 medical assistance not residing in a long-term care facility who 
 have slightly fluctuating income which is below the medical 
 assistance income limit shall report and verify their income on 
 a semiannual basis. 

    Subd. 5c.    Excess income standard.  (a) The excess 
 income standard for families with children is the standard 
 specified in subdivision 4. 

    (b) The excess income standard for a person whose 
 eligibility is based on blindness, disability, or age of 65 or 
 more years is 70 percent of the federal poverty guidelines for 
 the family size.  Effective July 1, 2002, the excess income 
 standard for this paragraph shall equal 75 percent of the 
 federal poverty guidelines. 

    Subd. 6.    Assignment of benefits.  To be eligible for 
 medical assistance a person must have applied or must agree to 
 apply all proceeds received or receivable by the person or the 
 person's spouse from any third person liable for the costs of 
 medical care for the person, the spouse, and children.  The 
 state agency shall require from any applicant or recipient of 
 medical assistance the assignment of any rights to medical 
 support and third party payments.  Persons must cooperate with 
 the state in establishing paternity and obtaining third party 
 payments.  By signing an application for medical assistance, a 
 person assigns to the department of human services all rights 
 the person may have to medical support or payments for medical 
 expenses from any other person or entity on their own or their 
 dependent's behalf and agrees to cooperate with the state in 
 establishing paternity and obtaining third party payments.  Any 
 rights or amounts so assigned shall be applied against the cost 
 of medical care paid for under this chapter.  Any assignment 
 takes effect upon the determination that the applicant is 
 eligible for medical assistance and up to three months prior to 
 the date of application if the applicant is determined eligible 
 for and receives medical assistance benefits.  The application 
 must contain a statement explaining this assignment.  Any 
 assignment shall not be effective as to benefits paid or 
 provided under automobile accident coverage and private health 
 care coverage prior to notification of the assignment by the 
 person or organization providing the benefits.  

    Subd. 7.    Period of eligibility.  Eligibility is 
 available for the month of application and for three months 
 prior to application if the person was eligible in those prior 
 months.  A redetermination of eligibility must occur every 12 
 months. 

    Subd. 8.    Cooperation.  To be eligible for medical 
 assistance, applicants and recipients must cooperate with the 
 state and local agency to identify potentially liable 
 third-party payers and assist the state in obtaining third party 
 payments, unless good cause for noncooperation is determined 
 according to Code of Federal Regulations, title 42, part 
 433.147.  "Cooperation" includes identifying any third party who 
 may be liable for care and services provided under this chapter 
 to the applicant, recipient, or any other family member for whom 
 application is made and providing relevant information to assist 
 the state in pursuing a potentially liable third party.  
 Cooperation also includes providing information about a group 
 health plan for which the person may be eligible and if the plan 
 is determined cost-effective by the state agency and premiums 
 are paid by the local agency or there is no cost to the 
 recipient, they must enroll or remain enrolled with the group.  
 For purposes of this subdivision, coverage provided by the 
 Minnesota comprehensive health association under chapter 62E 
 shall not be considered group health plan coverage or 
 cost-effective by the state and local agency.  Cost-effective 
 insurance premiums approved for payment by the state agency and 
 paid by the local agency are eligible for reimbursement 
 according to section 256B.19. 

    HIST: Ex1967 c 16 s 6; 1969 c 841 s 1; 1973 c 717 s 18; 1974 c 
 525 s 1,2; 1975 c 247 s 10; 1976 c 236 s 3; 1977 c 448 s 6; 1978 
 c 760 s 1; 1979 c 309 s 4; 1980 c 509 s 106; 1980 c 527 s 1; 
 1981 c 360 art 2 s 28; 1Sp1981 c 2 s 14; 3Sp1981 c 2 art 1 s 32; 
 3Sp1981 c 3 s 17; 1982 c 553 s 6; 1982 c 640 s 5; 1983 c 312 art 
 5 s 15; 1984 c 422 s 1; 1984 c 534 s 22; 1984 c 654 art 5 s 58; 
 1985 c 248 s 70; 1985 c 252 s 21; 1986 c 444; 1Sp1986 c 1 art 8 
 s 5; 1987 c 403 art 2 s 79,80; 1988 c 689 art 2 s 144,145,268; 
 1989 c 282 art 3 s 45-47; 1989 c 332 s 1; 1990 c 568 art 3 s 
 28-32; 1992 c 513 art 7 s 34-38; 1993 c 339 s 13; 1Sp1993 c 1 
 art 5 s 31; art 6 s 25; 1995 c 207 art 6 s 28,29; 1995 c 248 art 
 17 s 1-4; 1996 c 451 art 2 s 8,9; 1997 c 85 art 3 s 13-15; 1997 
 c 203 art 4 s 20,21; 1997 c 225 art 6 s 4; 1998 c 407 art 4 s 
 15,16; 1999 c 245 art 4 s 32; art 10 s 10; 2001 c 203 s 5,6; 
 1Sp2001 c 9 art 2 s 16-24; 2002 c 220 art 15 s 6; 2002 c 379 art 
 1 s 113 

     256B.057 Eligibility; income and asset limitations for 
  special categories. 

    Subdivision 1.    Pregnant women and infants.  (a) An 
 infant less than one year of age or a pregnant woman who has 
 written verification of a positive pregnancy test from a 
 physician or licensed registered nurse, is eligible for medical 
 assistance if countable family income is equal to or less than 
 275 percent of the federal poverty guideline for the same family 
 size.  For purposes of this subdivision, "countable family 
 income" means the amount of income considered available using 
 the methodology of the AFDC program under the state's AFDC plan 
 as of July 16, 1996, as required by the Personal Responsibility 
 and Work Opportunity Reconciliation Act of 1996 (PRWORA), Public 
 Law Number 104-193, except for the earned income disregard and 
 employment deductions.  An amount equal to the amount of earned 
 income exceeding 275 percent of the federal poverty guideline, 
 up to a maximum of the amount by which the combined total of 185 
 percent of the federal poverty guideline plus the earned income 
 disregards and deductions of the AFDC program under the state's 
 AFDC plan as of July 16, 1996, as required by the Personal 
 Responsibility and Work Opportunity Reconciliation Act of 1996 
 (PRWORA), Public Law Number 104-193, exceeds 275 percent of the 
 federal poverty guideline will be deducted for pregnant women 
 and infants less than one year of age.  

    (b) An infant born on or after January 1, 1991, to a woman 
 who was eligible for and receiving medical assistance on the 
 date of the child's birth shall continue to be eligible for 
 medical assistance without redetermination until the child's 
 first birthday, as long as the child remains in the woman's 
 household. 

    Subd. 1a. Repealed, 1998 c 407 art 5 s 48 

    Subd. 1b.    Pregnant women and infants; expansion.  (a) 
 This subdivision supersedes subdivision 1 as long as the 
 Minnesota health care reform waiver remains in effect.  When the 
 waiver expires, the commissioner of human services shall publish 
 a notice in the State Register and notify the revisor of 
 statutes.  An infant less than two years of age or a pregnant 
 woman who has written verification of a positive pregnancy test 
 from a physician or licensed registered nurse, is eligible for 
 medical assistance if countable family income is equal to or 
 less than 275 percent of the federal poverty guideline for the 
 same family size.  For purposes of this subdivision, "countable 
 family income" means the amount of income considered available 
 using the methodology of the AFDC program under the state's AFDC 
 plan as of July 16, 1996, as required by the Personal 
 Responsibility and Work Opportunity Reconciliation Act of 1996 
 (PRWORA), Public Law Number 104-193, except for the earned 
 income disregard and employment deductions.  An amount equal to 
 the amount of earned income exceeding 275 percent of the federal 
 poverty guideline, up to a maximum of the amount by which the 
 combined total of 185 percent of the federal poverty guideline 
 plus the earned income disregards and deductions of the AFDC 
 program under the state's AFDC plan as of July 16, 1996, as 
 required by the Personal Responsibility and Work Opportunity 
 Reconciliation Act of 1996 (PRWORA), Public Law Number 104-193, 
 exceeds 275 percent of the federal poverty guideline will be 
 deducted for pregnant women and infants less than two years of 
 age.  

    (b) An infant born on or after January 1, 1991, to a woman 
 who was eligible for and receiving medical assistance on the 
 date of the child's birth shall continue to be eligible for 
 medical assistance without redetermination until the child's 
 second birthday, as long as the child remains in the woman's 
 household. 

    Subd. 1c.    No asset test for pregnant women.  
 Beginning September 30, 1998, eligibility for medical assistance 
 for a pregnant woman must be determined without regard to asset 
 standards established in section 256B.056, subdivision 3.  

    Subd. 2.    Children.  Except as specified in 
 subdivision 1b, effective July 1, 2002, a child one through 18 
 years of age in a family whose countable income is no greater 
 than 170 percent of the federal poverty guidelines for the same 
 family size, is eligible for medical assistance.  

    Subd. 2a. Repealed, 1997 c 203 art 4 s 73 

    Subd. 2b. Repealed, 1997 c 203 art 4 s 73 

    Subd. 3.    Qualified Medicare beneficiaries.  A person 
 who is entitled to Part A Medicare benefits, whose income is 
 equal to or less than 100 percent of the federal poverty 
 guidelines, and whose assets are no more than $10,000 for a 
 single individual and $18,000 for a married couple or family of 
 two or more, is eligible for medical assistance reimbursement of 
 Part A and Part B premiums, Part A and Part B coinsurance and 
 deductibles, and cost-effective premiums for enrollment with a 
 health maintenance organization or a competitive medical plan 
 under section 1876 of the Social Security Act.  Reimbursement of 
 the Medicare coinsurance and deductibles, when added to the 
 amount paid by Medicare, must not exceed the total rate the 
 provider would have received for the same service or services if 
 the person were a medical assistance recipient with Medicare 
 coverage.  Increases in benefits under Title II of the Social 
 Security Act shall not be counted as income for purposes of this 
 subdivision until July 1 of each year.  

    Subd. 3a.    Eligibility for payment of Medicare Part B 
 premiums.  A person who would otherwise be eligible as a 
 qualified Medicare beneficiary under subdivision 3, except the 
 person's income is in excess of the limit, is eligible for 
 medical assistance reimbursement of Medicare Part B premiums if 
 the person's income is less than 120 percent of the official 
 federal poverty guidelines for the applicable family size.  

    Subd. 3b.    Qualifying individuals.  Beginning July 1, 
 1998, to the extent of the federal allocation to Minnesota, a 
 person who would otherwise be eligible as a qualified Medicare 
 beneficiary under subdivision 3, except that the person's income 
 is in excess of the limit, is eligible as a qualifying 
 individual according to the following criteria: 

    (1) if the person's income is greater than 120 percent, but 
 less than 135 percent of the official federal poverty guidelines 
 for the applicable family size, the person is eligible for 
 medical assistance reimbursement of Medicare Part B premiums; or 

    (2) if the person's income is equal to or greater than 135 
 percent but less than 175 percent of the official federal 
 poverty guidelines for the applicable family size, the person is 
 eligible for medical assistance reimbursement of that portion of 
 the Medicare Part B premium attributable to an increase in Part 
 B expenditures which resulted from the shift of home care 
 services from Medicare Part A to Medicare Part B under Public 
 Law Number 105-33, section 4732, the Balanced Budget Act of 1997.

    The commissioner shall limit enrollment of qualifying 
 individuals under this subdivision according to the requirements 
 of Public Law Number 105-33, section 4732. 

    Subd. 4.    Qualified working disabled adults.  A person 
 who is entitled to Medicare Part A benefits under section 1818A 
 of the Social Security Act; whose income does not exceed 200 
 percent of the federal poverty guidelines for the applicable 
 family size; whose nonexempt assets do not exceed twice the 
 maximum amount allowable under the supplemental security income 
 program, according to family size; and who is not otherwise 
 eligible for medical assistance, is eligible for medical 
 assistance reimbursement of the Medicare Part A premium.  

    Subd. 5.    Disabled adult children.  A person who is at 
 least 18 years old, who was eligible for supplemental security 
 income benefits on the basis of blindness or disability, who 
 became disabled or blind before reaching the age of 22, and who 
 lost eligibility as a result of becoming entitled to a child's 
 insurance benefits on or after July 1, 1987, under section 
 202(d) of the Social Security Act, or because of an increase in 
 those benefits effective on or after July 1, 1987, is eligible 
 for medical assistance as long as the person would be entitled 
 to supplemental security income in the absence of child's 
 insurance benefits or increases in those benefits. 

    Subd. 6.    Disabled widows and widowers.  A person who 
 is at least 50 years old who is entitled to disabled widow's or 
 widower's benefits under United States Code, title 42, section 
 402(e) or (f), who is not entitled to Medicare Part A, and who 
 received supplemental security income or Minnesota supplemental 
 aid in the month before the month the widow's or widower's 
 benefits began, is eligible for medical assistance as long as 
 the person would be entitled to supplemental security income or 
 Minnesota supplemental aid in the absence of the widow's or 
 widower's benefits. 

    Subd. 7.    Waiver of maintenance of effort requirement. 
  Unless a federal waiver of the maintenance of effort 
 requirement of section 2105(d) of title XXI of the Balanced 
 Budget Act of 1997, Public Law Number 105-33, Statutes at Large, 
 volume 111, page 251, is granted by the federal Department of 
 Health and Human Services by September 30, 1998, eligibility for 
 children under age 21 must be determined without regard to asset 
 standards established in section 256B.056, subdivision 3c.  The 
 commissioner of human services shall publish a notice in the 
 State Register upon receipt of a federal waiver. 

    Subd. 8.    Children under age two.  Medical assistance 
 may be paid for a child under two years of age whose countable 
 family income is above 275 percent of the federal poverty 
 guidelines for the same size family but less than or equal to 
 280 percent of the federal poverty guidelines for the same size 
 family. 

    Subd. 9.    Employed persons with disabilities.  (a) 
 Medical assistance may be paid for a person who is employed and 
 who: 

    (1) meets the definition of disabled under the supplemental 
 security income program; 

    (2) is at least 16 but less than 65 years of age; 

    (3) meets the asset limits in paragraph (b); and 

    (4) pays a premium, if required, under paragraph (c).  

 Any spousal income or assets shall be disregarded for purposes 
 of eligibility and premium determinations. 

    After the month of enrollment, a person enrolled in medical 
 assistance under this subdivision who is temporarily unable to 
 work and without receipt of earned income due to a medical 
 condition, as verified by a physician, may retain eligibility 
 for up to four calendar months. 

    (b) For purposes of determining eligibility under this 
 subdivision, a person's assets must not exceed $20,000, 
 excluding: 

    (1) all assets excluded under section 256B.056; 

    (2) retirement accounts, including individual accounts, 
 401(k) plans, 403(b) plans, Keogh plans, and pension plans; and 

    (3) medical expense accounts set up through the person's 
 employer. 

    (c) A person whose earned and unearned income is equal to 
 or greater than 100 percent of federal poverty guidelines for 
 the applicable family size must pay a premium to be eligible for 
 medical assistance under this subdivision.  The premium shall be 
 based on the person's gross earned and unearned income and the 
 applicable family size using a sliding fee scale established by 
 the commissioner, which begins at one percent of income at 100 
 percent of the federal poverty guidelines and increases to 7.5 
 percent of income for those with incomes at or above 300 percent 
 of the federal poverty guidelines.  Annual adjustments in the 
 premium schedule based upon changes in the federal poverty 
 guidelines shall be effective for premiums due in July of each 
 year.  

    (d) A person's eligibility and premium shall be determined 
 by the local county agency.  Premiums must be paid to the 
 commissioner.  All premiums are dedicated to the commissioner. 

    (e) Any required premium shall be determined at application 
 and redetermined annually at recertification or when a change in 
 income or family size occurs. 

    (f) Premium payment is due upon notification from the 
 commissioner of the premium amount required.  Premiums may be 
 paid in installments at the discretion of the commissioner. 

    (g) Nonpayment of the premium shall result in denial or 
 termination of medical assistance unless the person demonstrates 
 good cause for nonpayment.  Good cause exists if the 
 requirements specified in Minnesota Rules, part 9506.0040, 
 subpart 7, items B to D, are met.  Nonpayment shall include 
 payment with a returned, refused, or dishonored instrument.  The 
 commissioner may require a guaranteed form of payment as the 
 only means to replace a returned, refused, or dishonored 
 instrument. 

    Subd. 10.    Certain persons needing treatment for breast 
 or cervical cancer.  (a) Medical assistance may be paid for a 
 person who: 

    (1) has been screened for breast or cervical cancer by the 
 Minnesota breast and cervical cancer control program, and 
 program funds have been used to pay for the person's screening; 

    (2) according to the person's treating health professional, 
 needs treatment, including diagnostic services necessary to 
 determine the extent and proper course of treatment, for breast 
 or cervical cancer, including precancerous conditions and early 
 stage cancer; 

    (3) meets the income eligibility guidelines for the 
 Minnesota breast and cervical cancer control program; 

    (4) is under age 65; 

    (5) is not otherwise eligible for medical assistance under 
 United States Code, title 42, section 1396(a)(10)(A)(i); and 

    (6) is not otherwise covered under creditable coverage, as 
 defined under United States Code, title 42, section 300gg(c). 

    (b) Medical assistance provided for an eligible person 
 under this subdivision shall be limited to services provided 
 during the period that the person receives treatment for breast 
 or cervical cancer. 

    (c) A person meeting the criteria in paragraph (a) is 
 eligible for medical assistance without meeting the eligibility 
 criteria relating to income and assets in section 256B.056, 
 subdivisions 1a to 5b. 

    HIST: 1986 c 444; 1989 c 282 art 3 s 48; 1990 c 568 art 3 s 
 33-36; 1991 c 292 art 4 s 35-39; 1992 c 513 art 7 s 39; 1992 c 
 549 art 4 s 12; 1993 c 345 art 9 s 11-13; 1Sp1993 c 6 s 9; 1995 
 c 234 art 6 s 36,37; 1997 c 85 art 3 s 16-18; 1997 c 203 art 4 s 
 22-24; 1998 c 407 art 5 s 3-5; 1998 c 407 art 4 s 17,18; 1999 c 
 245 art 4 s 33,34; 2000 c 260 s 97; 2000 c 340 s 3; 2000 c 488 
 art 9 s 15; 1Sp2001 c 9 art 2 s 25-29; 2002 c 379 art 1 s 113 

     256B.0575 Availability of income for institutionalized 
  persons. 

    When an institutionalized person is determined eligible for 
 medical assistance, the income that exceeds the deductions in 
 paragraphs (a) and (b) must be applied to the cost of 
 institutional care.  

    (a) The following amounts must be deducted from the 
 institutionalized person's income in the following order: 

    (1) the personal needs allowance under section 256B.35 or, 
 for a veteran who does not have a spouse or child, or a 
 surviving spouse of a veteran having no child, the amount of an 
 improved pension received from the veteran's administration not 
 exceeding $90 per month; 

    (2) the personal allowance for disabled individuals under 
 section 256B.36; 

    (3) if the institutionalized person has a legally appointed 
 guardian or conservator, five percent of the recipient's gross 
 monthly income up to $100 as reimbursement for guardianship or 
 conservatorship services; 

    (4) a monthly income allowance determined under section 
 256B.058, subdivision 2, but only to the extent income of the 
 institutionalized spouse is made available to the community 
 spouse; 

    (5) a monthly allowance for children under age 18 which, 
 together with the net income of the children, would provide 
 income equal to the medical assistance standard for families and 
 children according to section 256B.056, subdivision 4, for a 
 family size that includes only the minor children.  This 
 deduction applies only if the children do not live with the 
 community spouse and only to the extent that the deduction is 
 not included in the personal needs allowance under section 
 256B.35, subdivision 1, as child support garnished under a court 
 order; 

    (6) a monthly family allowance for other family members, 
 equal to one-third of the difference between 122 percent of the 
 federal poverty guidelines and the monthly income for that 
 family member; 

    (7) reparations payments made by the Federal Republic of 
 Germany and reparations payments made by the Netherlands for 
 victims of Nazi persecution between 1940 and 1945; 

    (8) all other exclusions from income for institutionalized 
 persons as mandated by federal law; and 

    (9) amounts for reasonable expenses incurred for necessary 
 medical or remedial care for the institutionalized person that 
 are not medical assistance covered expenses and that are not 
 subject to payment by a third party.  

    For purposes of clause (6), "other family member" means a 
 person who resides with the community spouse and who is a minor 
 or dependent child, dependent parent, or dependent sibling of 
 either spouse.  "Dependent" means a person who could be claimed 
 as a dependent for federal income tax purposes under the 
 Internal Revenue Code. 

    (b) Income shall be allocated to an institutionalized 
 person for a period of up to three calendar months, in an amount 
 equal to the medical assistance standard for a family size of 
 one if:  

    (1) a physician certifies that the person is expected to 
 reside in the long-term care facility for three calendar months 
 or less; 

    (2) if the person has expenses of maintaining a residence 
 in the community; and 

    (3) if one of the following circumstances apply:  

    (i) the person was not living together with a spouse or a 
 family member as defined in paragraph (a) when the person 
 entered a long-term care facility; or 

    (ii) the person and the person's spouse become 
 institutionalized on the same date, in which case the allocation 
 shall be applied to the income of one of the spouses.  

 For purposes of this paragraph, a person is determined to be 
 residing in a licensed nursing home, regional treatment center, 
 or medical institution if the person is expected to remain for a 
 period of one full calendar month or more. 

    HIST: 1986 c 444; 1989 c 282 art 3 s 49; 1990 c 568 art 3 s 
 37; 1991 c 292 art 4 s 40; 1Sp1993 c 1 art 5 s 32; 1995 c 207 
 art 6 s 30,125; 1996 c 451 art 2 s 10; 1999 c 245 art 4 s 35; 
 2002 c 277 s 10 

     256B.058 Treatment of income of institutionalized spouse.

    Subdivision 1.    Income not available.  The income 
 described in subdivisions 2 and 3 shall be deducted from an 
 institutionalized spouse's monthly income and is not considered 
 available for payment of the monthly costs of an 
 institutionalized person in the institution after the person has 
 been determined eligible for medical assistance. 

    Subd. 2.    Monthly income allowance for community spouse. 
  (a) For an institutionalized spouse with a spouse residing in 
 the community, monthly income may be allocated to the community 
 spouse as a monthly income allowance for the community spouse.  
 Beginning with the first full calendar month the 
 institutionalized spouse is in the institution, the monthly 
 income allowance is not considered available to the 
 institutionalized spouse for monthly payment of costs of care in 
 the institution as long as the income is made available to the 
 community spouse. 

    (b) The monthly income allowance is the amount by which the 
 community spouse's monthly maintenance needs allowance under 
 paragraphs (c) and (d) exceeds the amount of monthly income 
 otherwise available to the community spouse.  

    (c) The community spouse's monthly maintenance needs 
 allowance is the lesser of $1,500 or 122 percent of the monthly 
 federal poverty guideline for a family of two plus an excess 
 shelter allowance.  The excess shelter allowance is for the 
 amount of shelter expenses that exceed 30 percent of 122 percent 
 of the federal poverty guideline line for a family of two.  
 Shelter expenses are the community spouse's expenses for rent, 
 mortgage payments including principal and interest, taxes, 
 insurance, required maintenance charges for a cooperative or 
 condominium that is the community spouse's principal residence, 
 and the standard utility allowance under section 5(e) of the 
 federal Food Stamp Act of 1977.  If the community spouse has a 
 required maintenance charge for a cooperative or condominium, 
 the standard utility allowance must be reduced by the amount of 
 utility expenses included in the required maintenance charge.  

    If the community or institutionalized spouse establishes 
 that the community spouse needs income greater than the monthly 
 maintenance needs allowance determined in this paragraph due to 
 exceptional circumstances resulting in significant financial 
 duress, the monthly maintenance needs allowance may be increased 
 to an amount that provides needed additional income.  

    (d) The percentage of the federal poverty guideline used to 
 determine the monthly maintenance needs allowance in paragraph 
 (c) is increased to 133 percent on July 1, 1991, and to 150 
 percent on July 1, 1992.  Adjustments in the income limits due 
 to annual changes in the federal poverty guidelines shall be 
 implemented the first day of July following publication of the 
 annual changes.  The $1,500 maximum must be adjusted January 1, 
 1990, and every January 1 after that by the same percentage 
 increase in the consumer price index for all urban consumers 
 (all items; United States city average) between the two previous 
 Septembers. 

    (e) If a court has entered an order against an 
 institutionalized spouse for monthly income for support of the 
 community spouse, the community spouse's monthly income 
 allowance under this subdivision shall not be less than the 
 amount of the monthly income ordered. 

    Subd. 3.    Family allowance.  (a) A family allowance 
 determined under paragraph (b) is not considered available to 
 the institutionalized spouse for monthly payment of costs of 
 care in the institution. 

    (b) The family allowance is equal to one-third of the 
 amount by which 122 percent of the monthly federal poverty 
 guideline for a family of two exceeds the monthly income for 
 that family member. 

    (c) For purposes of this subdivision, the term family 
 member only includes a minor or dependent child, dependent 
 parent, or dependent sibling of the institutionalized or 
 community spouse if the sibling resides with the community 
 spouse.  

    (d) The percentage of the federal poverty guideline used to 
 determine the family allowance in paragraph (b) is increased to 
 133 percent on July 1, 1991, and to 150 percent on July 1, 
 1992.  Adjustments in the income limits due to annual changes in 
 the federal poverty guidelines shall be implemented the first 
 day of July following publication of the annual changes. 

    Subd. 4.    Treatment of income.  (a) No income of the 
 community spouse will be considered available to an eligible 
 institutionalized spouse, beginning the first full calendar 
 month of institutionalization, except as provided in this 
 subdivision.  

    (b) In determining the income of an institutionalized 
 spouse or community spouse, after the institutionalized spouse 
 has been determined eligible for medical assistance, the 
 following rules apply.  

    (1) For income that is not from a trust, availability is 
 determined according to items (i) to (v), unless the instrument 
 providing the income otherwise specifically provides:  

    (i) if payment is made solely in the name of one spouse, 
 the income is considered available only to that spouse; 

    (ii) if payment is made in the names of both spouses, 
 one-half of the income is considered available to each; 

    (iii) if payment is made in the names of one or both 
 spouses together with one or more other persons, the income is 
 considered available to each spouse according to the spouse's 
 interest, or one-half of the joint interest is considered 
 available to each spouse if each spouse's interest is not 
 specified; 

    (iv) if there is no instrument that establishes ownership, 
 one-half of the income is considered available to each spouse; 
 and 

    (v) either spouse may rebut the determination of 
 availability of income by showing by a preponderance of the 
 evidence that ownership interests are different than provided 
 above.  

    (2) For income from a trust, income is considered available 
 to each spouse as provided in the trust.  If the trust does not 
 specify an amount available to either or both spouses, 
 availability will be determined according to items (i) to (iii): 

    (i) if payment of income is made only to one spouse, the 
 income is considered available only to that spouse; 

    (ii) if payment of income is made to both spouses, one-half 
 is considered available to each; and 

    (iii) if payment is made to either or both spouses and one 
 or more other persons, the income is considered available to 
 each spouse in proportion to each spouse's interest, or if no 
 such interest is specified, one-half of the joint interest is 
 considered available to each spouse. 

    HIST: 1989 c 282 art 3 s 50 

     256B.059 Treatment of assets when a spouse is 
  institutionalized. 

    Subdivision 1.    Definitions.  (a) For purposes of this 
 section and section 256B.0595, the terms defined in this 
 subdivision have the meanings given them. 

    (b) "Community spouse" means the spouse of an 
 institutionalized spouse. 

    (c) "Spousal share" means one-half of the total value of 
 all assets, to the extent that either the institutionalized 
 spouse or the community spouse had an ownership interest at the 
 time of institutionalization. 

    (d) "Assets otherwise available to the community spouse" 
 means assets individually or jointly owned by the community 
 spouse, other than assets excluded by subdivision 5, paragraph 
 (c). 

    (e) "Community spouse asset allowance" is the value of 
 assets that can be transferred under subdivision 3. 

    (f) "Institutionalized spouse" means a person who is: 

    (1) in a hospital, nursing facility, or intermediate care 
 facility for persons with mental retardation, or receiving home 
 and community-based services under section 256B.0915 or 256B.49, 
 and is expected to remain in the facility or institution or 
 receive the home and community-based services for at least 30 
 consecutive days; and 

    (2) married to a person who is not in a hospital, nursing 
 facility, or intermediate care facility for persons with mental 
 retardation, and is not receiving home and community-based 
 services under section 256B.0915 or 256B.49. 

    (g) "For the sole benefit of" means no other individual or 
 entity can benefit in any way from the assets or income at the 
 time of a transfer or at any time in the future. 

    Subd. 1a.    Institutionalized spouse.  The provisions 
 of this section apply only when a spouse is institutionalized 
 for a continuous period beginning on or after October 1, 1989. 

    Subd. 2.    Assessment of spousal share.  At the 
 beginning of the first continuous period of institutionalization 
 of a person beginning on or after October 1, 1989, at the 
 request of either the institutionalized spouse or the community 
 spouse, or upon application for medical assistance, the total 
 value of assets in which either the institutionalized spouse or 
 the community spouse had an interest at the time of the first 
 period of institutionalization of 30 days or more shall be 
 assessed and documented and the spousal share shall be assessed 
 and documented. 

    Subd. 3.    Community spouse asset allowance.  An 
 institutionalized spouse may transfer assets to the community 
 spouse for the sole benefit of the community spouse.  Except for 
 increased amounts allowable under subdivision 4, the maximum 
 amount of assets allowed to be transferred is the amount which, 
 when added to the assets otherwise available to the community 
 spouse, is as follows:  

    (1) prior to July 1, 1994, the greater of: 

    (i) $14,148; 

    (ii) the lesser of the spousal share or $70,740; or 

    (iii) the amount required by court order to be paid to the 
 community spouse; and 

    (2) for persons whose date of initial determination of 
 eligibility for medical assistance following their first 
 continuous period of institutionalization occurs on or after 
 July 1, 1994, the greater of: 

    (i) $20,000; 

    (ii) the lesser of the spousal share or $70,740; or 

    (iii) the amount required by court order to be paid to the 
 community spouse. 

    If the assets available to the community spouse are already 
 at the limit permissible under this section, or the higher limit 
 attributable to increases under subdivision 4, no assets may be 
 transferred from the institutionalized spouse to the community 
 spouse.  The transfer must be made as soon as practicable after 
 the date the institutionalized spouse is determined eligible for 
 medical assistance, or within the amount of time needed for any 
 court order required for the transfer.  On January 1, 1994, and 
 every January 1 thereafter, the limits in this subdivision shall 
 be adjusted by the same percentage change in the consumer price 
 index for all urban consumers (all items; United States city 
 average) between the two previous Septembers.  These adjustments 
 shall also be applied to the limits in subdivision 5. 

    Subd. 4.    Increased community spouse asset allowance; 
 when allowed.  (a) If either the institutionalized spouse or 
 community spouse establishes that the community spouse asset 
 allowance under subdivision 3 (in relation to the amount of 
 income generated by such an allowance) is not sufficient to 
 raise the community spouse's income to the minimum monthly 
 maintenance needs allowance in section 256B.058, subdivision 2, 
 paragraph (c), there shall be substituted for the amount allowed 
 to be transferred an amount sufficient, when combined with the 
 monthly income otherwise available to the spouse, to provide the 
 minimum monthly maintenance needs allowance.  A substitution 
 under this paragraph may be made only if the assets of the 
 couple have been arranged so that the maximum amount of 
 income-producing assets, at the maximum rate of return, are 
 available to the community spouse under the community spouse 
 asset allowance.  The maximum rate of return is the average rate 
 of return available from the financial institution holding the 
 asset, or a rate determined by the commissioner to be reasonable 
 according to community standards, if the asset is not held by a 
 financial institution. 

    (b) The community spouse asset allowance under subdivision 
 3 can be increased by court order or hearing that complies with 
 the requirements of United States Code, title 42, section 
 1396r-5. 

    Subd. 5.    Asset availability.  (a) At the time of 
 initial determination of eligibility for medical assistance 
 benefits following the first continuous period of 
 institutionalization on or after October 1, 1989, assets 
 considered available to the institutionalized spouse shall be 
 the total value of all assets in which either spouse has an 
 ownership interest, reduced by the following amount for the 
 community spouse: 

    (1) prior to July 1, 1994, the greater of:  

    (i) $14,148; 

    (ii) the lesser of the spousal share or $70,740; or 

    (iii) the amount required by court order to be paid to the 
 community spouse; 

    (2) for persons whose date of initial determination of 
 eligibility for medical assistance following their first 
 continuous period of institutionalization occurs on or after 
 July 1, 1994, the greater of:  

    (i) $20,000; 

    (ii) the lesser of the spousal share or $70,740; or 

    (iii) the amount required by court order to be paid to the 
 community spouse.  

 The value of assets transferred for the sole benefit of the 
 community spouse under section 256B.0595, subdivision 4, in 
 combination with other assets available to the community spouse 
 under this section, cannot exceed the limit for the community 
 spouse asset allowance determined under subdivision 3 or 4.  
 Assets that exceed this allowance shall be considered available 
 to the institutionalized spouse whether or not converted to 
 income.  If the community spouse asset allowance has been 
 increased under subdivision 4, then the assets considered 
 available to the institutionalized spouse under this subdivision 
 shall be further reduced by the value of additional amounts 
 allowed under subdivision 4. 

    (b) An institutionalized spouse may be found eligible for 
 medical assistance even though assets in excess of the allowable 
 amount are found to be available under paragraph (a) if the 
 assets are owned jointly or individually by the community 
 spouse, and the institutionalized spouse cannot use those assets 
 to pay for the cost of care without the consent of the community 
 spouse, and if:  (i) the institutionalized spouse assigns to the 
 commissioner the right to support from the community spouse 
 under section 256B.14, subdivision 3; (ii) the institutionalized 
 spouse lacks the ability to execute an assignment due to a 
 physical or mental impairment; or (iii) the denial of 
 eligibility would cause an imminent threat to the 
 institutionalized spouse's health and well-being. 

    (c) After the month in which the institutionalized spouse 
 is determined eligible for medical assistance, during the 
 continuous period of institutionalization, no assets of the 
 community spouse are considered available to the 
 institutionalized spouse, unless the institutionalized spouse 
 has been found eligible under paragraph (b). 

    (d) Assets determined to be available to the 
 institutionalized spouse under this section must be used for the 
 health care or personal needs of the institutionalized spouse. 

    (e) For purposes of this section, assets do not include 
 assets excluded under the supplemental security income program. 

    HIST: 1989 c 282 art 3 s 51; 1990 c 568 art 3 s 38,39; 1991 c 
 199 art 1 s 61; 1992 c 513 art 7 s 40,41; 1Sp1993 c 1 art 5 s 
 33,34; 1995 c 207 art 6 s 31-33; 1997 c 107 s 3-6; 2002 c 220 
 art 15 s 7-9 

     256B.0595 Prohibitions on transfer; exceptions. 

    Subdivision 1.    Prohibited transfers.  (a) For 
 transfers of assets made on or before August 10, 1993, if a 
 person or the person's spouse has given away, sold, or disposed 
 of, for less than fair market value, any asset or interest 
 therein, except assets other than the homestead that are 
 excluded under the supplemental security program, within 30 
 months before or any time after the date of institutionalization 
 if the person has been determined eligible for medical 
 assistance, or within 30 months before or any time after the 
 date of the first approved application for medical assistance if 
 the person has not yet been determined eligible for medical 
 assistance, the person is ineligible for long-term care services 
 for the period of time determined under subdivision 2.  

    (b) Effective for transfers made after August 10, 1993, a 
 person, a person's spouse, or any person, court, or 
 administrative body with legal authority to act in place of, on 
 behalf of, at the direction of, or upon the request of the 
 person or person's spouse, may not give away, sell, or dispose 
 of, for less than fair market value, any asset or interest 
 therein, except assets other than the homestead that are 
 excluded under the supplemental security income program, for the 
 purpose of establishing or maintaining medical assistance 
 eligibility.  For purposes of determining eligibility for 
 long-term care services, any transfer of such assets within 36 
 months before or any time after an institutionalized person 
 applies for medical assistance, or 36 months before or any time 
 after a medical assistance recipient becomes institutionalized, 
 for less than fair market value may be considered.  Any such 
 transfer is presumed to have been made for the purpose of 
 establishing or maintaining medical assistance eligibility and 
 the person is ineligible for long-term care services for the 
 period of time determined under subdivision 2, unless the person 
 furnishes convincing evidence to establish that the transaction 
 was exclusively for another purpose, or unless the transfer is 
 permitted under subdivision 3 or 4.  Notwithstanding the 
 provisions of this paragraph, in the case of payments from a 
 trust or portions of a trust that are considered transfers of 
 assets under federal law, any transfers made within 60 months 
 before or any time after an institutionalized person applies for 
 medical assistance and within 60 months before or any time after 
 a medical assistance recipient becomes institutionalized, may be 
 considered. 

    (c) This section applies to transfers, for less than fair 
 market value, of income or assets, including assets that are 
 considered income in the month received, such as inheritances, 
 court settlements, and retroactive benefit payments or income to 
 which the person or the person's spouse is entitled but does not 
 receive due to action by the person, the person's spouse, or any 
 person, court, or administrative body with legal authority to 
 act in place of, on behalf of, at the direction of, or upon the 
 request of the person or the person's spouse.  

    (d) This section applies to payments for care or personal 
 services provided by a relative, unless the compensation was 
 stipulated in a notarized, written agreement which was in 
 existence when the service was performed, the care or services 
 directly benefited the person, and the payments made represented 
 reasonable compensation for the care or services provided.  A 
 notarized written agreement is not required if payment for the 
 services was made within 60 days after the service was provided. 

    (e) This section applies to the portion of any asset or 
 interest that a person, a person's spouse, or any person, court, 
 or administrative body with legal authority to act in place of, 
 on behalf of, at the direction of, or upon the request of the 
 person or the person's spouse, transfers to any annuity that 
 exceeds the value of the benefit likely to be returned to the 
 person or spouse while alive, based on estimated life expectancy 
 using the life expectancy tables employed by the supplemental 
 security income program to determine the value of an agreement 
 for services for life.  The commissioner may adopt rules 
 reducing life expectancies based on the need for long-term 
 care.  This section applies to an annuity described in this 
 paragraph purchased on or after March 1, 2002, that: 

    (1) is not purchased from an insurance company or financial 
 institution that is subject to licensing or regulation by the 
 Minnesota department of commerce or a similar regulatory agency 
 of another state; 

    (2) does not pay out principal and interest in equal 
 monthly installments; or 

    (3) does not begin payment at the earliest possible date 
 after annuitization.  

    (f) For purposes of this section, long-term care services 
 include services in a nursing facility, services that are 
 eligible for payment according to section 256B.0625, subdivision 
 2, because they are provided in a swing bed, intermediate care 
 facility for persons with mental retardation, and home and 
 community-based services provided pursuant to sections 
 256B.0915, 256B.092, and 256B.49.  For purposes of this 
 subdivision and subdivisions 2, 3, and 4, "institutionalized 
 person" includes a person who is an inpatient in a nursing 
 facility or in a swing bed, or intermediate care facility for 
 persons with mental retardation or who is receiving home and 
 community-based services under sections 256B.0915, 256B.092, and 
 256B.49. 

    Subd. 1a. Repealed, 2001 c 203 s 19 

    Subd. 2.    Period of ineligibility.  (a) For any 
 uncompensated transfer occurring on or before August 10, 1993, 
 the number of months of ineligibility for long-term care 
 services shall be the lesser of 30 months, or the uncompensated 
 transfer amount divided by the average medical assistance rate 
 for nursing facility services in the state in effect on the date 
 of application.  The amount used to calculate the average 
 medical assistance payment rate shall be adjusted each July 1 to 
 reflect payment rates for the previous calendar year.  The 
 period of ineligibility begins with the month in which the 
 assets were transferred.  If the transfer was not reported to 
 the local agency at the time of application, and the applicant 
 received long-term care services during what would have been the 
 period of ineligibility if the transfer had been reported, a 
 cause of action exists against the transferee for the cost of 
 long-term care services provided during the period of 
 ineligibility, or for the uncompensated amount of the transfer, 
 whichever is less.  The action may be brought by the state or 
 the local agency responsible for providing medical assistance 
 under chapter 256G.  The uncompensated transfer amount is the 
 fair market value of the asset at the time it was given away, 
 sold, or disposed of, less the amount of compensation received.  

    (b) For uncompensated transfers made after August 10, 1993, 
 the number of months of ineligibility for long-term care 
 services shall be the total uncompensated value of the resources 
 transferred divided by the average medical assistance rate for 
 nursing facility services in the state in effect on the date of 
 application.  The amount used to calculate the average medical 
 assistance payment rate shall be adjusted each July 1 to reflect 
 payment rates for the previous calendar year.  The period of 
 ineligibility begins with the month in which the assets were 
 transferred except that if one or more uncompensated transfers 
 are made during a period of ineligibility, the total assets 
 transferred during the ineligibility period shall be combined 
 and a penalty period calculated to begin in the month the first 
 uncompensated transfer was made.  If the transfer was not 
 reported to the local agency at the time of application, and the 
 applicant received medical assistance services during what would 
 have been the period of ineligibility if the transfer had been 
 reported, a cause of action exists against the transferee for 
 the cost of medical assistance services provided during the 
 period of ineligibility, or for the uncompensated amount of the 
 transfer, whichever is less.  The action may be brought by the 
 state or the local agency responsible for providing medical 
 assistance under chapter 256G.  The uncompensated transfer 
 amount is the fair market value of the asset at the time it was 
 given away, sold, or disposed of, less the amount of 
 compensation received.  Effective for transfers made on or after 
 March 1, 1996, involving persons who apply for medical 
 assistance on or after April 13, 1996, no cause of action exists 
 for a transfer unless: 

    (1) the transferee knew or should have known that the 
 transfer was being made by a person who was a resident of a 
 long-term care facility or was receiving that level of care in 
 the community at the time of the transfer; 

    (2) the transferee knew or should have known that the 
 transfer was being made to assist the person to qualify for or 
 retain medical assistance eligibility; or 

    (3) the transferee actively solicited the transfer with 
 intent to assist the person to qualify for or retain eligibility 
 for medical assistance.  

    (c) If a calculation of a penalty period results in a 
 partial month, payments for long-term care services shall be 
 reduced in an amount equal to the fraction, except that in 
 calculating the value of uncompensated transfers, if the total 
 value of all uncompensated transfers made in a month not 
 included in an existing penalty period does not exceed $200, 
 then such transfers shall be disregarded for each month prior to 
 the month of application for or during receipt of medical 
 assistance. 

    Subd. 2a. Repealed, 2001 c 203 s 19 

    Subd. 3.    Homestead exception to transfer prohibition. 
  (a) An institutionalized person is not ineligible for 
 long-term care services due to a transfer of assets for less 
 than fair market value if the asset transferred was a homestead 
 and: 

    (1) title to the homestead was transferred to the 
 individual's 

    (i) spouse; 

    (ii) child who is under age 21; 

    (iii) blind or permanently and totally disabled child as 
 defined in the supplemental security income program; 

    (iv) sibling who has equity interest in the home and who 
 was residing in the home for a period of at least one year 
 immediately before the date of the individual's admission to the 
 facility; or 

    (v) son or daughter who was residing in the individual's 
 home for a period of at least two years immediately before the 
 date of the individual's admission to the facility, and who 
 provided care to the individual that, as certified by the 
 individual's attending physician, permitted the individual to 
 reside at home rather than in an institution or facility; 

    (2) a satisfactory showing is made that the individual 
 intended to dispose of the homestead at fair market value or for 
 other valuable consideration; or 

    (3) the local agency grants a waiver of a penalty resulting 
 from a transfer for less than fair market value because denial 
 of eligibility would cause undue hardship for the individual, 
 based on imminent threat to the individual's health and 
 well-being.  Whenever an applicant or recipient is denied 
 eligibility because of a transfer for less than fair market 
 value, the local agency shall notify the applicant or recipient 
 that the applicant or recipient may request a waiver of the 
 penalty if the denial of eligibility will cause undue hardship.  
 In evaluating a waiver, the local agency shall take into account 
 whether the individual was the victim of financial exploitation, 
 whether the individual has made reasonable efforts to recover 
 the transferred property or resource, and other factors relevant 
 to a determination of hardship.  If the local agency does not 
 approve a hardship waiver, the local agency shall issue a 
 written notice to the individual stating the reasons for the 
 denial and the process for appealing the local agency's decision.

    (b) When a waiver is granted under paragraph (a), clause 
 (3), a cause of action exists against the person to whom the 
 homestead was transferred for that portion of long-term care 
 services granted within: 

    (1) 30 months of a transfer made on or before August 10, 
 1993; 

    (2) 60 months if the homestead was transferred after August 
 10, 1993, to a trust or portion of a trust that is considered a 
 transfer of assets under federal law; or 

    (3) 36 months if transferred in any other manner after 
 August 10, 1993, 

 or the amount of the uncompensated transfer, whichever is less, 
 together with the costs incurred due to the action.  The action 
 shall be brought by the state unless the state delegates this 
 responsibility to the local agency responsible for providing 
 medical assistance under chapter 256G. 

    Subd. 3a. Repealed, 2001 c 203 s 19 

    Subd. 4.    Other exceptions to transfer prohibition.  
 An institutionalized person who has made, or whose spouse has 
 made a transfer prohibited by subdivision 1, is not ineligible 
 for long-term care services if one of the following conditions 
 applies: 

    (1) the assets were transferred to the individual's spouse 
 or to another for the sole benefit of the spouse; or 

    (2) the institutionalized spouse, prior to being 
 institutionalized, transferred assets to a spouse, provided that 
 the spouse to whom the assets were transferred does not then 
 transfer those assets to another person for less than fair 
 market value.  (At the time when one spouse is 
 institutionalized, assets must be allocated between the spouses 
 as provided under section 256B.059); or 

    (3) the assets were transferred to the individual's child 
 who is blind or permanently and totally disabled as determined 
 in the supplemental security income program; or 

    (4) a satisfactory showing is made that the individual 
 intended to dispose of the assets either at fair market value or 
 for other valuable consideration; or 

    (5) the local agency determines that denial of eligibility 
 for long-term care services would work an undue hardship and 
 grants a waiver of a penalty resulting from a transfer for less 
 than fair market value based on an imminent threat to the 
 individual's health and well-being.  Whenever an applicant or 
 recipient is denied eligibility because of a transfer for less 
 than fair market value, the local agency shall notify the 
 applicant or recipient that the applicant or recipient may 
 request a waiver of the penalty if the denial of eligibility 
 will cause undue hardship.  In evaluating a waiver, the local 
 agency shall take into account whether the individual was the 
 victim of financial exploitation, whether the individual has 
 made reasonable efforts to recover the transferred property or 
 resource, and other factors relevant to a determination of 
 hardship.  If the local agency does not approve a hardship 
 waiver, the local agency shall issue a written notice to the 
 individual stating the reasons for the denial and the process 
 for appealing the local agency's decision.  When a waiver is 
 granted, a cause of action exists against the person to whom the 
 assets were transferred for that portion of long-term care 
 services granted within: 

    (i) 30 months of a transfer made on or before August 10, 
 1993; 

    (ii) 60 months of a transfer if the assets were transferred 
 after August 30, 1993, to a trust or portion of a trust that is 
 considered a transfer of assets under federal law; or 

    (iii) 36 months of a transfer if transferred in any other 
 manner after August 10, 1993, 

 or the amount of the uncompensated transfer, whichever is less, 
 together with the costs incurred due to the action.  The action 
 shall be brought by the state unless the state delegates this 
 responsibility to the local agency responsible for providing 
 medical assistance under this chapter; or 

    (6) for transfers occurring after August 10, 1993, the 
 assets were transferred by the person or person's spouse:  (i) 
 into a trust established for the sole benefit of a son or 
 daughter of any age who is blind or disabled as defined by the 
 Supplemental Security Income program; or (ii) into a trust 
 established for the sole benefit of an individual who is under 
 65 years of age who is disabled as defined by the Supplemental 
 Security Income program. 

    "For the sole benefit of" has the meaning found in section 
 256B.059, subdivision 1. 

    Subd. 4a. Repealed, 2001 c 203 s 19 

    Subd. 5.    Notice of receipt of federal waiver.  In 
 every instance in which a federal waiver that allows the 
 implementation of a provision in this section is granted, the 
 commissioner shall publish notice of receipt of the waiver in 
 the State Register. 

    Subd. 6.    No bad effect on realty conveyance, 
 encumbrance.  This section does not invalidate or impair the 
 effectiveness of a conveyance or encumbrance of real estate. 

    Subd. 7.    Notice of rights.  If a period of 
 ineligibility is imposed under subdivision 2 or 2a, the local 
 agency shall inform the applicant or recipient subject to the 
 penalty of the person's rights under section 325F.71, 
 subdivision 2. 

    HIST: 1986 c 444; 1989 c 282 art 3 s 52; 1990 c 568 art 3 s 
 40-42; 1992 c 513 art 7 s 42; 1Sp1993 c 1 art 5 s 35; 1994 c 388 
 art 1 s 2; 1995 c 207 art 6 s 34-37; 1996 c 451 art 2 s 
 11-19,62; 2001 c 203 s 7,8,19; 2002 c 220 art 15 s 10-12 

*   NOTE:  The amendments to subdivisions 1, 2, 3, and 4, by 
*Laws 1995, chapter 207, article 6, sections 34 to 37, are 
*effective retroactive to August 11, 1993, except that portion 
*amending subdivision 2, paragraph (c), is effective retroactive 
*to transfers of income or assets made on or after September 1, 
*1994.  Laws 1995, chapter 207, article 6, section 125, 
*subdivision 2, and Laws 1995, chapter 263, section 6.

     256B.06 Eligibility; migrant workers; citizenship. 

    Subdivision 1. Renumbered 256B.055, subdivision 1 

    Subd. 1a. Renumbered 256B.055, subd 2 

    Subd. 1b. Renumbered 256B.055, subd 3 

    Subd. 1c. Renumbered 256B.055, subd 4 

    Subd. 1d. Renumbered 256B.055, subd 5 

    Subd. 1e. Renumbered 256B.055, subd 6 

    Subd. 1f. Renumbered 256B.055, subd 7 

    Subd. 1g. Renumbered 256B.055, subd 8 

    Subd. 1h. Renumbered 256B.055, subd 9 

    Subd. 1i. Renumbered 256B.055, subd 10 

    Subd. 1j. Renumbered 256B.055, subd 11 

    Subd. 1k. Renumbered 256B.056, subdivision 1 

    Subd. 1l. Renumbered 256B.056, subd 2 

    Subd. 1m. Renumbered 256B.056, subd 3 

    Subd. 1n. Renumbered 256B.056, subd 4 

    Subd. 1o. Renumbered 256B.056, subd 5 

    Subd. 1p. Renumbered 256B.056, subd 6 

    Subd. 1q. Renumbered 256B.055, subd 12 

    Subd. 1r. Renumbered 256B.056, subd 7 

    Subd. 2.  Repealed, 1974 c 525 s 3 

    Subd. 3.    Migrant worker.  Notwithstanding any law to 
 the contrary, a migrant worker who meets all of the eligibility 
 requirements of this section except for having a permanent place 
 of abode in another state, shall be eligible for medical 
 assistance and shall have medical needs met by the county in 
 which the worker resides at the time of making application.  

    Subd. 4.    Citizenship requirements.  (a) Eligibility 
 for medical assistance is limited to citizens of the United 
 States, qualified noncitizens as defined in this subdivision, 
 and other persons residing lawfully in the United States. 

    (b) "Qualified noncitizen" means a person who meets one of 
 the following immigration criteria: 

    (1) admitted for lawful permanent residence according to 
 United States Code, title 8; 

    (2) admitted to the United States as a refugee according to 
 United States Code, title 8, section 1157; 

    (3) granted asylum according to United States Code, title 
 8, section 1158; 

    (4) granted withholding of deportation according to United 
 States Code, title 8, section 1253(h); 

    (5) paroled for a period of at least one year according to 
 United States Code, title 8, section 1182(d)(5); 

    (6) granted conditional entrant status according to United 
 States Code, title 8, section 1153(a)(7); 

    (7) determined to be a battered noncitizen by the United 
 States Attorney General according to the Illegal Immigration 
 Reform and Immigrant Responsibility Act of 1996, title V of the 
 Omnibus Consolidated Appropriations Bill, Public Law Number 
 104-200; 

    (8) is a child of a noncitizen determined to be a battered 
 noncitizen by the United States Attorney General according to 
 the Illegal Immigration Reform and Immigrant Responsibility Act 
 of 1996, title V, of the Omnibus Consolidated Appropriations 
 Bill, Public Law Number 104-200; or 

    (9) determined to be a Cuban or Haitian entrant as defined 
 in section 501(e) of Public Law Number 96-422, the Refugee 
 Education Assistance Act of 1980. 

    (c) All qualified noncitizens who were residing in the 
 United States before August 22, 1996, who otherwise meet the 
 eligibility requirements of chapter 256B, are eligible for 
 medical assistance with federal financial participation. 

    (d) All qualified noncitizens who entered the United States 
 on or after August 22, 1996, and who otherwise meet the 
 eligibility requirements of chapter 256B, are eligible for 
 medical assistance with federal financial participation through 
 November 30, 1996. 

    Beginning December 1, 1996, qualified noncitizens who 
 entered the United States on or after August 22, 1996, and who 
 otherwise meet the eligibility requirements of chapter 256B are 
 eligible for medical assistance with federal participation for 
 five years if they meet one of the following criteria: 

    (i) refugees admitted to the United States according to 
 United States Code, title 8, section 1157; 

    (ii) persons granted asylum according to United States 
 Code, title 8, section 1158; 

    (iii) persons granted withholding of deportation according 
 to United States Code, title 8, section 1253(h); 

    (iv) veterans of the United States Armed Forces with an 
 honorable discharge for a reason other than noncitizen status, 
 their spouses and unmarried minor dependent children; or 

    (v) persons on active duty in the United States Armed 
 Forces, other than for training, their spouses and unmarried 
 minor dependent children. 

    Beginning December 1, 1996, qualified noncitizens who do 
 not meet one of the criteria in items (i) to (v) are eligible 
 for medical assistance without federal financial participation 
 as described in paragraph (j). 

    (e) Noncitizens who are not qualified noncitizens as 
 defined in paragraph (b), who are lawfully residing in the 
 United States and who otherwise meet the eligibility 
 requirements of chapter 256B, are eligible for medical 
 assistance under clauses (1) to (3).  These individuals must 
 cooperate with the Immigration and Naturalization Service to 
 pursue any applicable immigration status, including citizenship, 
 that would qualify them for medical assistance with federal 
 financial participation. 

    (1) Persons who were medical assistance recipients on 
 August 22, 1996, are eligible for medical assistance with 
 federal financial participation through December 31, 1996. 

    (2) Beginning January 1, 1997, persons described in clause 
 (1) are eligible for medical assistance without federal 
 financial participation as described in paragraph (j). 

    (3) Beginning December 1, 1996, persons residing in the 
 United States prior to August 22, 1996, who were not receiving 
 medical assistance and persons who arrived on or after August 
 22, 1996, are eligible for medical assistance without federal 
 financial participation as described in paragraph (j). 

    (f) Nonimmigrants who otherwise meet the eligibility 
 requirements of chapter 256B are eligible for the benefits as 
 provided in paragraphs (g) to (i).  For purposes of this 
 subdivision, a "nonimmigrant" is a person in one of the classes 
 listed in United States Code, title 8, section 1101(a)(15). 

    (g) Payment shall also be made for care and services that 
 are furnished to noncitizens, regardless of immigration status, 
 who otherwise meet the eligibility requirements of chapter 256B, 
 if such care and services are necessary for the treatment of an 
 emergency medical condition, except for organ transplants and 
 related care and services and routine prenatal care.  

    (h) For purposes of this subdivision, the term "emergency 
 medical condition" means a medical condition that meets the 
 requirements of United States Code, title 42, section 1396b(v). 

    (i) Pregnant noncitizens who are undocumented or 
 nonimmigrants, who otherwise meet the eligibility requirements 
 of chapter 256B, are eligible for medical assistance payment 
 without federal financial participation for care and services 
 through the period of pregnancy, and 60 days postpartum, except 
 for labor and delivery.  

    (j) Qualified noncitizens as described in paragraph (d), 
 and all other noncitizens lawfully residing in the United States 
 as described in paragraph (e), who are ineligible for medical 
 assistance with federal financial participation and who 
 otherwise meet the eligibility requirements of chapter 256B and 
 of this paragraph, are eligible for medical assistance without 
 federal financial participation.  Qualified noncitizens as 
 described in paragraph (d) are only eligible for medical 
 assistance without federal financial participation for five 
 years from their date of entry into the United States.  

    (k) The commissioner shall submit to the legislature by 
 December 31, 1998, a report on the number of recipients and cost 
 of coverage of care and services made according to paragraphs 
 (i) and (j). 

    Subd. 5.    Deeming of sponsor income and resources.  
 When determining eligibility for any federal or state funded 
 medical assistance under this section, the income and resources 
 of all noncitizens shall be deemed to include their sponsors' 
 income and resources as required under the Personal 
 Responsibility and Work Opportunity Reconciliation Act of 1996, 
 title IV, Public Law Number 104-193, sections 421 and 422, and 
 subsequently set out in federal rules.  This section is 
 effective May 1, 1997. 

    HIST: Ex1967 c 16 s 6; 1969 c 841 s 1; 1973 c 717 s 18; 1974 c 
 525 s 1,2; 1975 c 247 s 10; 1976 c 236 s 3; 1977 c 448 s 6; 1978 
 c 760 s 1; 1979 c 309 s 4; 1980 c 509 s 106; 1980 c 527 s 1; 
 1981 c 360 art 2 s 28; 1Sp1981 c 2 s 14; 3Sp1981 c 2 art 1 s 32; 
 3Sp1981 c 3 s 17; 1982 c 553 s 6; 1982 c 640 s 5; 1983 c 312 art 
 5 s 15; 1984 c 422 s 1; 1984 c 534 s 22; 1984 c 654 art 5 s 58; 
 1985 c 248 s 70; 1985 c 252 s 21; 1986 c 444; 1Sp1986 c 1 art 8 
 s 5; 1987 c 403 art 2 s 79,80; 1988 c 689 art 2 s 144,145,268; 
 1991 c 199 art 2 s 1; 1995 c 207 art 6 s 38; 1997 c 85 art 3 s 
 19,20; 1997 c 203 art 12 s 2; 1998 c 407 art 4 s 19 

     256B.061 Eligibility; retroactive effect; restrictions. 

    (a) If any individual has been determined to be eligible 
 for medical assistance, it will be made available for care and 
 services included under the plan and furnished in or after the 
 third month before the month in which the individual made 
 application for such assistance, if such individual was, or upon 
 application would have been, eligible for medical assistance at 
 the time the care and services were furnished.  The commissioner 
 may limit, restrict, or suspend the eligibility of an individual 
 for up to one year upon that individual's conviction of a 
 criminal offense related to application for or receipt of 
 medical assistance benefits. 

    (b) On the basis of information provided on the completed 
 application, an applicant who meets the following criteria shall 
 be determined eligible beginning in the month of application: 

    (1) whose gross income is less than 90 percent of the 
 applicable income standard; 

    (2) whose total liquid assets are less than 90 percent of 
 the asset limit; 

    (3) does not reside in a long-term care facility; and 

    (4) meets all other eligibility requirements. 

 The applicant must provide all required verifications within 30 
 days' notice of the eligibility determination or eligibility 
 shall be terminated. 

    HIST: 1973 c 717 s 3; 1983 c 312 art 5 s 16; 1986 c 444; 1999 
 c 245 art 4 s 36 

  256B.062 Repealed, 1998 c 407 art 6 s 12,118 

     256B.0621 Covered services:  targeted case management 
  services. 

    Subdivision 1. Repealed, 2002 c 375 art 2 s 56 

    Subd. 2.    Targeted case management; definitions.  For 
 purposes of subdivisions 3 to 10, the following terms have the 
 meanings given them: 

    (1) "home care service recipients" means those individuals 
 receiving the following services under section 256B.0627:  
 skilled nursing visits, home health aide visits, private duty 
 nursing, personal care assistants, or therapies provided through 
 a home health agency; 

    (2) "home care targeted case management" means the 
 provision of targeted case management services for the purpose 
 of assisting home care service recipients to gain access to 
 needed services and supports so that they may remain in the 
 community; 

    (3) "institutions" means hospitals, consistent with Code of 
 Federal Regulations, title 42, section 440.10; regional 
 treatment center inpatient services, consistent with section 
 245.474; nursing facilities; and intermediate care facilities 
 for persons with mental retardation; 

    (4) "relocation targeted case management" means the 
 provision of targeted case management services for the purpose 
 of assisting recipients to gain access to needed services and 
 supports if they choose to move from an institution to the 
 community.  Relocation targeted case management may be provided 
 during the last 180 consecutive days of an eligible recipient's 
 institutional stay; and 

    (5) "targeted case management" means case management 
 services provided to help recipients gain access to needed 
 medical, social, educational, and other services and supports. 

    Subd. 3.    Eligibility.  The following persons are 
 eligible for relocation targeted case management or home 
 care-targeted case management: 

    (1) medical assistance eligible persons residing in 
 institutions who choose to move into the community are eligible 
 for relocation targeted case management services; and 

    (2) medical assistance eligible persons receiving home care 
 services, who are not eligible for any other medical assistance 
 reimbursable case management service, are eligible for home 
 care-targeted case management services beginning January 1, 2003.

    Subd. 4.    Relocation targeted case management provider 
 qualifications.  The following qualifications and 
 certification standards must be met by providers of relocation 
 targeted case management: 

    (a) The commissioner must certify each provider of 
 relocation targeted case management before enrollment.  The 
 certification process shall examine the provider's ability to 
 meet the requirements in this subdivision and other federal and 
 state requirements of this service.  A certified relocation 
 targeted case management provider may subcontract with another 
 provider to deliver relocation targeted case management 
 services.  Subcontracted providers must demonstrate the ability 
 to provide the services outlined in subdivision 6. 

    (b) A relocation targeted case management provider is an 
 enrolled medical assistance provider who is determined by the 
 commissioner to have all of the following characteristics: 

    (1) the legal authority to provide public welfare under 
 sections 393.01, subdivision 7; and 393.07; or a federally 
 recognized Indian tribe; 

    (2) the demonstrated capacity and experience to provide the 
 components of case management to coordinate and link community 
 resources needed by the eligible population; 

    (3) the administrative capacity and experience to serve the 
 target population for whom it will provide services and ensure 
 quality of services under state and federal requirements; 

    (4) the legal authority to provide complete investigative 
 and protective services under section 626.556, subdivision 10; 
 and child welfare and foster care services under section 393.07, 
 subdivisions 1 and 2; or a federally recognized Indian tribe; 

    (5) a financial management system that provides accurate 
 documentation of services and costs under state and federal 
 requirements; and 

    (6) the capacity to document and maintain individual case 
 records under state and federal requirements. 

 A provider of targeted case management under subdivision 20 may 
 be deemed a certified provider of relocation targeted case 
 management. 

    Subd. 5.    Home care targeted case management provider 
 qualifications.  The following qualifications and 
 certification standards must be met by providers of home care 
 targeted case management. 

    (a) The commissioner must certify each provider of home 
 care targeted case management before enrollment.  The 
 certification process shall examine the provider's ability to 
 meet the requirements in this subdivision and other state and 
 federal requirements of this service. 

    (b) A home care targeted case management provider is an 
 enrolled medical assistance provider who has a minimum of a 
 bachelor's degree or a license in a health or human services 
 field, and is determined by the commissioner to have all of the 
 following characteristics: 

    (1) the demonstrated capacity and experience to provide the 
 components of case management to coordinate and link community 
 resources needed by the eligible population; 

    (2) the administrative capacity and experience to serve the 
 target population for whom it will provide services and ensure 
 quality of services under state and federal requirements; 

    (3) a financial management system that provides accurate 
 documentation of services and costs under state and federal 
 requirements; 

    (4) the capacity to document and maintain individual case 
 records under state and federal requirements; and 

    (5) the capacity to coordinate with county administrative 
 functions. 

    Subd. 6.    Eligible services.  Services eligible for 
 medical assistance reimbursement as targeted case management 
 include: 

    (1) assessment of the recipient's need for targeted case 
 management services; 

    (2) development, completion, and regular review of a 
 written individual service plan, which is based upon the 
 assessment of the recipient's needs and choices, and which will 
 ensure access to medical, social, educational, and other related 
 services and supports; 

    (3) routine contact or communication with the recipient, 
 recipient's family, primary caregiver, legal representative, 
 substitute care provider, service providers, or other relevant 
 persons identified as necessary to the development or 
 implementation of the goals of the individual service plan; 

    (4) coordinating referrals for, and the provision of, case 
 management services for the recipient with appropriate service 
 providers, consistent with section 1902(a)(23) of the Social 
 Security Act; 

    (5) coordinating and monitoring the overall service 
 delivery to ensure quality of services, appropriateness, and 
 continued need; 

    (6) completing and maintaining necessary documentation that 
 supports and verifies the activities in this subdivision; 

    (7) traveling to conduct a visit with the recipient or 
 other relevant person necessary to develop or implement the 
 goals of the individual service plan; and 

    (8) coordinating with the institution discharge planner in 
 the 180-day period before the recipient's discharge. 

    Subd. 7.    Time lines.  The following time lines must 
 be met for assigning a case manager: 

    (1) for relocation targeted case management, an eligible 
 recipient must be assigned a case manager who visits the person 
 within 20 working days of requesting a case manager from their 
 county of financial responsibility as determined under chapter 
 256G.  If a county agency does not provide case management 
 services as required, the recipient may, after written notice to 
 the county agency, obtain targeted relocation case management 
 services from a home care targeted case management provider, as 
 defined in subdivision 5; and 

    (2) for home care targeted case management, an eligible 
 recipient must be assigned a case manager within 20 working days 
 of requesting a case manager from a home care targeted case 
 management provider, as defined in subdivision 5. 

    Subd. 8.    Evaluation.  The commissioner shall evaluate 
 the delivery of targeted case management, including, but not 
 limited to, access to case management services, consumer 
 satisfaction with case management services, and quality of case 
 management services. 

    Subd. 9.    Contact documentation.  The case manager 
 must document each face-to-face and telephone contact with the 
 recipient and others involved in the recipient's individual 
 service plan. 

    Subd. 10.    Payment rates.  The commissioner shall set 
 payment rates for targeted case management under this 
 subdivision.  Case managers may bill according to the following 
 criteria: 

    (1) for relocation targeted case management, case managers 
 may bill for direct case management activities, including 
 face-to-face and telephone contacts, in the 180 days preceding 
 an eligible recipient's discharge from an institution; 

    (2) for home care targeted case management, case managers 
 may bill for direct case management activities, including 
 face-to-face and telephone contacts; and 

    (3) billings for targeted case management services under 
 this subdivision shall not duplicate payments made under other 
 program authorities for the same purpose. 

    HIST: 1Sp2001 c 9 art 2 s 39; art 3 s 20-28 

     256B.0623 Covered service:  adult rehabilitative mental 
  health services. 

    Subdivision 1.    Scope.  Medical assistance covers 
 adult rehabilitative mental health services as defined in 
 subdivision 2, subject to federal approval, if provided to 
 recipients as defined in subdivision 3 and provided by a 
 qualified provider entity meeting the standards in this section 
 and by a qualified individual provider working within the 
 provider's scope of practice and identified in the recipient's 
 individual treatment plan as defined in section 245.462, 
 subdivision 14, and if determined to be medically necessary 
 according to section 62Q.53. 

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

    (a) "Adult rehabilitative mental health services" means 
 mental health services which are rehabilitative and enable the 
 recipient to develop and enhance psychiatric stability, social 
 competencies, personal and emotional adjustment, and independent 
 living and community skills, when these abilities are impaired 
 by the symptoms of mental illness.  Adult rehabilitative mental 
 health services are also appropriate when provided to enable a 
 recipient to retain stability and functioning, if the recipient 
 would be at risk of significant functional decompensation or 
 more restrictive service settings without these services. 

    (1) Adult rehabilitative mental health services instruct, 
 assist, and support the recipient in areas such as:  
 interpersonal communication skills, community resource 
 utilization and integration skills, crisis assistance, relapse 
 prevention skills, health care directives, budgeting and 
 shopping skills, healthy lifestyle skills and practices, cooking 
 and nutrition skills, transportation skills, medication 
 education and monitoring, mental illness symptom management 
 skills, household management skills, employment-related skills, 
 and transition to community living services. 

    (2) These services shall be provided to the recipient on a 
 one-to-one basis in the recipient's home or another community 
 setting or in groups. 

    (b) "Medication education services" means services provided 
 individually or in groups which focus on educating the recipient 
 about mental illness and symptoms; the role and effects of 
 medications in treating symptoms of mental illness; and the side 
 effects of medications.  Medication education is coordinated 
 with medication management services and does not duplicate it.  
 Medication education services are provided by physicians, 
 pharmacists, or registered nurses. 

    (c) "Transition to community living services" means 
 services which maintain continuity of contact between the 
 rehabilitation services provider and the recipient and which 
 facilitate discharge from a hospital, residential treatment 
 program under Minnesota Rules, chapter 9505, board and lodging 
 facility, or nursing home.  Transition to community living 
 services are not intended to provide other areas of adult 
 rehabilitative mental health services.  

    Subd. 3.    Eligibility.  An eligible recipient is an 
 individual who: 

    (1) is age 18 or older; 

    (2) is diagnosed with a medical condition, such as mental 
 illness or traumatic brain injury, for which adult 
 rehabilitative mental health services are needed; 

    (3) has substantial disability and functional impairment in 
 three or more of the areas listed in section 245.462, 
 subdivision 11a, so that self-sufficiency is markedly reduced; 
 and 

    (4) has had a recent diagnostic assessment by a qualified 
 professional that documents adult rehabilitative mental health 
 services are medically necessary to address identified 
 disability and functional impairments and individual recipient 
 goals. 

    Subd. 4.    Provider entity standards.  (a) The provider 
 entity must be: 

    (1) a county operated entity certified by the state; or 

    (2) a noncounty entity certified by the entity's host 
 county. 

    (b) The certification process is a determination as to 
 whether the entity meets the standards in this subdivision.  The 
 certification must specify which adult rehabilitative mental 
 health services the entity is qualified to provide. 

    (c) If an entity seeks to provide services outside its host 
 county, it must obtain additional certification from each county 
 in which it will provide services.  The additional certification 
 must be based on the adequacy of the entity's knowledge of that 
 county's local health and human service system, and the ability 
 of the entity to coordinate its services with the other services 
 available in that county. 

    (d) Recertification must occur at least every two years. 

    (e) The commissioner may intervene at any time and 
 decertify providers with cause.  The decertification is subject 
 to appeal to the state.  A county board may recommend that the 
 state decertify a provider for cause. 

    (f) The adult rehabilitative mental health services 
 provider entity must meet the following standards: 

    (1) have capacity to recruit, hire, manage, and train 
 mental health professionals, mental health practitioners, and 
 mental health rehabilitation workers; 

    (2) have adequate administrative ability to ensure 
 availability of services; 

    (3) ensure adequate preservice and inservice training for 
 staff; 

    (4) ensure that mental health professionals, mental health 
 practitioners, and mental health rehabilitation workers are 
 skilled in the delivery of the specific adult rehabilitative 
 mental health services provided to the individual eligible 
 recipient; 

    (5) ensure that staff is capable of implementing culturally 
 specific services that are culturally competent and appropriate 
 as determined by the recipient's culture, beliefs, values, and 
 language as identified in the individual treatment plan; 

    (6) ensure enough flexibility in service delivery to 
 respond to the changing and intermittent care needs of a 
 recipient as identified by the recipient and the individual 
 treatment plan; 

    (7) ensure that the mental health professional or mental 
 health practitioner, who is under the clinical supervision of a 
 mental health professional, involved in a recipient's services 
 participates in the development of the individual treatment 
 plan; 

    (8) assist the recipient in arranging needed crisis 
 assessment, intervention, and stabilization services; 

    (9) ensure that services are coordinated with other 
 recipient mental health services providers and the county mental 
 health authority and the federally recognized American Indian 
 authority and necessary others after obtaining the consent of 
 the recipient.  Services must also be coordinated with the 
 recipient's case manager or care coordinator if the recipient is 
 receiving case management or care coordination services; 

    (10) develop and maintain recipient files, individual 
 treatment plans, and contact charting; 

    (11) develop and maintain staff training and personnel 
 files; 

    (12) submit information as required by the state; 

    (13) establish and maintain a quality assurance plan to 
 evaluate the outcome of services provided; 

    (14) keep all necessary records required by law; 

    (15) deliver services as required by section 245.461; 

    (16) comply with all applicable laws; 

    (17) be an enrolled Medicaid provider; 

    (18) maintain a quality assurance plan to determine 
 specific service outcomes and the recipient's satisfaction with 
 services; and 

    (19) develop and maintain written policies and procedures 
 regarding service provision and administration of the provider 
 entity. 

    (g) The commissioner shall develop statewide procedures for 
 provider certification, including timelines for counties to 
 certify qualified providers. 

    Subd. 5.    Qualifications of provider staff.  Adult 
 rehabilitative mental health services must be provided by 
 qualified individual provider staff of a certified provider 
 entity.  Individual provider staff must be qualified under one 
 of the following criteria: 

    (1) a mental health professional as defined in section 
 245.462, subdivision 18, clauses (1) to (5); 

    (2) a mental health practitioner as defined in section 
 245.462, subdivision 17.  The mental health practitioner must 
 work under the clinical supervision of a mental health 
 professional; or 

    (3) a mental health rehabilitation worker.  A mental health 
 rehabilitation worker means a staff person working under the 
 direction of a mental health practitioner or mental health 
 professional and under the clinical supervision of a mental 
 health professional in the implementation of rehabilitative 
 mental health services as identified in the recipient's 
 individual treatment plan who: 

    (i) is at least 21 years of age; 

    (ii) has a high school diploma or equivalent; 

    (iii) has successfully completed 30 hours of training 
 during the past two years in all of the following areas:  
 recipient rights, recipient-centered individual treatment 
 planning, behavioral terminology, mental illness, co-occurring 
 mental illness and substance abuse, psychotropic medications and 
 side effects, functional assessment, local community resources, 
 adult vulnerability, recipient confidentiality; and 

    (iv) meets the qualifications in subitem (A) or (B): 

    (A) has an associate of arts degree in one of the 
 behavioral sciences or human services, or is a registered nurse 
 without a bachelor's degree, or who within the previous ten 
 years has:  

    (1) three years of personal life experience with serious 
 and persistent mental illness; 

    (2) three years of life experience as a primary caregiver 
 to an adult with a serious mental illness or traumatic brain 
 injury; or 

    (3) 4,000 hours of supervised paid work experience in the 
 delivery of mental health services to adults with a serious 
 mental illness or traumatic brain injury; or 

    (B)(1) is fluent in the non-English language or competent 
 in the culture of the ethnic group to which at least 50 percent 
 of the mental health rehabilitation worker's clients belong; 

    (2) receives during the first 2,000 hours of work, monthly 
 documented individual clinical supervision by a mental health 
 professional; 

    (3) has 18 hours of documented field supervision by a 
 mental health professional or practitioner during the first 160 
 hours of contact work with recipients, and at least six hours of 
 field supervision quarterly during the following year; 

    (4) has review and cosignature of charting of recipient 
 contacts during field supervision by a mental health 
 professional or practitioner; and 

    (5) has 40 hours of additional continuing education on 
 mental health topics during the first year of employment. 

    Subd. 6.    Required training and supervision.  (a) 
 Mental health rehabilitation workers must receive ongoing 
 continuing education training of at least 30 hours every two 
 years in areas of mental illness and mental health services and 
 other areas specific to the population being served.  Mental 
 health rehabilitation workers must also be subject to the 
 ongoing direction and clinical supervision standards in 
 paragraphs (c) and (d). 

    (b) Mental health practitioners must receive ongoing 
 continuing education training as required by their professional 
 license; or if the practitioner is not licensed, the 
 practitioner must receive ongoing continuing education training 
 of at least 30 hours every two years in areas of mental illness 
 and mental health services.  Mental health practitioners must 
 meet the ongoing clinical supervision standards in paragraph (c).

    (c) A mental health professional providing clinical 
 supervision of staff delivering adult rehabilitative mental 
 health services must provide the following guidance: 

    (1) review the information in the recipient's file; 

    (2) review and approve initial and updates of individual 
 treatment plans; 

    (3) meet with mental health rehabilitation workers and 
 practitioners, individually or in small groups, at least monthly 
 to discuss treatment topics of interest to the workers and 
 practitioners; 

    (4) meet with mental health rehabilitation workers and 
 practitioners, individually or in small groups, at least monthly 
 to discuss treatment plans of recipients, and approve by 
 signature and document in the recipient's file any resulting 
 plan updates; 

    (5) meet at least twice a month with the directing mental 
 health practitioner, if there is one, to review needs of the 
 adult rehabilitative mental health services program, review 
 staff on-site observations and evaluate mental health 
 rehabilitation workers, plan staff training, review program 
 evaluation and development, and consult with the directing 
 practitioner; 

    (6) be available for urgent consultation as the individual 
 recipient needs or the situation necessitates; and 

    (7) provide clinical supervision by full- or part-time 
 mental health professionals employed by or under contract with 
 the provider entity. 

    (d) An adult rehabilitative mental health services provider 
 entity must have a treatment director who is a mental health 
 practitioner or mental health professional.  The treatment 
 director must ensure the following: 

    (1) while delivering direct services to recipients, a newly 
 hired mental health rehabilitation worker must be directly 
 observed delivering services to recipients by the mental health 
 practitioner or mental health professional for at least six 
 hours per 40 hours worked during the first 160 hours that the 
 mental health rehabilitation worker works; 

    (2) the mental health rehabilitation worker must receive 
 ongoing on-site direct service observation by a mental health 
 professional or mental health practitioner for at least six 
 hours for every six months of employment; 

    (3) progress notes are reviewed from on-site service 
 observation prepared by the mental health rehabilitation worker 
 and mental health practitioner for accuracy and consistency with 
 actual recipient contact and the individual treatment plan and 
 goals; 

    (4) immediate availability by phone or in person for 
 consultation by a mental health professional or a mental health 
 practitioner to the mental health rehabilitation services worker 
 during service provision; 

    (5) oversee the identification of changes in individual 
 recipient treatment strategies, revise the plan, and communicate 
 treatment instructions and methodologies as appropriate to 
 ensure that treatment is implemented correctly; 

    (6) model service practices which:  respect the recipient, 
 include the recipient in planning and implementation of the 
 individual treatment plan, recognize the recipient's strengths, 
 collaborate and coordinate with other involved parties and 
 providers; 

    (7) ensure that mental health practitioners and mental 
 health rehabilitation workers are able to effectively 
 communicate with the recipients, significant others, and 
 providers; and 

    (8) oversee the record of the results of on-site 
 observation and charting evaluation and corrective actions taken 
 to modify the work of the mental health practitioners and mental 
 health rehabilitation workers. 

    (e) A mental health practitioner who is providing treatment 
 direction for a provider entity must receive supervision at 
 least monthly from a mental health professional to: 

    (1) identify and plan for general needs of the recipient 
 population served; 

    (2) identify and plan to address provider entity program 
 needs and effectiveness; 

    (3) identify and plan provider entity staff training and 
 personnel needs and issues; and 

    (4) plan, implement, and evaluate provider entity quality 
 improvement programs.  

    Subd. 7.    Personnel file.  The adult rehabilitative 
 mental health services provider entity must maintain a personnel 
 file on each staff.  Each file must contain: 

    (1) an annual performance review; 

    (2) a summary of on-site service observations and charting 
 review; 

    (3) a criminal background check of all direct service 
 staff; 

    (4) evidence of academic degree and qualifications; 

    (5) a copy of professional license; 

    (6) any job performance recognition and disciplinary 
 actions; 

    (7) any individual staff written input into own personnel 
 file; 

    (8) all clinical supervision provided; and 

    (9) documentation of compliance with continuing education 
 requirements. 

    Subd. 8.    Diagnostic assessment.  Providers of adult 
 rehabilitative mental health services must complete a diagnostic 
 assessment as defined in section 245.462, subdivision 9, within 
 five days after the recipient's second visit or within 30 days 
 after intake, whichever occurs first.  In cases where a 
 diagnostic assessment is available that reflects the recipient's 
 current status, and has been completed within 180 days preceding 
 admission, an update must be completed.  An update shall include 
 a written summary by a mental health professional of the 
 recipient's current mental health status and service needs.  If 
 the recipient's mental health status has changed significantly 
 since the adult's most recent diagnostic assessment, a new 
 diagnostic assessment is required. 

    Subd. 9.    Functional assessment.  Providers of adult 
 rehabilitative mental health services must complete a written 
 functional assessment as defined in section 245.462, subdivision 
 11a, for each recipient.  The functional assessment must be 
 completed within 30 days of intake, and reviewed and updated at 
 least every six months after it is developed, unless there is a 
 significant change in the functioning of the recipient.  If 
 there is a significant change in functioning, the assessment 
 must be updated.  A single functional assessment can meet case 
 management and adult rehabilitative mental health services 
 requirements if agreed to by the recipient.  Unless the 
 recipient refuses, the recipient must have significant 
 participation in the development of the functional assessment. 

    Subd. 10.    Individual treatment plan.  All providers 
 of adult rehabilitative mental health services must develop and 
 implement an individual treatment plan for each recipient.  The 
 provisions in clauses (1) and (2) apply: 

    (1) Individual treatment plan means a plan of intervention, 
 treatment, and services for an individual recipient written by a 
 mental health professional or by a mental health practitioner 
 under the clinical supervision of a mental health professional.  
 The individual treatment plan must be based on diagnostic and 
 functional assessments.  To the extent possible, the development 
 and implementation of a treatment plan must be a collaborative 
 process involving the recipient, and with the permission of the 
 recipient, the recipient's family and others in the recipient's 
 support system.  Providers of adult rehabilitative mental health 
 services must develop the individual treatment plan within 30 
 calendar days of intake.  The treatment plan must be updated at 
 least every six months thereafter, or more often when there is 
 significant change in the recipient's situation or functioning, 
 or in services or service methods to be used, or at the request 
 of the recipient or the recipient's legal guardian. 

    (2) The individual treatment plan must include: 

    (i) a list of problems identified in the assessment; 

    (ii) the recipient's strengths and resources; 

    (iii) concrete, measurable goals to be achieved, including 
 time frames for achievement; 

    (iv) specific objectives directed toward the achievement of 
 each one of the goals; 

    (v) documentation of participants in the treatment planning.
 The recipient, if possible, must be a participant.  The 
 recipient or the recipient's legal guardian must sign the 
 treatment plan, or documentation must be provided why this was 
 not possible.  A copy of the plan must be given to the recipient 
 or legal guardian.  Referral to formal services must be 
 arranged, including specific providers where applicable; 

    (vi) cultural considerations, resources, and needs of the 
 recipient must be included; 

    (vii) planned frequency and type of services must be 
 initiated; and 

    (viii) clear progress notes on outcome of goals. 

    (3) The individual community support plan defined in 
 section 245.462, subdivision 12, may serve as the individual 
 treatment plan if there is involvement of a mental health case 
 manager, and with the approval of the recipient.  The individual 
 community support plan must include the criteria in clause (2). 

    Subd. 11.    Recipient file.  Providers of adult 
 rehabilitative mental health services must maintain a file for 
 each recipient that contains the following information: 

    (1) diagnostic assessment or verification of its location 
 that is current and that was reviewed by a mental health 
 professional who is employed by or under contract with the 
 provider entity; 

    (2) functional assessments; 

    (3) individual treatment plans signed by the recipient and 
 the mental health professional, or if the recipient refused to 
 sign the plan, the date and reason stated by the recipient as to 
 why the recipient would not sign the plan; 

    (4) recipient history; 

    (5) signed release forms; 

    (6) recipient health information and current medications; 

    (7) emergency contacts for the recipient; 

    (8) case records which document the date of service, the 
 place of service delivery, signature of the person providing the 
 service, nature, extent and units of service, and place of 
 service delivery; 

    (9) contacts, direct or by telephone, with recipient's 
 family or others, other providers, or other resources for 
 service coordination; 

    (10) summary of recipient case reviews by staff; and 

    (11) written information by the recipient that the 
 recipient requests be included in the file. 

    Subd. 12.    Additional requirements.  (a) Providers of 
 adult rehabilitative mental health services must comply with the 
 requirements relating to referrals for case management in 
 section 245.467, subdivision 4. 

    (b) Adult rehabilitative mental health services are 
 provided for most recipients in the recipient's home and 
 community.  Services may also be provided at the home of a 
 relative or significant other, job site, psychosocial clubhouse, 
 drop-in center, social setting, classroom, or other places in 
 the community.  Except for "transition to community services," 
 the place of service does not include a regional treatment 
 center, nursing home, residential treatment facility licensed 
 under Minnesota Rules, parts 9520.0500 to 9520.0670 (Rule 36), 
 or an acute care hospital. 

    (c) Adult rehabilitative mental health services may be 
 provided in group settings if appropriate to each participating 
 recipient's needs and treatment plan.  A group is defined as two 
 to ten clients, at least one of whom is a recipient, who is 
 concurrently receiving a service which is identified in this 
 section.  The service and group must be specified in the 
 recipient's treatment plan.  No more than two qualified staff 
 may bill Medicaid for services provided to the same group of 
 recipients.  If two adult rehabilitative mental health workers 
 bill for recipients in the same group session, they must each 
 bill for different recipients. 

    Subd. 13.    Excluded services.  The following services 
 are excluded from reimbursement as adult rehabilitative mental 
 health services: 

    (1) recipient transportation services; 

    (2) a service provided and billed by a provider who is not 
 enrolled to provide adult rehabilitative mental health service; 

    (3) adult rehabilitative mental health services performed 
 by volunteers; 

    (4) provider performance of household tasks, chores, or 
 related activities, such as laundering clothes, moving the 
 recipient's household, housekeeping, and grocery shopping for 
 the recipient; 

    (5) direct billing of time spent "on call" when not 
 delivering services to recipients; 

    (6) activities which are primarily social or recreational 
 in nature, rather than rehabilitative, for the individual 
 recipient, as determined by the individual's needs and treatment 
 plan; 

    (7) job-specific skills services, such as on-the-job 
 training; 

    (8) provider service time included in case management 
 reimbursement; 

    (9) outreach services to potential recipients; 

    (10) a mental health service that is not medically 
 necessary; and 

    (11) any services provided by a hospital, board and 
 lodging, or residential facility to an individual who is a 
 patient in or resident of that facility. 

    Subd. 14.    Billing when services are provided by 
 qualified state staff.  When rehabilitative services are 
 provided by qualified state staff who are assigned to pilot 
 projects under section 245.4661, the county or other local 
 entity to which the qualified state staff are assigned may 
 consider these staff part of the local provider entity for which 
 certification is sought under this section and may bill the 
 medical assistance program for qualifying services provided by 
 the qualified state staff.  Payments for services provided by 
 state staff who are assigned to adult mental health initiatives 
 shall only be made from federal funds. 

    HIST: 1Sp2001 c 9 art 9 s 39; 2002 c 277 s 11; 2002 c 379 art 
 1 s 113 

     256B.0624 Covered service:  adult mental health crisis 
  response services. 

    Subdivision 1.    Scope.  Medical assistance covers 
 adult mental health crisis response services as defined in 
 subdivision 2, paragraphs (c) to (e), subject to federal 
 approval, if provided to a recipient as defined in subdivision 3 
 and provided by a qualified provider entity as defined in this 
 section and by a qualified individual provider working within 
 the provider's scope of practice and as defined in this 
 subdivision and identified in the recipient's individual crisis 
 treatment plan as defined in subdivision 11 and if determined to 
 be medically necessary.  

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

    (a) "Mental health crisis" is an adult behavioral, 
 emotional, or psychiatric situation which, but for the provision 
 of crisis response services, would likely result in 
 significantly reduced levels of functioning in primary 
 activities of daily living, or in an emergency situation, or in 
 the placement of the recipient in a more restrictive setting, 
 including, but not limited to, inpatient hospitalization.  

    (b) "Mental health emergency" is an adult behavioral, 
 emotional, or psychiatric situation which causes an immediate 
 need for mental health services and is consistent with section 
 62Q.55. 

    A mental health crisis or emergency is determined for 
 medical assistance service reimbursement by a physician, a 
 mental health professional, or crisis mental health practitioner 
 with input from the recipient whenever possible. 

    (c) "Mental health crisis assessment" means an immediate 
 face-to-face assessment by a physician, a mental health 
 professional, or mental health practitioner under the clinical 
 supervision of a mental health professional, following a 
 screening that suggests that the adult may be experiencing a 
 mental health crisis or mental health emergency situation. 

    (d) "Mental health mobile crisis intervention services" 
 means face-to-face, short-term intensive mental health services 
 initiated during a mental health crisis or mental health 
 emergency to help the recipient cope with immediate stressors, 
 identify and utilize available resources and strengths, and 
 begin to return to the recipient's baseline level of functioning.

    (1) This service is provided on-site by a mobile crisis 
 intervention team outside of an inpatient hospital setting.  
 Mental health mobile crisis intervention services must be 
 available 24 hours a day, seven days a week.  

    (2) The initial screening must consider other available 
 services to determine which service intervention would best 
 address the recipient's needs and circumstances.  

    (3) The mobile crisis intervention team must be available 
 to meet promptly face-to-face with a person in mental health 
 crisis or emergency in a community setting.  

    (4) The intervention must consist of a mental health crisis 
 assessment and a crisis treatment plan.  

    (5) The treatment plan must include recommendations for any 
 needed crisis stabilization services for the recipient. 

    (e) "Mental health crisis stabilization services" means 
 individualized mental health services provided to a recipient 
 following crisis intervention services which are designed to 
 restore the recipient to the recipient's prior functional 
 level.  Mental health crisis stabilization services may be 
 provided in the recipient's home, the home of a family member or 
 friend of the recipient, another community setting, or a 
 short-term supervised, licensed residential program.  Mental 
 health crisis stabilization does not include partial 
 hospitalization or day treatment. 

    Subd. 3.    Eligibility.  An eligible recipient is an 
 individual who: 

    (1) is age 18 or older; 

    (2) is screened as possibly experiencing a mental health 
 crisis or emergency where a mental health crisis assessment is 
 needed; and 

    (3) is assessed as experiencing a mental health crisis or 
 emergency, and mental health crisis intervention or crisis 
 intervention and stabilization services are determined to be 
 medically necessary.  

    Subd. 4.    Provider entity standards.  (a) A provider 
 entity is an entity that meets the standards listed in paragraph 
 (b) and: 

    (1) is a county board operated entity; or 

    (2) is a provider entity that is under contract with the 
 county board in the county where the potential crisis or 
 emergency is occurring.  To provide services under this section, 
 the provider entity must directly provide the services; or if 
 services are subcontracted, the provider entity must maintain 
 responsibility for services and billing. 

    (b) The adult mental health crisis response services 
 provider entity must meet the following standards: 

    (1) has the capacity to recruit, hire, and manage and train 
 mental health professionals, practitioners, and rehabilitation 
 workers; 

    (2) has adequate administrative ability to ensure 
 availability of services; 

    (3) is able to ensure adequate preservice and in-service 
 training; 

    (4) is able to ensure that staff providing these services 
 are skilled in the delivery of mental health crisis response 
 services to recipients; 

    (5) is able to ensure that staff are capable of 
 implementing culturally specific treatment identified in the 
 individual treatment plan that is meaningful and appropriate as 
 determined by the recipient's culture, beliefs, values, and 
 language; 

    (6) is able to ensure enough flexibility to respond to the 
 changing intervention and care needs of a recipient as 
 identified by the recipient during the service partnership 
 between the recipient and providers; 

    (7) is able to ensure that mental health professionals and 
 mental health practitioners have the communication tools and 
 procedures to communicate and consult promptly about crisis 
 assessment and interventions as services occur; 

    (8) is able to coordinate these services with county 
 emergency services and mental health crisis services; 

    (9) is able to ensure that mental health crisis assessment 
 and mobile crisis intervention services are available 24 hours a 
 day, seven days a week; 

    (10) is able to ensure that services are coordinated with 
 other mental health service providers, county mental health 
 authorities, or federally recognized American Indian authorities 
 and others as necessary, with the consent of the adult.  
 Services must also be coordinated with the recipient's case 
 manager if the adult is receiving case management services; 

    (11) is able to ensure that crisis intervention services 
 are provided in a manner consistent with sections 245.461 to 
 245.486; 

    (12) is able to submit information as required by the 
 state; 

    (13) maintains staff training and personnel files; 

    (14) is able to establish and maintain a quality assurance 
 and evaluation plan to evaluate the outcomes of services and 
 recipient satisfaction; 

    (15) is able to keep records as required by applicable 
 laws; 

    (16) is able to comply with all applicable laws and 
 statutes; 

    (17) is an enrolled medical assistance provider; and 

    (18) develops and maintains written policies and procedures 
 regarding service provision and administration of the provider 
 entity, including safety of staff and recipients in high-risk 
 situations.  

    Subd. 5.    Mobile crisis intervention staff 
 qualifications.  For provision of adult mental health mobile 
 crisis intervention services, a mobile crisis intervention team 
 is comprised of at least two mental health professionals as 
 defined in section 245.462, subdivision 18, clauses (1) to (5), 
 or a combination of at least one mental health professional and 
 one mental health practitioner as defined in section 245.462, 
 subdivision 17, with the required mental health crisis training 
 and under the clinical supervision of a mental health 
 professional on the team.  The team must have at least two 
 people with at least one member providing on-site crisis 
 intervention services when needed.  Team members must be 
 experienced in mental health assessment, crisis intervention 
 techniques, and clinical decision-making under emergency 
 conditions and have knowledge of local services and resources.  
 The team must recommend and coordinate the team's services with 
 appropriate local resources such as the county social services 
 agency, mental health services, and local law enforcement when 
 necessary. 

    Subd. 6.    Initial screening, crisis assessment, and 
 mobile intervention treatment planning.  (a) Prior to 
 initiating mobile crisis intervention services, a screening of 
 the potential crisis situation must be conducted.  The screening 
 may use the resources of crisis assistance and emergency 
 services as defined in sections 245.462, subdivision 6, and 
 245.469, subdivisions 1 and 2.  The screening must gather 
 information, determine whether a crisis situation exists, 
 identify parties involved, and determine an appropriate response.

    (b) If a crisis exists, a crisis assessment must be 
 completed.  A crisis assessment evaluates any immediate needs 
 for which emergency services are needed and, as time permits, 
 the recipient's current life situation, sources of stress, 
 mental health problems and symptoms, strengths, cultural 
 considerations, support network, vulnerabilities, and current 
 functioning. 

    (c) If the crisis assessment determines mobile crisis 
 intervention services are needed, the intervention services must 
 be provided promptly.  As opportunity presents during the 
 intervention, at least two members of the mobile crisis 
 intervention team must confer directly or by telephone about the 
 assessment, treatment plan, and actions taken and needed.  At 
 least one of the team members must be on site providing crisis 
 intervention services.  If providing on-site crisis intervention 
 services, a mental health practitioner must seek clinical 
 supervision as required in subdivision 9. 

    (d) The mobile crisis intervention team must develop an 
 initial, brief crisis treatment plan as soon as appropriate but 
 no later than 24 hours after the initial face-to-face 
 intervention.  The plan must address the needs and problems 
 noted in the crisis assessment and include measurable short-term 
 goals, cultural considerations, and frequency and type of 
 services to be provided to achieve the goals and reduce or 
 eliminate the crisis.  The treatment plan must be updated as 
 needed to reflect current goals and services. 

    (e) The team must document which short-term goals have been 
 met and when no further crisis intervention services are 
 required. 

    (f) If the recipient's crisis is stabilized, but the 
 recipient needs a referral to other services, the team must 
 provide referrals to these services.  If the recipient has a 
 case manager, planning for other services must be coordinated 
 with the case manager. 

    Subd. 7.    Crisis stabilization services.  (a) Crisis 
 stabilization services must be provided by qualified staff of a 
 crisis stabilization services provider entity and must meet the 
 following standards: 

    (1) a crisis stabilization treatment plan must be developed 
 which meets the criteria in subdivision 11; 

    (2) staff must be qualified as defined in subdivision 8; 
 and 

    (3) services must be delivered according to the treatment 
 plan and include face-to-face contact with the recipient by 
 qualified staff for further assessment, help with referrals, 
 updating of the crisis stabilization treatment plan, supportive 
 counseling, skills training, and collaboration with other 
 service providers in the community. 

    (b) If crisis stabilization services are provided in a 
 supervised, licensed residential setting, the recipient must be 
 contacted face-to-face daily by a qualified mental health 
 practitioner or mental health professional.  The program must 
 have 24-hour-a-day residential staffing which may include staff 
 who do not meet the qualifications in subdivision 8.  The 
 residential staff must have 24-hour-a-day immediate direct or 
 telephone access to a qualified mental health professional or 
 practitioner. 

    (c) If crisis stabilization services are provided in a 
 supervised, licensed residential setting that serves no more 
 than four adult residents, and no more than two are recipients 
 of crisis stabilization services, the residential staff must 
 include, for at least eight hours per day, at least one 
 individual who meets the qualifications in subdivision 8. 

    (d) If crisis stabilization services are provided in a 
 supervised, licensed residential setting that serves more than 
 four adult residents, and one or more are recipients of crisis 
 stabilization services, the residential staff must include, for 
 24 hours a day, at least one individual who meets the 
 qualifications in subdivision 8.  During the first 48 hours that 
 a recipient is in the residential program, the residential 
 program must have at least two staff working 24 hours a day.  
 Staffing levels may be adjusted thereafter according to the 
 needs of the recipient as specified in the crisis stabilization 
 treatment plan. 

    Subd. 8.    Adult crisis stabilization staff 
 qualifications.  (a) Adult mental health crisis stabilization 
 services must be provided by qualified individual staff of a 
 qualified provider entity.  Individual provider staff must have 
 the following qualifications: 

    (1) be a mental health professional as defined in section 
 245.462, subdivision 18, clauses (1) to (5); 

    (2) be a mental health practitioner as defined in section 
 245.462, subdivision 17.  The mental health practitioner must 
 work under the clinical supervision of a mental health 
 professional; or 

    (3) be a mental health rehabilitation worker who meets the 
 criteria in section 256B.0623, subdivision 5, clause (3); works 
 under the direction of a mental health practitioner as defined 
 in section 245.462, subdivision 17, or under direction of a 
 mental health professional; and works under the clinical 
 supervision of a mental health professional. 

    (b) Mental health practitioners and mental health 
 rehabilitation workers must have completed at least 30 hours of 
 training in crisis intervention and stabilization during the 
 past two years. 

    Subd. 9.    Supervision.  Mental health practitioners 
 may provide crisis assessment and mobile crisis intervention 
 services if the following clinical supervision requirements are 
 met: 

    (1) the mental health provider entity must accept full 
 responsibility for the services provided; 

    (2) the mental health professional of the provider entity, 
 who is an employee or under contract with the provider entity, 
 must be immediately available by phone or in person for clinical 
 supervision; 

    (3) the mental health professional is consulted, in person 
 or by phone, during the first three hours when a mental health 
 practitioner provides on-site service; 

    (4) the mental health professional must: 

    (i) review and approve of the tentative crisis assessment 
 and crisis treatment plan; 

    (ii) document the consultation; and 

    (iii) sign the crisis assessment and treatment plan within 
 the next business day; 

    (5) if the mobile crisis intervention services continue 
 into a second calendar day, a mental health professional must 
 contact the recipient face-to-face on the second day to provide 
 services and update the crisis treatment plan; and 

    (6) the on-site observation must be documented in the 
 recipient's record and signed by the mental health professional. 

    Subd. 10.    Recipient file.  Providers of mobile crisis 
 intervention or crisis stabilization services must maintain a 
 file for each recipient containing the following information: 

    (1) individual crisis treatment plans signed by the 
 recipient, mental health professional, and mental health 
 practitioner who developed the crisis treatment plan, or if the 
 recipient refused to sign the plan, the date and reason stated 
 by the recipient as to why the recipient would not sign the 
 plan; 

    (2) signed release forms; 

    (3) recipient health information and current medications; 

    (4) emergency contacts for the recipient; 

    (5) case records which document the date of service, place 
 of service delivery, signature of the person providing the 
 service, and the nature, extent, and units of service.  Direct 
 or telephone contact with the recipient's family or others 
 should be documented; 

    (6) required clinical supervision by mental health 
 professionals; 

    (7) summary of the recipient's case reviews by staff; and 

    (8) any written information by the recipient that the 
 recipient wants in the file. 

 Documentation in the file must comply with all requirements of 
 the commissioner. 

    Subd. 11.    Treatment plan.  The individual crisis 
 stabilization treatment plan must include, at a minimum: 

    (1) a list of problems identified in the assessment; 

    (2) a list of the recipient's strengths and resources; 

    (3) concrete, measurable short-term goals and tasks to be 
 achieved, including time frames for achievement; 

    (4) specific objectives directed toward the achievement of 
 each one of the goals; 

    (5) documentation of the participants involved in the 
 service planning.  The recipient, if possible, must be a 
 participant.  The recipient or the recipient's legal guardian 
 must sign the service plan or documentation must be provided why 
 this was not possible.  A copy of the plan must be given to the 
 recipient and the recipient's legal guardian.  The plan should 
 include services arranged, including specific providers where 
 applicable; 

    (6) planned frequency and type of services initiated; 

    (7) a crisis response action plan if a crisis should occur; 

    (8) clear progress notes on outcome of goals; 

    (9) a written plan must be completed within 24 hours of 
 beginning services with the recipient; and 

    (10) a treatment plan must be developed by a mental health 
 professional or mental health practitioner under the clinical 
 supervision of a mental health professional.  The mental health 
 professional must approve and sign all treatment plans. 

    Subd. 12.    Excluded services.  The following services 
 are excluded from reimbursement under this section: 

    (1) room and board services; 

    (2) services delivered to a recipient while admitted to an 
 inpatient hospital; 

    (3) recipient transportation costs may be covered under 
 other medical assistance provisions, but transportation services 
 are not an adult mental health crisis response service; 

    (4) services provided and billed by a provider who is not 
 enrolled under medical assistance to provide adult mental health 
 crisis response services; 

    (5) services performed by volunteers; 

    (6) direct billing of time spent "on call" when not 
 delivering services to a recipient; 

    (7) provider service time included in case management 
 reimbursement.  When a provider is eligible to provide more than 
 one type of medical assistance service, the recipient must have 
 a choice of provider for each service, unless otherwise provided 
 for by law; 

    (8) outreach services to potential recipients; and 

    (9) a mental health service that is not medically necessary.

    HIST: 1Sp2001 c 9 art 9 s 40; 2002 c 379 art 1 s 113 

     256B.0625 Covered services. 

    Subdivision 1.    Inpatient hospital services.  Medical 
 assistance covers inpatient hospital services.  A second medical 
 opinion is required prior to reimbursement for elective 
 surgeries requiring a second opinion.  The commissioner shall 
 publish in the State Register a list of elective surgeries that 
 require a second medical opinion prior to reimbursement, and the 
 criteria and standards for deciding whether an elective surgery 
 should require a second medical opinion.  The list and the 
 criteria and standards are not subject to the requirements of 
 sections 14.001 to 14.69.  The commissioner's decision whether a 
 second medical opinion is required, made in accordance with 
 rules governing that decision, is not subject to administrative 
 appeal. 

    Subd. 2.    Skilled and intermediate nursing care.  
 Medical assistance covers skilled nursing home services and 
 services of intermediate care facilities, including training and 
 habilitation services, as defined in section 252.41, subdivision 
 3, for persons with mental retardation or related conditions who 
 are residing in intermediate care facilities for persons with 
 mental retardation or related conditions.  Medical assistance 
 must not be used to pay the costs of nursing care provided to a 
 patient in a swing bed as defined in section 144.562, unless (a) 
 the facility in which the swing bed is located is eligible as a 
 sole community provider, as defined in Code of Federal 
 Regulations, title 42, section 412.92, or the facility is a 
 public hospital owned by a governmental entity with 15 or fewer 
 licensed acute care beds; (b) the Centers for Medicare and 
 Medicaid Services approves the necessary state plan amendments; 
 (c) the patient was screened as provided by law; (d) the patient 
 no longer requires acute care services; and (e) no nursing home 
 beds are available within 25 miles of the facility.  Medical 
 assistance also covers up to ten days of nursing care provided 
 to a patient in a swing bed if:  (1) the patient's physician 
 certifies that the patient has a terminal illness or condition 
 that is likely to result in death within 30 days and that moving 
 the patient would not be in the best interests of the patient 
 and patient's family; (2) no open nursing home beds are 
 available within 25 miles of the facility; and (3) no open beds 
 are available in any Medicare hospice program within 50 miles of 
 the facility.  The daily medical assistance payment for nursing 
 care for the patient in the swing bed is the statewide average 
 medical assistance skilled nursing care per diem as computed 
 annually by the commissioner on July 1 of each year. 

    Subd. 3.    Physicians' services.  Medical assistance 
 covers physicians' services.  Rates paid for anesthesiology 
 services provided by physicians shall be according to the 
 formula utilized in the Medicare program and shall use a 
 conversion factor "at percentile of calendar year set by 
 legislature." 

    Subd. 3a.    Gender reassignment surgery.  Gender 
 reassignment surgery and other gender reassignment medical 
 procedures including drug therapy for gender reassignment are 
 not covered unless the individual began receiving gender 
 reassignment services prior to July 1, 1998. 

    Subd. 3b.    Telemedicine consultations.  Medical 
 assistance covers telemedicine consultations.  Telemedicine 
 consultations must be made via two-way, interactive video or 
 store-and-forward technology.  Store-and-forward technology 
 includes telemedicine consultations that do not occur in real 
 time via synchronous transmissions, and that do not require a 
 face-to-face encounter with the patient for all or any part of 
 any such telemedicine consultation.  The patient record must 
 include a written opinion from the consulting physician 
 providing the telemedicine consultation.  A communication 
 between two physicians that consists solely of a telephone 
 conversation is not a telemedicine consultation.  Coverage is 
 limited to three telemedicine consultations per recipient per 
 calendar week.  Telemedicine consultations shall be paid at the 
 full allowable rate. 

    Subd. 4.    Outpatient and physician-directed clinic 
 services.  Medical assistance covers outpatient hospital or 
 physician-directed clinic services.  The physician-directed 
 clinic staff shall include at least two physicians and all 
 services shall be provided under the direct supervision of a 
 physician.  Hospital outpatient departments are subject to the 
 same limitations and reimbursements as other enrolled vendors 
 for all services, except initial triage, emergency services, and 
 services not provided or immediately available in clinics, 
 physicians' offices, or by other enrolled providers.  "Emergency 
 services" means those medical services required for the 
 immediate diagnosis and treatment of medical conditions that, if 
 not immediately diagnosed and treated, could lead to serious 
 physical or mental disability or death or are necessary to 
 alleviate severe pain.  Neither the hospital, its employees, nor 
 any physician or dentist, shall be liable in any action arising 
 out of a determination not to render emergency services or care 
 if reasonable care is exercised in determining the condition of 
 the person, or in determining the appropriateness of the 
 facilities, or the qualifications and availability of personnel 
 to render these services consistent with this section.  

    Subd. 4a.    Second medical opinion for surgery.  
 Certain surgeries require a second medical opinion to confirm 
 the necessity of the procedure, in order for reimbursement to be 
 made.  The commissioner shall publish in the State Register a 
 list of surgeries that require a second medical opinion and the 
 criteria and standards for deciding whether a surgery should 
 require a second medical opinion.  The list and the criteria and 
 standards are not subject to the requirements of sections 14.01 
 to 14.69.  The commissioner's decision about whether a second 
 medical opinion is required, made according to rules governing 
 that decision, is not subject to administrative appeal. 

    Subd. 5.    Community mental health center services.  
 Medical assistance covers community mental health center 
 services provided by a community mental health center that meets 
 the requirements in paragraphs (a) to (j). 

    (a) The provider is licensed under Minnesota Rules, parts 
 9520.0750 to 9520.0870.  

    (b) The provider provides mental health services under the 
 clinical supervision of a mental health professional who is 
 licensed for independent practice at the doctoral level or by a 
 board-certified psychiatrist or a psychiatrist who is eligible 
 for board certification.  Clinical supervision has the meaning 
 given in Minnesota Rules, part 9505.0323, subpart 1, item F.  

    (c) The provider must be a private nonprofit corporation or 
 a governmental agency and have a community board of directors as 
 specified by section 245.66.  

    (d) The provider must have a sliding fee scale that meets 
 the requirements in Minnesota Rules, part 9550.0060, and agree 
 to serve within the limits of its capacity all individuals 
 residing in its service delivery area.  

    (e) At a minimum, the provider must provide the following 
 outpatient mental health services:  diagnostic assessment; 
 explanation of findings; family, group, and individual 
 psychotherapy, including crisis intervention psychotherapy 
 services, multiple family group psychotherapy, psychological 
 testing, and medication management.  In addition, the provider 
 must provide or be capable of providing upon request of the 
 local mental health authority day treatment services and 
 professional home-based mental health services.  The provider 
 must have the capacity to provide such services to specialized 
 populations such as the elderly, families with children, persons 
 who are seriously and persistently mentally ill, and children 
 who are seriously emotionally disturbed.  

    (f) The provider must be capable of providing the services 
 specified in paragraph (e) to individuals who are diagnosed with 
 both mental illness or emotional disturbance, and chemical 
 dependency, and to individuals dually diagnosed with a mental 
 illness or emotional disturbance and mental retardation or a 
 related condition.  

    (g) The provider must provide 24-hour emergency care 
 services or demonstrate the capacity to assist recipients in 
 need of such services to access such services on a 24-hour basis.

    (h) The provider must have a contract with the local mental 
 health authority to provide one or more of the services 
 specified in paragraph (e).  

    (i) The provider must agree, upon request of the local 
 mental health authority, to enter into a contract with the 
 county to provide mental health services not reimbursable under 
 the medical assistance program.  

    (j) The provider may not be enrolled with the medical 
 assistance program as both a hospital and a community mental 
 health center.  The community mental health center's 
 administrative, organizational, and financial structure must be 
 separate and distinct from that of the hospital. 

    Subd. 5a.    Intensive early intervention behavior therapy 
 services for children with autism spectrum disorders.  (a)   
 Coverage.  Medical assistance covers home-based intensive 
 early intervention behavior therapy for children with autism 
 spectrum disorders.  Children with autism spectrum disorder, and 
 their custodial parents or foster parents, may access other 
 covered services to treat autism spectrum disorder, and are not 
 required to receive intensive early intervention behavior 
 therapy services under this subdivision.  Intensive early 
 intervention behavior therapy does not include coverage for 
 services to treat developmental disorders of language, early 
 onset psychosis, Rett's disorder, selective mutism, social 
 anxiety disorder, stereotypic movement disorder, dementia, 
 obsessive compulsive disorder, schizoid personality disorder, 
 avoidant personality disorder, or reactive attachment disorder.  
 If a child with autism spectrum disorder is diagnosed to have 
 one or more of these conditions, intensive early intervention 
 behavior therapy includes coverage only for services necessary 
 to treat the autism spectrum disorder. 

    (b)    Purpose of intensive early intervention behavior 
 therapy services (IEIBTS).  The purpose of IEIBTS is to 
 improve the child's behavioral functioning, to prevent 
 development of challenging behaviors, to eliminate autistic 
 behaviors, to reduce the risk of out-of-home placement, and to 
 establish independent typical functioning in language and social 
 behavior.  The procedures used to accomplish these goals are 
 based upon research in applied behavior analysis. 

    (c)    Eligible children.  A child is eligible to 
 initiate IEIBTS if, the child meets the additional eligibility 
 criteria in paragraph (d) and in a diagnostic assessment by a 
 mental health professional who is not under the employ of the 
 service provider, the child: 

    (1) is found to have an autism spectrum disorder; 

    (2) has a current IQ of either untestable, or at least 30; 

    (3) if nonverbal, initiated behavior therapy by 42 months 
 of age; 

    (4) if verbal, initiated behavior therapy by 48 months of 
 age; or 

    (5) if having an IQ of at least 50, initiated behavior 
 therapy by 84 months of age. 

 To continue after six-month individualized treatment plan (ITP) 
 reviews, at least one of the child's custodial parents or foster 
 parents must participate in an average of at least five hours of 
 documented behavior therapy per week for six months, and 
 consistently implement behavior therapy recommendations 24 hours 
 a day.  To continue after six-month individualized treatment 
 plan (ITP) reviews, the child must show documented progress 
 toward mastery of six-month benchmark behavior objectives.  The 
 maximum number of months during which services may be billed is 
 54, or up to the month of August in the first year in which the 
 child completes first grade, whichever comes last.  If 
 significant progress towards treatment goals has not been 
 achieved after 24 months of treatment, treatment must be 
 discontinued. 

    (d)    Additional eligibility criteria.  A child is 
 eligible to initiate IEIBTS if: 

    (1) in medical and diagnostic assessments by medical and 
 mental health professionals, it is determined that the child 
 does not have severe or profound mental retardation; 

    (2) an accurate assessment of the child's hearing has been 
 performed, including audiometry if the brain stem auditory 
 evokes response; 

    (3) a blood lead test has been performed prior to 
 initiation of treatment; and 

    (4) an EEG or neurologic evaluation is done, prior to 
 initiation of treatment, if the child has a history of staring 
 spells or developmental regression.  

    (e)    Covered services.  The focus of IEIBTS must be to 
 treat the principal diagnostic features of the autism spectrum 
 disorder.  All IEIBTS must be delivered by a team of 
 practitioners under the consistent supervision of a single 
 clinical supervisor.  A mental health professional must develop 
 the ITP for IEIBTS.  The ITP must include six-month benchmark 
 behavior objectives.  All behavior therapy must be based upon 
 research in applied behavior analysis, with an emphasis upon 
 positive reinforcement of carefully task-analyzed skills for 
 optimum rates of progress.  All behavior therapy must be 
 consistently applied and generalized throughout the 24-hour day 
 and seven-day week by all of the child's regular care 
 providers.  When placing the child in school activities, a 
 majority of the peers must have no mental health diagnosis, and 
 the child must have sufficient social skills to succeed with 80 
 percent of the school activities.  Reactive consequences, such 
 as redirection, correction, positive practice, or time-out, must 
 be used only when necessary to improve the child's success when 
 proactive procedures alone have not been effective.  IEIBTS must 
 be delivered by a team of behavior therapy practitioners who are 
 employed under the direction of the same agency.  The team may 
 deliver up to 200 billable hours per year of direct clinical 
 supervisor services, up to 700 billable hours per year of senior 
 behavior therapist services, and up to 1,800 billable hours per 
 year of direct behavior therapist services.  A one-hour clinical 
 review meeting for the child, parents, and staff must be 
 scheduled 50 weeks a year, at which behavior therapy is reviewed 
 and planned.  At least one-quarter of the annual clinical 
 supervisor billable hours shall consist of on-site clinical 
 meeting time.  At least one-half of the annual senior behavior 
 therapist billable hours shall consist of direct services to the 
 child or parents.  All of the behavioral therapist billable 
 hours shall consist of direct on-site services to the child or 
 parents.  None of the senior behavior therapist billable hours 
 or behavior therapist billable hours shall consist of clinical 
 meeting time.  If there is any regression of the autistic 
 spectrum disorder after 12 months of therapy, a neurologic 
 consultation must be performed. 

    (f)    Provider qualifications.  The provider agency 
 must be capable of delivering consistent applied behavior 
 analysis (ABA) based behavior therapy in the home.  The site 
 director of the agency must be a mental health professional and 
 a board certified behavior analyst certified by the behavior 
 analyst certification board.  Each clinical supervisor must be a 
 certified associate behavior analyst certified by the behavior 
 analyst certification board or have equivalent experience in 
 applied behavior analysis. 

    (g)    Supervision requirements.  (1) Each behavior 
 therapist practitioner must be continuously supervised while in 
 the home until the practitioner has mastered competencies for 
 independent practice.  Each behavior therapist must have 
 mastered three credits of academic content and practice in an 
 applied behavior analysis sequence at an accredited university 
 before providing more than 12 months of therapy.  A college 
 degree or minimum hours of experience are not required.  Each 
 behavior therapist must continue training through weekly direct 
 observation by the senior behavior therapist, through 
 demonstrated performance in clinical meetings with the clinical 
 supervisor, and annual training in applied behavior analysis. 

    (2) Each senior behavior therapist practitioner must have 
 mastered the senior behavior therapy competencies, completed one 
 year of practice as a behavior therapist, and six months of 
 co-therapy training with another senior behavior therapist or 
 have an equivalent amount of experience in applied behavior 
 analysis.  Each senior behavior therapist must have mastered 12 
 credits of academic content and practice in an applied behavior 
 analysis sequence at an accredited university before providing 
 more than 12 months of senior behavior therapy.  Each senior 
 behavior therapist must continue training through demonstrated 
 performance in clinical meetings with the clinical supervisor, 
 and annual training in applied behavior analysis. 

    (3) Each clinical supervisor practitioner must have 
 mastered the clinical supervisor and family consultation 
 competencies, completed two years of practice as a senior 
 behavior therapist and one year of co-therapy training with 
 another clinical supervisor, or equivalent experience in applied 
 behavior analysis.  Each clinical supervisor must continue 
 training through annual training in applied behavior analysis. 

    (h)    Place of service.  IEIBTS are provided primarily 
 in the child's home and community.  Services may be provided in 
 the child's natural school or preschool classroom, home of a 
 relative, natural recreational setting, or day care. 

    (i)    Prior authorization requirements.  Prior 
 authorization shall be required for services provided after 200 
 hours of clinical supervisor, 700 hours of senior behavior 
 therapist, or 1,800 hours of behavior therapist services per 
 year. 

    (j)    Payment rates.  The following payment rates apply:

    (1) for an IEIBTS clinical supervisor practitioner under 
 supervision of a mental health professional, the lower of the 
 submitted charge or $67 per hour unit; 

    (2) for an IEIBTS senior behavior therapist practitioner 
 under supervision of a mental health professional, the lower of 
 the submitted charge or $37 per hour unit; or 

    (3) for an IEIBTS behavior therapist practitioner under 
 supervision of a mental health professional, the lower of the 
 submitted charge or $27 per hour unit. 

 An IEIBTS practitioner may receive payment for travel time which 
 exceeds 50 minutes one-way.  The maximum payment allowed will be 
 $0.51 per minute for up to a maximum of 300 hours per year. 

    For any week during which the above charges are made to 
 medical assistance, payments for the following services are 
 excluded:  supervising mental health professional hours and 
 personal care attendant, home-based mental health, 
 family-community support, or mental health behavioral aide hours.

    (k)    Report.  The commissioner shall collect evidence 
 of the effectiveness of intensive early intervention behavior 
 therapy services and present a report to the legislature by July 
 1, 2006. 

    Subd. 6. Repealed, 1991 c 292 art 7 s 26 

    Subd. 6a.    Home health services.  Home health services 
 are those services specified in Minnesota Rules, part 9505.0290. 
 Medical assistance covers home health services at a recipient's 
 home residence.  Medical assistance does not cover home health 
 services for residents of a hospital, nursing facility, or 
 intermediate care facility, unless the commissioner of human 
 services has prior authorized skilled nurse visits for less than 
 90 days for a resident at an intermediate care facility for 
 persons with mental retardation, to prevent an admission to a 
 hospital or nursing facility or unless a resident who is 
 otherwise eligible is on leave from the facility and the 
 facility either pays for the home health services or forgoes the 
 facility per diem for the leave days that home health services 
 are used.  Home health services must be provided by a Medicare 
 certified home health agency.  All nursing and home health aide 
 services must be provided according to section 256B.0627. 

    Subd. 7.    Private duty nursing.  Medical assistance 
 covers private duty nursing services in a recipient's home.  
 Recipients who are authorized to receive private duty nursing 
 services in their home may use approved hours outside of the 
 home during hours when normal life activities take them outside 
 of their home.  To use private duty nursing services at school, 
 the recipient or responsible party must provide written 
 authorization in the care plan identifying the chosen provider 
 and the daily amount of services to be used at school.  Medical 
 assistance does not cover private duty nursing services for 
 residents of a hospital, nursing facility, intermediate care 
 facility, or a health care facility licensed by the commissioner 
 of health, except as authorized in section 256B.64 for 
 ventilator-dependent recipients in hospitals or unless a 
 resident who is otherwise eligible is on leave from the facility 
 and the facility either pays for the private duty nursing 
 services or forgoes the facility per diem for the leave days 
 that private duty nursing services are used.  Total hours of 
 service and payment allowed for services outside the home cannot 
 exceed that which is otherwise allowed in an in-home setting 
 according to section 256B.0627.  All private duty nursing 
 services must be provided according to the limits established 
 under section 256B.0627.  Private duty nursing services may not 
 be reimbursed if the nurse is the foster care provider of a 
 recipient who is under age 18. 

    Subd. 8.    Physical therapy.  Medical assistance covers 
 physical therapy and related services, including specialized 
 maintenance therapy.  Services provided by a physical therapy 
 assistant shall be reimbursed at the same rate as services 
 performed by a physical therapist when the services of the 
 physical therapy assistant are provided under the direction of a 
 physical therapist who is on the premises.  Services provided by 
 a physical therapy assistant that are provided under the 
 direction of a physical therapist who is not on the premises 
 shall be reimbursed at 65 percent of the physical therapist rate.

    Subd. 8a.    Occupational therapy.  Medical assistance 
 covers occupational therapy and related services, including 
 specialized maintenance therapy.  Services provided by an 
 occupational therapy assistant shall be reimbursed at the same 
 rate as services performed by an occupational therapist when the 
 services of the occupational therapy assistant are provided 
 under the direction of the occupational therapist who is on the 
 premises.  Services provided by an occupational therapy 
 assistant that are provided under the direction of an 
 occupational therapist who is not on the premises shall be 
 reimbursed at 65 percent of the occupational therapist rate. 

    Subd. 8b.    Speech language pathology and audiology 
 services.  Medical assistance covers speech language pathology 
 and related services, including specialized maintenance 
 therapy.  Medical assistance covers audiology services and 
 related services.  Services provided by a person who has been 
 issued a temporary registration under section 148.5161 shall be 
 reimbursed at the same rate as services performed by a speech 
 language pathologist or audiologist as long as the requirements 
 of section 148.5161, subdivision 3, are met. 

    Subd. 8c.    Care management; rehabilitation services.  
 (a) Effective July 1, 1999, onetime thresholds shall replace 
 annual thresholds for provision of rehabilitation services 
 described in subdivisions 8, 8a, and 8b.  The onetime thresholds 
 will be the same in amount and description as the thresholds 
 prescribed by the department of human services health care 
 programs provider manual for calendar year 1997, except they 
 will not be renewed annually, and they will include sensory 
 skills and cognitive training skills. 

    (b) A care management approach for authorization of 
 services beyond the threshold shall be instituted in conjunction 
 with the onetime thresholds.  The care management approach shall 
 require the provider and the department rehabilitation reviewer 
 to work together directly through written communication, or 
 telephone communication when appropriate, to establish a 
 medically necessary care management plan. Authorization for 
 rehabilitation services shall include approval for up to 12 
 months of services at a time without additional documentation 
 from the provider during the extended period, when the 
 rehabilitation services are medically necessary due to an 
 ongoing health condition. 

    (c) The commissioner shall implement an expedited five-day 
 turnaround time to review authorization requests for recipients 
 who need emergency rehabilitation services and who have 
 exhausted their onetime threshold limit for those services. 

    Subd. 9.    Dental services.  Medical assistance covers 
 dental services.  Dental services include, with prior 
 authorization, fixed bridges that are cost-effective for persons 
 who cannot use removable dentures because of their medical 
 condition. 

    Subd. 10.    Laboratory and x-ray services.  Medical 
 assistance covers laboratory and x-ray services. 

    Subd. 11.    Nurse anesthetist services.  Medical 
 assistance covers nurse anesthetist services.  Rates paid for 
 anesthesiology services provided by certified registered nurse 
 anesthetists shall be according to the formula utilized in the 
 Medicare program and shall use the conversion factor that is 
 used by the Medicare program. 

    Subd. 12.    Eyeglasses, dentures, and prosthetic devices. 
  Medical assistance covers eyeglasses, dentures, and 
 prosthetic devices if prescribed by a licensed practitioner.  

    Subd. 13.    Drugs.  (a) Medical assistance covers 
 drugs, except for fertility drugs when specifically used to 
 enhance fertility, if prescribed by a licensed practitioner and 
 dispensed by a licensed pharmacist, by a physician enrolled in 
 the medical assistance program as a dispensing physician, or by 
 a physician or a nurse practitioner employed by or under 
 contract with a community health board as defined in section 
 145A.02, subdivision 5, for the purposes of communicable disease 
 control.  The commissioner, after receiving recommendations from 
 professional medical associations and professional pharmacist 
 associations, shall designate a formulary committee to advise 
 the commissioner on the names of drugs for which payment is 
 made, recommend a system for reimbursing providers on a set fee 
 or charge basis rather than the present system, and develop 
 methods encouraging use of generic drugs when they are less 
 expensive and equally effective as trademark drugs.  The 
 formulary committee shall consist of nine members, four of whom 
 shall be physicians who are not employed by the department of 
 human services, and a majority of whose practice is for persons 
 paying privately or through health insurance, three of whom 
 shall be pharmacists who are not employed by the department of 
 human services, and a majority of whose practice is for persons 
 paying privately or through health insurance, a consumer 
 representative, and a nursing home representative.  Committee 
 members shall serve three-year terms and shall serve without 
 compensation.  Members may be reappointed once.  

    (b) The commissioner shall establish a drug formulary.  Its 
 establishment and publication shall not be subject to the 
 requirements of the Administrative Procedure Act, but the 
 formulary committee shall review and comment on the formulary 
 contents.  

    The formulary shall not include:  

    (i) drugs or products for which there is no federal 
 funding; 

    (ii) over-the-counter drugs, except for antacids, 
 acetaminophen, family planning products, aspirin, insulin, 
 products for the treatment of lice, vitamins for adults with 
 documented vitamin deficiencies, vitamins for children under the 
 age of seven and pregnant or nursing women, and any other 
 over-the-counter drug identified by the commissioner, in 
 consultation with the drug formulary committee, as necessary, 
 appropriate, and cost-effective for the treatment of certain 
 specified chronic diseases, conditions or disorders, and this 
 determination shall not be subject to the requirements of 
 chapter 14; 

    (iii) anorectics, except that medically necessary 
 anorectics shall be covered for a recipient previously diagnosed 
 as having pickwickian syndrome and currently diagnosed as having 
 diabetes and being morbidly obese; 

    (iv) drugs for which medical value has not been 
 established; and 

    (v) drugs from manufacturers who have not signed a rebate 
 agreement with the Department of Health and Human Services 
 pursuant to section 1927 of title XIX of the Social Security Act.

    The commissioner shall publish conditions for prohibiting 
 payment for specific drugs after considering the formulary 
 committee's recommendations.  An honorarium of $100 per meeting 
 and reimbursement for mileage shall be paid to each committee 
 member in attendance.  

    (c) The basis for determining the amount of payment shall 
 be the lower of the actual acquisition costs of the drugs plus a 
 fixed dispensing fee; the maximum allowable cost set by the 
 federal government or by the commissioner plus the fixed 
 dispensing fee; or the usual and customary price charged to the 
 public.  The amount of payment basis must be reduced to reflect 
 all discount amounts applied to the charge by any 
 provider/insurer agreement or contract for submitted charges to 
 medical assistance programs.  The net submitted charge may not 
 be greater than the patient liability for the service.  The 
 pharmacy dispensing fee shall be $3.65, except that the 
 dispensing fee for intravenous solutions which must be 
 compounded by the pharmacist shall be $8 per bag, $14 per bag 
 for cancer chemotherapy products, and $30 per bag for total 
 parenteral nutritional products dispensed in one liter 
 quantities, or $44 per bag for total parenteral nutritional 
 products dispensed in quantities greater than one liter.  Actual 
 acquisition cost includes quantity and other special discounts 
 except time and cash discounts.  The actual acquisition cost of 
 a drug shall be estimated by the commissioner, at average 
 wholesale price minus nine percent, except that where a drug has 
 had its wholesale price reduced as a result of the actions of 
 the National Association of Medicaid Fraud Control Units, the 
 estimated actual acquisition cost shall be the reduced average 
 wholesale price, without the nine percent deduction.  The 
 maximum allowable cost of a multisource drug may be set by the 
 commissioner and it shall be comparable to, but no higher than, 
 the maximum amount paid by other third-party payors in this 
 state who have maximum allowable cost programs.  The 
 commissioner shall set maximum allowable costs for multisource 
 drugs that are not on the federal upper limit list as described 
 in United States Code, title 42, chapter 7, section 1396r-8(e), 
 the Social Security Act, and Code of Federal Regulations, title 
 42, part 447, section 447.332.  Establishment of the amount of 
 payment for drugs shall not be subject to the requirements of 
 the Administrative Procedure Act.  An additional dispensing fee 
 of $.30 may be added to the dispensing fee paid to pharmacists 
 for legend drug prescriptions dispensed to residents of 
 long-term care facilities when a unit dose blister card system, 
 approved by the department, is used.  Under this type of 
 dispensing system, the pharmacist must dispense a 30-day supply 
 of drug.  The National Drug Code (NDC) from the drug container 
 used to fill the blister card must be identified on the claim to 
 the department.  The unit dose blister card containing the drug 
 must meet the packaging standards set forth in Minnesota Rules, 
 part 6800.2700, that govern the return of unused drugs to the 
 pharmacy for reuse.  The pharmacy provider will be required to 
 credit the department for the actual acquisition cost of all 
 unused drugs that are eligible for reuse.  Over-the-counter 
 medications must be dispensed in the manufacturer's unopened 
 package.  The commissioner may permit the drug clozapine to be 
 dispensed in a quantity that is less than a 30-day supply.  
 Whenever a generically equivalent product is available, payment 
 shall be on the basis of the actual acquisition cost of the 
 generic drug, unless the prescriber specifically indicates 
 "dispense as written - brand necessary" on the prescription as 
 required by section 151.21, subdivision 2. 

    (d) For purposes of this subdivision, "multisource drugs" 
 means covered outpatient drugs, excluding innovator multisource 
 drugs for which there are two or more drug products, which: 

    (1) are related as therapeutically equivalent under the 
 Food and Drug Administration's most recent publication of 
 "Approved Drug Products with Therapeutic Equivalence 
 Evaluations"; 

    (2) are pharmaceutically equivalent and bioequivalent as 
 determined by the Food and Drug Administration; and 

    (3) are sold or marketed in Minnesota. 

 "Innovator multisource drug" means a multisource drug that was 
 originally marketed under an original new drug application 
 approved by the Food and Drug Administration. 

    (e) The formulary committee shall review and recommend 
 drugs which require prior authorization.  The formulary 
 committee may recommend drugs for prior authorization directly 
 to the commissioner, as long as opportunity for public input is 
 provided.  Prior authorization may be requested by the 
 commissioner based on medical and clinical criteria and on cost 
 before certain drugs are eligible for payment.  Before a drug 
 may be considered for prior authorization at the request of the 
 commissioner: 

    (1) the drug formulary committee must develop criteria to 
 be used for identifying drugs; the development of these criteria 
 is not subject to the requirements of chapter 14, but the 
 formulary committee shall provide opportunity for public input 
 in developing criteria; 

    (2) the drug formulary committee must hold a public forum 
 and receive public comment for an additional 15 days; 

    (3) the drug formulary committee must consider data from 
 the state Medicaid program if such data is available; and 

    (4) the commissioner must provide information to the 
 formulary committee on the impact that placing the drug on prior 
 authorization will have on the quality of patient care and on 
 program costs, and information regarding whether the drug is 
 subject to clinical abuse or misuse.  

    Prior authorization may be required by the commissioner 
 before certain formulary drugs are eligible for payment.  If 
 prior authorization of a drug is required by the commissioner, 
 the commissioner must provide a 30-day notice period before 
 implementing the prior authorization.  If a prior authorization 
 request is denied by the department, the recipient may appeal 
 the denial in accordance with section 256.045.  If an appeal is 
 filed, the drug must be provided without prior authorization 
 until a decision is made on the appeal.  

    (f) The basis for determining the amount of payment for 
 drugs administered in an outpatient setting shall be the lower 
 of the usual and customary cost submitted by the provider; the 
 average wholesale price minus five percent; or the maximum 
 allowable cost set by the federal government under United States 
 Code, title 42, chapter 7, section 1396r-8(e), and Code of 
 Federal Regulations, title 42, section 447.332, or by the 
 commissioner under paragraph (c). 

    (g) Prior authorization shall not be required or utilized 
 for any antipsychotic drug prescribed for the treatment of 
 mental illness where there is no generically equivalent drug 
 available unless the commissioner determines that prior 
 authorization is necessary for patient safety.  This paragraph 
 applies to any supplemental drug rebate program established or 
 administered by the commissioner. 

    (h) Prior authorization shall not be required or utilized 
 for any antihemophilic factor drug prescribed for the treatment 
 of hemophilia and blood disorders where there is no generically 
 equivalent drug available unless the commissioner determines 
 that prior authorization is necessary for patient safety.  This 
 paragraph applies to any supplemental drug rebate program 
 established or administered by the commissioner.  This paragraph 
 expires July 1, 2003. 

    Subd. 13a.    Drug utilization review board.  A 
 nine-member drug utilization review board is established.  The 
 board is comprised of at least three but no more than four 
 licensed physicians actively engaged in the practice of medicine 
 in Minnesota; at least three licensed pharmacists actively 
 engaged in the practice of pharmacy in Minnesota; and one 
 consumer representative; the remainder to be made up of health 
 care professionals who are licensed in their field and have 
 recognized knowledge in the clinically appropriate prescribing, 
 dispensing, and monitoring of covered outpatient drugs.  The 
 board shall be staffed by an employee of the department who 
 shall serve as an ex officio nonvoting member of the board.  The 
 members of the board shall be appointed by the commissioner and 
 shall serve three-year terms.  The members shall be selected 
 from lists submitted by professional associations.  The 
 commissioner shall appoint the initial members of the board for 
 terms expiring as follows:  three members for terms expiring 
 June 30, 1996; three members for terms expiring June 30, 1997; 
 and three members for terms expiring June 30, 1998.  Members may 
 be reappointed once.  The board shall annually elect a chair 
 from among the members. 

    The commissioner shall, with the advice of the board: 

    (1) implement a medical assistance retrospective and 
 prospective drug utilization review program as required by 
 United States Code, title 42, section 1396r-8(g)(3); 

    (2) develop and implement the predetermined criteria and 
 practice parameters for appropriate prescribing to be used in 
 retrospective and prospective drug utilization review; 

    (3) develop, select, implement, and assess interventions 
 for physicians, pharmacists, and patients that are educational 
 and not punitive in nature; 

    (4) establish a grievance and appeals process for 
 physicians and pharmacists under this section; 

    (5) publish and disseminate educational information to 
 physicians and pharmacists regarding the board and the review 
 program; 

    (6) adopt and implement procedures designed to ensure the 
 confidentiality of any information collected, stored, retrieved, 
 assessed, or analyzed by the board, staff to the board, or 
 contractors to the review program that identifies individual 
 physicians, pharmacists, or recipients; 

    (7) establish and implement an ongoing process to (i) 
 receive public comment regarding drug utilization review 
 criteria and standards, and (ii) consider the comments along 
 with other scientific and clinical information in order to 
 revise criteria and standards on a timely basis; and 

    (8) adopt any rules necessary to carry out this section. 

    The board may establish advisory committees.  The 
 commissioner may contract with appropriate organizations to 
 assist the board in carrying out the board's duties.  The 
 commissioner may enter into contracts for services to develop 
 and implement a retrospective and prospective review program. 

    The board shall report to the commissioner annually on the 
 date the Drug Utilization Review Annual Report is due to the 
 Centers for Medicare and Medicaid Services.  This report is to 
 cover the preceding federal fiscal year.  The commissioner shall 
 make the report available to the public upon request.  The 
 report must include information on the activities of the board 
 and the program; the effectiveness of implemented interventions; 
 administrative costs; and any fiscal impact resulting from the 
 program.  An honorarium of $100 per meeting and reimbursement 
 for mileage shall be paid to each board member in attendance. 

    Subd. 13b. Repealed, 1997 c 203 art 4 s 73 

    Subd. 14.    Diagnostic, screening, and preventive 
 services.  (a) Medical assistance covers diagnostic, 
 screening, and preventive services.  

    (b) "Preventive services" include services related to 
 pregnancy, including: 

    (1) services for those conditions which may complicate a 
 pregnancy and which may be available to a pregnant woman 
 determined to be at risk of poor pregnancy outcome; 

    (2) prenatal HIV risk assessment, education, counseling, 
 and testing; and 

    (3) alcohol abuse assessment, education, and counseling on 
 the effects of alcohol usage while pregnant.  Preventive 
 services available to a woman at risk of poor pregnancy outcome 
 may differ in an amount, duration, or scope from those available 
 to other individuals eligible for medical assistance. 

    (c) "Screening services" include, but are not limited to, 
 blood lead tests. 

    Subd. 15.    Health plan premiums and copayments.  (a) 
 Medical assistance covers health care prepayment plan premiums, 
 insurance premiums, and copayments if determined to be 
 cost-effective by the commissioner.  For purposes of obtaining 
 Medicare part A and part B, and copayments, expenditures may be 
 made even if federal funding is not available. 

    (b) Effective for all premiums due on or after June 30, 
 1997, medical assistance does not cover premiums that a 
 recipient is required to pay under a qualified or Medicare 
 supplement plan issued by the Minnesota comprehensive health 
 association.  Medical assistance shall continue to cover 
 premiums for recipients who are covered under a plan issued by 
 the Minnesota comprehensive health association on June 30, 1997, 
 for a period of six months following receipt of the notice of 
 termination or until December 31, 1997, whichever is later. 

    Subd. 16.    Abortion services.  Medical assistance 
 covers abortion services, but only if one of the following 
 conditions is met: 

    (a) The abortion is a medical necessity.  "Medical 
 necessity" means (1) the signed written statement of two 
 physicians indicating the abortion is medically necessary to 
 prevent the death of the mother, and (2) the patient has given 
 her consent to the abortion in writing unless the patient is 
 physically or legally incapable of providing informed consent to 
 the procedure, in which case consent will be given as otherwise 
 provided by law; 

    (b) The pregnancy is the result of criminal sexual conduct 
 as defined in section 609.342, clauses (c), (d), (e)(i), and 
 (f), and the incident is reported within 48 hours after the 
 incident occurs to a valid law enforcement agency for 
 investigation, unless the victim is physically unable to report 
 the criminal sexual conduct, in which case the report shall be 
 made within 48 hours after the victim becomes physically able to 
 report the criminal sexual conduct; or 

    (c) The pregnancy is the result of incest, but only if the 
 incident and relative are reported to a valid law enforcement 
 agency for investigation prior to the abortion. 

    Subd. 17.    Transportation costs.  (a) Medical 
 assistance covers transportation costs incurred solely for 
 obtaining emergency medical care or transportation costs 
 incurred by nonambulatory persons in obtaining emergency or 
 nonemergency medical care when paid directly to an ambulance 
 company, common carrier, or other recognized providers of 
 transportation services.  For the purpose of this subdivision, a 
 person who is incapable of transport by taxicab or bus shall be 
 considered to be nonambulatory. 

    (b) Medical assistance covers special transportation, as 
 defined in Minnesota Rules, part 9505.0315, subpart 1, item F, 
 if the provider receives and maintains a current physician's 
 order by the recipient's attending physician certifying that the 
 recipient has a physical or mental impairment that would 
 prohibit the recipient from safely accessing and using a bus, 
 taxi, other commercial transportation, or private automobile.  
 Special transportation includes driver-assisted service to 
 eligible individuals.  Driver-assisted service includes 
 passenger pickup at and return to the individual's residence or 
 place of business, assistance with admittance of the individual 
 to the medical facility, and assistance in passenger securement 
 or in securing of wheelchairs or stretchers in the vehicle.  The 
 commissioner shall establish maximum medical assistance 
 reimbursement rates for special transportation services for 
 persons who need a wheelchair-accessible van or 
 stretcher-accessible vehicle and for those who do not need a 
 wheelchair-accessible van or stretcher-accessible vehicle.  The 
 average of these two rates per trip must not exceed $15 for the 
 base rate and $1.40 per mile.  Special transportation provided 
 to nonambulatory persons who do not need a wheelchair-accessible 
 van or stretcher-accessible vehicle, may be reimbursed at a 
 lower rate than special transportation provided to persons who 
 need a wheelchair-accessible van or stretcher-accessible vehicle.

    Subd. 17a.    Payment for ambulance services.  Effective 
 for services rendered on or after July 1, 2001, medical 
 assistance payments for ambulance services shall be paid at the 
 Medicare reimbursement rate or at the medical assistance payment 
 rate in effect on July 1, 2000, whichever is greater.  

    Subd. 18.    Bus or taxicab transportation.  To the 
 extent authorized by rule of the state agency, medical 
 assistance covers costs of the most appropriate and 
 cost-effective form of transportation incurred by any ambulatory 
 eligible person for obtaining nonemergency medical care. 

    Subd. 18a.    Access to medical services.  (a) Medical 
 assistance reimbursement for meals for persons traveling to 
 receive medical care may not exceed $5.50 for breakfast, $6.50 
 for lunch, or $8 for dinner. 

    (b) Medical assistance reimbursement for lodging for 
 persons traveling to receive medical care may not exceed $50 per 
 day unless prior authorized by the local agency. 

    (c) Medical assistance direct mileage reimbursement to the 
 eligible person or the eligible person's driver may not exceed 
 20 cents per mile. 

    (d) Medical assistance covers oral language interpreter 
 services when provided by an enrolled health care provider 
 during the course of providing a direct, person-to-person 
 covered health care service to an enrolled recipient with 
 limited English proficiency. 

    Subd. 19. Repealed, 1991 c 292 art 7 s 26 

    Subd. 19a.    Personal care assistant services.  Medical 
 assistance covers personal care assistant services in a 
 recipient's home.  To qualify for personal care assistant 
 services, recipients or responsible parties must be able to 
 identify the recipient's needs, direct and evaluate task 
 accomplishment, and provide for health and safety.  Approved 
 hours may be used outside the home when normal life activities 
 take them outside the home.  To use personal care assistant 
 services at school, the recipient or responsible party must 
 provide written authorization in the care plan identifying the 
 chosen provider and the daily amount of services to be used at 
 school.  Total hours for services, whether actually performed 
 inside or outside the recipient's home, cannot exceed that which 
 is otherwise allowed for personal care assistant services in an 
 in-home setting according to section 256B.0627.  Medical 
 assistance does not cover personal care assistant services for 
 residents of a hospital, nursing facility, intermediate care 
 facility, health care facility licensed by the commissioner of 
 health, or unless a resident who is otherwise eligible is on 
 leave from the facility and the facility either pays for the 
 personal care assistant services or forgoes the facility per 
 diem for the leave days that personal care assistant services 
 are used.  All personal care assistant services must be provided 
 according to section 256B.0627.  Personal care assistant 
 services may not be reimbursed if the personal care assistant is 
 the spouse or legal guardian of the recipient or the parent of a 
 recipient under age 18, or the responsible party or the foster 
 care provider of a recipient who cannot direct the recipient's 
 own care unless, in the case of a foster care provider, a county 
 or state case manager visits the recipient as needed, but not 
 less than every six months, to monitor the health and safety of 
 the recipient and to ensure the goals of the care plan are met.  
 Parents of adult recipients, adult children of the recipient or 
 adult siblings of the recipient may be reimbursed for personal 
 care assistant services, if they are granted a waiver under 
 section 256B.0627.  Notwithstanding the provisions of section 
 256B.0627, subdivision 4, paragraph (b), clause (4), the 
 noncorporate legal guardian or conservator of an adult, who is 
 not the responsible party and not the personal care provider 
 organization, may be granted a hardship waiver under section 
 256B.0627, to be reimbursed to provide personal care assistant 
 services to the recipient, and shall not be considered to have a 
 service provider interest for purposes of participation on the 
 screening team under section 256B.092, subdivision 7. 

    Subd. 19b.    No automatic adjustment.  For fiscal years 
 beginning on or after July 1, 1993, the commissioner of human 
 services shall not provide automatic annual inflation 
 adjustments for home care services.  The commissioner of finance 
 shall include as a budget change request in each biennial 
 detailed expenditure budget submitted to the legislature under 
 section 16A.11 annual adjustments in reimbursement rates for 
 home care services. 

    Subd. 19c.    Personal care.  Medical assistance covers 
 personal care assistant services provided by an individual who 
 is qualified to provide the services according to subdivision 
 19a and section 256B.0627, where the services are prescribed by 
 a physician in accordance with a plan of treatment and are 
 supervised by the recipient or a qualified professional.  
 "Qualified professional" means a mental health professional as 
 defined in section 245.462, subdivision 18, or 245.4871, 
 subdivision 27; or a registered nurse as defined in sections 
 148.171 to 148.285.  As part of the assessment, the county 
 public health nurse will assist the recipient or responsible 
 party to identify the most appropriate person to provide 
 supervision of the personal care assistant.  The qualified 
 professional shall perform the duties described in Minnesota 
 Rules, part 9505.0335, subpart 4.  

    Subd. 20.    Mental health case management.  (a) To the 
 extent authorized by rule of the state agency, medical 
 assistance covers case management services to persons with 
 serious and persistent mental illness and children with severe 
 emotional disturbance.  Services provided under this section 
 must meet the relevant standards in sections 245.461 to 
 245.4888, the Comprehensive Adult and Children's Mental Health 
 Acts, Minnesota Rules, parts 9520.0900 to 9520.0926, and 
 9505.0322, excluding subpart 10. 

    (b) Entities meeting program standards set out in rules 
 governing family community support services as defined in 
 section 245.4871, subdivision 17, are eligible for medical 
 assistance reimbursement for case management services for 
 children with severe emotional disturbance when these services 
 meet the program standards in Minnesota Rules, parts 9520.0900 
 to 9520.0926 and 9505.0322, excluding subparts 6 and 10. 

    (c) Medical assistance and MinnesotaCare payment for mental 
 health case management shall be made on a monthly basis.  In 
 order to receive payment for an eligible child, the provider 
 must document at least a face-to-face contact with the child, 
 the child's parents, or the child's legal representative.  To 
 receive payment for an eligible adult, the provider must 
 document: 

    (1) at least a face-to-face contact with the adult or the 
 adult's legal representative; or 

    (2) at least a telephone contact with the adult or the 
 adult's legal representative and document a face-to-face contact 
 with the adult or the adult's legal representative within the 
 preceding two months. 

    (d) Payment for mental health case management provided by 
 county or state staff shall be based on the monthly rate 
 methodology under section 256B.094, subdivision 6, paragraph 
 (b), with separate rates calculated for child welfare and mental 
 health, and within mental health, separate rates for children 
 and adults. 

    (e) Payment for mental health case management provided by 
 Indian health services or by agencies operated by Indian tribes 
 may be made according to this section or other relevant 
 federally approved rate setting methodology. 

    (f) Payment for mental health case management provided by 
 vendors who contract with a county or Indian tribe shall be 
 based on a monthly rate negotiated by the host county or tribe.  
 The negotiated rate must not exceed the rate charged by the 
 vendor for the same service to other payers.  If the service is 
 provided by a team of contracted vendors, the county or tribe 
 may negotiate a team rate with a vendor who is a member of the 
 team.  The team shall determine how to distribute the rate among 
 its members.  No reimbursement received by contracted vendors 
 shall be returned to the county or tribe, except to reimburse 
 the county or tribe for advance funding provided by the county 
 or tribe to the vendor. 

    (g) If the service is provided by a team which includes 
 contracted vendors, tribal staff, and county or state staff, the 
 costs for county or state staff participation in the team shall 
 be included in the rate for county-provided services.  In this 
 case, the contracted vendor, the tribal agency, and the county 
 may each receive separate payment for services provided by each 
 entity in the same month.  In order to prevent duplication of 
 services, each entity must document, in the recipient's file, 
 the need for team case management and a description of the roles 
 of the team members. 

    (h) The commissioner shall calculate the nonfederal share 
 of actual medical assistance and general assistance medical care 
 payments for each county, based on the higher of calendar year 
 1995 or 1996, by service date, project that amount forward to 
 1999, and transfer one-half of the result from medical 
 assistance and general assistance medical care to each county's 
 mental health grants under sections 245.4886 and 256E.12 for 
 calendar year 1999.  The annualized minimum amount added to each 
 county's mental health grant shall be $3,000 per year for 
 children and $5,000 per year for adults.  The commissioner may 
 reduce the statewide growth factor in order to fund these 
 minimums.  The annualized total amount transferred shall become 
 part of the base for future mental health grants for each county.

    (i) Any net increase in revenue to the county or tribe as a 
 result of the change in this section must be used to provide 
 expanded mental health services as defined in sections 245.461 
 to 245.4888, the Comprehensive Adult and Children's Mental 
 Health Acts, excluding inpatient and residential treatment.  For 
 adults, increased revenue may also be used for services and 
 consumer supports which are part of adult mental health projects 
 approved under Laws 1997, chapter 203, article 7, section 25.  
 For children, increased revenue may also be used for respite 
 care and nonresidential individualized rehabilitation services 
 as defined in section 245.492, subdivisions 17 and 23.  
 "Increased revenue" has the meaning given in Minnesota Rules, 
 part 9520.0903, subpart 3.  

    (j) Notwithstanding section 256B.19, subdivision 1, the 
 nonfederal share of costs for mental health case management 
 shall be provided by the recipient's county of responsibility, 
 as defined in sections 256G.01 to 256G.12, from sources other 
 than federal funds or funds used to match other federal funds.  
 If the service is provided by a tribal agency, the nonfederal 
 share, if any, shall be provided by the recipient's tribe.  

    (k) The commissioner may suspend, reduce, or terminate the 
 reimbursement to a provider that does not meet the reporting or 
 other requirements of this section.  The county of 
 responsibility, as defined in sections 256G.01 to 256G.12, or, 
 if applicable, the tribal agency, is responsible for any federal 
 disallowances.  The county or tribe may share this 
 responsibility with its contracted vendors.  

    (l) The commissioner shall set aside a portion of the 
 federal funds earned under this section to repay the special 
 revenue maximization account under section 256.01, subdivision 
 2, clause (15).  The repayment is limited to: 

    (1) the costs of developing and implementing this section; 
 and 

    (2) programming the information systems. 

    (m) Payments to counties and tribal agencies for case 
 management expenditures under this section shall only be made 
 from federal earnings from services provided under this 
 section.  Payments to county-contracted vendors shall include 
 both the federal earnings and the county share. 

    (n) Notwithstanding section 256B.041, county payments for 
 the cost of mental health case management services provided by 
 county or state staff shall not be made to the state treasurer.  
 For the purposes of mental health case management services 
 provided by county or state staff under this section, the 
 centralized disbursement of payments to counties under section 
 256B.041 consists only of federal earnings from services 
 provided under this section. 

    (o) Case management services under this subdivision do not 
 include therapy, treatment, legal, or outreach services. 

    (p) If the recipient is a resident of a nursing facility, 
 intermediate care facility, or hospital, and the recipient's 
 institutional care is paid by medical assistance, payment for 
 case management services under this subdivision is limited to 
 the last 180 days of the recipient's residency in that facility 
 and may not exceed more than six months in a calendar year. 

    (q) Payment for case management services under this 
 subdivision shall not duplicate payments made under other 
 program authorities for the same purpose. 

    (r) By July 1, 2000, the commissioner shall evaluate the 
 effectiveness of the changes required by this section, including 
 changes in number of persons receiving mental health case 
 management, changes in hours of service per person, and changes 
 in caseload size. 

    (s) For each calendar year beginning with the calendar year 
 2001, the annualized amount of state funds for each county 
 determined under paragraph (h) shall be adjusted by the county's 
 percentage change in the average number of clients per month who 
 received case management under this section during the fiscal 
 year that ended six months prior to the calendar year in 
 question, in comparison to the prior fiscal year. 

    (t) For counties receiving the minimum allocation of $3,000 
 or $5,000 described in paragraph (h), the adjustment in 
 paragraph (s) shall be determined so that the county receives 
 the higher of the following amounts: 

    (1) a continuation of the minimum allocation in paragraph 
 (h); or 

    (2) an amount based on that county's average number of 
 clients per month who received case management under this 
 section during the fiscal year that ended six months prior to 
 the calendar year in question, times the average statewide grant 
 per person per month for counties not receiving the minimum 
 allocation. 

    (u) The adjustments in paragraphs (s) and (t) shall be 
 calculated separately for children and adults. 

    Subd. 20a.    Case management for persons with mental 
 retardation or a related condition.  To the extent defined in 
 the state Medicaid plan, case management service activities for 
 persons with mental retardation or a related condition as 
 defined in section 256B.092, and rules promulgated thereunder, 
 are covered services under medical assistance.  

    Subd. 21. Repealed, 1989 c 282 art 3 s 98 

    Subd. 22.    Hospice care.  Medical assistance covers 
 hospice care services under Public Law Number 99-272, section 
 9505, to the extent authorized by rule. 

    Subd. 23.    Day treatment services.  Medical assistance 
 covers day treatment services as specified in sections 245.462, 
 subdivision 8, and 245.4871, subdivision 10, that are provided 
 under contract with the county board. 

    Subd. 24.    Other medical or remedial care.  Medical 
 assistance covers any other medical or remedial care licensed 
 and recognized under state law unless otherwise prohibited by 
 law, except licensed chemical dependency treatment programs or 
 primary treatment or extended care treatment units in hospitals 
 that are covered under chapter 254B.  The commissioner shall 
 include chemical dependency services in the state medical 
 assistance plan for federal reporting purposes, but payment must 
 be made under chapter 254B.  The commissioner shall publish in 
 the State Register a list of elective surgeries that require a 
 second medical opinion before medical assistance reimbursement, 
 and the criteria and standards for deciding whether an elective 
 surgery should require a second medical opinion.  The list and 
 criteria and standards are not subject to the requirements of 
 sections 14.01 to 14.69.  

    Subd. 25.    Prior authorization required.  The 
 commissioner shall publish in the State Register a list of 
 health services that require prior authorization, as well as the 
 criteria and standards used to select health services on the 
 list.  The list and the criteria and standards used to formulate 
 it are not subject to the requirements of sections 14.001 to 
 14.69.  The commissioner's decision whether prior authorization 
 is required for a health service is not subject to 
 administrative appeal. 

    Subd. 26.    Special education services.  (a) Medical 
 assistance covers medical services identified in a recipient's 
 individualized education plan and covered under the medical 
 assistance state plan.  Covered services include occupational 
 therapy, physical therapy, speech-language therapy, clinical 
 psychological services, nursing services, school psychological 
 services, school social work services, personal care assistants 
 serving as management aides, assistive technology devices, 
 transportation services, health assessments, and other services 
 covered under the medical assistance state plan.  Mental health 
 services eligible for medical assistance reimbursement must be 
 provided or coordinated through a children's mental health 
 collaborative where a collaborative exists if the child is 
 included in the collaborative operational target population.  
 The provision or coordination of services does not require that 
 the individual education plan be developed by the collaborative. 

    The services may be provided by a Minnesota school district 
 that is enrolled as a medical assistance provider or its 
 subcontractor, and only if the services meet all the 
 requirements otherwise applicable if the service had been 
 provided by a provider other than a school district, in the 
 following areas:  medical necessity, physician's orders, 
 documentation, personnel qualifications, and prior authorization 
 requirements.  The nonfederal share of costs for services 
 provided under this subdivision is the responsibility of the 
 local school district as provided in section 125A.74.  Services 
 listed in a child's individual education plan are eligible for 
 medical assistance reimbursement only if those services meet 
 criteria for federal financial participation under the Medicaid 
 program.  

    (b) Approval of health-related services for inclusion in 
 the individual education plan does not require prior 
 authorization for purposes of reimbursement under this chapter.  
 The commissioner may require physician review and approval of 
 the plan not more than once annually or upon any modification of 
 the individual education plan that reflects a change in 
 health-related services. 

    (c) Services of a speech-language pathologist provided 
 under this section are covered notwithstanding Minnesota Rules, 
 part 9505.0390, subpart 1, item L, if the person: 

    (1) holds a masters degree in speech-language pathology; 

    (2) is licensed by the Minnesota board of teaching as an 
 educational speech-language pathologist; and 

    (3) either has a certificate of clinical competence from 
 the American Speech and Hearing Association, has completed the 
 equivalent educational requirements and work experience 
 necessary for the certificate or has completed the academic 
 program and is acquiring supervised work experience to qualify 
 for the certificate. 

    (d) Medical assistance coverage for medically necessary 
 services provided under other subdivisions in this section may 
 not be denied solely on the basis that the same or similar 
 services are covered under this subdivision. 

    (e) The commissioner shall develop and implement package 
 rates, bundled rates, or per diem rates for special education 
 services under which separately covered services are grouped 
 together and billed as a unit in order to reduce administrative 
 complexity.  

    (f) The commissioner shall develop a cost-based payment 
 structure for payment of these services.  

    (g) Effective July 1, 2000, medical assistance services 
 provided under an individual education plan or an individual 
 family service plan by local school districts shall not count 
 against medical assistance authorization thresholds for that 
 child. 

    (h) Nursing services as defined in section 148.171, 
 subdivision 15, and provided as an individual education plan 
 health-related service, are eligible for medical assistance 
 payment if they are otherwise a covered service under the 
 medical assistance program.  Medical assistance covers the 
 administration of prescription medications by a licensed nurse 
 who is employed by or under contract with a school district when 
 the administration of medications is identified in the child's 
 individualized education plan.  The simple administration of 
 medications alone is not covered under medical assistance when 
 administered by a provider other than a school district or when 
 it is not identified in the child's individualized education 
 plan. 

    Subd. 27.    Organ and tissue transplants.  Medical 
 assistance coverage for organ and tissue transplant procedures 
 is limited to those procedures covered by the Medicare program 
 or approved by the Advisory Committee on Organ and Tissue 
 Transplants.  All organ transplants must be performed at 
 transplant centers meeting united network for organ sharing 
 criteria or at Medicare-approved organ transplant centers.  Stem 
 cell or bone marrow transplant centers must meet the standards 
 established by the Foundation for the Accreditation of 
 Hematopoietic Cell Therapy or be approved by the Advisory 
 Committee on Organ and Tissue Transplants.  Transplant 
 procedures must comply with all applicable laws, rules, and 
 regulations governing (1) coverage by the Medicare program, (2) 
 federal financial participation by the Medicaid program, and (3) 
 coverage by the Minnesota medical assistance program.  
 Transplants performed out of Minnesota or the local trade area 
 must be prior authorized. 

    Subd. 28.    Certified nurse practitioner services.  
 Medical assistance covers services performed by a certified 
 pediatric nurse practitioner, a certified family nurse 
 practitioner, a certified adult nurse practitioner, a certified 
 obstetric/gynecological nurse practitioner, a certified neonatal 
 nurse practitioner, or a certified geriatric nurse practitioner 
 in independent practice, if:  

    (1) the service provided on an inpatient basis is not 
 included as part of the cost for inpatient services included in 
 the operating payment rate; 

    (2) the service is otherwise covered under this chapter as 
 a physician service; and 

    (3) the service is within the scope of practice of the 
 nurse practitioner's license as a registered nurse, as defined 
 in section 148.171. 

    Subd. 28a.    Registered physician assistant services.  
 Medical assistance covers services performed by a registered 
 physician assistant if the service is otherwise covered under 
 this chapter as a physician service and if the service is within 
 the scope of practice of a registered physician assistant as 
 defined in section 147A.09. 

    Subd. 29.    Public health nursing clinic services.  
 Medical assistance covers the services of a certified public 
 health nurse or a registered nurse practicing in a public health 
 nursing clinic that is a department of, or that operates under 
 the direct authority of, a unit of government, if the service is 
 within the scope of practice of the public health or registered 
 nurse's license as a registered nurse, as defined in section 
 148.171. 

    Subd. 30.    Other clinic services.  (a) Medical 
 assistance covers rural health clinic services, federally 
 qualified health center services, nonprofit community health 
 clinic services, public health clinic services, and the services 
 of a clinic meeting the criteria established in rule by the 
 commissioner.  Rural health clinic services and federally 
 qualified health center services mean services defined in United 
 States Code, title 42, section 1396d(a)(2)(B) and (C).  Payment 
 for rural health clinic and federally qualified health center 
 services shall be made according to applicable federal law and 
 regulation. 

    (b) A federally qualified health center that is beginning 
 initial operation shall submit an estimate of budgeted costs and 
 visits for the initial reporting period in the form and detail 
 required by the commissioner.  A federally qualified health 
 center that is already in operation shall submit an initial 
 report using actual costs and visits for the initial reporting 
 period.  Within 90 days of the end of its reporting period, a 
 federally qualified health center shall submit, in the form and 
 detail required by the commissioner, a report of its operations, 
 including allowable costs actually incurred for the period and 
 the actual number of visits for services furnished during the 
 period, and other information required by the commissioner.  
 Federally qualified health centers that file Medicare cost 
 reports shall provide the commissioner with a copy of the most 
 recent Medicare cost report filed with the Medicare program 
 intermediary for the reporting year which support the costs 
 claimed on their cost report to the state. 

    (c) In order to continue cost-based payment under the 
 medical assistance program according to paragraphs (a) and (b), 
 a federally qualified health center or rural health clinic must 
 apply for designation as an essential community provider within 
 six months of final adoption of rules by the department of 
 health according to section 62Q.19, subdivision 7.  For those 
 federally qualified health centers and rural health clinics that 
 have applied for essential community provider status within the 
 six-month time prescribed, medical assistance payments will 
 continue to be made according to paragraphs (a) and (b) for the 
 first three years after application.  For federally qualified 
 health centers and rural health clinics that either do not apply 
 within the time specified above or who have had essential 
 community provider status for three years, medical assistance 
 payments for health services provided by these entities shall be 
 according to the same rates and conditions applicable to the 
 same service provided by health care providers that are not 
 federally qualified health centers or rural health clinics.  

    (d) Effective July 1, 1999, the provisions of paragraph (c) 
 requiring a federally qualified health center or a rural health 
 clinic to make application for an essential community provider 
 designation in order to have cost-based payments made according 
 to paragraphs (a) and (b) no longer apply. 

    (e) Effective January 1, 2000, payments made according to 
 paragraphs (a) and (b) shall be limited to the cost phase-out 
 schedule of the Balanced Budget Act of 1997. 

    (f) Effective January 1, 2001, each federally qualified 
 health center and rural health clinic may elect to be paid 
 either under the prospective payment system established in 
 United States Code, title 42, section 1396a(aa), or under an 
 alternative payment methodology consistent with the requirements 
 of United States Code, title 42, section 1396a(aa), and approved 
 by the Centers for Medicare and Medicaid Services.  The 
 alternative payment methodology shall be 100 percent of cost as 
 determined according to Medicare cost principles. 

    Subd. 31.    Medical supplies and equipment.  Medical 
 assistance covers medical supplies and equipment.  Separate 
 payment outside of the facility's payment rate shall be made for 
 wheelchairs and wheelchair accessories for recipients who are 
 residents of intermediate care facilities for the mentally 
 retarded.  Reimbursement for wheelchairs and wheelchair 
 accessories for ICF/MR recipients shall be subject to the same 
 conditions and limitations as coverage for recipients who do not 
 reside in institutions.  A wheelchair purchased outside of the 
 facility's payment rate is the property of the recipient. 

    Subd. 31a.    Augmentative and alternative communication 
 systems.  (a) Medical assistance covers augmentative and 
 alternative communication systems consisting of electronic or 
 nonelectronic devices and the related components necessary to 
 enable a person with severe expressive communication limitations 
 to produce or transmit messages or symbols in a manner that 
 compensates for that disability. 

    (b) Until the volume of systems purchased increases to 
 allow a discount price, the commissioner shall reimburse 
 augmentative and alternative communication manufacturers and 
 vendors at the manufacturer's suggested retail price for 
 augmentative and alternative communication systems and related 
 components.  The commissioner shall separately reimburse 
 providers for purchasing and integrating individual 
 communication systems which are unavailable as a package from an 
 augmentative and alternative communication vendor. 

    (c) Reimbursement rates established by this purchasing 
 program are not subject to Minnesota Rules, part 9505.0445, item 
 S or T. 

    Subd. 32.    Nutritional products.  Medical assistance 
 covers nutritional products needed for nutritional 
 supplementation because solid food or nutrients thereof cannot 
 be properly absorbed by the body or needed for treatment of 
 phenylketonuria, hyperlysinemia, maple syrup urine disease, a 
 combined allergy to human milk, cow's milk, and soy formula, or 
 any other childhood or adult diseases, conditions, or disorders 
 identified by the commissioner as requiring a similarly 
 necessary nutritional product.  Nutritional products needed for 
 the treatment of a combined allergy to human milk, cow's milk, 
 and soy formula require prior authorization.  Separate payment 
 shall not be made for nutritional products for residents of 
 long-term care facilities.  Payment for dietary requirements is 
 a component of the per diem rate paid to these facilities. 

    Subd. 33.    Child welfare targeted case management.  
 Medical assistance, subject to federal approval, covers child 
 welfare targeted case management services as defined in section 
 256B.094 to children under age 21 who have been assessed and 
 determined in accordance with section 256F.095 to be:  

    (1) at risk of placement or in placement as defined in 
 section 260C.212, subdivision 1; 

    (2) at risk of maltreatment or experiencing maltreatment as 
 defined in section 626.556, subdivision 10e; or 

    (3) in need of protection or services as defined in section 
 260C.007, subdivision 6. 

    Subd. 34.    Indian health services facilities.  Medical 
 assistance payments and MinnesotaCare payments to facilities of 
 the Indian health service 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, for enrollees who are eligible for federal 
 financial participation, shall be at the option of the facility 
 in accordance with the rate published by the United States 
 Assistant Secretary for Health under the authority of United 
 States Code, title 42, sections 248(a) and 249(b).  General 
 assistance medical care payments to facilities of the Indian 
 health services and facilities operated by a tribe or tribal 
 organization for the provision of outpatient medical care 
 services billed after June 30, 1990, must be in accordance with 
 the general assistance medical care rates paid for the same 
 services when provided in a facility other than a facility of 
 the Indian health service or a facility operated by a tribe or 
 tribal organization.  MinnesotaCare payments for enrollees who 
 are not eligible for federal financial participation at 
 facilities of the Indian health service and facilities operated 
 by a tribe or tribal organization for the provision of 
 outpatient medical services must be in accordance with the 
 medical assistance rates paid for the same services when 
 provided in a facility other than a facility of the Indian 
 health service or a facility operated by a tribe or tribal 
 organization. 

    Subd. 35.    Family community support services.  (a) 
 Medical assistance covers family community support services as 
 defined in section 245.4871, subdivision 17.  In addition to the 
 provisions of section 245.4871, and to the extent authorized by 
 rules promulgated by the state agency, medical assistance covers 
 the following services as family community support services: 

    (1) services identified in an individual treatment plan 
 when provided by a trained mental health behavioral aide under 
 the direction of a mental health practitioner or mental health 
 professional; 

    (2) mental health crisis intervention and crisis 
 stabilization services provided outside of hospital inpatient 
 settings; and 

    (3) the therapeutic components of preschool and therapeutic 
 camp programs. 

    (b) Notwithstanding the provisions of Minnesota Rules, 
 parts 9505.0324, subpart 2, 9505.0326, subpart 2, and 9505.0327, 
 subpart 2, a provider of family community support services, 
 home-based mental health services, or therapeutic support of 
 foster care services under contract with a county may continue 
 to provide existing services, and may provide new services, to a 
 child if that child is placed in foster care, or the child and 
 family relocate, outside the original county of residence. 

    Subd. 36.    Therapeutic support of foster care.  
 Medical assistance covers therapeutic support of foster care as 
 defined in section 245.4871, subdivision 34. 

    Subd. 37.    Individualized rehabilitation services.  
 Medical assistance covers individualized rehabilitation services 
 as defined in section 245.492, subdivision 23, that are provided 
 by a collaborative, county, or an entity under contract with a 
 county through an integrated service system, as described in 
 section 245.4931, that is approved by the state coordinating 
 council, subject to federal approval. 

    Subd. 38.    Payments for mental health services.  
 Payments for mental health services covered under the medical 
 assistance program that are provided by masters-prepared mental 
 health professionals shall be 80 percent of the rate paid to 
 doctoral-prepared professionals.  Payments for mental health 
 services covered under the medical assistance program that are 
 provided by masters-prepared mental health professionals 
 employed by community mental health centers shall be 100 percent 
 of the rate paid to doctoral-prepared professionals.  For 
 purposes of reimbursement of mental health professionals under 
 the medical assistance program, all social workers who: 

    (1) have received a master's degree in social work from a 
 program accredited by the council on social work education; 

    (2) are licensed at the level of graduate social worker or 
 independent social worker; and 

    (3) are practicing clinical social work under appropriate 
 supervision, as defined by section 148B.18; meet all 
 requirements under Minnesota Rules, part 9505.0323, subpart 24, 
 and shall be paid accordingly.  

    Subd. 39.    Childhood immunizations.  Providers who 
 administer pediatric vaccines within the scope of their 
 licensure, and who are enrolled as a medical assistance 
 provider, must enroll in the pediatric vaccine administration 
 program established by section 13631 of the Omnibus Budget 
 Reconciliation Act of 1993.  Medical assistance shall pay an 
 $8.50 fee per dose for administration of the vaccine to children 
 eligible for medical assistance.  Medical assistance does not 
 pay for vaccines that are available at no cost from the 
 pediatric vaccine administration program. 

    Subd. 40.    Tuberculosis related services.  (a) For 
 persons infected with tuberculosis, medical assistance covers 
 case management services and direct observation of the intake of 
 drugs prescribed to treat tuberculosis. 

    (b) "Case management services" means services furnished to 
 assist persons infected with tuberculosis in gaining access to 
 needed medical services.  Case management services include at a 
 minimum: 

    (1) assessing a person's need for medical services to treat 
 tuberculosis; 

    (2) developing a care plan that addresses the needs 
 identified in clause (1); 

    (3) assisting the person in accessing medical services 
 identified in the care plan; and 

    (4) monitoring the person's compliance with the care plan 
 to ensure completion of tuberculosis therapy.  Medical 
 assistance covers case management services under this 
 subdivision only if the services are provided by a certified 
 public health nurse who is employed by a community health board 
 as defined in section 145A.02, subdivision 5. 

    (c) To be covered by medical assistance, direct observation 
 of the intake of drugs prescribed to treat tuberculosis must be 
 provided by a community outreach worker, licensed practical 
 nurse, registered nurse who is trained and supervised by a 
 public health nurse employed by a community health board as 
 defined in section 145A.02, subdivision 5, or a public health 
 nurse employed by a community health board. 

    Subd. 41.    Residential services for children with severe 
 emotional disturbance.  Medical assistance covers 
 rehabilitative services in accordance with section 256B.0945 
 that are provided by a county through a residential facility, 
 for children who have been diagnosed with severe emotional 
 disturbance and have been determined to require the level of 
 care provided in a residential facility. 

    Subd. 42.    Mental health professional.  
 Notwithstanding Minnesota Rules, part 9505.0175, subpart 28, the 
 definition of a mental health professional shall include a 
 person who is qualified as specified in section 245.462, 
 subdivision 18, clause (5); or 245.4871, subdivision 27, clause 
 (5), for the purpose of this section and Minnesota Rules, parts 
 9505.0170 to 9505.0475.  

    Subd. 43.    Mental health provider travel time.  
 Medical assistance covers provider travel time if a recipient's 
 individual treatment plan requires the provision of mental 
 health services outside of the provider's normal place of 
 business.  This does not include any travel time which is 
 included in other billable services, and is only covered when 
 the mental health service being provided to a recipient is 
 covered under medical assistance. 

    Subd. 44.    Targeted case management services.  Medical 
 assistance covers case management services for vulnerable adults 
 and adults with developmental disabilities, as provided under 
 section 256B.0924. 

    HIST: Ex1967 c 16 s 2; 1969 c 395 s 1; 1973 c 717 s 17; 1975 c 
 247 s 9; 1975 c 384 s 1; 1975 c 437 art 2 s 3; 1976 c 173 s 56; 
 1976 c 236 s 1; 1976 c 312 s 1; 1978 c 508 s 2; 1978 c 560 s 10; 
 1981 c 360 art 2 s 26,54; 1Sp1981 c 2 s 12; 1Sp1981 c 4 art 4 s 
 22; 3Sp1981 c 2 art 1 s 31; 1982 c 562 s 2; 1983 c 151 s 1,2; 
 1983 c 312 art 1 s 27; art 5 s 10; art 9 s 4; 1984 c 654 art 5 s 
 58; 1985 c 21 s 52-54; 1985 c 49 s 41; 1985 c 252 s 19,20; 
 1Sp1985 c 3 s 19; 1986 c 394 s 17; 1986 c 444; 1987 c 309 s 24; 
 1987 c 370 art 1 s 3; art 2 s 4; 1987 c 374 s 1; 1987 c 403 art 
 2 s 73,74; art 5 s 16; 1988 c 689 art 2 s 141,268; 1989 c 282 
 art 3 s 54-58; 1990 c 422 s 10; 1990 c 568 art 3 s 43-50,104; 
 1991 c 199 art 2 s 1; 1991 c 292 art 4 s 41-49; art 6 s 45; art 
 7 s 5,9-11; 1992 c 391 s 1,2; 1992 c 513 art 7 s 43-49; art 9 s 
 25; 1993 c 246 s 1,2; 1993 c 247 art 4 s 11; 1993 c 345 art 13 s 
 1; 1Sp1993 c 1 art 3 s 23; art 5 s 36-49; art 7 s 41-44; art 9 s 
 71; 1Sp1993 c 6 s 10; 1994 c 465 art 3 s 52; 1994 c 625 art 8 s 
 72; 1995 c 178 art 2 s 26; 1995 c 207 art 6 s 38-51; art 8 s 33; 
 1995 c 234 art 6 s 38; 1995 c 263 s 10; 1996 c 451 art 2 s 20; 
 art 5 s 15,16; 1997 c 203 art 2 s 25; art 4 s 25,26; 1997 c 225 
 art 4 s 3; art 6 s 5,8; 1998 c 398 art 2 s 46; 1998 c 407 art 4 
 s 20-28; 1999 c 86 art 2 s 4; 1999 c 139 art 4 s 2; 1999 c 245 
 art 4 s 37-49,121; art 5 s 20; art 8 s 5,87; art 10 s 10; 2000 c 
 298 s 3; 2000 c 347 s 1; 2000 c 474 s 6,7; 2000 c 488 art 9 s 
 16; 2001 c 178 art 1 s 44; 2001 c 203 s 9; 1Sp2001 c 9 art 2 s 
 30-38; art 3 s 16-19; art 9 s 41,42; 2002 c 220 art 15 s 13; 
 2002 c 277 s 12-14,32; 2002 c 294 s 6; 2002 c 375 art 2 s 13-16; 
 2002 c 379 art 1 s 113 

*   NOTE:  The amendment to subdivision 26 by Laws 2002, 
*chapter 375, article 2, section 14, is effective for services 
*provided on or after April 1, 2002, upon federal approval, if 
*federal approval is required.  Laws 2002, chapter 375, article 
*2, section 14, the effective date.

     256B.0626 Estimation of 50th percentile of prevailing 
  charges. 

    (a) The 50th percentile of the prevailing charge for the 
 base year identified in statute must be estimated by the 
 commissioner in the following situations: 

    (1) there were less than five billings in the calendar year 
 specified in legislation governing maximum payment rates; 

    (2) the service was not available in the calendar year 
 specified in legislation governing maximum payment rates; 

    (3) the payment amount is the result of a provider appeal; 

    (4) the procedure code description has changed since the 
 calendar year specified in legislation governing maximum payment 
 rates, and, therefore, the prevailing charge information 
 reflects the same code but a different procedure description; or 

    (5) the 50th percentile reflects a payment which is grossly 
 inequitable when compared with payment rates for procedures or 
 services which are substantially similar. 

    (b) When one of the situations identified in paragraph (a) 
 occurs, the commissioner shall use the following methodology to 
 reconstruct a rate comparable to the 50th percentile of the 
 prevailing rate: 

    (1) refer to information which exists for the first four 
 billings in the calendar year specified in legislation governing 
 maximum payment rates; or 

    (2) refer to surrounding or comparable procedure codes; or 

    (3) refer to the 50th percentile of years subsequent to the 
 calendar year specified in legislation governing maximum payment 
 rates, and reduce that amount by applying an appropriate 
 Consumer Price Index formula; or 

    (4) refer to relative value indexes; or 

    (5) refer to reimbursement information from other third 
 parties, such as Medicare. 

    HIST: 1Sp1993 c 1 art 5 s 50; 1997 c 203 art 4 s 27 

     256B.0627 Covered service; home care services. 

    Subdivision 1.    Definition.  (a) "Activities of daily 
 living" includes eating, toileting, grooming, dressing, bathing, 
 transferring, mobility, and positioning.  

    (b) "Assessment" means a review and evaluation of a 
 recipient's need for home care services conducted in person.  
 Assessments for private duty nursing shall be conducted by a 
 registered private duty nurse.  Assessments for home health 
 agency services shall be conducted by a home health agency 
 nurse.  Assessments for personal care assistant services shall 
 be conducted by the county public health nurse or a certified 
 public health nurse under contract with the county.  A 
 face-to-face assessment must include:  documentation of health 
 status, determination of need, evaluation of service 
 effectiveness, identification of appropriate services, service 
 plan development or modification, coordination of services, 
 referrals and follow-up to appropriate payers and community 
 resources, completion of required reports, recommendation of 
 service authorization, and consumer education.  Once the need 
 for personal care assistant services is determined under this 
 section, the county public health nurse or certified public 
 health nurse under contract with the county is responsible for 
 communicating this recommendation to the commissioner and the 
 recipient.  A face-to-face assessment for personal care 
 assistant services is conducted on those recipients who have 
 never had a county public health nurse assessment.  A 
 face-to-face assessment must occur at least annually or when 
 there is a significant change in the recipient's condition or 
 when there is a change in the need for personal care assistant 
 services.  A service update may substitute for the annual 
 face-to-face assessment when there is not a significant change 
 in recipient condition or a change in the need for personal care 
 assistant service.  A service update or review for temporary 
 increase includes a review of initial baseline data, evaluation 
 of service effectiveness, redetermination of service need, 
 modification of service plan and appropriate referrals, update 
 of initial forms, obtaining service authorization, and on going 
 consumer education.  Assessments for medical assistance home 
 care services for mental retardation or related conditions and 
 alternative care services for developmentally disabled home and 
 community-based waivered recipients may be conducted by the 
 county public health nurse to ensure coordination and avoid 
 duplication.  Assessments must be completed on forms provided by 
 the commissioner within 30 days of a request for home care 
 services by a recipient or responsible party. 

    (c) "Care plan" means a written description of personal 
 care assistant services developed by the qualified professional 
 or the recipient's physician with the recipient or responsible 
 party to be used by the personal care assistant with a copy 
 provided to the recipient or responsible party. 

    (d) "Complex and regular private duty nursing care" means: 

    (1) complex care is private duty nursing provided to 
 recipients who are ventilator dependent or for whom a physician 
 has certified that were it not for private duty nursing the 
 recipient would meet the criteria for inpatient hospital 
 intensive care unit (ICU) level of care; and 

    (2) regular care is private duty nursing provided to all 
 other recipients. 

    (e) "Health-related functions" means functions that can be 
 delegated or assigned by a licensed health care professional 
 under state law to be performed by a personal care attendant. 

    (f) "Home care services" means a health service, determined 
 by the commissioner as medically necessary, that is ordered by a 
 physician and documented in a service plan that is reviewed by 
 the physician at least once every 60 days for the provision of 
 home health services, or private duty nursing, or at least once 
 every 365 days for personal care.  Home care services are 
 provided to the recipient at the recipient's residence that is a 
 place other than a hospital or long-term care facility or as 
 specified in section 256B.0625.  

    (g) "Instrumental activities of daily living" includes meal 
 planning and preparation, managing finances, shopping for food, 
 clothing, and other essential items, performing essential 
 household chores, communication by telephone and other media, 
 and getting around and participating in the community. 

    (h) "Medically necessary" has the meaning given in 
 Minnesota Rules, parts 9505.0170 to 9505.0475.  

    (i) "Personal care assistant" means a person who:  

    (1) is at least 18 years old, except for persons 16 to 18 
 years of age who participated in a related school-based job 
 training program or have completed a certified home health aide 
 competency evaluation; 

    (2) is able to effectively communicate with the recipient 
 and personal care provider organization; 

    (3) effective July 1, 1996, has completed one of the 
 training requirements as specified in Minnesota Rules, part 
 9505.0335, subpart 3, items A to D; 

    (4) has the ability to, and provides covered personal care 
 assistant services according to the recipient's care plan, 
 responds appropriately to recipient needs, and reports changes 
 in the recipient's condition to the supervising qualified 
 professional or physician; 

    (5) is not a consumer of personal care assistant services; 
 and 

    (6) is subject to criminal background checks and procedures 
 specified in section 245A.04.  

    (j) "Personal care provider organization" means an 
 organization enrolled to provide personal care assistant 
 services under the medical assistance program that complies with 
 the following:  (1) owners who have a five percent interest or 
 more, and managerial officials are subject to a background study 
 as provided in section 245A.04.  This applies to currently 
 enrolled personal care provider organizations and those agencies 
 seeking enrollment as a personal care provider organization.  An 
 organization will be barred from enrollment if an owner or 
 managerial official of the organization has been convicted of a 
 crime specified in section 245A.04, or a comparable crime in 
 another jurisdiction, unless the owner or managerial official 
 meets the reconsideration criteria specified in section 245A.04; 
 (2) the organization must maintain a surety bond and liability 
 insurance throughout the duration of enrollment and provides 
 proof thereof.  The insurer must notify the department of human 
 services of the cancellation or lapse of policy; and (3) the 
 organization must maintain documentation of services as 
 specified in Minnesota Rules, part 9505.2175, subpart 7, as well 
 as evidence of compliance with personal care assistant training 
 requirements. 

    (k) "Responsible party" means an individual residing with a 
 recipient of personal care assistant services who is capable of 
 providing the supportive care necessary to assist the recipient 
 to live in the community, is at least 18 years old, and is not a 
 personal care assistant.  Responsible parties who are parents of 
 minors or guardians of minors or incapacitated persons may 
 delegate the responsibility to another adult during a temporary 
 absence of at least 24 hours but not more than six months.  The 
 person delegated as a responsible party must be able to meet the 
 definition of responsible party, except that the delegated 
 responsible party is required to reside with the recipient only 
 while serving as the responsible party.  Foster care license 
 holders may be designated the responsible party for residents of 
 the foster care home if case management is provided as required 
 in section 256B.0625, subdivision 19a.  For persons who, as of 
 April 1, 1992, are sharing personal care assistant services in 
 order to obtain the availability of 24-hour coverage, an 
 employee of the personal care provider organization may be 
 designated as the responsible party if case management is 
 provided as required in section 256B.0625, subdivision 19a. 

    (l) "Service plan" means a written description of the 
 services needed based on the assessment developed by the nurse 
 who conducts the assessment together with the recipient or 
 responsible party.  The service plan shall include a description 
 of the covered home care services, frequency and duration of 
 services, and expected outcomes and goals.  The recipient and 
 the provider chosen by the recipient or responsible party must 
 be given a copy of the completed service plan within 30 calendar 
 days of the request for home care services by the recipient or 
 responsible party. 

    (m) "Skilled nurse visits" are provided in a recipient's 
 residence under a plan of care or service plan that specifies a 
 level of care which the nurse is qualified to provide.  These 
 services are: 

    (1) nursing services according to the written plan of care 
 or service plan and accepted standards of medical and nursing 
 practice in accordance with chapter 148; 

    (2) services which due to the recipient's medical condition 
 may only be safely and effectively provided by a registered 
 nurse or a licensed practical nurse; 

    (3) assessments performed only by a registered nurse; and 

    (4) teaching and training the recipient, the recipient's 
 family, or other caregivers requiring the skills of a registered 
 nurse or licensed practical nurse. 

    (n) "Telehomecare" means the use of telecommunications 
 technology by a home health care professional to deliver home 
 health care services, within the professional's scope of 
 practice, to a patient located at a site other than the site 
 where the practitioner is located. 

    Subd. 2.    Services covered.  Home care services 
 covered under this section include:  

    (1) nursing services under section 256B.0625, subdivision 
 6a; 

    (2) private duty nursing services under section 256B.0625, 
 subdivision 7; 

    (3) home health services under section 256B.0625, 
 subdivision 6a; 

    (4) personal care assistant services under section 
 256B.0625, subdivision 19a; 

    (5) supervision of personal care assistant services 
 provided by a qualified professional under section 256B.0625, 
 subdivision 19a; 

    (6) qualified professional of personal care assistant 
 services under the fiscal intermediary option as specified in 
 subdivision 10; 

    (7) face-to-face assessments by county public health nurses 
 for services under section 256B.0625, subdivision 19a; and 

    (8) service updates and review of temporary increases for 
 personal care assistant services by the county public health 
 nurse for services under section 256B.0625, subdivision 19a. 

    Subd. 3. Repealed, 1991 c 292 art 7 s 26 

    Subd. 4.    Personal care assistant services.  (a) The 
 personal care assistant services that are eligible for payment 
 are services and supports furnished to an individual, as needed, 
 to assist in accomplishing activities of daily living; 
 instrumental activities of daily living; health-related 
 functions through hands-on assistance, supervision, and cuing; 
 and redirection and intervention for behavior including 
 observation and monitoring.  

    (b) Payment for services will be made within the limits 
 approved using the prior authorized process established in 
 subdivision 5. 

    (c) The amount and type of services authorized shall be 
 based on an assessment of the recipient's needs in these areas: 

    (1) bowel and bladder care; 

    (2) skin care to maintain the health of the skin; 

    (3) repetitive maintenance range of motion, muscle 
 strengthening exercises, and other tasks specific to maintaining 
 a recipient's optimal level of function; 

    (4) respiratory assistance; 

    (5) transfers and ambulation; 

    (6) bathing, grooming, and hairwashing necessary for 
 personal hygiene; 

    (7) turning and positioning; 

    (8) assistance with furnishing medication that is 
 self-administered; 

    (9) application and maintenance of prosthetics and 
 orthotics; 

    (10) cleaning medical equipment; 

    (11) dressing or undressing; 

    (12) assistance with eating and meal preparation and 
 necessary grocery shopping; 

    (13) accompanying a recipient to obtain medical diagnosis 
 or treatment; 

    (14) assisting, monitoring, or prompting the recipient to 
 complete the services in clauses (1) to (13); 

    (15) redirection, monitoring, and observation that are 
 medically necessary and an integral part of completing the 
 personal care assistant services described in clauses (1) to 
 (14); 

    (16) redirection and intervention for behavior, including 
 observation and monitoring; 

    (17) interventions for seizure disorders, including 
 monitoring and observation if the recipient has had a seizure 
 that requires intervention within the past three months; 

    (18) tracheostomy suctioning using a clean procedure if the 
 procedure is properly delegated by a registered nurse.  Before 
 this procedure can be delegated to a personal care assistant, a 
 registered nurse must determine that the tracheostomy suctioning 
 can be accomplished utilizing a clean rather than a sterile 
 procedure and must ensure that the personal care assistant has 
 been taught the proper procedure; and 

    (19) incidental household services that are an integral 
 part of a personal care service described in clauses (1) to (18).

 For purposes of this subdivision, monitoring and observation 
 means watching for outward visible signs that are likely to 
 occur and for which there is a covered personal care service or 
 an appropriate personal care intervention.  For purposes of this 
 subdivision, a clean procedure refers to a procedure that 
 reduces the numbers of microorganisms or prevents or reduces the 
 transmission of microorganisms from one person or place to 
 another.  A clean procedure may be used beginning 14 days after 
 insertion. 

    (d) The personal care assistant services that are not 
 eligible for payment are the following:  

    (1) services not ordered by the physician; 

    (2) assessments by personal care assistant provider 
 organizations or by independently enrolled registered nurses; 

    (3) services that are not in the service plan; 

    (4) services provided by the recipient's spouse, legal 
 guardian for an adult or child recipient, or parent of a 
 recipient under age 18; 

    (5) services provided by a foster care provider of a 
 recipient who cannot direct the recipient's own care, unless 
 monitored by a county or state case manager under section 
 256B.0625, subdivision 19a; 

    (6) services provided by the residential or program license 
 holder in a residence for more than four persons; 

    (7) services that are the responsibility of a residential 
 or program license holder under the terms of a service agreement 
 and administrative rules; 

    (8) sterile procedures; 

    (9) injections of fluids into veins, muscles, or skin; 

    (10) services provided by parents of adult recipients, 
 adult children, or siblings of the recipient, unless these 
 relatives meet one of the following hardship criteria and the 
 commissioner waives this requirement: 

    (i) the relative resigns from a part-time or full-time job 
 to provide personal care for the recipient; 

    (ii) the relative goes from a full-time to a part-time job 
 with less compensation to provide personal care for the 
 recipient; 

    (iii) the relative takes a leave of absence without pay to 
 provide personal care for the recipient; 

    (iv) the relative incurs substantial expenses by providing 
 personal care for the recipient; or 

    (v) because of labor conditions, special language needs, or 
 intermittent hours of care needed, the relative is needed in 
 order to provide an adequate number of qualified personal care 
 assistants to meet the medical needs of the recipient; 

    (11) homemaker services that are not an integral part of a 
 personal care assistant services; 

    (12) home maintenance, or chore services; 

    (13) services not specified under paragraph (a); and 

    (14) services not authorized by the commissioner or the 
 commissioner's designee. 

    (e) The recipient or responsible party may choose to 
 supervise the personal care assistant or to have a qualified 
 professional, as defined in section 256B.0625, subdivision 19c, 
 provide the supervision.  As required under section 256B.0625, 
 subdivision 19c, the county public health nurse, as a part of 
 the assessment, will assist the recipient or responsible party 
 to identify the most appropriate person to provide supervision 
 of the personal care assistant.  Health-related delegated tasks 
 performed by the personal care assistant will be under the 
 supervision of a qualified professional or the direction of the 
 recipient's physician.  If the recipient has a qualified 
 professional, Minnesota Rules, part 9505.0335, subpart 4, 
 applies. 

    Subd. 5.    Limitation on payments.  Medical assistance 
 payments for home care services shall be limited according to 
 this subdivision.  

    (a)    Limits on services without prior authorization.  
 A recipient may receive the following home care services during 
 a calendar year: 

    (1) up to two face-to-face assessments to determine a 
 recipient's need for personal care assistant services; 

    (2) one service update done to determine a recipient's need 
 for personal care assistant services; and 

    (3) up to nine skilled nurse visits.  

    (b)    Prior authorization; exceptions.  All home care 
 services above the limits in paragraph (a) must receive the 
 commissioner's prior authorization, except when: 

    (1) the home care services were required to treat an 
 emergency medical condition that if not immediately treated 
 could cause a recipient serious physical or mental disability, 
 continuation of severe pain, or death.  The provider must 
 request retroactive authorization no later than five working 
 days after giving the initial service.  The provider must be 
 able to substantiate the emergency by documentation such as 
 reports, notes, and admission or discharge histories; 

    (2) the home care services were provided on or after the 
 date on which the recipient's eligibility began, but before the 
 date on which the recipient was notified that the case was 
 opened.  Authorization will be considered if the request is 
 submitted by the provider within 20 working days of the date the 
 recipient was notified that the case was opened; 

    (3) a third-party payor for home care services has denied 
 or adjusted a payment.  Authorization requests must be submitted 
 by the provider within 20 working days of the notice of denial 
 or adjustment.  A copy of the notice must be included with the 
 request; 

    (4) the commissioner has determined that a county or state 
 human services agency has made an error; or 

    (5) the professional nurse determines an immediate need for 
 up to 40 skilled nursing or home health aide visits per calendar 
 year and submits a request for authorization within 20 working 
 days of the initial service date, and medical assistance is 
 determined to be the appropriate payer. 

    (c)    Retroactive authorization.  A request for 
 retroactive authorization will be evaluated according to the 
 same criteria applied to prior authorization requests.  

    (d)    Assessment and service plan.  Assessments under 
 section 256B.0627, subdivision 1, paragraph (a), shall be 
 conducted initially, and at least annually thereafter, in person 
 with the recipient and result in a completed service plan using 
 forms specified by the commissioner.  Within 30 days of 
 recipient or responsible party request for home care services, 
 the assessment, the service plan, and other information 
 necessary to determine medical necessity such as diagnostic or 
 testing information, social or medical histories, and hospital 
 or facility discharge summaries shall be submitted to the 
 commissioner.  Notwithstanding the provisions of section 
 256B.0627, subdivision 12, the commissioner shall maximize 
 federal financial participation to pay for public health nurse 
 assessments for personal care services.  For personal care 
 assistant services: 

    (1) The amount and type of service authorized based upon 
 the assessment and service plan will follow the recipient if the 
 recipient chooses to change providers.  

    (2) If the recipient's medical need changes, the 
 recipient's provider may assess the need for a change in service 
 authorization and request the change from the county public 
 health nurse.  Within 30 days of the request, the public health 
 nurse will determine whether to request the change in services 
 based upon the provider assessment, or conduct a home visit to 
 assess the need and determine whether the change is appropriate. 

    (3) To continue to receive personal care assistant services 
 after the first year, the recipient or the responsible party, in 
 conjunction with the public health nurse, may complete a service 
 update on forms developed by the commissioner according to 
 criteria and procedures in subdivision 1.  

    (e)    Prior authorization.  The commissioner, or the 
 commissioner's designee, shall review the assessment, service 
 update, request for temporary services, service plan, and any 
 additional information that is submitted.  The commissioner 
 shall, within 30 days after receiving a complete request, 
 assessment, and service plan, authorize home care services as 
 follows:  

    (1)    Home health services.  All home health services 
 provided by a home health aide must be prior authorized by the 
 commissioner or the commissioner's designee.  Prior 
 authorization must be based on medical necessity and 
 cost-effectiveness when compared with other care options.  When 
 home health services are used in combination with personal care 
 and private duty nursing, the cost of all home care services 
 shall be considered for cost-effectiveness.  The commissioner 
 shall limit home health aide visits to no more than one visit 
 each per day.  The commissioner, or the commissioner's designee, 
 may authorize up to two skilled nurse visits per day. 

    (2)    Personal care assistant services.  (i) All 
 personal care assistant services and supervision by a qualified 
 professional, if requested by the recipient, must be prior 
 authorized by the commissioner or the commissioner's designee 
 except for the assessments established in paragraph (a).  The 
 amount of personal care assistant services authorized must be 
 based on the recipient's home care rating.  A child may not be 
 found to be dependent in an activity of daily living if because 
 of the child's age an adult would either perform the activity 
 for the child or assist the child with the activity and the 
 amount of assistance needed is similar to the assistance 
 appropriate for a typical child of the same age.  Based on 
 medical necessity, the commissioner may authorize: 

    (A) up to two times the average number of direct care hours 
 provided in nursing facilities for the recipient's comparable 
 case mix level; or 

    (B) up to three times the average number of direct care 
 hours provided in nursing facilities for recipients who have 
 complex medical needs or are dependent in at least seven 
 activities of daily living and need physical assistance with 
 eating or have a neurological diagnosis; or 

    (C) up to 60 percent of the average reimbursement rate, as 
 of July 1, 1991, for care provided in a regional treatment 
 center for recipients who have Level I behavior, plus any 
 inflation adjustment as provided by the legislature for personal 
 care service; or 

    (D) up to the amount the commissioner would pay, as of July 
 1, 1991, plus any inflation adjustment provided for home care 
 services, for care provided in a regional treatment center for 
 recipients referred to the commissioner by a regional treatment 
 center preadmission evaluation team.  For purposes of this 
 clause, home care services means all services provided in the 
 home or community that would be included in the payment to a 
 regional treatment center; or 

    (E) up to the amount medical assistance would reimburse for 
 facility care for recipients referred to the commissioner by a 
 preadmission screening team established under section 256B.0911 
 or 256B.092; and 

    (F) a reasonable amount of time for the provision of 
 supervision by a qualified professional of personal care 
 assistant services, if a qualified professional is requested by 
 the recipient or responsible party.  

    (ii) The number of direct care hours shall be determined 
 according to the annual cost report submitted to the department 
 by nursing facilities.  The average number of direct care hours, 
 as established by May 1, 1992, shall be calculated and 
 incorporated into the home care limits on July 1, 1992.  These 
 limits shall be calculated to the nearest quarter hour. 

    (iii) The home care rating shall be determined by the 
 commissioner or the commissioner's designee based on information 
 submitted to the commissioner by the county public health nurse 
 on forms specified by the commissioner.  The home care rating 
 shall be a combination of current assessment tools developed 
 under sections 256B.0911 and 256B.501 with an addition for 
 seizure activity that will assess the frequency and severity of 
 seizure activity and with adjustments, additions, and 
 clarifications that are necessary to reflect the needs and 
 conditions of recipients who need home care including children 
 and adults under 65 years of age.  The commissioner shall 
 establish these forms and protocols under this section and shall 
 use an advisory group, including representatives of recipients, 
 providers, and counties, for consultation in establishing and 
 revising the forms and protocols. 

    (iv) A recipient shall qualify as having complex medical 
 needs if the care required is difficult to perform and because 
 of recipient's medical condition requires more time than 
 community-based standards allow or requires more skill than 
 would ordinarily be required and the recipient needs or has one 
 or more of the following: 

    (A) daily tube feedings; 

    (B) daily parenteral therapy; 

    (C) wound or decubiti care; 

    (D) postural drainage, percussion, nebulizer treatments, 
 suctioning, tracheotomy care, oxygen, mechanical ventilation; 

    (E) catheterization; 

    (F) ostomy care; 

    (G) quadriplegia; or 

    (H) other comparable medical conditions or treatments the 
 commissioner determines would otherwise require institutional 
 care.  

    (v) A recipient shall qualify as having Level I behavior if 
 there is reasonable supporting evidence that the recipient 
 exhibits, or that without supervision, observation, or 
 redirection would exhibit, one or more of the following 
 behaviors that cause, or have the potential to cause: 

    (A) injury to the recipient's own body; 

    (B) physical injury to other people; or 

    (C) destruction of property. 

    (vi) Time authorized for personal care relating to Level I 
 behavior in subclause (v), items (A) to (C), shall be based on 
 the predictability, frequency, and amount of intervention 
 required. 

    (vii) A recipient shall qualify as having Level II behavior 
 if the recipient exhibits on a daily basis one or more of the 
 following behaviors that interfere with the completion of 
 personal care assistant services under subdivision 4, paragraph 
 (a): 

    (A) unusual or repetitive habits; 

    (B) withdrawn behavior; or 

    (C) offensive behavior. 

    (viii) A recipient with a home care rating of Level II 
 behavior in subclause (vii), items (A) to (C), shall be rated as 
 comparable to a recipient with complex medical needs under 
 subclause (iv).  If a recipient has both complex medical needs 
 and Level II behavior, the home care rating shall be the next 
 complex category up to the maximum rating under subclause (i), 
 item (B). 

    (3)    Private duty nursing services.  All private duty 
 nursing services shall be prior authorized by the commissioner 
 or the commissioner's designee.  Prior authorization for private 
 duty nursing services shall be based on medical necessity and 
 cost-effectiveness when compared with alternative care options.  
 The commissioner may authorize medically necessary private duty 
 nursing services in quarter-hour units when: 

    (i) the recipient requires more individual and continuous 
 care than can be provided during a nurse visit; or 

    (ii) the cares are outside of the scope of services that 
 can be provided by a home health aide or personal care assistant.

    The commissioner may authorize: 

    (A) up to two times the average amount of direct care hours 
 provided in nursing facilities statewide for case mix 
 classification "K" as established by the annual cost report 
 submitted to the department by nursing facilities in May 1992; 

    (B) private duty nursing in combination with other home 
 care services up to the total cost allowed under clause (2); 

    (C) up to 16 hours per day if the recipient requires more 
 nursing than the maximum number of direct care hours as 
 established in item (A) and the recipient meets the hospital 
 admission criteria established under Minnesota Rules, parts 
 9505.0501 to 9505.0540.  

    The commissioner may authorize up to 16 hours per day of 
 medically necessary private duty nursing services or up to 24 
 hours per day of medically necessary private duty nursing 
 services until such time as the commissioner is able to make a 
 determination of eligibility for recipients who are 
 cooperatively applying for home care services under the 
 community alternative care program developed under section 
 256B.49, or until it is determined by the appropriate regulatory 
 agency that a health benefit plan is or is not required to pay 
 for appropriate medically necessary health care services.  
 Recipients or their representatives must cooperatively assist 
 the commissioner in obtaining this determination.  Recipients 
 who are eligible for the community alternative care program may 
 not receive more hours of nursing under this section than would 
 otherwise be authorized under section 256B.49.  

    (4)    Ventilator-dependent recipients.  If the 
 recipient is ventilator-dependent, the monthly medical 
 assistance authorization for home care services shall not exceed 
 what the commissioner would pay for care at the highest cost 
 hospital designated as a long-term hospital under the Medicare 
 program.  For purposes of this clause, home care services means 
 all services provided in the home that would be included in the 
 payment for care at the long-term hospital.  
 "Ventilator-dependent" means an individual who receives 
 mechanical ventilation for life support at least six hours per 
 day and is expected to be or has been dependent for at least 30 
 consecutive days.  

    (f)    Prior authorization; time limits.  The 
 commissioner or the commissioner's designee shall determine the 
 time period for which a prior authorization shall be effective.  
 If the recipient continues to require home care services beyond 
 the duration of the prior authorization, the home care provider 
 must request a new prior authorization.  Under no circumstances, 
 other than the exceptions in paragraph (b), shall a prior 
 authorization be valid prior to the date the commissioner 
 receives the request or for more than 12 months.  A recipient 
 who appeals a reduction in previously authorized home care 
 services may continue previously authorized services, other than 
 temporary services under paragraph (h), pending an appeal under 
 section 256.045.  The commissioner must provide a detailed 
 explanation of why the authorized services are reduced in amount 
 from those requested by the home care provider.  

    (g)    Approval of home care services.  The commissioner 
 or the commissioner's designee shall determine the medical 
 necessity of home care services, the level of caregiver 
 according to subdivision 2, and the institutional comparison 
 according to this subdivision, the cost-effectiveness of 
 services, and the amount, scope, and duration of home care 
 services reimbursable by medical assistance, based on the 
 assessment, primary payer coverage determination information as 
 required, the service plan, the recipient's age, the cost of 
 services, the recipient's medical condition, and diagnosis or 
 disability.  The commissioner may publish additional criteria 
 for determining medical necessity according to section 256B.04. 

    (h)    Prior authorization requests; temporary services. 
  The agency nurse, the independently enrolled private duty 
 nurse, or county public health nurse may request a temporary 
 authorization for home care services by telephone.  The 
 commissioner may approve a temporary level of home care services 
 based on the assessment, and service or care plan information, 
 and primary payer coverage determination information as required.
 Authorization for a temporary level of home care services 
 including nurse supervision is limited to the time specified by 
 the commissioner, but shall not exceed 45 days, unless extended 
 because the county public health nurse has not completed the 
 required assessment and service plan, or the commissioner's 
 determination has not been made.  The level of services 
 authorized under this provision shall have no bearing on a 
 future prior authorization. 

    (i)    Prior authorization required in foster care 
 setting.  Home care services provided in an adult or child 
 foster care setting must receive prior authorization by the 
 department according to the limits established in paragraph (a). 

    The commissioner may not authorize: 

    (1) home care services that are the responsibility of the 
 foster care provider under the terms of the foster care 
 placement agreement and administrative rules; 

    (2) personal care assistant services when the foster care 
 license holder is also the personal care provider or personal 
 care assistant unless the recipient can direct the recipient's 
 own care, or case management is provided as required in section 
 256B.0625, subdivision 19a; 

    (3) personal care assistant services when the responsible 
 party is an employee of, or under contract with, or has any 
 direct or indirect financial relationship with the personal care 
 provider or personal care assistant, unless case management is 
 provided as required in section 256B.0625, subdivision 19a; or 

    (4) personal care assistant and private duty nursing 
 services when the number of foster care residents is greater 
 than four unless the county responsible for the recipient's 
 foster placement made the placement prior to April 1, 1992, 
 requests that personal care assistant and private duty nursing 
 services be provided, and case management is provided as 
 required in section 256B.0625, subdivision 19a. 

    Subd. 6.    Recovery of excessive payments.  The 
 commissioner shall seek monetary recovery from providers of 
 payments made for services which exceed the limits established 
 in this section.  This subdivision does not apply to services 
 provided to a recipient at the previously authorized level 
 pending an appeal under section 256.045, subdivision 10. 

    Subd. 7.    Noncovered home care services.  The 
 following home care services are not eligible for payment under 
 medical assistance:  

    (1) skilled nurse visits for the sole purpose of 
 supervision of the home health aide; 

    (2) a skilled nursing visit: 

    (i) only for the purpose of monitoring medication 
 compliance with an established medication program for a 
 recipient; or 

    (ii) to administer or assist with medication 
 administration, including injections, prefilling syringes for 
 injections, or oral medication set-up of an adult recipient, 
 when as determined and documented by the registered nurse, the 
 need can be met by an available pharmacy or the recipient is 
 physically and mentally able to self-administer or prefill a 
 medication; 

    (3) home care services to a recipient who is eligible for 
 covered services under the Medicare program or any other 
 insurance held by the recipient; 

    (4) services to other members of the recipient's household; 

    (5) a visit made by a skilled nurse solely to train other 
 home health agency workers; 

    (6) any home care service included in the daily rate of the 
 community-based residential facility where the recipient is 
 residing; 

    (7) nursing and rehabilitation therapy services that are 
 reasonably accessible to a recipient outside the recipient's 
 place of residence, excluding the assessment, counseling and 
 education, and personal assistant care; 

    (8) any home health agency service, excluding personal care 
 assistant services and private duty nursing services, which are 
 performed in a place other than the recipient's residence; and 

    (9) Medicare evaluation or administrative nursing visits on 
 dual-eligible recipients that do not qualify for Medicare visit 
 billing. 

    Subd. 8.    Shared personal care assistant services.  (a)
 Medical assistance payments for shared personal care assistance 
 services shall be limited according to this subdivision. 

    (b) Recipients of personal care assistant services may 
 share staff and the commissioner shall provide a rate system for 
 shared personal care assistant services.  For two persons 
 sharing services, the rate paid to a provider shall not exceed 
 1-1/2 times the rate paid for serving a single individual, and 
 for three persons sharing services, the rate paid to a provider 
 shall not exceed twice the rate paid for serving a single 
 individual.  These rates apply only to situations in which all 
 recipients were present and received shared services on the date 
 for which the service is billed.  No more than three persons may 
 receive shared services from a personal care assistant in a 
 single setting. 

    (c) Shared service is the provision of personal care 
 assistant services by a personal care assistant to two or three 
 recipients at the same time and in the same setting.  For the 
 purposes of this subdivision, "setting" means: 

    (1) the home or foster care home of one of the individual 
 recipients; or 

    (2) a child care program in which all recipients served by 
 one personal care assistant are participating, which is licensed 
 under chapter 245A or operated by a local school district or 
 private school; or 

    (3) outside the home or foster care home of one of the 
 recipients when normal life activities take the recipients 
 outside the home.  

    The provisions of this subdivision do not apply when a 
 personal care assistant is caring for multiple recipients in 
 more than one setting. 

    (d) The recipient or the recipient's responsible party, in 
 conjunction with the county public health nurse, shall determine:

    (1) whether shared personal care assistant services is an 
 appropriate option based on the individual needs and preferences 
 of the recipient; and 

    (2) the amount of shared services allocated as part of the 
 overall authorization of personal care assistant services. 

    The recipient or the responsible party, in conjunction with 
 the supervising qualified professional, if a qualified 
 professional is requested by any one of the recipients or 
 responsible parties, shall arrange the setting and grouping of 
 shared services based on the individual needs and preferences of 
 the recipients.  Decisions on the selection of recipients to 
 share services must be based on the ages of the recipients, 
 compatibility, and coordination of their care needs. 

    (e) The following items must be considered by the recipient 
 or the responsible party and the supervising qualified 
 professional, if a qualified professional has been requested by 
 any one of the recipients or responsible parties, and documented 
 in the recipient's health service record: 

    (1) the additional qualifications needed by the personal 
 care assistant to provide care to several recipients in the same 
 setting; 

    (2) the additional training and supervision needed by the 
 personal care assistant to ensure that the needs of the 
 recipient are met appropriately and safely.  The provider must 
 provide on-site supervision by a qualified professional within 
 the first 14 days of shared services, and monthly thereafter, if 
 supervision by a qualified provider has been requested by any 
 one of the recipients or responsible parties; 

    (3) the setting in which the shared services will be 
 provided; 

    (4) the ongoing monitoring and evaluation of the 
 effectiveness and appropriateness of the service and process 
 used to make changes in service or setting; and 

    (5) a contingency plan which accounts for absence of the 
 recipient in a shared services setting due to illness or other 
 circumstances and staffing contingencies. 

    (f) The provider must offer the recipient or the 
 responsible party the option of shared or one-on-one personal 
 care assistant services.  The recipient or the responsible party 
 can withdraw from participating in a shared services arrangement 
 at any time. 

    (g) In addition to documentation requirements under 
 Minnesota Rules, part 9505.2175, a personal care provider must 
 meet documentation requirements for shared personal care 
 assistant services and must document the following in the health 
 service record for each individual recipient sharing services: 

    (1) permission by the recipient or the recipient's 
 responsible party, if any, for the maximum number of shared 
 services hours per week chosen by the recipient; 

    (2) permission by the recipient or the recipient's 
 responsible party, if any, for personal care assistant services 
 provided outside the recipient's residence; 

    (3) permission by the recipient or the recipient's 
 responsible party, if any, for others to receive shared services 
 in the recipient's residence; 

    (4) revocation by the recipient or the recipient's 
 responsible party, if any, of the shared service authorization, 
 or the shared service to be provided to others in the 
 recipient's residence, or the shared service to be provided 
 outside the recipient's residence; 

    (5) supervision of the shared personal care assistant 
 services by the qualified professional, if a qualified 
 professional is requested by one of the recipients or 
 responsible parties, including the date, time of day, number of 
 hours spent supervising the provision of shared services, 
 whether the supervision was face-to-face or another method of 
 supervision, changes in the recipient's condition, shared 
 services scheduling issues and recommendations; 

    (6) documentation by the qualified professional, if a 
 qualified professional is requested by one of the recipients or 
 responsible parties, of telephone calls or other discussions 
 with the personal care assistant regarding services being 
 provided to the recipient who has requested the supervision; and 

    (7) daily documentation of the shared services provided by 
 each identified personal care assistant including: 

    (i) the names of each recipient receiving shared services 
 together; 

    (ii) the setting for the shared services, including the 
 starting and ending times that the recipient received shared 
 services; and 

    (iii) notes by the personal care assistant regarding 
 changes in the recipient's condition, problems that may arise 
 from the sharing of services, scheduling issues, care issues, 
 and other notes as required by the qualified professional, if a 
 qualified professional is requested by one of the recipients or 
 responsible parties. 

    (h) Unless otherwise provided in this subdivision, all 
 other statutory and regulatory provisions relating to personal 
 care assistant services apply to shared services. 

    (i) In the event that supervision by a qualified 
 professional has been requested by one or more recipients, but 
 not by all of the recipients, the supervision duties of the 
 qualified professional shall be limited to only those recipients 
 who have requested the supervision. 

    Nothing in this subdivision shall be construed to reduce 
 the total number of hours authorized for an individual recipient.

    Subd. 9.    Flexible use of personal care assistant hours. 
  (a) The commissioner may allow for the flexible use of 
 personal care assistant hours.  "Flexible use" means the 
 scheduled use of authorized hours of personal care assistant 
 services, which vary within the length of the service 
 authorization in order to more effectively meet the needs and 
 schedule of the recipient.  Recipients may use their approved 
 hours flexibly within the service authorization period for 
 medically necessary covered services specified in the assessment 
 required in subdivision 1.  The flexible use of authorized hours 
 does not increase the total amount of authorized hours available 
 to a recipient as determined under subdivision 5.  The 
 commissioner shall not authorize additional personal care 
 assistant services to supplement a service authorization that is 
 exhausted before the end date under a flexible service use plan, 
 unless the county public health nurse determines a change in 
 condition and a need for increased services is established. 

    (b) The recipient or responsible party, together with the 
 county public health nurse, shall determine whether flexible use 
 is an appropriate option based on the needs and preferences of 
 the recipient or responsible party, and, if appropriate, must 
 ensure that the allocation of hours covers the ongoing needs of 
 the recipient over the entire service authorization period.  As 
 part of the assessment and service planning process, the 
 recipient or responsible party must work with the county public 
 health nurse to develop a written month-to-month plan of the 
 projected use of personal care assistant services that is part 
 of the service plan and ensures that the: 

    (1) health and safety needs of the recipient will be met; 

    (2) total annual authorization will not exceed before the 
 end date; and 

    (3) how actual use of hours will be monitored.  

    (c) If the actual use of personal care assistant service 
 varies significantly from the use projected in the plan, the 
 written plan must be promptly updated by the recipient or 
 responsible party and the county public health nurse. 

    (d) The recipient or responsible party, together with the 
 provider, must work to monitor and document the use of 
 authorized hours and ensure that a recipient is able to manage 
 services effectively throughout the authorized period.  The 
 provider must ensure that the month-to-month plan is 
 incorporated into the care plan.  Upon request of the recipient 
 or responsible party, the provider must furnish regular updates 
 to the recipient or responsible party on the amount of personal 
 care assistant services used.  

    (e) The recipient or responsible party may revoke the 
 authorization for flexible use of hours by notifying the 
 provider and county public health nurse in writing. 

    (f) If the requirements in paragraphs (a) to (e) have not 
 substantially been met, the commissioner shall deny, revoke, or 
 suspend the authorization to use authorized hours flexibly.  The 
 recipient or responsible party may appeal the commissioner's 
 action according to section 256.045.  The denial, revocation, or 
 suspension to use the flexible hours option shall not affect the 
 recipient's authorized level of personal care assistant services 
 as determined under subdivision 5. 

    Subd. 10.    Fiscal intermediary option available for 
 personal care assistant services.  (a) The commissioner may 
 allow a recipient of personal care assistant services to use a 
 fiscal intermediary to assist the recipient in paying and 
 accounting for medically necessary covered personal care 
 assistant services authorized in subdivision 4 and within the 
 payment parameters of subdivision 5.  Unless otherwise provided 
 in this subdivision, all other statutory and regulatory 
 provisions relating to personal care assistant services apply to 
 a recipient using the fiscal intermediary option. 

    (b) The recipient or responsible party shall: 

    (1) recruit, hire, and terminate a qualified professional, 
 if a qualified professional is requested by the recipient or 
 responsible party; 

    (2) verify and document the credentials of the qualified 
 professional, if a qualified professional is requested by the 
 recipient or responsible party; 

    (3) develop a service plan based on physician orders and 
 public health nurse assessment with the assistance of a 
 qualified professional, if a qualified professional is requested 
 by the recipient or responsible party, that addresses the health 
 and safety of the recipient; 

    (4) recruit, hire, and terminate the personal care 
 assistant; 

    (5) orient and train the personal care assistant with 
 assistance as needed from the qualified professional; 

    (6) supervise and evaluate the personal care assistant with 
 assistance as needed from the recipient's physician or the 
 qualified professional; 

    (7) monitor and verify in writing and report to the fiscal 
 intermediary the number of hours worked by the personal care 
 assistant and the qualified professional; and 

    (8) enter into a written agreement, as specified in 
 paragraph (f). 

    (c) The duties of the fiscal intermediary shall be to: 

    (1) bill the medical assistance program for personal care 
 assistant and qualified professional services; 

    (2) request and secure background checks on personal care 
 assistants and qualified professionals according to section 
 245A.04; 

    (3) pay the personal care assistant and qualified 
 professional based on actual hours of services provided; 

    (4) withhold and pay all applicable federal and state 
 taxes; 

    (5) verify and keep records of hours worked by the personal 
 care assistant and qualified professional; 

    (6) make the arrangements and pay unemployment insurance, 
 taxes, workers' compensation, liability insurance, and other 
 benefits, if any; 

    (7) enroll in the medical assistance program as a fiscal 
 intermediary; and 

    (8) enter into a written agreement as specified in 
 paragraph (f) before services are provided. 

    (d) The fiscal intermediary: 

    (1) may not be related to the recipient, qualified 
 professional, or the personal care assistant; 

    (2) must ensure arm's-length transactions with the 
 recipient and personal care assistant; and 

    (3) shall be considered a joint employer of the personal 
 care assistant and qualified professional to the extent 
 specified in this section. 

    The fiscal intermediary or owners of the entity that 
 provides fiscal intermediary services under this subdivision 
 must pass a criminal background check as required in section 
 256B.0627, subdivision 1, paragraph (e). 

    (e) If the recipient or responsible party requests a 
 qualified professional, the qualified professional providing 
 assistance to the recipient shall meet the qualifications 
 specified in section 256B.0625, subdivision 19c.  The qualified 
 professional shall assist the recipient in developing and 
 revising a plan to meet the recipient's needs, as assessed by 
 the public health nurse.  In performing this function, the 
 qualified professional must visit the recipient in the 
 recipient's home at least once annually.  The qualified 
 professional must report any suspected abuse, neglect, or 
 financial exploitation of the recipient to the appropriate 
 authorities.  

    (f) The fiscal intermediary, recipient or responsible 
 party, personal care assistant, and qualified professional shall 
 enter into a written agreement before services are started.  The 
 agreement shall include: 

    (1) the duties of the recipient, qualified professional, 
 personal care assistant, and fiscal agent based on paragraphs 
 (a) to (e); 

    (2) the salary and benefits for the personal care assistant 
 and the qualified professional; 

    (3) the administrative fee of the fiscal intermediary and 
 services paid for with that fee, including background check 
 fees; 

    (4) procedures to respond to billing or payment complaints; 
 and 

    (5) procedures for hiring and terminating the personal care 
 assistant and the qualified professional. 

    (g) The rates paid for personal care assistant services, 
 shared care services, qualified professional services, and 
 fiscal intermediary services under this subdivision shall be the 
 same rates paid for personal care assistant services and 
 qualified professional services under subdivision 2 
 respectively.  Except for the administrative fee of the fiscal 
 intermediary specified in paragraph (f), the remainder of the 
 rates paid to the fiscal intermediary must be used to pay for 
 the salary and benefits for the personal care assistant or the 
 qualified professional. 

    (h) As part of the assessment defined in subdivision 1, the 
 following conditions must be met to use or continue use of a 
 fiscal intermediary: 

    (1) the recipient must be able to direct the recipient's 
 own care, or the responsible party for the recipient must be 
 readily available to direct the care of the personal care 
 assistant; 

    (2) the recipient or responsible party must be 
 knowledgeable of the health care needs of the recipient and be 
 able to effectively communicate those needs; 

    (3) a face-to-face assessment must be conducted by the 
 local county public health nurse at least annually, or when 
 there is a significant change in the recipient's condition or 
 change in the need for personal care assistant services; 

    (4) recipients who choose to use the shared care option as 
 specified in subdivision 8 must utilize the same fiscal 
 intermediary; and 

    (5) parties must be in compliance with the written 
 agreement specified in paragraph (f). 

    (i) The commissioner shall deny, revoke, or suspend the 
 authorization to use the fiscal intermediary option if: 

    (1) it has been determined by the qualified professional or 
 local county public health nurse that the use of this option 
 jeopardizes the recipient's health and safety; 

    (2) the parties have failed to comply with the written 
 agreement specified in paragraph (f); or 

    (3) the use of the option has led to abusive or fraudulent 
 billing for personal care assistant services.  

    The recipient or responsible party may appeal the 
 commissioner's action according to section 256.045.  The denial, 
 revocation, or suspension to use the fiscal intermediary option 
 shall not affect the recipient's authorized level of personal 
 care assistant services as determined in subdivision 5. 

    Subd. 11.    Shared private duty nursing care option.  
 (a) Medical assistance payments for shared private duty nursing 
 services by a private duty nurse shall be limited according to 
 this subdivision.  For the purposes of this section, "private 
 duty nursing agency" means an agency licensed under chapter 144A 
 to provide private duty nursing services. 

    (b) Recipients of private duty nursing services may share 
 nursing staff and the commissioner shall provide a rate 
 methodology for shared private duty nursing.  For two persons 
 sharing nursing care, the rate paid to a provider shall not 
 exceed 1.5 times the regular private duty nursing rates paid for 
 serving a single individual by a registered nurse or licensed 
 practical nurse.  These rates apply only to situations in which 
 both recipients are present and receive shared private duty 
 nursing care on the date for which the service is billed.  No 
 more than two persons may receive shared private duty nursing 
 services from a private duty nurse in a single setting. 

    (c) Shared private duty nursing care is the provision of 
 nursing services by a private duty nurse to two recipients at 
 the same time and in the same setting.  For the purposes of this 
 subdivision, "setting" means: 

    (1) the home or foster care home of one of the individual 
 recipients; or 

    (2) a child care program licensed under chapter 245A or 
 operated by a local school district or private school; or 

    (3) an adult day care service licensed under chapter 245A; 
 or 

    (4) outside the home or foster care home of one of the 
 recipients when normal life activities take the recipients 
 outside the home.  

    This subdivision does not apply when a private duty nurse 
 is caring for multiple recipients in more than one setting. 

    (d) The recipient or the recipient's legal representative, 
 and the recipient's physician, in conjunction with the home 
 health care agency, shall determine: 

    (1) whether shared private duty nursing care is an 
 appropriate option based on the individual needs and preferences 
 of the recipient; and 

    (2) the amount of shared private duty nursing services 
 authorized as part of the overall authorization of nursing 
 services. 

    (e) The recipient or the recipient's legal representative, 
 in conjunction with the private duty nursing agency, shall 
 approve the setting, grouping, and arrangement of shared private 
 duty nursing care based on the individual needs and preferences 
 of the recipients.  Decisions on the selection of recipients to 
 share services must be based on the ages of the recipients, 
 compatibility, and coordination of their care needs. 

    (f) The following items must be considered by the recipient 
 or the recipient's legal representative and the private duty 
 nursing agency, and documented in the recipient's health service 
 record: 

    (1) the additional training needed by the private duty 
 nurse to provide care to two recipients in the same setting and 
 to ensure that the needs of the recipients are met appropriately 
 and safely; 

    (2) the setting in which the shared private duty nursing 
 care will be provided; 

    (3) the ongoing monitoring and evaluation of the 
 effectiveness and appropriateness of the service and process 
 used to make changes in service or setting; 

    (4) a contingency plan which accounts for absence of the 
 recipient in a shared private duty nursing setting due to 
 illness or other circumstances; 

    (5) staffing backup contingencies in the event of employee 
 illness or absence; and 

    (6) arrangements for additional assistance to respond to 
 urgent or emergency care needs of the recipients. 

    (g) The provider must offer the recipient or responsible 
 party the option of shared or one-on-one private duty nursing 
 services.  The recipient or responsible party can withdraw from 
 participating in a shared service arrangement at any time. 

    (h) The private duty nursing agency must document the 
 following in the health service record for each individual 
 recipient sharing private duty nursing care: 

    (1) permission by the recipient or the recipient's legal 
 representative for the maximum number of shared nursing care 
 hours per week chosen by the recipient; 

    (2) permission by the recipient or the recipient's legal 
 representative for shared private duty nursing services provided 
 outside the recipient's residence; 

    (3) permission by the recipient or the recipient's legal 
 representative for others to receive shared private duty nursing 
 services in the recipient's residence; 

    (4) revocation by the recipient or the recipient's legal 
 representative of the shared private duty nursing care 
 authorization, or the shared care to be provided to others in 
 the recipient's residence, or the shared private duty nursing 
 services to be provided outside the recipient's residence; and 

    (5) daily documentation of the shared private duty nursing 
 services provided by each identified private duty nurse, 
 including: 

    (i) the names of each recipient receiving shared private 
 duty nursing services together; 

    (ii) the setting for the shared services, including the 
 starting and ending times that the recipient received shared 
 private duty nursing care; and 

    (iii) notes by the private duty nurse regarding changes in 
 the recipient's condition, problems that may arise from the 
 sharing of private duty nursing services, and scheduling and 
 care issues. 

    (i) Unless otherwise provided in this subdivision, all 
 other statutory and regulatory provisions relating to private 
 duty nursing services apply to shared private duty nursing 
 services. 

    Nothing in this subdivision shall be construed to reduce 
 the total number of private duty nursing hours authorized for an 
 individual recipient under subdivision 5. 

    Subd. 12.    Public health nurse assessment rate.  (a) 
 The reimbursement rates for public health nurse visits that 
 relate to the provision of personal care services under this 
 section and section 256B.0625, subdivision 19a, are: 

    (i) $210.50 for a face-to-face assessment visit; 

    (ii) $105.25 for each service update; and 

    (iii) $105.25 for each request for a temporary service 
 increase. 

    (b) The rates specified in paragraph (a) must be adjusted 
 to reflect provider rate increases for personal care assistant 
 services that are approved by the legislature for the fiscal 
 year ending June 30, 2000, and subsequent fiscal years.  Any 
 requirements applied by the legislature to provider rate 
 increases for personal care assistant services also apply to 
 adjustments under this paragraph. 

    Subd. 13.    Consumer-directed home care demonstration 
 project.  (a) Upon the receipt of federal waiver authority, 
 the commissioner shall implement a consumer-directed home care 
 demonstration project.  The consumer-directed home care 
 demonstration project must demonstrate and evaluate the outcomes 
 of a consumer-directed service delivery alternative to improve 
 access, increase consumer control and accountability over 
 available resources, and enable the use of supports that are 
 more individualized and cost-effective for eligible medical 
 assistance recipients receiving certain medical assistance home 
 care services.  The consumer-directed home care demonstration 
 project will be administered locally by county agencies, tribal 
 governments, or administrative entities under contract with the 
 state in regions where counties choose not to provide this 
 service. 

    (b) Grant awards for persons who have been receiving 
 medical assistance covered personal care, home health aide, or 
 private duty nursing services for a period of 12 consecutive 
 months or more prior to enrollment in the consumer-directed home 
 care demonstration project will be established on a case-by-case 
 basis using historical service expenditure data.  An average 
 monthly expenditure for each continuing enrollee will be 
 calculated based on historical expenditures made on behalf of 
 the enrollee for personal care, home health aide, or private 
 duty nursing services during the 12 month period directly prior 
 to enrollment in the project.  The grant award will equal 90 
 percent of the average monthly expenditure. 

    (c) Grant awards for project enrollees who have been 
 receiving medical assistance covered personal care, home health 
 aide, or private duty nursing services for a period of less than 
 12 consecutive months prior to project enrollment will be 
 calculated on a case-by-case basis using the service 
 authorization in place at the time of enrollment.  The total 
 number of units of personal care, home health aide, or private 
 duty nursing services the enrollee has been authorized to 
 receive will be converted to the total cost of the authorized 
 services in a given month using the statewide average service 
 payment rates.  To determine an estimated monthly expenditure, 
 the total authorized monthly personal care, home health aide or 
 private duty nursing service costs will be reduced by a 
 percentage rate equivalent to the difference between the 
 statewide average service authorization and the statewide 
 average utilization rate for each of the services by medical 
 assistance eligibles during the most recent fiscal year for 
 which 12 months of data is available.  The grant award will 
 equal 90 percent of the estimated monthly expenditure. 

    (d) The state of Minnesota, county agencies, tribal 
 governments, or administrative entities under contract with the 
 state that participate in the implementation and administration 
 of the consumer-directed home care demonstration project, shall 
 not be liable for damages, injuries, or liabilities sustained 
 through the purchase of support by the individual, the 
 individual's family, legal representative, or the authorized 
 representative under this section with funds received through 
 the consumer-directed home care demonstration project.  
 Liabilities include but are not limited to:  workers' 
 compensation liability, the Federal Insurance Contributions Act 
 (FICA), or the Federal Unemployment Tax Act (FUTA). 

    (e) With federal approval, the commissioner may adjust 
 methodologies in paragraphs (b) and (c) to simplify program 
 administration, improve consistency between state and federal 
 programs, and maximize federal financial participation. 

    Subd. 14.    Telehomecare; skilled nurse visits.  
 Medical assistance covers skilled nurse visits according to 
 section 256B.0625, subdivision 6a, provided via telehomecare, 
 for services which do not require hands-on care between the home 
 care nurse and recipient.  The provision of telehomecare must be 
 made via live, two-way interactive audiovisual technology and 
 may be augmented by utilizing store-and-forward technologies.  
 Store-and-forward technology includes telehomecare services that 
 do not occur in real time via synchronous transmissions, and 
 that do not require a face-to-face encounter with the recipient 
 for all or any part of any such telehomecare visit.  
 Individually identifiable patient data obtained through 
 real-time or store-and-forward technology must be maintained as 
 health records according to section 144.335.  If the video is 
 used for research, training, or other purposes unrelated to the 
 care of the patient, the identity of the patient must be 
 concealed.  A communication between the home care nurse and 
 recipient that consists solely of a telephone conversation, 
 facsimile, electronic mail, or a consultation between two health 
 care practitioners, is not to be considered a telehomecare visit.
 Multiple daily skilled nurse visits provided via telehomecare 
 are allowed.  Coverage of telehomecare is limited to two visits 
 per day.  All skilled nurse visits provided via telehomecare 
 must be prior authorized by the commissioner or the 
 commissioner's designee and will be covered at the same 
 allowable rate as skilled nurse visits provided in-person. 

    Subd. 15.    Therapies through home health agencies.  (a)
   Physical therapy.  Medical assistance covers physical 
 therapy and related services, including specialized maintenance 
 therapy.  Services provided by a physical therapy assistant 
 shall be reimbursed at the same rate as services performed by a 
 physical therapist when the services of the physical therapy 
 assistant are provided under the direction of a physical 
 therapist who is on the premises.  Services provided by a 
 physical therapy assistant that are provided under the direction 
 of a physical therapist who is not on the premises shall be 
 reimbursed at 65 percent of the physical therapist rate.  
 Direction of the physical therapy assistant must be provided by 
 the physical therapist as described in Minnesota Rules, part 
 9505.0390, subpart 1, item B.  The physical therapist and 
 physical therapist assistant may not both bill for services 
 provided to a recipient on the same day. 

    (b)    Occupational therapy.  Medical assistance covers 
 occupational therapy and related services, including specialized 
 maintenance therapy.  Services provided by an occupational 
 therapy assistant shall be reimbursed at the same rate as 
 services performed by an occupational therapist when the 
 services of the occupational therapy assistant are provided 
 under the direction of the occupational therapist who is on the 
 premises.  Services provided by an occupational therapy 
 assistant under the direction of an occupational therapist who 
 is not on the premises shall be reimbursed at 65 percent of the 
 occupational therapist rate.  Direction of the occupational 
 therapy assistant must be provided by the occupational therapist 
 as described in Minnesota Rules, part 9505.0390, subpart 1, item 
 B.  The occupational therapist and occupational therapist 
 assistant may not both bill for services provided to a recipient 
 on the same day. 

    Subd. 16.    Hardship criteria; private duty nursing.  
 (a) Payment is allowed for extraordinary services that require 
 specialized nursing skills and are provided by parents of minor 
 children, spouses, and legal guardians who are providing private 
 duty nursing care under the following conditions: 

    (1) the provision of these services is not legally required 
 of the parents, spouses, or legal guardians; 

    (2) the services are necessary to prevent hospitalization 
 of the recipient; and 

    (3) the recipient is eligible for state plan home care or a 
 home and community-based waiver and one of the following 
 hardship criteria are met: 

    (i) the parent, spouse, or legal guardian resigns from a 
 part-time or full-time job to provide nursing care for the 
 recipient; or 

    (ii) the parent, spouse, or legal guardian goes from a 
 full-time to a part-time job with less compensation to provide 
 nursing care for the recipient; or 

    (iii) the parent, spouse, or legal guardian takes a leave 
 of absence without pay to provide nursing care for the 
 recipient; or 

    (iv) because of labor conditions, special language needs, 
 or intermittent hours of care needed, the parent, spouse, or 
 legal guardian is needed in order to provide adequate private 
 duty nursing services to meet the medical needs of the recipient.

    (b) Private duty nursing may be provided by a parent, 
 spouse, or legal guardian who is a nurse licensed in Minnesota.  
 Private duty nursing services provided by a parent, spouse, or 
 legal guardian cannot be used in lieu of nursing services 
 covered and available under liable third-party payors, including 
 Medicare.  The private duty nursing provided by a parent, 
 spouse, or legal guardian must be included in the service plan.  
 Authorized skilled nursing services provided by the parent, 
 spouse, or legal guardian may not exceed 50 percent of the total 
 approved nursing hours, or eight hours per day, whichever is 
 less, up to a maximum of 40 hours per week.  Nothing in this 
 subdivision precludes the parent's, spouse's, or legal 
 guardian's obligation of assuming the nonreimbursed family 
 responsibilities of emergency backup caregiver and primary 
 caregiver. 

    (c) A parent or a spouse may not be paid to provide private 
 duty nursing care if the parent or spouse fails to pass a 
 criminal background check according to section 245A.04, or if it 
 has been determined by the home health agency, the case manager, 
 or the physician that the private duty nursing care provided by 
 the parent, spouse, or legal guardian is unsafe. 

    Subd. 17.    Quality assurance plan for personal care 
 assistant services.  The commissioner shall establish a 
 quality assurance plan for personal care assistant services that 
 includes: 

    (1) performance-based provider agreements; 

    (2) meaningful consumer input, which may include consumer 
 surveys, that measure the extent to which participants receive 
 the services and supports described in the individual plan and 
 participant satisfaction with such services and supports; 

    (3) ongoing monitoring of the health and well-being of 
 consumers; and 

    (4) an ongoing public process for development, 
 implementation, and review of the quality assurance plan.  

    HIST: 1986 c 444; 1990 c 568 art 3 s 51; 1991 c 292 art 7 s 
 12,25; 1992 c 391 s 3-6; 1992 c 464 art 2 s 1; 1992 c 513 art 7 
 s 50; 1Sp1993 c 1 art 5 s 51-53; 1995 c 207 art 6 s 52-55; 1996 
 c 451 art 5 s 17-20; 1997 c 203 art 4 s 28,29; 3Sp1997 c 3 s 9; 
 1998 c 407 art 4 s 29-31; 1999 c 245 art 4 s 50-58; 2000 c 474 s 
 8-11; 1Sp2001 c 9 art 3 s 29-41; 2002 c 375 art 2 s 17; 2002 c 
 379 art 1 s 113 

     256B.0628 Prior authorization and review of home care 
  services. 

    Subdivision 1.    State coordination.  The commissioner 
 shall supervise the coordination of the prior authorization and 
 review of home care services that are reimbursed by medical 
 assistance. 

    Subd. 2.    Duties.  (a) The commissioner may contract 
 with or employ qualified registered nurses and necessary support 
 staff, or contract with qualified agencies, to provide home care 
 prior authorization and review services for medical assistance 
 recipients who are receiving home care services. 

    (b) Reimbursement for the prior authorization function 
 shall be made through the medical assistance administrative 
 authority.  The state shall pay the nonfederal share.  The 
 functions will be to: 

    (1) assess the recipient's individual need for services 
 required to be cared for safely in the community; 

    (2) ensure that a service plan that meets the recipient's 
 needs is developed by the appropriate agency or individual; 

    (3) ensure cost-effectiveness of medical assistance home 
 care services; 

    (4) recommend the approval or denial of the use of medical 
 assistance funds to pay for home care services; 

    (5) reassess the recipient's need for and level of home 
 care services at a frequency determined by the commissioner; and 

    (6) conduct on-site assessments when determined necessary 
 by the commissioner and recommend changes to care plans that 
 will provide more efficient and appropriate home care. 

    (c) In addition, the commissioner or the commissioner's 
 designee may: 

    (1) review service plans and reimbursement data for 
 utilization of services that exceed community-based standards 
 for home care, inappropriate home care services, medical 
 necessity, home care services that do not meet quality of care 
 standards, or unauthorized services and make appropriate 
 referrals within the department or to other appropriate entities 
 based on the findings; 

    (2) assist the recipient in obtaining services necessary to 
 allow the recipient to remain safely in or return to the 
 community; 

    (3) coordinate home care services with other medical 
 assistance services under section 256B.0625; 

    (4) assist the recipient with problems related to the 
 provision of home care services; 

    (5) assure the quality of home care services; and 

    (6) assure that all liable third-party payers including 
 Medicare have been used prior to medical assistance for home 
 care services, including but not limited to, home health agency, 
 elected hospice benefit, waivered services, alternative care 
 program services, and personal care services. 

    (d) For the purposes of this section, "home care services"  
 means medical assistance services defined under section 
 256B.0625, subdivisions 6a, 7, and 19a. 

    Subd. 3.    Assessment and prior authorization process for 
 recipients of both home care and home and community-based 
 waivered services for persons with mental retardation or related 
 conditions.  Effective January 1, 1996, for purposes of 
 providing informed choice, coordinating of local planning 
 decisions, and streamlining administrative requirements, the 
 assessment and prior authorization process for persons receiving 
 both home care and home and community-based waivered services 
 for persons with mental retardation or related conditions shall 
 meet the requirements of this section and section 256B.0627 with 
 the following exceptions: 

    (a) Upon request for home care services and subsequent 
 assessment by the public health nurse under section 256B.0627, 
 the public health nurse shall participate in the screening 
 process, as appropriate, and, if home care services are 
 determined to be necessary, participate in the development of a 
 service plan coordinating the need for home care and home and 
 community-based waivered services with the assigned county case 
 manager, the recipient of services, and the recipient's legal 
 representative, if any. 

    (b) The public health nurse shall give prior authorization 
 for home care services to the extent that home care services are:

    (1) medically necessary; 

    (2) chosen by the recipient and their legal representative, 
 if any, from the array of home care and home and community-based 
 waivered services available; 

    (3) coordinated with other services to be received by the 
 recipient as described in the service plan; and 

    (4) provided within the county's reimbursement limits for 
 home care and home and community-based waivered services for 
 persons with mental retardation or related conditions. 

    (c) If the public health agency is or may be the provider 
 of home care services to the recipient, the public health agency 
 shall provide the commissioner of human services with a written 
 plan that specifies how the assessment and prior authorization 
 process will be held separate and distinct from the provision of 
 services. 

    HIST: 1991 c 292 art 7 s 13; 1Sp1993 c 1 art 5 s 54; 1995 c 
 207 art 3 s 18; art 6 s 56; 1996 c 451 art 2 s 21 

     256B.0629 Advisory committee on organ and tissue 
  transplants. 

    Subdivision 1.    Creation and membership.  By July 1, 
 1990, the commissioner shall appoint and convene a 12-member 
 advisory committee to provide advice and recommendations to the 
 commissioner concerning the eligibility of organ and tissue 
 transplant procedures for reimbursement by medical assistance 
 and general assistance medical care.  The committee must include 
 representatives of the transplant provider community, hospitals, 
 patient recipient groups or organizations, the department of 
 human services, the department of finance, and the department of 
 health, at least one representative of a health plan regulated 
 under chapter 62A, 62C, or 62D, and persons with expertise in 
 ethics, law, and economics.  The terms and removal of members 
 shall be governed by section 15.059.  Members shall not receive 
 per diems but shall be compensated for expenses.  The advisory 
 committee does not expire as provided in section 15.059, 
 subdivision 6. 

    Subd. 2.    Function and objectives.  The committee's 
 activities include, but are not limited to: 

    (1) collection of information on the efficacy and 
 experience of various forms of transplantation not approved by 
 Medicare; 

    (2) collection of information from Minnesota transplant 
 providers on available services, success rates, and the current 
 status of transplant activity in the state; 

    (3) development of guidelines for determining when and 
 under what conditions organ and tissue transplants not approved 
 by Medicare should be eligible for reimbursement by medical 
 assistance and general assistance medical care; 

    (4) providing recommendations to the commissioner on:  (i) 
 organ and tissue transplant procedures, beyond those approved by 
 Medicare, that should also be eligible for reimbursement under 
 medical assistance and general assistance medical care; and (ii) 
 which transplant centers should be eligible for reimbursement 
 from medical assistance and general assistance medical care. 

    Subd. 3. Repealed, 1997 c 7 art 2 s 67 

    Subd. 4.    Responsibilities of the commissioner.  The 
 commissioner shall periodically: 

    (1) Determine criteria governing the eligibility of organ 
 and tissue transplant procedures for reimbursement from medical 
 assistance and general assistance medical care.  Procedures 
 approved by Medicare are automatically eligible for medical 
 assistance and general assistance medical care reimbursement.  
 Additional procedures are eligible for reimbursement only if 
 they are recommended by the task force, approved by the 
 commissioner, and published in the State Register.  

    (2) Determine criteria for certifying transplant centers 
 within and outside of Minnesota where Minnesotans receiving 
 medical assistance and general assistance medical care may 
 obtain transplants.  Only centers recommended by the task force 
 and approved by the commissioner may be certified by the 
 commissioner. 

    HIST: 1990 c 568 art 3 s 52; 1993 c 4 s 29; 1993 c 339 s 24; 
 1Sp1993 c 1 art 5 s 55; 1Sp1993 c 6 s 11; 1994 c 529 s 9,10,19; 
 2002 c 277 s 15 

     256B.063 Cost sharing.  

    Notwithstanding the provisions of section 256B.05, 
 subdivision 2, the commissioner is authorized to promulgate 
 rules pursuant to the Administrative Procedure Act, and to 
 require a nominal enrollment fee, premium, or similar charge for 
 recipients of medical assistance, if and to the extent required 
 by applicable federal regulation.  

    HIST: 1973 c 717 s 5 

     256B.0635 Continued eligibility in special circumstances.

    Subdivision 1.    Increased employment.  (a) Until June 
 30, 2002, medical assistance may be paid for persons who 
 received MFIP or medical assistance for families and children 
 in at least three of six months preceding the month in which the 
 person became ineligible for MFIP or medical assistance, if 
 the ineligibility was due to an increase in hours of employment 
 or employment income or due to the loss of an earned income 
 disregard.  In addition, to receive continued assistance under 
 this section, persons who received medical assistance for 
 families and children but did not receive MFIP must have had 
 income less than or equal to the assistance standard for their 
 family size under the state's AFDC plan in effect as of July 16, 
 1996, increased by three percent effective July 1, 2000, at the 
 time medical assistance eligibility began.  A person who is 
 eligible for extended medical assistance is entitled to six 
 months of assistance without reapplication, unless the 
 assistance unit ceases to include a dependent child.  For a 
 person under 21 years of age, medical assistance may not be 
 discontinued within the six-month period of extended eligibility 
 until it has been determined that the person is not otherwise 
 eligible for medical assistance.  Medical assistance may be 
 continued for an additional six months if the person meets all 
 requirements for the additional six months, according to title 
 XIX of the Social Security Act, as amended by section 303 of the 
 Family Support Act of 1988, Public Law Number 100-485. 

    (b) Beginning July 1, 2002, medical assistance for families 
 and children may be paid for persons who were eligible under 
 section 256B.055, subdivision 3a, in at least three of six 
 months preceding the month in which the person became ineligible 
 under that section if the ineligibility was due to an increase 
 in hours of employment or employment income or due to the loss 
 of an earned income disregard.  A person who is eligible for 
 extended medical assistance is entitled to six months of 
 assistance without reapplication, unless the assistance unit 
 ceases to include a dependent child, except medical assistance 
 may not be discontinued for that dependent child under 21 years 
 of age within the six-month period of extended eligibility until 
 it has been determined that the person is not otherwise eligible 
 for medical assistance.  Medical assistance may be continued for 
 an additional six months if the person meets all requirements 
 for the additional six months, according to title XIX of the 
 Social Security Act, as amended by section 303 of the Family 
 Support Act of 1988, Public Law Number 100-485. 

    Subd. 2.    Increased child or spousal support.  (a) 
 Until June 30, 2002, medical assistance may be paid for persons 
 who received MFIP or medical assistance for families and 
 children in at least three of the six months preceding the month 
 in which the person became ineligible for MFIP or medical 
 assistance, if the ineligibility was the result of the 
 collection of child or spousal support under part D of title IV 
 of the Social Security Act.  In addition, to receive continued 
 assistance under this section, persons who received medical 
 assistance for families and children but did not receive MFIP 
 must have had income less than or equal to the assistance 
 standard for their family size under the state's AFDC plan in 
 effect as of July 16, 1996, increased by three percent effective 
 July 1, 2000, at the time medical assistance eligibility began.  
 A person who is eligible for extended medical assistance under 
 this subdivision is entitled to four months of assistance 
 without reapplication, unless the assistance unit ceases to 
 include a dependent child, except medical assistance may not be 
 discontinued for that dependent child under 21 years of age 
 within the four-month period of extended eligibility until it 
 has been determined that the person is not otherwise eligible 
 for medical assistance. 

    (b) Beginning July 1, 2002, medical assistance for families 
 and children may be paid for persons who were eligible under 
 section 256B.055, subdivision 3a, in at least three of the six 
 months preceding the month in which the person became ineligible 
 under that section if the ineligibility was the result of the 
 collection of child or spousal support under part D of title IV 
 of the Social Security Act.  A person who is eligible for 
 extended medical assistance under this subdivision is entitled 
 to four months of assistance without reapplication, unless the 
 assistance unit ceases to include a dependent child, except 
 medical assistance may not be discontinued for that dependent 
 child under 21 years of age within the four-month period of 
 extended eligibility until it has been determined that the 
 person is not otherwise eligible for medical assistance. 

    Subd. 3. Repealed, 2002 c 277 s 34 

    HIST: 1997 c 85 art 3 s 22; 1998 c 407 art 6 s 13; 1999 c 245 
 art 4 s 59; 1Sp2001 c 9 art 2 s 40,41,76; 2002 c 277 s 31,33; 
 2002 c 379 art 1 s 113 

     256B.0637 Presumptive eligibility for certain persons 
  needing treatment for breast or cervical cancer. 

    Medical assistance is available during a presumptive 
 eligibility period for persons who meet the criteria in section 
 256B.057, subdivision 10.  For purposes of this section, the 
 presumptive eligibility period begins on the date on which an 
 entity designated by the commissioner determines, based on 
 preliminary information, that the person meets the criteria in 
 section 256B.057, subdivision 10.  The presumptive eligibility 
 period ends on the day on which a determination is made as to 
 the person's eligibility, except that if an application is not 
 submitted by the last day of the month following the month 
 during which the determination based on preliminary information 
 is made, the presumptive eligibility period ends on that last 
 day of the month. 

    HIST: 1Sp2001 c 9 art 2 s 42; 2002 c 379 art 1 s 113 

     256B.064 Sanctions; monetary recovery. 

    Subdivision 1.    Terminating payments to ineligible 
 vendors.  The commissioner may terminate payments under this 
 chapter to any person or facility that, under applicable federal 
 law or regulation, has been determined to be ineligible for 
 payments under Title XIX of the Social Security Act. 

    Subd. 1a.    Grounds for sanctions against vendors.  The 
 commissioner may impose sanctions against a vendor of medical 
 care for any of the following:  (1) fraud, theft, or abuse in 
 connection with the provision of medical care to recipients of 
 public assistance; (2) a pattern of presentment of false or 
 duplicate claims or claims for services not medically necessary; 
 (3) a pattern of making false statements of material facts for 
 the purpose of obtaining greater compensation than that to which 
 the vendor is legally entitled; (4) suspension or termination as 
 a Medicare vendor; (5) refusal to grant the state agency access 
 during regular business hours to examine all records necessary 
 to disclose the extent of services provided to program 
 recipients and appropriateness of claims for payment; (6) 
 failure to repay an overpayment finally established under this 
 section; and (7) any reason for which a vendor could be excluded 
 from participation in the Medicare program under section 1128, 
 1128A, or 1866(b)(2) of the Social Security Act.  The 
 determination of services not medically necessary may be made by 
 the commissioner in consultation with a peer advisory task force 
 appointed by the commissioner on the recommendation of 
 appropriate professional organizations.  The task force expires 
 as provided in section 15.059, subdivision 5. 

    Subd. 1b.    Sanctions available.  The commissioner may 
 impose the following sanctions for the conduct described in 
 subdivision 1a:  suspension or withholding of payments to a 
 vendor and suspending or terminating participation in the 
 program.  Regardless of imposition of sanctions, the 
 commissioner may make a referral to the appropriate state 
 licensing board. 

    Subd. 1c.    Grounds for and methods of monetary recovery. 
  (a) The commissioner may obtain monetary recovery from a 
 vendor who has been improperly paid either as a result of 
 conduct described in subdivision 1a or as a result of a vendor 
 or department error, regardless of whether the error was 
 intentional.  Patterns need not be proven as a precondition to 
 monetary recovery of erroneous or false claims, duplicate 
 claims, claims for services not medically necessary, or claims 
 based on false statements.  

    (b) The commissioner may obtain monetary recovery using 
 methods including but not limited to the following:  assessing 
 and recovering money improperly paid and debiting from future 
 payments any money improperly paid.  The commissioner shall 
 charge interest on money to be recovered if the recovery is to 
 be made by installment payments or debits, except when the 
 monetary recovery is of an overpayment that resulted from a 
 department error.  The interest charged shall be the rate 
 established by the commissioner of revenue under section 270.75. 

    Subd. 1d.    Investigative costs.  The commissioner may 
 seek recovery of investigative costs from any vendor of medical 
 care or services who willfully submits a claim for reimbursement 
 for services that the vendor knows, or reasonably should have 
 known, is a false representation and that results in the payment 
 of public funds for which the vendor is ineligible.  Billing 
 errors that result in unintentional overcharges shall not be 
 grounds for investigative cost recoupment. 

    Subd. 2.    Imposition of monetary recovery and sanctions. 
  (a) The commissioner shall determine any monetary amounts to 
 be recovered and sanctions to be imposed upon a vendor of 
 medical care under this section.  Except as provided in 
 paragraph (b), neither a monetary recovery nor a sanction will 
 be imposed by the commissioner without prior notice and an 
 opportunity for a hearing, according to chapter 14, on the 
 commissioner's proposed action, provided that the commissioner 
 may suspend or reduce payment to a vendor of medical care, 
 except a nursing home or convalescent care facility, after 
 notice and prior to the hearing if in the commissioner's opinion 
 that action is necessary to protect the public welfare and the 
 interests of the program. 

    (b) Except for a nursing home or convalescent care 
 facility, the commissioner may withhold or reduce payments to a 
 vendor of medical care without providing advance notice of such 
 withholding or reduction if either of the following occurs: 

    (1) the vendor is convicted of a crime involving the 
 conduct described in subdivision 1a; or 

    (2) the commissioner receives reliable evidence of fraud or 
 willful misrepresentation by the vendor. 

    (c) The commissioner must send notice of the withholding or 
 reduction of payments under paragraph (b) within five days of 
 taking such action.  The notice must: 

    (1) state that payments are being withheld according to 
 paragraph (b); 

    (2) except in the case of a conviction for conduct 
 described in subdivision 1a, state that the withholding is for a 
 temporary period and cite the circumstances under which 
 withholding will be terminated; 

    (3) identify the types of claims to which the withholding 
 applies; and 

    (4) inform the vendor of the right to submit written 
 evidence for consideration by the commissioner. 

    The withholding or reduction of payments will not continue 
 after the commissioner determines there is insufficient evidence 
 of fraud or willful misrepresentation by the vendor, or after 
 legal proceedings relating to the alleged fraud or willful 
 misrepresentation are completed, unless the commissioner has 
 sent notice of intention to impose monetary recovery or 
 sanctions under paragraph (a). 

    (d) Upon receipt of a notice under paragraph (a) that a 
 monetary recovery or sanction is to be imposed, a vendor may 
 request a contested case, as defined in section 14.02, 
 subdivision 3, by filing with the commissioner a written request 
 of appeal.  The appeal request must be received by the 
 commissioner no later than 30 days after the date the 
 notification of monetary recovery or sanction was mailed to the 
 vendor.  The appeal request must specify: 

    (1) each disputed item, the reason for the dispute, and an 
 estimate of the dollar amount involved for each disputed item; 

    (2) the computation that the vendor believes is correct; 

    (3) the authority in statute or rule upon which the vendor 
 relies for each disputed item; 

    (4) the name and address of the person or entity with whom 
 contacts may be made regarding the appeal; and 

    (5) other information required by the commissioner. 

    HIST: 1973 c 717 s 6; 1976 c 188 s 1; 1980 c 349 s 5,6; 1982 c 
 424 s 130; 1983 c 312 art 5 s 17; 1987 c 370 art 1 s 4; 1987 c 
 403 art 2 s 81; 1988 c 629 s 52; 1991 c 292 art 5 s 29; 1992 c 
 513 art 7 s 51,52; 1997 c 203 art 4 s 30-32; 2000 c 400 s 1 

     256B.0641 Recovery of overpayments. 

    Subdivision 1.    Recovery procedures; sources.  
 Notwithstanding section 256B.72 or any law or rule to the 
 contrary, when the commissioner or the federal government 
 determines that an overpayment has been made by the state to any 
 medical assistance vendor, the commissioner shall recover the 
 overpayment as follows:  

    (1) if the federal share of the overpayment amount is due 
 and owing to the federal government under federal law and 
 regulations, the commissioner shall recover from the medical 
 assistance vendor the federal share of the determined 
 overpayment amount paid to that provider using the schedule of 
 payments required by the federal government; 

    (2) if the overpayment to a medical assistance vendor is 
 due to a retroactive adjustment made because the medical 
 assistance vendor's temporary payment rate was higher than the 
 established desk audit payment rate or because of a department 
 error in calculating a payment rate, the commissioner shall 
 recover from the medical assistance vendor the total amount of 
 the overpayment within 120 days after the date on which written 
 notice of the adjustment is sent to the medical assistance 
 vendor or according to a schedule of payments approved by the 
 commissioner; and 

    (3) a medical assistance vendor is liable for the 
 overpayment amount owed by a long-term care provider if the 
 vendors or their owners are under common control or ownership.  

    Subd. 2.    Overpayments to prior owners.  The current 
 owner of a nursing home, boarding care home, or intermediate 
 care facility for persons with mental retardation or a related 
 condition is liable for the overpayment amount owed by a former 
 owner for any facility sold, transferred, or reorganized after 
 May 15, 1987.  Within 12 months of a written request by the 
 current owner, the commissioner shall conduct a field audit of 
 the facility for the auditable rate years during which the 
 former owner owned the facility and issue a report of the field 
 audit within 15 months of the written request.  Nothing in this 
 subdivision limits the liability of a former owner. 

    Subd. 3.    Facility in receivership.  Subdivision 2 
 does not apply to the change of ownership of a facility to a 
 nonrelated organization while the facility to be sold, 
 transferred or reorganized is in receivership under section 
 245A.12 or 245A.13, and the commissioner during the receivership 
 has not determined the need to place residents of the facility 
 into a newly constructed or newly established facility.  Nothing 
 in this subdivision limits the liability of a former owner.  

    HIST: 1Sp1985 c 9 art 2 s 39; 1987 c 133 s 1; 1991 c 292 art 6 
 s 46; 1995 c 207 art 7 s 22 

     256B.0642 Federal financial participation. 

    The commissioner may, in the aggregate, prospectively 
 reduce payment rates for medical assistance providers receiving 
 federal funds to avoid reduced federal financial participation 
 resulting from rates that are in excess of the Medicare 
 limitations. 

    HIST: 1989 c 282 art 3 s 59 

     256B.0643 Vendor request for contested case proceeding. 

    Unless otherwise provided by law, a vendor of medical care, 
 as defined in section 256B.02, subdivision 7, must use this 
 procedure to request a contested case, as defined in section 
 14.02, subdivision 3.  A request for a contested case must be 
 filed with the commissioner in writing within 60 days after the 
 date the notification of an action or determination was mailed.  
 The appeal request must specify: 

    (1) each disputed action or item; 

    (2) the reason for the dispute; 

    (3) an estimate of the dollar amount involved, if any, for 
 each disputed item; 

    (4) the computation or other disposition that the appealing 
 party believes is correct; 

    (5) the authority in statute or rule upon which the 
 appealing party relies for each disputed item; 

    (6) the name and address of the person or firm with whom 
 contacts may be made regarding the appeal; and 

    (7) other information required by the commissioner.  
 Nothing in this section shall be construed to create a right to 
 an administrative appeal or contested case proceeding. 

    HIST: 1990 c 568 art 3 s 53 

     256B.0644 Participation required for reimbursement under 
  other state health care programs. 

    A vendor of medical care, as defined in section 256B.02, 
 subdivision 7, and a health maintenance organization, as defined 
 in chapter 62D, must participate as a provider or contractor in 
 the medical assistance program, general assistance medical care 
 program, and MinnesotaCare as a condition of participating as a 
 provider in health insurance plans and programs or contractor 
 for state employees established under section 43A.18, the public 
 employees insurance program under section 43A.316, for health 
 insurance plans offered to local statutory or home rule charter 
 city, county, and school district employees, the workers' 
 compensation system under section 176.135, and insurance plans 
 provided through the Minnesota comprehensive health association 
 under sections 62E.01 to 62E.19.  The limitations on insurance 
 plans offered to local government employees shall not be 
 applicable in geographic areas where provider participation is 
 limited by managed care contracts with the department of human 
 services.  For providers other than health maintenance 
 organizations, participation in the medical assistance program 
 means that (1) the provider accepts new medical assistance, 
 general assistance medical care, and MinnesotaCare patients or 
 (2) for providers other than dental service providers, at least 
 20 percent of the provider's patients are covered by medical 
 assistance, general assistance medical care, and MinnesotaCare 
 as their primary source of coverage, or (3) for dental service 
 providers, at least ten percent of the provider's patients are 
 covered by medical assistance, general assistance medical care, 
 and MinnesotaCare as their primary source of coverage.  Patients 
 seen on a volunteer basis by the provider at a location other 
 than the provider's usual place of practice may be considered in 
 meeting this participation requirement.  The commissioner shall 
 establish participation requirements for health maintenance 
 organizations.  The commissioner shall provide lists of 
 participating medical assistance providers on a quarterly basis 
 to the commissioner of employee relations, the commissioner of 
 labor and industry, and the commissioner of commerce.  Each of 
 the commissioners shall develop and implement procedures to 
 exclude as participating providers in the program or programs 
 under their jurisdiction those providers who do not participate 
 in the medical assistance program.  The commissioner of employee 
 relations shall implement this section through contracts with 
 participating health and dental carriers. 

    HIST: 1992 c 549 art 4 s 13; 1993 c 13 art 2 s 7; 1993 c 247 
 art 4 s 9; 1993 c 339 s 14; 1993 c 345 art 9 s 14; 1995 c 248 
 art 10 s 16; 1997 c 203 art 4 s 33,72; 1999 c 177 s 87; 1Sp2001 
 c 9 art 2 s 43; 2002 c 275 s 3; 2002 c 379 art 1 s 113 

     256B.0645 Provider payments; retroactive changes in 
  eligibility. 

    Payment to a provider for a health care service provided to 
 a general assistance medical care recipient who is later 
 determined eligible for medical assistance or MinnesotaCare 
 according to section 256L.03, subdivision 1a, for the period in 
 which the health care service was provided, may be adjusted due 
 to the change in eligibility.  This section does not apply to 
 payments made to health plans on a prepaid capitated basis. 

    HIST: 1995 c 234 art 6 s 39; 1998 c 407 art 4 s 32 

     256B.065 Social security amendments.  

    The commissioner shall comply with requirements of the 
 social security amendments of 1972 (Public Law Number 92-603) 
 necessary in order to avoid loss of federal funds, and shall 
 implement by rule, pursuant to the Administrative Procedure Act, 
 those provisions required of state agencies supervising Title 
 XIX of the Social Security Act.  

    HIST: 1973 c 717 s 7 

  256B.07 Repealed, 1987 c 403 art 2 s 164 

     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.  

    (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.  

    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. Repealed, 2001 c 161 s 58; 2001 c 203 s 19 

    HIST: 1996 c 451 art 2 s 22; 1997 c 195 s 2-4; 2001 c 203 s 10 

     256B.08 Application. 

    Subdivision 1.    Application process.  An applicant for 
 medical assistance, or a person acting in the applicant's 
 behalf, shall file an application with a local agency in the 
 manner and form prescribed by the state agency.  When a married 
 applicant resides in a nursing home or applies for medical 
 assistance for nursing home services, the local agency shall 
 consider an application on behalf of the applicant's spouse only 
 upon specific request of the applicant or upon specific request 
 of the spouse and separate filing of an application. 

    Subd. 2.    Expedited review for pregnant women.  A 
 pregnant woman who may be eligible for assistance under section 
 256B.055, subdivision 1, must receive an appointment for 
 eligibility determination no later than five working days from 
 the date of her request for assistance from the local agency.  
 The local agency shall expedite processing her application for 
 assistance and shall make a determination of eligibility on a 
 completed application no later than ten working days following 
 the applicant's initial appointment.  The local agency shall 
 assist the applicant to provide all necessary information and 
 documentation in order to process the application within the 
 time period required under this subdivision.  The state agency 
 shall provide for the placement of applications for medical 
 assistance in eligible provider offices, community health 
 offices, and Women, Infants and Children (WIC) program sites. 

    Subd. 3.    Outreach locations.  The local agency must 
 establish locations, other than those used to process 
 applications for cash assistance, to receive and perform initial 
 processing of applications for pregnant women and children who 
 want medical assistance only.  At a minimum, these locations 
 must be in federally qualified health centers and in hospitals 
 that receive disproportionate share adjustments under section 
 256.969, subdivision 8, except that hospitals located outside of 
 this state that receive the disproportionate share adjustment 
 are not included.  Initial processing of the application need 
 not include a final determination of eligibility.  Local 
 agencies shall designate a person or persons within the agency 
 who will receive the applications taken at an outreach location 
 and the local agency will be responsible for timely 
 determination of eligibility. 

    HIST: Ex1967 c 16 s 8; 1Sp1981 c 2 s 15; 1986 c 444; 1988 c 
 689 art 2 s 146,268; 1991 c 292 art 4 s 50 

     256B.09 Investigations.  

    When an application for medical assistance hereunder is 
 filed with a county agency, such county agency shall promptly 
 make or cause to be made such investigation as it may deem 
 necessary.  The object of such investigation shall be to 
 ascertain the facts supporting the application made hereunder 
 and such other information as may be required by the rules of 
 the state agency.  Upon the completion of such investigation the 
 county agency shall promptly determine eligibility.  No approval 
 by the county agency shall be required prior to payment for 
 medical care provided to recipients determined to be eligible 
 pursuant to this section.  

    HIST: Ex1967 c 16 s 9; 1973 c 717 s 19 

  256B.091 Repealed, 1991 c 292 art 7 s 26 

     256B.0911 Long-term care consultation services. 

    Subdivision 1.    Purpose and goal.  (a) The purpose of 
 long-term care consultation services is to assist persons with 
 long-term or chronic care needs in making long-term care 
 decisions and selecting options that meet their needs and 
 reflect their preferences.  The availability of, and access to, 
 information and other types of assistance is also intended to 
 prevent or delay certified nursing facility placements and to 
 provide transition assistance after admission.  Further, the 
 goal of these services is to contain costs associated with 
 unnecessary certified nursing facility admissions.  The 
 commissioners of human services and health shall seek to 
 maximize use of available federal and state funds and establish 
 the broadest program possible within the funding available. 

    (b) These services must be coordinated with services 
 provided under sections 256.975, subdivision 7, and 256.9772, 
 and with services provided by other public and private agencies 
 in the community to offer a variety of cost-effective 
 alternatives to persons with disabilities and elderly persons.  
 The county agency providing long-term care consultation services 
 shall encourage the use of volunteers from families, religious 
 organizations, social clubs, and similar civic and service 
 organizations to provide community-based services. 

    Subd. 1a.    Definitions.  For purposes of this section, 
 the following definitions apply: 

    (a) "Long-term care consultation services" means: 

    (1) providing information and education to the general 
 public regarding availability of the services authorized under 
 this section; 

    (2) an intake process that provides access to the services 
 described in this section; 

    (3) assessment of the health, psychological, and social 
 needs of referred individuals; 

    (4) assistance in identifying services needed to maintain 
 an individual in the least restrictive environment; 

    (5) providing recommendations on cost-effective community 
 services that are available to the individual; 

    (6) development of an individual's community support plan; 

    (7) providing information regarding eligibility for 
 Minnesota health care programs; 

    (8) preadmission screening to determine the need for a 
 nursing facility level of care; 

    (9) preliminary determination of Minnesota health care 
 programs eligibility for individuals who need a nursing facility 
 level of care, with appropriate referrals for final 
 determination; 

    (10) providing recommendations for nursing facility 
 placement when there are no cost-effective community services 
 available; and 

    (11) assistance to transition people back to community 
 settings after facility admission. 

    (b) "Minnesota health care programs" means the medical 
 assistance program under chapter 256B, the alternative care 
 program under section 256B.0913, and the prescription drug 
 program under section 256.955. 

    Subd. 2. Repealed, 1Sp2001 c 9 art 4 s 34 

    Subd. 2a. Repealed, 1Sp2001 c 9 art 4 s 34 

    Subd. 3.    Long-term care consultation team.  (a) A 
 long-term care consultation team shall be established by the 
 county board of commissioners.  Each local consultation team 
 shall consist of at least one social worker and at least one 
 public health nurse from their respective county agencies.  The 
 board may designate public health or social services as the lead 
 agency for long-term care consultation services.  If a county 
 does not have a public health nurse available, it may request 
 approval from the commissioner to assign a county registered 
 nurse with at least one year experience in home care to 
 participate on the team.  Two or more counties may collaborate 
 to establish a joint local consultation team or teams. 

    (b) The team is responsible for providing long-term care 
 consultation services to all persons located in the county who 
 request the services, regardless of eligibility for Minnesota 
 health care programs. 

    Subd. 3a.    Assessment and support planning.  (a) 
 Persons requesting assessment, services planning, or other 
 assistance intended to support community-based living must be 
 visited by a long-term care consultation team within ten working 
 days after the date on which an assessment was requested or 
 recommended.  Assessments must be conducted according to 
 paragraphs (b) to (g). 

    (b) The county may utilize a team of either the social 
 worker or public health nurse, or both, to conduct the 
 assessment in a face-to-face interview.  The consultation team 
 members must confer regarding the most appropriate care for each 
 individual screened or assessed. 

    (c) The long-term care consultation team must assess the 
 health and social needs of the person, using an assessment form 
 provided by the commissioner. 

    (d) The team must conduct the assessment in a face-to-face 
 interview with the person being assessed and the person's legal 
 representative, if applicable. 

    (e) The team must provide the person, or the person's legal 
 representative, with written recommendations for facility- or 
 community-based services.  The team must document that the most 
 cost-effective alternatives available were offered to the 
 individual.  For purposes of this requirement, "cost-effective 
 alternatives" means community services and living arrangements 
 that cost the same as or less than nursing facility care. 

    (f) If the person chooses to use community-based services, 
 the team must provide the person or the person's legal 
 representative with a written community support plan, regardless 
 of whether the individual is eligible for Minnesota health care 
 programs.  The person may request assistance in developing a 
 community support plan without participating in a complete 
 assessment. 

    (g) The team must give the person receiving assessment or 
 support planning, or the person's legal representative, 
 materials supplied by the commissioner containing the following 
 information: 

    (1) the purpose of preadmission screening and assessment; 

    (2) information about Minnesota health care programs; 

    (3) the person's freedom to accept or reject the 
 recommendations of the team; 

    (4) the person's right to confidentiality under the 
 Minnesota Government Data Practices Act, chapter 13; and 

    (5) the person's right to appeal the decision regarding the 
 need for nursing facility level of care or the county's final 
 decisions regarding public programs eligibility according to 
 section 256.045, subdivision 3. 

    Subd. 3b.    Transition assistance.  (a) A long-term 
 care consultation team shall provide assistance to persons 
 residing in a nursing facility, hospital, regional treatment 
 center, or intermediate care facility for persons with mental 
 retardation who request or are referred for assistance.  
 Transition assistance must include assessment, community support 
 plan development, referrals to Minnesota health care programs, 
 and referrals to programs that provide assistance with housing. 

    (b) The county shall develop transition processes with 
 institutional social workers and discharge planners to ensure 
 that: 

    (1) persons admitted to facilities receive information 
 about transition assistance that is available; 

    (2) the assessment is completed for persons within ten 
 working days of the date of request or recommendation for 
 assessment; and 

    (3) there is a plan for transition and follow-up for the 
 individual's return to the community.  The plan must require 
 notification of other local agencies when a person who may 
 require assistance is screened by one county for admission to a 
 facility located in another county. 

    (c) If a person who is eligible for a Minnesota health care 
 program is admitted to a nursing facility, the nursing facility 
 must include a consultation team member or the case manager in 
 the discharge planning process. 

    Subd. 4. Repealed, 1Sp2001 c 9 art 4 s 34 

    Subd. 4a.    Preadmission screening activities related to 
 nursing facility admissions.  (a) All applicants to Medicaid 
 certified nursing facilities, including certified boarding care 
 facilities, must be screened prior to admission regardless of 
 income, assets, or funding sources for nursing facility care, 
 except as described in subdivision 4b.  The purpose of the 
 screening is to determine the need for nursing facility level of 
 care as described in paragraph (d) and to complete activities 
 required under federal law related to mental illness and mental 
 retardation as outlined in paragraph (b). 

    (b) A person who has a diagnosis or possible diagnosis of 
 mental illness, mental retardation, or a related condition must 
 receive a preadmission screening before admission regardless of 
 the exemptions outlined in subdivision 4b, paragraph (b), to 
 identify the need for further evaluation and specialized 
 services, unless the admission prior to screening is authorized 
 by the local mental health authority or the local developmental 
 disabilities case manager, or unless authorized by the county 
 agency according to Public Law Number 100-508.  

    The following criteria apply to the preadmission screening: 

    (1) the county must use forms and criteria developed by the 
 commissioner to identify persons who require referral for 
 further evaluation and determination of the need for specialized 
 services; and 

    (2) the evaluation and determination of the need for 
 specialized services must be done by: 

    (i) a qualified independent mental health professional, for 
 persons with a primary or secondary diagnosis of a serious 
 mental illness; or 

    (ii) a qualified mental retardation professional, for 
 persons with a primary or secondary diagnosis of mental 
 retardation or related conditions.  For purposes of this 
 requirement, a qualified mental retardation professional must 
 meet the standards for a qualified mental retardation 
 professional under Code of Federal Regulations, title 42, 
 section 483.430. 

    (c) The local county mental health authority or the state 
 mental retardation authority under Public Law Numbers 100-203 
 and 101-508 may prohibit admission to a nursing facility if the 
 individual does not meet the nursing facility level of care 
 criteria or needs specialized services as defined in Public Law 
 Numbers 100-203 and 101-508.  For purposes of this section, 
 "specialized services" for a person with mental retardation or a 
 related condition means active treatment as that term is defined 
 under Code of Federal Regulations, title 42, section 483.440 
 (a)(1). 

    (d) The determination of the need for nursing facility 
 level of care must be made according to criteria developed by 
 the commissioner.  In assessing a person's needs, consultation 
 team members shall have a physician available for consultation 
 and shall consider the assessment of the individual's attending 
 physician, if any.  The individual's physician must be included 
 if the physician chooses to participate.  Other personnel may be 
 included on the team as deemed appropriate by the county. 

    Subd. 4b.    Exemptions and emergency admissions.  (a) 
 Exemptions from the federal screening requirements outlined in 
 subdivision 4a, paragraphs (b) and (c), are limited to: 

    (1) a person who, having entered an acute care facility 
 from a certified nursing facility, is returning to a certified 
 nursing facility; 

    (2) a person transferring from one certified nursing 
 facility in Minnesota to another certified nursing facility in 
 Minnesota; and 

    (3) a person, 21 years of age or older, who satisfies the 
 following criteria, as specified in Code of Federal Regulations, 
 title 42, section 483.106(b)(2): 

    (i) the person is admitted to a nursing facility directly 
 from a hospital after receiving acute inpatient care at the 
 hospital; 

    (ii) the person requires nursing facility services for the 
 same condition for which care was provided in the hospital; and 

    (iii) the attending physician has certified before the 
 nursing facility admission that the person is likely to receive 
 less than 30 days of nursing facility services. 

    (b) Persons who are exempt from preadmission screening for 
 purposes of level of care determination include: 

    (1) persons described in paragraph (a); 

    (2) an individual who has a contractual right to have 
 nursing facility care paid for indefinitely by the veterans' 
 administration; 

    (3) an individual enrolled in a demonstration project under 
 section 256B.69, subdivision 8, at the time of application to a 
 nursing facility; 

    (4) an individual currently being served under the 
 alternative care program or under a home and community-based 
 services waiver authorized under section 1915(c) of the federal 
 Social Security Act; and 

    (5) individuals admitted to a certified nursing facility 
 for a short-term stay, which is expected to be 14 days or less 
 in duration based upon a physician's certification, and who have 
 been assessed and approved for nursing facility admission within 
 the previous six months.  This exemption applies only if the 
 consultation team member determines at the time of the initial 
 assessment of the six-month period that it is appropriate to use 
 the nursing facility for short-term stays and that there is an 
 adequate plan of care for return to the home or community-based 
 setting.  If a stay exceeds 14 days, the individual must be 
 referred no later than the first county working day following 
 the 14th resident day for a screening, which must be completed 
 within five working days of the referral.  The payment 
 limitations in subdivision 7 apply to an individual found at 
 screening to not meet the level of care criteria for admission 
 to a certified nursing facility. 

    (c) Persons admitted to a Medicaid-certified nursing 
 facility from the community on an emergency basis as described 
 in paragraph (d) or from an acute care facility on a nonworking 
 day must be screened the first working day after admission. 

    (d) Emergency admission to a nursing facility prior to 
 screening is permitted when all of the following conditions are 
 met: 

    (1) a person is admitted from the community to a certified 
 nursing or certified boarding care facility during county 
 nonworking hours; 

    (2) a physician has determined that delaying admission 
 until preadmission screening is completed would adversely affect 
 the person's health and safety; 

    (3) there is a recent precipitating event that precludes 
 the client from living safely in the community, such as 
 sustaining an injury, sudden onset of acute illness, or a 
 caregiver's inability to continue to provide care; 

    (4) the attending physician has authorized the emergency 
 placement and has documented the reason that the emergency 
 placement is recommended; and 

    (5) the county is contacted on the first working day 
 following the emergency admission. 

 Transfer of a patient from an acute care hospital to a nursing 
 facility is not considered an emergency except for a person who 
 has received hospital services in the following situations: 
 hospital admission for observation, care in an emergency room 
 without hospital admission, or following hospital 24-hour bed 
 care. 

    (e) A nursing facility must provide a written notice to 
 persons who satisfy the criteria in paragraph (a), clause (3), 
 regarding the person's right to request and receive long-term 
 care consultation services as defined in subdivision 1a.  The 
 notice must be provided prior to the person's discharge from the 
 facility and in a format specified by the commissioner. 

    Subd. 4c.    Screening requirements.  (a) A person may 
 be screened for nursing facility admission by telephone or in a 
 face-to-face screening interview.  Consultation team members 
 shall identify each individual's needs using the following 
 categories: 

    (1) the person needs no face-to-face screening interview to 
 determine the need for nursing facility level of care based on 
 information obtained from other health care professionals; 

    (2) the person needs an immediate face-to-face screening 
 interview to determine the need for nursing facility level of 
 care and complete activities required under subdivision 4a; or 

    (3) the person may be exempt from screening requirements as 
 outlined in subdivision 4b, but will need transitional 
 assistance after admission or in-person follow-along after a 
 return home. 

    (b) Persons admitted on a nonemergency basis to a 
 Medicaid-certified nursing facility must be screened prior to 
 admission. 

    (c) The long-term care consultation team shall recommend a 
 case mix classification for persons admitted to a certified 
 nursing facility when sufficient information is received to make 
 that classification.  The nursing facility is authorized to 
 conduct all case mix assessments for persons who have been 
 screened prior to admission for whom the county did not 
 recommend a case mix classification.  The nursing facility is 
 authorized to conduct all case mix assessments for persons 
 admitted to the facility prior to a preadmission screening.  The 
 county retains the responsibility of distributing appropriate 
 case mix forms to the nursing facility. 

    (d) The county screening or intake activity must include 
 processes to identify persons who may require transition 
 assistance as described in subdivision 3b. 

    Subd. 4d.    Preadmission screening of individuals under 
 65 years of age.  (a) It is the policy of the state of 
 Minnesota to ensure that individuals with disabilities or 
 chronic illness are served in the most integrated setting 
 appropriate to their needs and have the necessary information to 
 make informed choices about home and community-based service 
 options. 

    (b) Individuals under 65 years of age who are admitted to a 
 nursing facility from a hospital must be screened prior to 
 admission as outlined in subdivisions 4a through 4c. 

    (c) Individuals under 65 years of age who are admitted to 
 nursing facilities with only a telephone screening must receive 
 a face-to-face assessment from the long-term care consultation 
 team member of the county in which the facility is located or 
 from the recipient's county case manager within 20 working days 
 of admission. 

    (d) Individuals under 65 years of age who are admitted to a 
 nursing facility without preadmission screening according to the 
 exemption described in subdivision 4b, paragraph (a), clause 
 (3), and who remain in the facility longer than 30 days must 
 receive a face-to-face assessment within 40 days of admission.  

    (e) At the face-to-face assessment, the long-term care 
 consultation team member or county case manager must perform the 
 activities required under subdivision 3b. 

    (f) For individuals under 21 years of age, a screening 
 interview which recommends nursing facility admission must be 
 face-to-face and approved by the commissioner before the 
 individual is admitted to the nursing facility. 

    (g) In the event that an individual under 65 years of age 
 is admitted to a nursing facility on an emergency basis, the 
 county must be notified of the admission on the next working 
 day, and a face-to-face assessment as described in paragraph (c) 
 must be conducted within 20 working days of admission. 

    (h) At the face-to-face assessment, the long-term care 
 consultation team member or the case manager must present 
 information about home and community-based options so the 
 individual can make informed choices.  If the individual chooses 
 home and community-based services, the long-term care 
 consultation team member or case manager must complete a written 
 relocation plan within 20 working days of the visit.  The plan 
 shall describe the services needed to move out of the facility 
 and a time line for the move which is designed to ensure a 
 smooth transition to the individual's home and community. 

    (i) An individual under 65 years of age residing in a 
 nursing facility shall receive a face-to-face assessment at 
 least every 12 months to review the person's service choices and 
 available alternatives unless the individual indicates, in 
 writing, that annual visits are not desired.  In this case, the 
 individual must receive a face-to-face assessment at least once 
 every 36 months for the same purposes. 

    (j) Notwithstanding the provisions of subdivision 6, the 
 commissioner may pay county agencies directly for face-to-face 
 assessments for individuals under 65 years of age who are being 
 considered for placement or residing in a nursing facility. 

    Subd. 5.    Administrative activity.  The commissioner 
 shall minimize the number of forms required in the provision of 
 long-term care consultation services and shall limit the 
 screening document to items necessary for community support plan 
 approval, reimbursement, program planning, evaluation, and 
 policy development. 

    Subd. 6.    Payment for long-term care consultation 
 services.  (a) The total payment for each county must be paid 
 monthly by certified nursing facilities in the county.  The 
 monthly amount to be paid by each nursing facility for each 
 fiscal year must be determined by dividing the county's annual 
 allocation for long-term care consultation services by 12 to 
 determine the monthly payment and allocating the monthly payment 
 to each nursing facility based on the number of licensed beds in 
 the nursing facility.  Payments to counties in which there is no 
 certified nursing facility must be made by increasing the 
 payment rate of the two facilities located nearest to the county 
 seat. 

    (b) The commissioner shall include the total annual payment 
 determined under paragraph (a) for each nursing facility 
 reimbursed under section 256B.431 or 256B.434 according to 
 section 256B.431, subdivision 2b, paragraph (g), or 256B.435. 

    (c) In the event of the layaway, delicensure and 
 decertification, or removal from layaway of 25 percent or more 
 of the beds in a facility, the commissioner may adjust the per 
 diem payment amount in paragraph (b) and may adjust the monthly 
 payment amount in paragraph (a).  The effective date of an 
 adjustment made under this paragraph shall be on or after the 
 first day of the month following the effective date of the 
 layaway, delicensure and decertification, or removal from 
 layaway. 

    (d) Payments for long-term care consultation services are 
 available to the county or counties to cover staff salaries and 
 expenses to provide the services described in subdivision 1a.  
 The county shall employ, or contract with other agencies to 
 employ, within the limits of available funding, sufficient 
 personnel to provide long-term care consultation services while 
 meeting the state's long-term care outcomes and objectives as 
 defined in section 256B.0917, subdivision 1.  The county shall 
 be accountable for meeting local objectives as approved by the 
 commissioner in the CSSA biennial plan. 

    (e) Notwithstanding section 256B.0641, overpayments 
 attributable to payment of the screening costs under the medical 
 assistance program may not be recovered from a facility.  

    (f) The commissioner of human services shall amend the 
 Minnesota medical assistance plan to include reimbursement for 
 the local consultation teams. 

    (g) The county may bill, as case management services, 
 assessments, support planning, and follow-along provided to 
 persons determined to be eligible for case management under 
 Minnesota health care programs.  No individual or family member 
 shall be charged for an initial assessment or initial support 
 plan development provided under subdivision 3a or 3b. 

    Subd. 7.    Reimbursement for certified nursing 
 facilities.  (a) Medical assistance reimbursement for nursing 
 facilities shall be authorized for a medical assistance 
 recipient only if a preadmission screening has been conducted 
 prior to admission or the county has authorized an exemption.  
 Medical assistance reimbursement for nursing facilities shall 
 not be provided for any recipient who the local screener has 
 determined does not meet the level of care criteria for nursing 
 facility placement or, if indicated, has not had a level II OBRA 
 evaluation as required under the federal Omnibus Budget 
 Reconciliation Act of 1987 completed unless an admission for a 
 recipient with mental illness is approved by the local mental 
 health authority or an admission for a recipient with mental 
 retardation or related condition is approved by the state mental 
 retardation authority. 

    (b) The nursing facility must not bill a person who is not 
 a medical assistance recipient for resident days that preceded 
 the date of completion of screening activities as required under 
 subdivisions 4a, 4b, and 4c.  The nursing facility must include 
 unreimbursed resident days in the nursing facility resident day 
 totals reported to the commissioner. 

    (c) The commissioner shall make a request to the Centers 
 for Medicare and Medicaid Services for a waiver allowing team 
 approval of Medicaid payments for certified nursing facility 
 care.  An individual has a choice and makes the final decision 
 between nursing facility placement and community placement after 
 the screening team's recommendation, except as provided in 
 subdivision 4a, paragraph (c). 

    Subd. 8. Repealed, 2001 c 161 s 58 

    Subd. 9. Repealed, 1Sp2001 c 9 art 4 s 34 

    HIST: 1991 c 292 art 7 s 14; 1992 c 513 art 7 s 53-55; 1Sp1993 
 c 1 art 5 s 56-61,135; 1995 c 207 art 6 s 57-61; 1997 c 203 art 
 4 s 34; art 9 s 10; 1997 c 225 art 8 s 6; 1998 c 407 art 4 s 
 33-35; 1999 c 245 art 3 s 12; 1Sp2001 c 9 art 3 s 42; art 4 s 
 4-14; 2002 c 277 s 32; 2002 c 375 art 2 s 18,19; 2002 c 379 art 
 1 s 113 

  256B.0912 Repealed, 1Sp2001 c 9 art 3 s 76 

     256B.0913 Alternative care program. 

    Subdivision 1.    Purpose and goals.  The purpose of the 
 alternative care program is to provide funding for home and 
 community-based services for elderly persons, in order to limit 
 nursing facility placements.  The program is designed to support 
 elderly persons in their desire to remain in the community as 
 independently and as long as possible and to support informal 
 caregivers in their efforts to provide care for elderly people.  
 Further, the goals of the program are: 

    (1) to contain medical assistance expenditures by funding 
 care in the community; and 

    (2) to maintain the moratorium on new construction of 
 nursing home beds. 

    Subd. 2.    Eligibility for services.  Alternative care 
 services are available to Minnesotans age 65 or older who are 
 not eligible for medical assistance without a spenddown or 
 waiver obligation but who would be eligible for medical 
 assistance within 180 days of admission to a nursing facility 
 and subject to subdivisions 4 to 13. 

    Subd. 3. Repealed, 1Sp2001 c 9 art 4 s 34 

    Subd. 4.    Eligibility for funding for services for 
 nonmedical assistance recipients.  (a) Funding for services 
 under the alternative care program is available to persons who 
 meet the following criteria: 

    (1) the person has been determined by a community 
 assessment under section 256B.0911 to be a person who would 
 require the level of care provided in a nursing facility, but 
 for the provision of services under the alternative care 
 program; 

    (2) the person is age 65 or older; 

    (3) the person would be eligible for medical assistance 
 within 180 days of admission to a nursing facility; 

    (4) the person is not ineligible for the medical assistance 
 program due to an asset transfer penalty; 

    (5) the person needs services that are not funded through 
 other state or federal funding; and 

    (6) the monthly cost of the alternative care services 
 funded by the program for this person does not exceed 75 percent 
 of the statewide weighted average monthly nursing facility rate 
 of the case mix resident class to which the individual 
 alternative care client would be assigned under Minnesota Rules, 
 parts 9549.0050 to 9549.0059, less the recipient's maintenance 
 needs allowance as described in section 256B.0915, subdivision 
 1d, paragraph (a), until the first day of the state fiscal year 
 in which the resident assessment system, under section 256B.437, 
 for nursing home rate determination is implemented.  Effective 
 on the first day of the state fiscal year in which a resident 
 assessment system, under section 256B.437, for nursing home rate 
 determination is implemented and the first day of each 
 subsequent state fiscal year, the monthly cost of alternative 
 care services for this person shall not exceed the alternative 
 care monthly cap for the case mix resident class to which the 
 alternative care client would be assigned under Minnesota Rules, 
 parts 9549.0050 to 9549.0059, which was in effect on the last 
 day of the previous state fiscal year, and adjusted by the 
 greater of any legislatively adopted home and community-based 
 services cost-of-living percentage increase or any legislatively 
 adopted statewide percent rate increase for nursing facilities.  
 This monthly limit does not prohibit the alternative care client 
 from payment for additional services, but in no case may the 
 cost of additional services purchased under this section exceed 
 the difference between the client's monthly service limit 
 defined under section 256B.0915, subdivision 3, and the 
 alternative care program monthly service limit defined in this 
 paragraph.  If medical supplies and equipment or environmental 
 modifications are or will be purchased for an alternative care 
 services recipient, the costs may be prorated on a monthly basis 
 for up to 12 consecutive months beginning with the month of 
 purchase.  If the monthly cost of a recipient's other 
 alternative care services exceeds the monthly limit established 
 in this paragraph, the annual cost of the alternative care 
 services shall be determined.  In this event, the annual cost of 
 alternative care services shall not exceed 12 times the monthly 
 limit described in this paragraph. 

    (b) Alternative care funding under this subdivision is not 
 available for a person who is a medical assistance recipient or 
 who would be eligible for medical assistance without a spenddown 
 or waiver obligation.  A person whose initial application for 
 medical assistance is being processed may be served under the 
 alternative care program for a period up to 60 days.  If the 
 individual is found to be eligible for medical assistance, 
 medical assistance must be billed for services payable under the 
 federally approved elderly waiver plan and delivered from the 
 date the individual was found eligible for the federally 
 approved elderly waiver plan.  Notwithstanding this provision, 
 upon federal approval, alternative care funds may not be used to 
 pay for any service the cost of which is payable by medical 
 assistance or which is used by a recipient to meet a medical 
 assistance income spenddown or waiver obligation.  

    (c) Alternative care funding is not available for a person 
 who resides in a licensed nursing home, certified boarding care 
 home, hospital, or intermediate care facility, except for case 
 management services which are provided in support of the 
 discharge planning process to a nursing home resident or 
 certified boarding care home resident. 

    Subd. 5.    Services covered under alternative care.  (a)
 Alternative care funding may be used for payment of costs of: 

    (1) adult foster care; 

    (2) adult day care; 

    (3) home health aide; 

    (4) homemaker services; 

    (5) personal care; 

    (6) case management; 

    (7) respite care; 

    (8) assisted living; 

    (9) residential care services; 

    (10) care-related supplies and equipment; 

    (11) meals delivered to the home; 

    (12) transportation; 

    (13) nursing services; 

    (14) chore services; 

    (15) companion services; 

    (16) nutrition services; 

    (17) training for direct informal caregivers; 

    (18) telehome care devices to monitor recipients in their 
 own homes as an alternative to hospital care, nursing home care, 
 or home visits; 

    (19) other services which includes discretionary funds and 
 direct cash payments to clients, following approval by the 
 commissioner, subject to the provisions of paragraph (j).  Total 
 annual payments for "other services" for all clients within a 
 county may not exceed 25 percent of that county's annual 
 alternative care program base allocation; and 

    (20) environmental modifications. 

    (b) The county agency must ensure that the funds are not 
 used to supplant services available through other public 
 assistance or services programs. 

    (c) Unless specified in statute, the services, service 
 definitions, and standards for alternative care services shall 
 be the same as the services, service definitions, and standards 
 specified in the federally approved elderly waiver plan.  Except 
 for the county agencies' approval of direct cash payments to 
 clients as described in paragraph (j) or for a provider of 
 supplies and equipment when the monthly cost of the supplies and 
 equipment is less than $250, persons or agencies must be 
 employed by or under a contract with the county agency or the 
 public health nursing agency of the local board of health in 
 order to receive funding under the alternative care program.  
 Supplies and equipment may be purchased from a vendor not 
 certified to participate in the Medicaid program if the cost for 
 the item is less than that of a Medicaid vendor.  

    (d) The adult foster care rate shall be considered a 
 difficulty of care payment and shall not include room and 
 board.  The adult foster care rate shall be negotiated between 
 the county agency and the foster care provider.  The alternative 
 care payment for the foster care service in combination with the 
 payment for other alternative care services, including case 
 management, must not exceed the limit specified in subdivision 
 4, paragraph (a), clause (6). 

    (e) Personal care services must meet the service standards 
 defined in the federally approved elderly waiver plan, except 
 that a county agency may contract with a client's relative who 
 meets the relative hardship waiver requirement as defined in 
 section 256B.0627, subdivision 4, paragraph (b), clause (10), to 
 provide personal care services if the county agency ensures 
 supervision of this service by a qualified professional as 
 defined in section 256B.0625, subdivision 19c.  

    (f) For purposes of this section, residential care services 
 are services which are provided to individuals living in 
 residential care homes.  Residential care homes are currently 
 licensed as board and lodging establishments and are registered 
 with the department of health as providing special services 
 under section 157.17 and are not subject to registration under 
 chapter 144D.  Residential care services are defined as 
 "supportive services" and "health-related services."  
 "Supportive services" means the provision of up to 24-hour 
 supervision and oversight.  Supportive services includes:  (1) 
 transportation, when provided by the residential care home only; 
 (2) socialization, when socialization is part of the plan of 
 care, has specific goals and outcomes established, and is not 
 diversional or recreational in nature; (3) assisting clients in 
 setting up meetings and appointments; (4) assisting clients in 
 setting up medical and social services; (5) providing assistance 
 with personal laundry, such as carrying the client's laundry to 
 the laundry room.  Assistance with personal laundry does not 
 include any laundry, such as bed linen, that is included in the 
 room and board rate.  "Health-related services" are limited to 
 minimal assistance with dressing, grooming, and bathing and 
 providing reminders to residents to take medications that are 
 self-administered or providing storage for medications, if 
 requested.  Individuals receiving residential care services 
 cannot receive homemaking services funded under this section.  

    (g) For the purposes of this section, "assisted living" 
 refers to supportive services provided by a single vendor to 
 clients who reside in the same apartment building of three or 
 more units which are not subject to registration under chapter 
 144D and are licensed by the department of health as a class A 
 home care provider or a class E home care provider.  Assisted 
 living services are defined as up to 24-hour supervision, and 
 oversight, supportive services as defined in clause (1), 
 individualized home care aide tasks as defined in clause (2), 
 and individualized home management tasks as defined in clause 
 (3) provided to residents of a residential center living in 
 their units or apartments with a full kitchen and bathroom.  A 
 full kitchen includes a stove, oven, refrigerator, food 
 preparation counter space, and a kitchen utensil storage 
 compartment.  Assisted living services must be provided by the 
 management of the residential center or by providers under 
 contract with the management or with the county. 

    (1) Supportive services include:  

    (i) socialization, when socialization is part of the plan 
 of care, has specific goals and outcomes established, and is not 
 diversional or recreational in nature; 

    (ii) assisting clients in setting up meetings and 
 appointments; and 

    (iii) providing transportation, when provided by the 
 residential center only.  

    (2) Home care aide tasks means:  

    (i) preparing modified diets, such as diabetic or low 
 sodium diets; 

    (ii) reminding residents to take regularly scheduled 
 medications or to perform exercises; 

    (iii) household chores in the presence of technically 
 sophisticated medical equipment or episodes of acute illness or 
 infectious disease; 

    (iv) household chores when the resident's care requires the 
 prevention of exposure to infectious disease or containment of 
 infectious disease; and 

    (v) assisting with dressing, oral hygiene, hair care, 
 grooming, and bathing, if the resident is ambulatory, and if the 
 resident has no serious acute illness or infectious disease.  
 Oral hygiene means care of teeth, gums, and oral prosthetic 
 devices.  

    (3) Home management tasks means:  

    (i) housekeeping; 

    (ii) laundry; 

    (iii) preparation of regular snacks and meals; and 

    (iv) shopping.  

    Individuals receiving assisted living services shall not 
 receive both assisted living services and homemaking services.  
 Individualized means services are chosen and designed 
 specifically for each resident's needs, rather than provided or 
 offered to all residents regardless of their illnesses, 
 disabilities, or physical conditions.  Assisted living services 
 as defined in this section shall not be authorized in boarding 
 and lodging establishments licensed according to sections 
 157.011 and 157.15 to 157.22. 

    (h) For establishments registered under chapter 144D, 
 assisted living services under this section means either the 
 services described in paragraph (g) and delivered by a class E 
 home care provider licensed by the department of health or the 
 services described under section 144A.4605 and delivered by an 
 assisted living home care provider or a class A home care 
 provider licensed by the commissioner of health. 

    (i) Payment for assisted living services and residential 
 care services shall be a monthly rate negotiated and authorized 
 by the county agency based on an individualized service plan for 
 each resident and may not cover direct rent or food costs.  

    (1) The individualized monthly negotiated payment for 
 assisted living services as described in paragraph (g) or (h), 
 and residential care services as described in paragraph (f), 
 shall not exceed the nonfederal share in effect on July 1 of the 
 state fiscal year for which the rate limit is being calculated 
 of the greater of either the statewide or any of the geographic 
 groups' weighted average monthly nursing facility payment rate 
 of the case mix resident class to which the alternative care 
 eligible client would be assigned under Minnesota Rules, parts 
 9549.0050 to 9549.0059, less the maintenance needs allowance as 
 described in section 256B.0915, subdivision 1d, paragraph (a), 
 until the first day of the state fiscal year in which a resident 
 assessment system, under section 256B.437, of nursing home rate 
 determination is implemented.  Effective on the first day of the 
 state fiscal year in which a resident assessment system, under 
 section 256B.437, of nursing home rate determination is 
 implemented and the first day of each subsequent state fiscal 
 year, the individualized monthly negotiated payment for the 
 services described in this clause shall not exceed the limit 
 described in this clause which was in effect on the last day of 
 the previous state fiscal year and which has been adjusted by 
 the greater of any legislatively adopted home and 
 community-based services cost-of-living percentage increase or 
 any legislatively adopted statewide percent rate increase for 
 nursing facilities. 

    (2) The individualized monthly negotiated payment for 
 assisted living services described under section 144A.4605 and 
 delivered by a provider licensed by the department of health as 
 a class A home care provider or an assisted living home care 
 provider and provided in a building that is registered as a 
 housing with services establishment under chapter 144D and that 
 provides 24-hour supervision in combination with the payment for 
 other alternative care services, including case management, must 
 not exceed the limit specified in subdivision 4, paragraph (a), 
 clause (6). 

    (j) A county agency may make payment from their alternative 
 care program allocation for "other services" which include use 
 of "discretionary funds" for services that are not otherwise 
 defined in this section and direct cash payments to the client 
 for the purpose of purchasing the services.  The following 
 provisions apply to payments under this paragraph: 

    (1) a cash payment to a client under this provision cannot 
 exceed the monthly payment limit for that client as specified in 
 subdivision 4, paragraph (a), clause (6); 

    (2) a county may not approve any cash payment for a client 
 who meets either of the following: 

    (i) has been assessed as having a dependency in 
 orientation, unless the client has an authorized 
 representative.  An "authorized representative" means an 
 individual who is at least 18 years of age and is designated by 
 the person or the person's legal representative to act on the 
 person's behalf.  This individual may be a family member, 
 guardian, representative payee, or other individual designated 
 by the person or the person's legal representative, if any, to 
 assist in purchasing and arranging for supports; or 

    (ii) is concurrently receiving adult foster care, 
 residential care, or assisted living services; 

    (3) cash payments to a person or a person's family will be 
 provided through a monthly payment and be in the form of cash, 
 voucher, or direct county payment to a vendor.  Fees or premiums 
 assessed to the person for eligibility for health and human 
 services are not reimbursable through this service option.  
 Services and goods purchased through cash payments must be 
 identified in the person's individualized care plan and must 
 meet all of the following criteria: 

    (i) they must be over and above the normal cost of caring 
 for the person if the person did not have functional 
 limitations; 

    (ii) they must be directly attributable to the person's 
 functional limitations; 

    (iii) they must have the potential to be effective at 
 meeting the goals of the program; 

    (iv) they must be consistent with the needs identified in 
 the individualized service plan.  The service plan shall specify 
 the needs of the person and family, the form and amount of 
 payment, the items and services to be reimbursed, and the 
 arrangements for management of the individual grant; and 

    (v) the person, the person's family, or the legal 
 representative shall be provided sufficient information to 
 ensure an informed choice of alternatives.  The local agency 
 shall document this information in the person's care plan, 
 including the type and level of expenditures to be reimbursed; 

    (4) the state of Minnesota, county, lead agency under 
 contract, or tribal government under contract to administer the 
 alternative care program shall not be liable for damages, 
 injuries, or liabilities sustained through the purchase of 
 direct supports or goods by the person, the person's family, or 
 the authorized representative with funds received through the 
 cash payments under this section.  Liabilities include, but are 
 not limited to, workers' compensation, the Federal Insurance 
 Contributions Act (FICA), or the Federal Unemployment Tax Act 
 (FUTA); 

    (5) persons receiving grants under this section shall have 
 the following responsibilities: 

    (i) spend the grant money in a manner consistent with their 
 individualized service plan with the local agency; 

    (ii) notify the local agency of any necessary changes in 
 the grant expenditures; 

    (iii) arrange and pay for supports; and 

    (iv) inform the local agency of areas where they have 
 experienced difficulty securing or maintaining supports; and 

    (6) the county shall report client outcomes, services, and 
 costs under this paragraph in a manner prescribed by the 
 commissioner. 

    Subd. 6.    Alternative care program administration.  
 The alternative care program is administered by the county 
 agency.  This agency is the lead agency responsible for the 
 local administration of the alternative care program as 
 described in this section.  However, it may contract with the 
 public health nursing service to be the lead agency.  The 
 commissioner may contract with federally recognized Indian 
 tribes with a reservation in Minnesota to serve as the lead 
 agency responsible for the local administration of the 
 alternative care program as described in the contract. 

    Subd. 7.    Case management.  Providers of case 
 management services for persons receiving services funded by the 
 alternative care program must meet the qualification 
 requirements and standards specified in section 256B.0915, 
 subdivision 1b.  The case manager must not approve alternative 
 care funding for a client in any setting in which the case 
 manager cannot reasonably ensure the client's health and 
 safety.  The case manager is responsible for the 
 cost-effectiveness of the alternative care individual care plan 
 and must not approve any care plan in which the cost of services 
 funded by alternative care and client contributions exceeds the 
 limit specified in section 256B.0915, subdivision 3, paragraph 
 (b).  The county may allow a case manager employed by the county 
 to delegate certain aspects of the case management activity to 
 another individual employed by the county provided there is 
 oversight of the individual by the case manager.  The case 
 manager may not delegate those aspects which require 
 professional judgment including assessments, reassessments, and 
 care plan development. 

    Subd. 8.    Requirements for individual care plan.  (a) 
 The case manager shall implement the plan of care for each 
 alternative care client and ensure that a client's service needs 
 and eligibility are reassessed at least every 12 months.  The 
 plan shall include any services prescribed by the individual's 
 attending physician as necessary to allow the individual to 
 remain in a community setting.  In developing the individual's 
 care plan, the case manager should include the use of volunteers 
 from families and neighbors, religious organizations, social 
 clubs, and civic and service organizations to support the formal 
 home care services.  The county shall be held harmless for 
 damages or injuries sustained through the use of volunteers 
 under this subdivision including workers' compensation 
 liability.  The lead agency shall provide documentation in each 
 individual's plan of care and, if requested, to the commissioner 
 that the most cost-effective alternatives available have been 
 offered to the individual and that the individual was free to 
 choose among available qualified providers, both public and 
 private.  The case manager must give the individual a ten-day 
 written notice of any denial, termination, or reduction of 
 alternative care services. 

    (b) If the county administering alternative care services 
 is different than the county of financial responsibility, the 
 care plan may be implemented without the approval of the county 
 of financial responsibility. 

    Subd. 9.    Contracting provisions for providers.  
 Alternative care funds paid to service providers are subject to 
 audit by the commissioner for fiscal and utilization control.  

    The lead agency must select providers for contracts or 
 agreements using the following criteria and other criteria 
 established by the county: 

    (1) the need for the particular services offered by the 
 provider; 

    (2) the population to be served, including the number of 
 clients, the length of time services will be provided, and the 
 medical condition of clients; 

    (3) the geographic area to be served; 

    (4) quality assurance methods, including appropriate 
 licensure, certification, or standards, and supervision of 
 employees when needed; 

    (5) rates for each service and unit of service exclusive of 
 county administrative costs; 

    (6) evaluation of services previously delivered by the 
 provider; and 

    (7) contract or agreement conditions, including billing 
 requirements, cancellation, and indemnification. 

    The county must evaluate its own agency services under the 
 criteria established for other providers.  

    Subd. 10.    Allocation formula.  (a) The alternative 
 care appropriation for fiscal years 1992 and beyond shall cover 
 only alternative care eligible clients.  By July 1 of each year, 
 the commissioner shall allocate to county agencies the state 
 funds available for alternative care for persons eligible under 
 subdivision 2. 

    (b) The adjusted base for each county is the county's 
 current fiscal year base allocation plus any targeted funds 
 approved during the current fiscal year.  Calculations for 
 paragraphs (c) and (d) are to be made as follows:  for each 
 county, the determination of alternative care program 
 expenditures shall be based on payments for services rendered 
 from April 1 through March 31 in the base year, to the extent 
 that claims have been submitted and paid by June 1 of that year. 

    (c) If the alternative care program expenditures as defined 
 in paragraph (b) are 95 percent or more of the county's adjusted 
 base allocation, the allocation for the next fiscal year is 100 
 percent of the adjusted base, plus inflation to the extent that 
 inflation is included in the state budget. 

    (d) If the alternative care program expenditures as defined 
 in paragraph (b) are less than 95 percent of the county's 
 adjusted base allocation, the allocation for the next fiscal 
 year is the adjusted base allocation less the amount of unspent 
 funds below the 95 percent level. 

    (e) If the annual legislative appropriation for the 
 alternative care program is inadequate to fund the combined 
 county allocations for a biennium, the commissioner shall 
 distribute to each county the entire annual appropriation as 
 that county's percentage of the computed base as calculated in 
 paragraphs (c) and (d). 

    Subd. 11.    Targeted funding.  (a) The purpose of 
 targeted funding is to make additional money available to 
 counties with the greatest need.  Targeted funds are not 
 intended to be distributed equitably among all counties, but 
 rather, allocated to those with long-term care strategies that 
 meet state goals. 

    (b) The funds available for targeted funding shall be the 
 total appropriation for each fiscal year minus county 
 allocations determined under subdivision 10 as adjusted for any 
 inflation increases provided in appropriations for the biennium. 

    (c) The commissioner shall allocate targeted funds to 
 counties that demonstrate to the satisfaction of the 
 commissioner that they have developed feasible plans to increase 
 alternative care spending.  In making targeted funding 
 allocations, the commissioner shall use the following priorities:

    (1) counties that received a lower allocation in fiscal 
 year 1991 than in fiscal year 1990.  Counties remain in this 
 priority until they have been restored to their fiscal year 1990 
 level plus inflation; 

    (2) counties that sustain a base allocation reduction for 
 failure to spend 95 percent of the allocation if they 
 demonstrate that the base reduction should be restored; 

    (3) counties that propose projects to divert community 
 residents from nursing home placement or convert nursing home 
 residents to community living; and 

    (4) counties that can otherwise justify program growth by 
 demonstrating the existence of waiting lists, demographically 
 justified needs, or other unmet needs. 

    (d) Counties that would receive targeted funds according to 
 paragraph (c) must demonstrate to the commissioner's 
 satisfaction that the funds would be appropriately spent by 
 showing how the funds would be used to further the state's 
 alternative care goals as described in subdivision 1, and that 
 the county has the administrative and service delivery 
 capability to use them.  

    (e) The commissioner shall request applications for 
 targeted funds by November 1 of each year.  The counties 
 selected for targeted funds shall be notified of the amount of 
 their additional funding.  Targeted funds allocated to a county 
 agency in one year shall be treated as part of the county's base 
 allocation for that year in determining allocations for 
 subsequent years.  No reallocations between counties shall be 
 made. 

    Subd. 12.    Client premiums.  (a) A premium is required 
 for all alternative care eligible clients to help pay for the 
 cost of participating in the program.  The amount of the premium 
 for the alternative care client shall be determined as follows: 

    (1) when the alternative care client's income less 
 recurring and predictable medical expenses is greater than the 
 recipient's maintenance needs allowance as defined in section 
 256B.0915, subdivision 1d, paragraph (a), but less than 150 
 percent of the federal poverty guideline effective on July 1 of 
 the state fiscal year in which the premium is being computed, 
 and total assets are less than $10,000, the fee is zero; 

    (2) when the alternative care client's income less 
 recurring and predictable medical expenses is greater than 150 
 percent of the federal poverty guideline effective on July 1 of 
 the state fiscal year in which the premium is being computed, 
 and total assets are less than $10,000, the fee is 25 percent of 
 the cost of alternative care services or the difference between 
 150 percent of the federal poverty guideline effective on July 1 
 of the state fiscal year in which the premium is being computed 
 and the client's income less recurring and predictable medical 
 expenses, whichever is less; and 

    (3) when the alternative care client's total assets are 
 greater than $10,000, the fee is 25 percent of the cost of 
 alternative care services.  

    For married persons, total assets are defined as the total 
 marital assets less the estimated community spouse asset 
 allowance, under section 256B.059, if applicable.  For married 
 persons, total income is defined as the client's income less the 
 monthly spousal allotment, under section 256B.058. 

    All alternative care services except case management shall 
 be included in the estimated costs for the purpose of 
 determining 25 percent of the costs. 

    Premiums are due and payable each month alternative care 
 services are received unless the actual cost of the services is 
 less than the premium. 

    (b) The fee shall be waived by the commissioner when: 

    (1) a person who is residing in a nursing facility is 
 receiving case management only; 

    (2) a person is applying for medical assistance; 

    (3) a married couple is requesting an asset assessment 
 under the spousal impoverishment provisions; 

    (4) a person is found eligible for alternative care, but is 
 not yet receiving alternative care services; or 

    (5) a person's fee under paragraph (a) is less than $25. 

    (c) The county agency must record in the state's receivable 
 system the client's assessed premium amount or the reason the 
 premium has been waived.  The commissioner will bill and collect 
 the premium from the client.  Money collected must be deposited 
 in the general fund and is appropriated to the commissioner for 
 the alternative care program.  The client must supply the county 
 with the client's social security number at the time of 
 application.  The county shall supply the commissioner with the 
 client's social security number and other information the 
 commissioner requires to collect the premium from the client.  
 The commissioner shall collect unpaid premiums using the Revenue 
 Recapture Act in chapter 270A and other methods available to the 
 commissioner.  The commissioner may require counties to inform 
 clients of the collection procedures that may be used by the 
 state if a premium is not paid.  This paragraph does not apply 
 to alternative care pilot projects authorized in Laws 1993, 
 First Special Session chapter 1, article 5, section 133, if a 
 county operating under the pilot project reports the following 
 dollar amounts to the commissioner quarterly: 

    (1) total premiums billed to clients; 

    (2) total collections of premiums billed; and 

    (3) balance of premiums owed by clients. 

 If a county does not adhere to these reporting requirements, the 
 commissioner may terminate the billing, collecting, and 
 remitting portions of the pilot project and require the county 
 involved to operate under the procedures set forth in this 
 paragraph. 

    Subd. 13.    County biennial plan.  The county biennial 
 plan for long-term care consultation services under section 
 256B.0911, the alternative care program under this section, and 
 waivers for the elderly under section 256B.0915, shall be 
 incorporated into the biennial Community Social Services Act 
 plan and shall meet the regulations and timelines of that plan.  

    Subd. 14.    Provider requirements, payment, and rate 
 adjustments.  (a) Unless otherwise specified in statute, 
 providers must be enrolled as Minnesota health care program 
 providers and abide by the requirements for provider 
 participation according to Minnesota Rules, part 9505.0195. 

    (b) Payment for provided alternative care services as 
 approved by the client's case manager shall occur through the 
 invoice processing procedures of the department's Medicaid 
 Management Information System (MMIS).  To receive payment, the 
 county or vendor must submit invoices within 12 months following 
 the date of service.  The county agency and its vendors under 
 contract shall not be reimbursed for services which exceed the 
 county allocation. 

    (c) The county shall negotiate individual rates with 
 vendors and may authorize service payment for actual costs up to 
 the county's current approved rate.  Notwithstanding any other 
 rule or statutory provision to the contrary, the commissioner 
 shall not be authorized to increase rates by an annual inflation 
 factor, unless so authorized by the legislature.  To improve 
 access to community services and eliminate payment disparities 
 between the alternative care program and the elderly waiver 
 program, the commissioner shall establish statewide maximum 
 service rate limits and eliminate county-specific service rate 
 limits. 

    (1) Effective July 1, 2001, for service rate limits, except 
 those in subdivision 5, paragraphs (d) and (i), the rate limit 
 for each service shall be the greater of the alternative care 
 statewide maximum rate or the elderly waiver statewide maximum 
 rate. 

    (2) Counties may negotiate individual service rates with 
 vendors for actual costs up to the statewide maximum service 
 rate limit. 

    Subd. 15. Repealed, 1998 c 407 art 4 s 69 

    Subd. 15a. Repealed, 1Sp2001 c 9 art 4 s 34 

    Subd. 15b. Repealed, 1Sp2001 c 9 art 4 s 34 

    Subd. 15c. Repealed, 1Sp2001 c 9 art 4 s 34 

    Subd. 16. Repealed, 1Sp2001 c 9 art 4 s 34 

    HIST: 1991 c 292 art 7 s 15; 1992 c 464 art 2 s 1; 1992 c 513 
 art 7 s 56-61; 1Sp1993 c 1 art 5 s 62-67; 1Sp1993 c 6 s 12; 1995 
 c 207 art 6 s 63-69; art 9 s 60; 1995 c 263 s 8; 1996 c 451 art 
 2 s 23-25; art 4 s 70; art 5 s 21,22; 1997 c 113 s 17; 1997 c 
 203 art 4 s 36-39; art 11 s 6; 1997 c 225 art 8 s 3; 1998 c 407 
 art 4 s 36; 1999 c 245 art 3 s 13-16; 2000 c 449 s 1; 1Sp2001 c 
 9 art 4 s 15-27; 2002 c 375 art 2 s 20-25; 2002 c 379 art 1 s 
 113 

     256B.0914 Conflicts of interest related to Medicaid 
  expenditures. 

    Subdivision 1.    Definitions.  (a) "Contract" means a 
 written, fully executed agreement for the purchase of goods and 
 services involving a substantial expenditure of Medicaid 
 funding.  A contract under a renewal period shall be considered 
 a separate contract. 

    (b) "Contractor bid or proposal information" means cost or 
 pricing data, indirect costs, and proprietary information marked 
 as such by the bidder in accordance with applicable law. 

    (c) "Particular expenditure" means a substantial 
 expenditure as defined below, for a specified term, involving 
 specific parties.  The renewal of an existing contract for the 
 substantial expenditure of Medicaid funds is considered a 
 separate, particular expenditure from the original contract. 

    (d) "Source selection information" means any of the 
 following information prepared for use by the state, county, or 
 independent contractor for the purpose of evaluating a bid or 
 proposal to enter into a Medicaid procurement contract, if that 
 information has not been previously made available to the public 
 or disclosed publicly: 

    (1) bid prices submitted in response to a solicitation for 
 sealed bids, or lists of the bid prices before bid opening; 

    (2) proposed costs or prices submitted in response to a 
 solicitation, or lists of those proposed costs or prices; 

    (3) source selection plans; 

    (4) technical evaluations plans; 

    (5) technical evaluations of proposals; 

    (6) cost or price evaluation of proposals; 

    (7) competitive range determinations that identify 
 proposals that have a reasonable chance of being selected for 
 award of a contract; 

    (8) rankings of bids, proposals, or competitors; 

    (9) the reports and evaluations of source selection panels, 
 boards, or advisory councils; and 

    (10) other information marked as "source selection 
 information" based on a case-by-case determination by the head 
 of the agency, contractor, designees, or the contracting officer 
 that disclosure of the information would jeopardize the 
 integrity or successful completion of the Medicaid procurement 
 to which the information relates. 

    (e) "Substantial expenditure" and "substantial amounts" 
 mean a purchase of goods or services in excess of $10,000,000 in 
 Medicaid funding under this chapter or chapter 256L. 

    Subd. 2.    Applicability.  (a) Unless provided 
 otherwise, this section applies to:  

    (1) any state or local officer, employee, or independent 
 contractor who is responsible for the substantial expenditures 
 of medical assistance or MinnesotaCare funding under this 
 chapter or chapter 256L for which federal Medicaid matching 
 funds are available; 

    (2) any individual who formerly was such an officer, 
 employee, or independent contractor; and 

    (3) any partner of such a state or local officer, employee, 
 or independent contractor. 

    (b) This section is intended to meet the requirements of 
 state participation in the Medicaid program at United States 
 Code, title 42, sections 1396a(a)(4) and 1396u-2(d)(3), which 
 require that states have in place restrictions against conflicts 
 of interest in the Medicaid procurement process, that are at 
 least as stringent as those in effect under United States Code, 
 title 41, section 423, and title 18, sections 207 and 208, as 
 they apply to federal employees. 

    Subd. 3.    Disclosure of procurement information.  A 
 person described in subdivision 2 may not knowingly disclose 
 contractor bid or proposal information, or source selection 
 information before the award by the state, county, or 
 independent contractor of a Medicaid procurement contract to 
 which the information relates unless the disclosure is otherwise 
 authorized by law.  No person, other than as provided by law, 
 shall knowingly obtain contractor bid or proposal information or 
 source selection information before the award of a Medicaid 
 procurement contract to which the information relates. 

    Subd. 4.    Offers of employment.  When a person 
 described in subdivision 2, paragraph (a), is participating 
 personally and substantially in a Medicaid procurement for a 
 contract contacts or is contacted by a person who is a bidder or 
 offeror in the same procurement regarding possible employment 
 outside of the entity by which the person is currently employed, 
 the person must:  

    (1) report the contact in writing to the person's 
 supervisor and employer's ethics officer; and 

    (2) either: 

    (i) reject the possibility of employment with the bidder or 
 offeror; or 

    (ii) be disqualified from further participation in the 
 procurement until the bidder or offeror is no longer involved in 
 that procurement, or all discussions with the bidder or offeror 
 regarding possible employment have terminated without an 
 arrangement for employment.  A bidder or offeror may not engage 
 in employment discussions with an official who is subject to 
 this subdivision, until the bidder or offeror is no longer 
 involved in that procurement. 

    Subd. 5.    Acceptance of compensation by a former 
 official.  (a) A former official of the state or county, or a 
 former independent contractor, described in subdivision 2 may 
 not accept compensation from a Medicaid contractor of a 
 substantial expenditure as an employee, officer, director, or 
 consultant of the contractor within one year after the former 
 official or independent contractor: 

    (1) served as the procuring contracting officer, the source 
 selection authority, a member of the source selection evaluation 
 board, or the chief of a financial or technical evaluation team 
 in a procurement in which the contractor was selected for award; 

    (2) served as the program manager, deputy program manager, 
 or administrative contracting officer for a contract awarded to 
 the contractor; or 

    (3) personally made decisions for the state, county, or 
 independent contractor to: 

    (i) award a contract, subcontract, modification of a 
 contract or subcontract, or a task order or delivery order to 
 the contractor; 

    (ii) establish overhead or other rates applicable to a 
 contract or contracts with the contractor; 

    (iii) approve issuance of a contract payment or payments to 
 the contractor; or 

    (iv) pay or settle a claim with the contractor. 

    (b) Paragraph (a) does not prohibit a former official of 
 the state, county, or independent contractor from accepting 
 compensation from any division or affiliate of a contractor not 
 involved in the same or similar products or services as the 
 division or affiliate of the contractor that is responsible for 
 the contract referred to in paragraph (a), clause (1), (2), or 
 (3). 

    (c) A contractor shall not provide compensation to a former 
 official knowing that the former official is accepting that 
 compensation in violation of this subdivision. 

    Subd. 6.    Permanent restrictions on representation and 
 communication.  (a) A person described in subdivision 2, after 
 termination of service with the state, county, or independent 
 contractor, is permanently restricted from knowingly making, 
 with the intent to influence, any communication to or appearance 
 before an officer or employee of a department, agency, or court 
 of the United States, the state of Minnesota and its counties in 
 connection with a particular expenditure: 

    (1) in which the United States, the state of Minnesota, or 
 a Minnesota county is a party or has a direct and substantial 
 interest; 

    (2) in which the person participated personally and 
 substantially as an officer, employee, or independent 
 contractor; and 

    (3) which involved a specific party or parties at the time 
 of participation. 

    (b) For purposes of this subdivision and subdivisions 7 and 
 9, "participated" means an action taken through decision, 
 approval, disapproval, recommendation, the rendering of advice, 
 investigation, or other such action. 

    Subd. 7.    Two-year restrictions on representation and 
 communication.  No person described in subdivision 2, within 
 two years after termination of service with the state, county, 
 or independent contractor, shall knowingly make, with the intent 
 to influence, any communication to or appearance before any 
 officer or employee of any government department, agency, or 
 court in connection with a particular expenditure: 

    (1) in which the United States, the state of Minnesota, or 
 a Minnesota county is a party or has a direct and substantial 
 interest; 

    (2) which the person knows or reasonably should know was 
 actually pending under the official's responsibility as an 
 officer, employee, or independent contractor within one year 
 before the termination of the official's service with the state, 
 county, or independent contractor; and 

    (3) which involved a specific party or parties at the time 
 the expenditure was pending. 

    Subd. 8.    Exceptions to permanent and two-year 
 restrictions on representation and communication.  
 Subdivisions 6 and 7 do not apply to: 

    (1) communications or representations made in carrying out 
 official duties on behalf of the United States, the state of 
 Minnesota or local government, or as an elected official of the 
 state or local government; 

    (2) communications made solely for the purpose of 
 furnishing scientific or technological information; or 

    (3) giving testimony under oath.  A person subject to 
 subdivisions 6 and 7 may serve as an expert witness in that 
 matter, without restriction, for the state, county, or 
 independent contractor.  Under court order, a person subject to 
 subdivisions 6 and 7 may serve as an expert witness for others.  
 Otherwise, the person may not serve as an expert witness in that 
 matter. 

    Subd. 9.    Waiver.  The commissioner of human services, 
 or the governor in the case of the commissioner, may grant a 
 waiver of a restriction in subdivisions 6 and 7 upon determining 
 that a waiver is in the public interest and that the services of 
 the officer or employee are critically needed for the benefit of 
 the state or county government. 

    Subd. 10.    Acts affecting a personal financial interest. 
  A person described in subdivision 2, paragraph (a), clause 
 (1), who participates in a particular expenditure in which the 
 person has knowledge or has a financial interest, is subject to 
 the penalties in subdivision 12.  For purposes of this 
 subdivision, "financial interest" also includes the financial 
 interest of a spouse, minor child, general partner, organization 
 in which the officer or employee is serving as an officer, 
 director, trustee, general partner, or employee, or any person 
 or organization with whom the individual is negotiating or has 
 any arrangement concerning prospective employment. 

    Subd. 11.    Exceptions to prohibitions regarding 
 financial interest.  Subdivision 10 does not apply if: 

    (1) the person first advises the person's supervisor and 
 the employer's ethics officer regarding the nature and 
 circumstances of the particular expenditure and makes full 
 disclosure of the financial interest and receives in advance a 
 written determination made by the commissioner of human 
 services, or the governor in the case of the commissioner, that 
 the interest is not so substantial as to likely affect the 
 integrity of the services which the government may expect from 
 the officer, employee, or independent contractor; 

    (2) the financial interest is listed as an exemption at 
 Code of Federal Regulations, title 5, sections 2640.201 to 
 2640.203, as too remote or inconsequential to affect the 
 integrity of the services of the office, employee, or 
 independent contractor to which the requirement applies. 

    Subd. 12.    Criminal penalties.  (a) A person who 
 violates subdivisions 3 to 5 for the purpose of either 
 exchanging the information covered by this section for anything 
 of value, or for obtaining or giving anyone a competitive 
 advantage in the award of a Medicaid contract, may be sentenced 
 to imprisonment for not more than five years or payment of a 
 fine of not more than $50,000 for each violation, or the amount 
 of compensation which the person received or offered for the 
 prohibited conduct, whichever is greater, or both. 

    (b) A person who violates a provision of subdivisions 6 to 
 11 may be sentenced to imprisonment for not more than one year 
 or payment of a fine of not more than $50,000 for each violation 
 or the amount of compensation which the person received or 
 offered for the prohibited conduct, whichever amount is greater, 
 or both.  A person who willfully engages in conduct in violation 
 of subdivisions 6 to 11 may be sentenced to imprisonment for not 
 more than five years or to payment of a fine of not more than 
 $50,000 for each violation or the amount of compensation which 
 the person received or offered for the prohibited conduct, 
 whichever amount is greater, or both. 

    (c) Nothing in this section precludes prosecution under 
 other laws such as section 609.43. 

    Subd. 13.    Civil penalties and injunctive relief.  (a) 
 The Minnesota attorney general may bring a civil action in 
 Ramsey county district court against a person who violates this 
 section. Upon proof of such conduct by a preponderance of 
 evidence, the person is subject to a civil penalty.  An 
 individual who violates this section is subject to a civil 
 penalty of not more than $50,000 for each violation plus twice 
 the amount of compensation which the individual received or 
 offered for the prohibited conduct.  An organization that 
 violates this section is subject to a civil penalty of not more 
 than $500,000 for each violation plus twice the amount of 
 compensation which the organization received or offered for the 
 prohibited conduct. 

    (b) If the Minnesota attorney general has reason to believe 
 that a person is engaging in conduct in violation of this 
 section, the attorney general may petition the Ramsey county 
 district court for an order prohibiting that person from 
 engaging in such conduct.  The court may issue an order 
 prohibiting that person from engaging in such conduct if the 
 court finds that the conduct constitutes such a violation.  The 
 filing of a petition under this subdivision does not preclude 
 any other remedy which is available by law. 

    Subd. 14.    Administrative actions.  (a) If a state 
 agency, local agency, or independent contractor receives 
 information that a contractor or a person has violated this 
 section, the state agency, local agency, or independent 
 contractor may: 

    (1) cancel the procurement if a contract has not already 
 been awarded; 

    (2) rescind the contract; or 

    (3) initiate suspension or debarment proceedings according 
 to applicable state or federal law. 

    (b) If the contract is rescinded, the state agency, local 
 agency, or independent contractor is entitled to recover, in 
 addition to any penalty prescribed by law, the amount expended 
 under the contract. 

    (c) This section does not: 

    (1) restrict the disclosure of information to or from any 
 person or class of persons authorized to receive that 
 information; 

    (2) restrict a contractor from disclosing the contractor's 
 bid or proposal information or the recipient from receiving that 
 information; 

    (3) restrict the disclosure or receipt of information 
 relating to a Medicaid procurement after it has been canceled by 
 the state agency, county agency, or independent contractor 
 before the contract award unless the agency or independent 
 contractor plans to resume the procurement; or 

    (4) limit the applicability of any requirements, sanctions, 
 contract penalties, and remedies established under any other law 
 or regulation. 

    (d) No person may file a protest against the award or 
 proposed award of a Medicaid contract alleging a violation of 
 this section unless that person reported the information the 
 person believes constitutes evidence of the offense to the 
 applicable state agency, local agency, or independent contractor 
 responsible for the procurement.  The report must be made no 
 later than 14 days after the person first discovered the 
 possible violation. 

    HIST: 1986 c 444; 1999 c 245 art 4 s 60 

     256B.0915 Medicaid waiver for home and community-based 
  services for the elderly. 

    Subdivision 1.    Authority.  The commissioner is 
 authorized to apply for a home and community-based services 
 waiver for the elderly, authorized under section 1915(c) of the 
 Social Security Act, in order to obtain federal financial 
 participation to expand the availability of services for persons 
 who are eligible for medical assistance.  The commissioner may 
 apply for additional waivers or pursue other federal financial 
 participation which is advantageous to the state for funding 
 home care services for the frail elderly who are eligible for 
 medical assistance.  The provision of waivered services to 
 elderly and disabled medical assistance recipients must comply 
 with the criteria approved in the waiver. 

    Subd. 1a.    Elderly waiver case management services.  
 Elderly case management services under the home and 
 community-based services waiver for elderly individuals are 
 available from providers meeting qualification requirements and 
 the standards specified in subdivision 1b.  Eligible recipients 
 may choose any qualified provider of elderly case management 
 services. 

    Subd. 1b.    Provider qualifications and standards.  The 
 commissioner must enroll qualified providers of elderly case 
 management services under the home and community-based waiver 
 for the elderly under section 1915(c) of the Social Security 
 Act.  The enrollment process shall ensure the provider's ability 
 to meet the qualification requirements and standards in this 
 subdivision and other federal and state requirements of this 
 service.  An elderly case management provider is an enrolled 
 medical assistance provider who is determined by the 
 commissioner to have all of the following characteristics: 

    (1) the demonstrated capacity and experience to provide the 
 components of case management to coordinate and link community 
 resources needed by the eligible population; 

    (2) administrative capacity and experience in serving the 
 target population for whom it will provide services and in 
 ensuring quality of services under state and federal 
 requirements; 

    (3) a financial management system that provides accurate 
 documentation of services and costs under state and federal 
 requirements; 

    (4) the capacity to document and maintain individual case 
 records under state and federal requirements; and 

    (5) the county may allow a case manager employed by the 
 county to delegate certain aspects of the case management 
 activity to another individual employed by the county provided 
 there is oversight of the individual by the case manager.  The 
 case manager may not delegate those aspects which require 
 professional judgment including assessments, reassessments, and 
 care plan development. 

    Subd. 1c.    Case management activities under the state 
 plan.  The commissioner shall seek an amendment to the home 
 and community-based services waiver for the elderly to implement 
 the provisions of subdivisions 1a and 1b.  If the commissioner 
 is unable to secure the approval of the secretary of health and 
 human services for the requested waiver amendment by December 
 31, 1993, the commissioner shall amend the medical assistance 
 state plan to provide that case management provided under the 
 home and community-based services waiver for the elderly is 
 performed by counties as an administrative function for the 
 proper and effective administration of the state medical 
 assistance plan.  The state shall reimburse counties for the 
 nonfederal share of costs for case management performed as an 
 administrative function under the home and community-based 
 services waiver for the elderly. 

    Subd. 1d.    Posteligibility treatment of income and 
 resources for elderly waiver.  Notwithstanding the provisions 
 of section 256B.056, the commissioner shall make the following 
 amendment to the medical assistance elderly waiver program 
 effective July 1, 1999, or upon federal approval, whichever is 
 later. 

    A recipient's maintenance needs will be an amount equal to 
 the Minnesota supplemental aid equivalent rate as defined in 
 section 256I.03, subdivision 5, plus the medical assistance 
 personal needs allowance as defined in section 256B.35, 
 subdivision 1, paragraph (a), when applying posteligibility 
 treatment of income rules to the gross income of elderly waiver 
 recipients, except for individuals whose income is in excess of 
 the special income standard according to Code of Federal 
 Regulations, title 42, section 435.236.  Recipient maintenance 
 needs shall be adjusted under this provision each July 1. 

    Subd. 2.    Spousal impoverishment policies.  The 
 commissioner shall seek to amend the federal waiver and the 
 medical assistance state plan to allow spousal impoverishment 
 criteria as authorized under United States Code, title 42, 
 section 1396r-5, and as implemented in sections 256B.0575, 
 256B.058, and 256B.059, except that the amendment shall seek to 
 add to the personal needs allowance permitted in section 
 256B.0575, an amount equivalent to the group residential housing 
 rate as set by section 256I.03, subdivision 5. 

    Subd. 3.    Limits of cases, rates, payments, and 
 forecasting.  (a) The number of medical assistance waiver 
 recipients that a county may serve must be allocated according 
 to the number of medical assistance waiver cases open on July 1 
 of each fiscal year.  Additional recipients may be served with 
 the approval of the commissioner. 

    (b) The monthly limit for the cost of waivered services to 
 an individual elderly waiver client shall be the weighted 
 average monthly nursing facility rate of the case mix resident 
 class to which the elderly waiver client would be assigned under 
 Minnesota Rules, parts 9549.0050 to 9549.0059, less the 
 recipient's maintenance needs allowance as described in 
 subdivision 1d, paragraph (a), until the first day of the state 
 fiscal year in which the resident assessment system as described 
 in section 256B.437 for nursing home rate determination is 
 implemented.  Effective on the first day of the state fiscal 
 year in which the resident assessment system as described in 
 section 256B.437 for nursing home rate determination is 
 implemented and the first day of each subsequent state fiscal 
 year, the monthly limit for the cost of waivered services to an 
 individual elderly waiver client shall be the rate of the case 
 mix resident class to which the waiver client would be assigned 
 under Minnesota Rules, parts 9549.0050 to 9549.0059, in effect 
 on the last day of the previous state fiscal year, adjusted by 
 the greater of any legislatively adopted home and 
 community-based services cost-of-living percentage increase or 
 any legislatively adopted statewide percent rate increase for 
 nursing facilities. 

    (c) If extended medical supplies and equipment or 
 environmental modifications are or will be purchased for an 
 elderly waiver client, the costs may be prorated for up to 12 
 consecutive months beginning with the month of purchase.  If the 
 monthly cost of a recipient's waivered services exceeds the 
 monthly limit established in paragraph (b), the annual cost of 
 all waivered services shall be determined.  In this event, the 
 annual cost of all waivered services shall not exceed 12 times 
 the monthly limit of waivered services as described in paragraph 
 (b).  

    (d) For a person who is a nursing facility resident at the 
 time of requesting a determination of eligibility for elderly 
 waivered services, a monthly conversion limit for the cost of 
 elderly waivered services may be requested.  The monthly 
 conversion limit for the cost of elderly waiver services shall 
 be the resident class assigned under Minnesota Rules, parts 
 9549.0050 to 9549.0059, for that resident in the nursing 
 facility where the resident currently resides until July 1 of 
 the state fiscal year in which the resident assessment system as 
 described in section 256B.437 for nursing home rate 
 determination is implemented.  Effective on July 1 of the state 
 fiscal year in which the resident assessment system as described 
 in section 256B.437 for nursing home rate determination is 
 implemented, the monthly conversion limit for the cost of 
 elderly waiver services shall be the per diem nursing facility 
 rate as determined by the resident assessment system as 
 described in section 256B.437 for that resident in the nursing 
 facility where the resident currently resides multiplied by 365 
 and divided by 12, less the recipient's maintenance needs 
 allowance as described in subdivision 1d.  The initially 
 approved conversion rate may be adjusted by the greater of any 
 subsequent legislatively adopted home and community-based 
 services cost-of-living percentage increase or any subsequent 
 legislatively adopted statewide percentage rate increase for 
 nursing facilities.  The limit under this clause only applies to 
 persons discharged from a nursing facility after a minimum 
 30-day stay and found eligible for waivered services on or after 
 July 1, 1997.  The following costs must be included in 
 determining the total monthly costs for the waiver client: 

    (1) cost of all waivered services, including extended 
 medical supplies and equipment and environmental modifications; 
 and 

    (2) cost of skilled nursing, home health aide, and personal 
 care services reimbursable by medical assistance.  

    (e) Medical assistance funding for skilled nursing 
 services, private duty nursing, home health aide, and personal 
 care services for waiver recipients must be approved by the case 
 manager and included in the individual care plan. 

    (f) A county is not required to contract with a provider of 
 supplies and equipment if the monthly cost of the supplies and 
 equipment is less than $250.  

    (g) The adult foster care rate shall be considered a 
 difficulty of care payment and shall not include room and 
 board.  The adult foster care service rate shall be negotiated 
 between the county agency and the foster care provider.  The 
 elderly waiver payment for the foster care service in 
 combination with the payment for all other elderly waiver 
 services, including case management, must not exceed the limit 
 specified in paragraph (b). 

    (h) Payment for assisted living service shall be a monthly 
 rate negotiated and authorized by the county agency based on an 
 individualized service plan for each resident and may not cover 
 direct rent or food costs. 

    (1) The individualized monthly negotiated payment for 
 assisted living services as described in section 256B.0913, 
 subdivision 5, paragraph (g) or (h), and residential care 
 services as described in section 256B.0913, subdivision 5, 
 paragraph (f), shall not exceed the nonfederal share, in effect 
 on July 1 of the state fiscal year for which the rate limit is 
 being calculated, of the greater of either the statewide or any 
 of the geographic groups' weighted average monthly nursing 
 facility rate of the case mix resident class to which the 
 elderly waiver eligible client would be assigned under Minnesota 
 Rules, parts 9549.0050 to 9549.0059, less the maintenance needs 
 allowance as described in subdivision 1d, paragraph (a), until 
 the July 1 of the state fiscal year in which the resident 
 assessment system as described in section 256B.437 for nursing 
 home rate determination is implemented.  Effective on July 1 of 
 the state fiscal year in which the resident assessment system as 
 described in section 256B.437 for nursing home rate 
 determination is implemented and July 1 of each subsequent state 
 fiscal year, the individualized monthly negotiated payment for 
 the services described in this clause shall not exceed the limit 
 described in this clause which was in effect on June 30 of the 
 previous state fiscal year and which has been adjusted by the 
 greater of any legislatively adopted home and community-based 
 services cost-of-living percentage increase or any legislatively 
 adopted statewide percent rate increase for nursing facilities. 

    (2) The individualized monthly negotiated payment for 
 assisted living services described in section 144A.4605 and 
 delivered by a provider licensed by the department of health as 
 a class A home care provider or an assisted living home care 
 provider and provided in a building that is registered as a 
 housing with services establishment under chapter 144D and that 
 provides 24-hour supervision in combination with the payment for 
 other elderly waiver services, including case management, must 
 not exceed the limit specified in paragraph (b). 

    (i) The county shall negotiate individual service rates 
 with vendors and may authorize payment for actual costs up to 
 the county's current approved rate.  Persons or agencies must be 
 employed by or under a contract with the county agency or the 
 public health nursing agency of the local board of health in 
 order to receive funding under the elderly waiver program, 
 except as a provider of supplies and equipment when the monthly 
 cost of the supplies and equipment is less than $250.  

    (j) Reimbursement for the medical assistance recipients 
 under the approved waiver shall be made from the medical 
 assistance account through the invoice processing procedures of 
 the department's Medicaid Management Information System (MMIS), 
 only with the approval of the client's case manager.  The budget 
 for the state share of the Medicaid expenditures shall be 
 forecasted with the medical assistance budget, and shall be 
 consistent with the approved waiver.  

    (k) To improve access to community services and eliminate 
 payment disparities between the alternative care program and the 
 elderly waiver, the commissioner shall establish statewide 
 maximum service rate limits and eliminate county-specific 
 service rate limits. 

    (1) Effective July 1, 2001, for service rate limits, except 
 those described or defined in paragraphs (g) and (h), the rate 
 limit for each service shall be the greater of the alternative 
 care statewide maximum rate or the elderly waiver statewide 
 maximum rate. 

    (2) Counties may negotiate individual service rates with 
 vendors for actual costs up to the statewide maximum service 
 rate limit. 

    Subd. 3a. Repealed, 1Sp2001 c 9 art 3 s 76; art 4 s 34 

    Subd. 3b. Repealed, 1Sp2001 c 9 art 3 s 76; art 4 s 34 

    Subd. 3c. Repealed, 1Sp2001 c 9 art 3 s 76; art 4 s 34 

    Subd. 4.    Termination notice.  The case manager must 
 give the individual a ten-day written notice of any denial, 
 reduction, or termination of waivered services. 

    Subd. 5.    Assessments and reassessments for waiver 
 clients.  Each client shall receive an initial assessment of 
 strengths, informal supports, and need for services in 
 accordance with section 256B.0911, subdivisions 3, 3a, and 3b.  
 A reassessment of a client served under the elderly waiver must 
 be conducted at least every 12 months and at other times when 
 the case manager determines that there has been significant 
 change in the client's functioning.  This may include instances 
 where the client is discharged from the hospital.  

    Subd. 6.    Implementation of care plan.  Each elderly 
 waiver client shall be provided a copy of a written care plan 
 that meets the requirements outlined in section 256B.0913, 
 subdivision 8.  If the county administering waivered services is 
 different than the county of financial responsibility, the care 
 plan may be implemented without the approval of the county of 
 financial responsibility. 

    Subd. 7.    Prepaid elderly waiver services.  An 
 individual for whom a prepaid health plan is liable for nursing 
 home services or elderly waiver services according to section 
 256B.69, subdivision 6a, is not eligible to receive 
 county-administered elderly waiver services under this section. 

    Subd. 8.    Services and supports.  (a) Services and 
 supports shall meet the requirements set out in United States 
 Code, title 42, section 1396n. 

    (b) Services and supports shall promote consumer choice and 
 be arranged and provided consistent with individualized, written 
 care plans. 

    (c) The state of Minnesota, county, or tribal government 
 under contract to administer the elderly waiver shall not be 
 liable for damages, injuries, or liabilities sustained through 
 the purchase of direct supports or goods by the person, the 
 person's family, or the authorized representatives with funds 
 received through consumer-directed community support services 
 under the federally approved waiver plan.  Liabilities include, 
 but are not limited to, workers' compensation liability, the 
 Federal Insurance Contributions Act (FICA), or the Federal 
 Unemployment Tax Act (FUTA). 

    HIST: 1991 c 292 art 7 s 16; 1992 c 513 art 7 s 62-64; 1Sp1993 
 c 1 art 5 s 68-72; 1Sp1993 c 6 s 13; 1995 c 207 art 6 s 70-74; 
 1995 c 263 s 9; 1996 c 451 art 2 s 26-28; art 5 s 23,24; 1997 c 
 113 s 18; 1997 c 203 art 4 s 40-43; 1998 c 407 art 4 s 37,38; 
 1Sp2001 c 9 art 4 s 28-30; 2002 c 277 s 16,17; 2002 c 375 art 2 
 s 26-30; 2002 c 379 art 1 s 113 

     256B.0916 Expansion of home and community-based 
  services; management and allocation responsibilities. 

    Subdivision 1. Repealed, 2002 c 220 art 14 s 20 

    Subd. 2.    Distribution of funds; partnerships.  (a) 
 Beginning with fiscal year 2000, the commissioner shall 
 distribute all funding available for home and community-based 
 waiver services for persons with mental retardation or related 
 conditions to individual counties or to groups of counties that 
 form partnerships to jointly plan, administer, and authorize 
 funding for eligible individuals.  The commissioner shall 
 encourage counties to form partnerships that have a sufficient 
 number of recipients and funding to adequately manage the risk 
 and maximize use of available resources.  

    (b) Counties must submit a request for funds and a plan for 
 administering the program as required by the commissioner.  The 
 plan must identify the number of clients to be served, their 
 ages, and their priority listing based on: 

    (1) requirements in Minnesota Rules, part 9525.1880; 

    (2) unstable living situations due to the age or incapacity 
 of the primary caregiver; 

    (3) the need for services to avoid out-of-home placement of 
 children; and 

    (4) the need to serve persons affected by private sector 
 ICF/MR closures. 

 The plan must also identify changes made to improve services to 
 eligible persons and to improve program management. 

    (c) In allocating resources to counties, priority must be 
 given to groups of counties that form partnerships to jointly 
 plan, administer, and authorize funding for eligible individuals 
 and to counties determined by the commissioner to have 
 sufficient waiver capacity to maximize resource use. 

    (d) Within 30 days after receiving the county request for 
 funds and plans, the commissioner shall provide a written 
 response to the plan that includes the level of resources 
 available to serve additional persons. 

    (e) Counties are eligible to receive medical assistance 
 administrative reimbursement for administrative costs under 
 criteria established by the commissioner.  

    Subd. 3.    Failure to develop partnerships or submit a 
 plan.  (a) By October 1 of each year the commissioner shall 
 notify the county board if any county determined by the 
 commissioner to have insufficient capacity to maximize use of 
 available resources fails to develop a partnership with other 
 counties or fails to submit a plan as required in subdivision 
 2.  The commissioner shall provide needed technical assistance 
 to a county or group of counties that fails to form a 
 partnership or submit a plan.  If a county has not joined a 
 county partnership or submitted a plan within 30 days following 
 the notice by the commissioner of its failure, the commissioner 
 shall require and assist that county to develop a plan or 
 contract with another county or group of counties to plan and 
 administer the waiver services program in that county. 

    (b) Counties may request technical assistance, management 
 information, and administrative support from the commissioner at 
 any time.  The commissioner shall respond to county requests 
 within 30 days.  Priority shall be given to activities that 
 support the administrative needs of newly formed county 
 partnerships. 

    Subd. 4.    Allowed reserve.  Counties or groups of 
 counties participating in partnerships that have submitted a 
 plan under this section may develop an allowed reserve amount to 
 meet crises and other unmet needs of current home and 
 community-based waiver recipients.  The amount of the allowed 
 reserve shall be a county specific amount based upon documented 
 past experience and projected need for the coming year described 
 in an allowed reserve plan submitted for approval to the 
 commissioner with the allocation request for the fiscal year. 

    Subd. 5.    Allocation of new diversions and priorities 
 for reassignment of resources for the home and community-based 
 waiver for persons with mental retardation or related 
 conditions.  (a) The commissioner shall monitor county 
 utilization of allocated resources and, as appropriate, reassign 
 resources not utilized.  

    (b) Effective July 1, 2002, the commissioner shall 
 authorize the spending of new diversion resources beginning 
 January 1 of each year. 

    (c) Effective July 1, 2002, the commissioner shall manage 
 the reassignment of waiver resources that occur from persons who 
 have left the waiver in a manner that results in the cost 
 reduction equivalent to delaying the reuse of those waiver 
 resources by 180 days. 

    (d) Priority consideration for reassignment of resources 
 shall be given to counties that form partnerships.  In addition 
 to the priorities listed in Minnesota Rules, part 9525.1880, the 
 commissioner shall also give priority consideration to persons 
 whose living situations are unstable due to the age or 
 incapacity of the primary caregiver and to children to avoid 
 out-of-home placement. 

    Subd. 6.    Waiver request.  (a) The commissioner shall 
 submit to the federal Health Care Financing Administration by 
 September 1, 1999, a request for a waiver to include an option 
 that would allow waiver service recipients to directly receive 
 95 percent of the funds that would be allocated to individuals 
 based on written county criteria and procedures approved by the 
 commissioner for the purchase of services to meet their 
 long-term care needs.  The waiver request must include a 
 provision requiring recipients who receive funds directly to 
 provide to the commissioner annually, a description of the type 
 of services used, the amount paid for the services purchased, 
 and the amount of unspent funds. 

    (b) The commissioner, in cooperation with county 
 representatives, waiver service providers, recipients, 
 recipients' families, legal guardians, and advocacy groups, 
 shall develop criteria for: 

    (1) eligibility to receive funding directly; 

    (2) determination of the amount of funds made available to 
 each eligible person based on need; and 

    (3) the accountability required of persons directly 
 receiving funds. 

    (c) If this waiver is approved and implemented, any unspent 
 money from the waiver services allocation, including the five 
 percent not directly allocated to recipients and any unspent 
 portion of the money that is directly allocated, shall be used 
 to meet the needs of other eligible persons waiting for services 
 funded through the waiver. 

    (d) The commissioner, in consultation with county social 
 services agencies, waiver services providers, recipients, 
 recipients' families, legal guardians, and advocacy groups shall 
 evaluate the effectiveness of this option within two years of 
 its implementation. 

    Subd. 6a.    Statewide availability of consumer-directed 
 community support services.  (a) The commissioner shall submit 
 to the federal Health Care Financing Administration by August 1, 
 2001, an amendment to the home and community-based waiver for 
 persons with mental retardation or related conditions to make 
 consumer-directed community support services available in every 
 county of the state by January 1, 2002. 

    (b) If a county declines to meet the requirements for 
 provision of consumer-directed community supports, the 
 commissioner shall contract with another county, a group of 
 counties, or a private agency to plan for and administer 
 consumer-directed community supports in that county. 

    (c) The state of Minnesota, county agencies, tribal 
 governments, or administrative entities under contract to 
 participate in the implementation and administration of the home 
 and community-based waiver for persons with mental retardation 
 or a related condition, shall not be liable for damages, 
 injuries, or liabilities sustained through the purchase of 
 support by the individual, the individual's family, legal 
 representative, or the authorized representative with funds 
 received through the consumer-directed community support service 
 under this section.  Liabilities include but are not limited 
 to:  workers' compensation liability, the Federal Insurance 
 Contributions Act (FICA), or the Federal Unemployment Tax Act 
 (FUTA). 

    Subd. 7.    Annual report by commissioner.  Beginning 
 November 1, 2001, and each November 1 thereafter, the 
 commissioner shall issue an annual report on county and state 
 use of available resources for the home and community-based 
 waiver for persons with mental retardation or related 
 conditions.  For each county or county partnership, the report 
 shall include: 

    (1) the amount of funds allocated but not used; 

    (2) the county specific allowed reserve amount approved and 
 used; 

    (3) the number, ages, and living situations of individuals 
 screened and waiting for services; 

    (4) the urgency of need for services to begin within one, 
 two, or more than two years for each individual; 

    (5) the services needed; 

    (6) the number of additional persons served by approval of 
 increased capacity within existing allocations; 

    (7) results of action by the commissioner to streamline 
 administrative requirements and improve county resource 
 management; and 

    (8) additional action that would decrease the number of 
 those eligible and waiting for waivered services. 

 The commissioner shall specify intended outcomes for the program 
 and the degree to which these specified outcomes are attained. 

    Subd. 8.    Financial information by county.  The 
 commissioner shall make available to interested parties, upon 
 request, financial information by county including the amount of 
 resources allocated for the home and community-based waiver for 
 persons with mental retardation and related conditions, the 
 resources committed, the number of persons screened and waiting 
 for services, the type of services requested by those waiting, 
 and the amount of allocated resources not committed. 

    Subd. 9.    Legal representative participation exception. 
  The commissioner, in cooperation with representatives of 
 counties, service providers, service recipients, family members, 
 legal representatives and advocates, shall develop criteria to 
 allow legal representatives to be reimbursed for providing 
 specific support services to meet the person's needs when a plan 
 which assures health and safety has been agreed upon and carried 
 out by the legal representative, the person, and the county.  
 Legal representatives providing support under the home and 
 community-based waiver for persons with mental retardation or 
 related conditions or the consumer support grant program 
 pursuant to section 256.476, shall not be considered to have a 
 direct or indirect service provider interest under section 
 256B.092, subdivision 7, if a health and safety plan which meets 
 the criteria established has been agreed upon and implemented.  
 By August 1, 2001, the commissioner shall submit, for federal 
 approval, amendments to allow legal representatives to provide 
 support and receive reimbursement under the home and 
 community-based waiver plan. 

    HIST: 1Sp1993 c 1 art 4 s 8; 1998 c 407 art 4 s 39; 1999 c 245 
 art 4 s 61; 2000 c 488 art 11 s 7; 1Sp2001 c 9 art 3 s 43-45; 
 2002 c 220 art 14 s 6; 2002 c 379 art 1 s 113 

     256B.0917 Seniors' Agenda for Independent Living (SAIL) 
  projects for a new long-term care strategy. 

    Subdivision 1.    Purpose, mission, goals, and objectives. 
  (a) The purpose of implementing seniors' agenda for 
 independent living (SAIL) projects under this section is to 
 demonstrate a new cooperative strategy for the long-term care 
 system in the state of Minnesota.  

    The projects are part of the initial plan for a 20-year 
 strategy.  The mission of the 20-year strategy is to create a 
 new community-based care paradigm for long-term care in 
 Minnesota in order to maximize independence of the older adult 
 population, and to ensure cost-effective use of financial and 
 human resources.  The goals for the 20-year strategy are to: 

    (1) achieve a broad awareness and use of low-cost home care 
 and other residential alternatives to nursing homes; 

    (2) develop a statewide system of information and 
 assistance to enable easy access to long-term care services; 

    (3) develop sufficient alternatives to nursing homes to 
 serve the increased number of people needing long-term care; 

    (4) maintain the moratorium on new construction of nursing 
 home beds and to lower the percentage of elderly persons served 
 in institutional settings; and 

    (5) build a community-based approach and community 
 commitment to delivering long-term care services for elderly 
 persons in their homes. 

    (b) The objective for the fiscal years 1994 and 1995 
 biennial plan is to continue at least four but not more than six 
 projects in anticipation of a statewide program.  These projects 
 will continue the process of implementing: 

    (1) a coordinated planning and administrative process; 

    (2) a refocused function of the preadmission screening 
 program; 

    (3) the development of additional home, community, and 
 residential alternatives to nursing homes; 

    (4) a program to support the informal caregivers for 
 elderly persons; 

    (5) programs to strengthen the use of volunteers; and 

    (6) programs to support the building of community 
 commitment to provide long-term care for elderly persons.  

    The services offered through these projects are available 
 to those who have their own funds to pay for services, as well 
 as to persons who are eligible for medical assistance and to 
 persons who are 180-day eligible clients to the extent 
 authorized in this section. 

    Subd. 2.    Design of SAIL projects; local long-term care 
 coordinating team.  (a) The commissioner of human services 
 shall contract with SAIL projects in four to six counties or 
 groups of counties to demonstrate the feasibility and 
 cost-effectiveness of a local long-term care strategy that is 
 consistent with the state's long-term care goals identified in 
 subdivision 1.  The commissioner shall publish a notice in the 
 State Register announcing the availability of project funding 
 and giving instructions for making an application.  The 
 instructions for the application shall identify the amount of 
 funding available for project components. 

    (b) To be selected for the project, a county board or 
 boards must establish a long-term care coordinating team 
 consisting of county social service agencies, public health 
 nursing service agencies, local boards of health, a 
 representative of local nursing home providers, a representative 
 of local home care providers, and the area agencies on aging in 
 a geographic area which is responsible for: 

    (1) developing a local long-term care strategy consistent 
 with state goals and objectives; 

    (2) submitting an application to be selected as a project; 

    (3) coordinating planning for funds to provide services to 
 elderly persons, including funds received under Title III of the 
 Older Americans Act, Community Social Services Act, Title XX of 
 the Social Security Act and the Local Public Health Act; and 

    (4) ensuring efficient services provision and 
 nonduplication of funding. 

    (c) The board or boards shall designate a public agency to 
 serve as the lead agency.  The lead agency receives and manages 
 the project funds from the state and is responsible for the 
 implementation of the local strategy.  If selected as a project, 
 the local long-term care coordinating team must semiannually 
 evaluate the progress of the local long-term care strategy in 
 meeting state measures of performance and results as established 
 in the contract. 

    (d) Each member of the local coordinating team must 
 indicate its endorsement of the local strategy.  The local 
 long-term care coordinating team may include in its membership 
 other units of government which provide funding for services to 
 the frail elderly.  The team must cooperate with consumers and 
 other public and private agencies, including nursing homes, in 
 the geographic area in order to develop and offer a variety of 
 cost-effective services to the elderly and their caregivers. 

    (e) The board or boards shall apply to be selected as a 
 project.  If the project is selected, the commissioner of human 
 services shall contract with the lead agency for the project and 
 shall provide additional administrative funds for implementing 
 the provisions of the contract, within the appropriation 
 available for this purpose. 

    (f) Projects shall be selected according to the following 
 conditions.  

    No project may be selected unless it demonstrates that: 

    (i) the objectives of the local project will help to 
 achieve the state's long-term care goals as defined in 
 subdivision 1; 

    (ii) in the case of a project submitted jointly by several 
 counties, all of the participating counties are contiguous; 

    (iii) there is a designated local lead agency that is 
 empowered to make contracts with the state and local vendors on 
 behalf of all participants; 

    (iv) the project proposal demonstrates that the local 
 cooperating agencies have the ability to perform the project as 
 described and that the implementation of the project has a 
 reasonable chance of achieving its objectives; 

    (v) the project will serve an area that covers at least 
 four counties or contains at least 2,500 persons who are 85 
 years of age or older, according to the projections of the state 
 demographer or the census if the data is more recent; and 

    (vi) the local coordinating team documents efforts of 
 cooperation with consumers and other agencies and organizations, 
 both public and private, in planning for service delivery. 

    Subd. 3.    Local long-term care strategy.  The local 
 long-term care strategy must list performance outcomes and 
 indicators which meet the state's objectives.  The local 
 strategy must provide for: 

    (1) accessible information, assessment, and preadmission 
 screening activities as described in subdivision 4; 

    (2) an increase in numbers of alternative care clients 
 served under section 256B.0913, including those who are 
 relocated from nursing homes, which results in a reduction of 
 the medical assistance nursing home caseload; and 

    (3) the development of additional services such as adult 
 family foster care homes; family adult day care; assisted living 
 projects and congregate housing service projects in apartment 
 buildings; expanded home care services for evenings and 
 weekends; expanded volunteer services; and caregiver support and 
 respite care projects. 

    The county or groups of counties selected for the projects 
 shall be required to comply with federal regulations, 
 alternative care funding policies in section 256B.0913, and the 
 federal waiver programs' policies in section 256B.0915.  The 
 requirements for preadmission screening are defined in section 
 256B.0911, subdivisions 1 to 6.  Requirements for an access, 
 screening, and assessment function are defined in subdivision 
 4.  Requirements for the service development and service 
 provision are defined in subdivision 5. 

    Subd. 4.    Accessible information, screening, and 
 assessment function.  (a) The projects selected by and under 
 contract with the commissioner shall establish an accessible 
 information, screening, and assessment function for persons who 
 need assistance and information regarding long-term care.  This 
 accessible information, screening, and assessment activity shall 
 include information and referral, early intervention, follow-up 
 contacts, telephone screening, home visits, assessments, 
 preadmission screening, and relocation case management for the 
 frail elderly and their caregivers in the area served by the 
 county or counties.  The purpose is to ensure that information 
 and help is provided to elderly persons and their families in a 
 timely fashion, when they are making decisions about long-term 
 care.  These functions may be split among various agencies, but 
 must be coordinated by the local long-term care coordinating 
 team. 

    (b) Accessible information, screening, and assessment 
 functions shall be reimbursed as follows: 

    (1) The screenings of all persons entering nursing homes 
 shall be reimbursed as defined in section 256B.0911, subdivision 
 6; and 

    (2) Additional state administrative funds shall be 
 available for the access, screening, and assessment activities 
 that are not reimbursed under clause (1).  This amount shall not 
 exceed the amount authorized in the guidelines and in 
 instructions for the application and must be within the amount 
 appropriated for this activity. 

    (c) Any information and referral functions funded by other 
 sources, such as Title III of the Older Americans Act and Title 
 XX of the Social Security Act and the Community Social Services 
 Act, shall be considered by the local long-term care 
 coordinating team in establishing this function to avoid 
 duplication and to ensure access to information for persons 
 needing help and information regarding long-term care. 

    (d) The lead agency or the agencies under contract with the 
 lead agency which are responsible for the accessible 
 information, screening, and assessment function must complete 
 the forms and reports required by the commissioner as specified 
 in the contract. 

    Subd. 5.    Service development and service delivery.  
 (a) In addition to the access, screening, and assessment 
 activity, each local strategy may include provisions for the 
 following: 

    (1) the addition of a full-time staff person who is 
 responsible to develop the following services and recruit 
 providers as established in the contract: 

    (i) additional adult family foster care homes; 

    (ii) family adult day care providers as defined in section 
 256B.0919, subdivision 2; 

    (iii) an assisted living program in an apartment; 

    (iv) a congregate housing service project in a subsidized 
 housing project; and 

    (v) the expansion of evening and weekend coverage of home 
 care services as deemed necessary by the local strategic plan; 

    (2) small incentive grants to new adult family care 
 providers for renovations needed to meet licensure requirements; 

    (3) a plan to apply for a congregate housing service 
 project as identified in section 256.9731, authorized by the 
 Minnesota board on aging, to the extent that funds are 
 available; 

    (4) a plan to divert new applicants to nursing homes and to 
 relocate a targeted population from nursing homes, using the 
 individual's own resources or the funding available for 
 services; 

    (5) one or more caregiver support and respite care 
 projects, as described in subdivision 6; and 

    (6) one or more living-at-home/block nurse projects, as 
 described in subdivisions 7 to 10. 

    (b) The expansion of alternative care clients under 
 paragraph (a) shall be accomplished with the funds provided 
 under section 256B.0913, and includes the allocation of targeted 
 funds.  The funding for all participating counties must be 
 coordinated by the local long-term care coordinating team and 
 must be part of the local long-term care strategy.  Alternative 
 care funds may be transferred from one SAIL county to another 
 within a designated SAIL project area during a fiscal year as 
 authorized by the local long-term care coordinating team and 
 approved by the commissioner.  The base allocation used for a 
 future year shall reflect the final transfer.  Each county 
 retains responsibility for reimbursement as defined in section 
 256B.0913, subdivision 12.  All other requirements for the 
 alternative care program must be met unless an exception is 
 provided in this section.  The commissioner may establish by 
 contract a reimbursement mechanism for alternative care that 
 does not require invoice processing through the Medical 
 Assistance Management Information System (MMIS).  The 
 commissioner and local agencies must assure that the same client 
 and reimbursement data is obtained as is available under MMIS.  

    (c) The administration of these components is the 
 responsibility of the agencies selected by the local 
 coordinating team and under contract with the local lead 
 agency.  However, administrative funds for paragraph (a), 
 clauses (2) to (5), and grant funds for paragraph (a), clauses 
 (6) and (7), shall be granted to the local lead agency.  The 
 funding available for each component is based on the plan 
 submitted and the amount negotiated in the contract. 

    Subd. 6.    Caregiver support and respite care projects. 
  (a) The commissioner shall establish up to 36 projects to 
 expand the respite care network in the state and to support 
 caregivers in their responsibilities for care.  The purpose of 
 each project shall be to: 

    (1) establish a local coordinated network of volunteer and 
 paid respite workers; 

    (2) coordinate assignment of respite workers to clients and 
 care receivers and assure the health and safety of the client; 
 and 

    (3) provide training for caregivers and ensure that support 
 groups are available in the community. 

    (b) The caregiver support and respite care funds shall be 
 available to the four to six local long-term care strategy 
 projects designated in subdivisions 1 to 5. 

    (c) The commissioner shall publish a notice in the State 
 Register to solicit proposals from public or private nonprofit 
 agencies for the projects not included in the four to six local 
 long-term care strategy projects defined in subdivision 2.  A 
 county agency may, alone or in combination with other county 
 agencies, apply for caregiver support and respite care project 
 funds.  A public or nonprofit agency within a designated SAIL 
 project area may apply for project funds if the agency has a 
 letter of agreement with the county or counties in which 
 services will be developed, stating the intention of the county 
 or counties to coordinate their activities with the agency 
 requesting a grant.  

    (d) The commissioner shall select grantees based on the 
 following criteria: 

    (1) the ability of the proposal to demonstrate need in the 
 area served, as evidenced by a community needs assessment or 
 other demographic data; 

    (2) the ability of the proposal to clearly describe how the 
 project will achieve the purpose defined in paragraph (b); 

    (3) the ability of the proposal to reach underserved 
 populations; 

    (4) the ability of the proposal to demonstrate community 
 commitment to the project, as evidenced by letters of support 
 and cooperation as well as formation of a community task force; 

    (5) the ability of the proposal to clearly describe the 
 process for recruiting, training, and retraining volunteers; and 

    (6) the inclusion in the proposal of the plan to promote 
 the project in the community, including outreach to persons 
 needing the services. 

    (e) Funds for all projects under this subdivision may be 
 used to: 

    (1) hire a coordinator to develop a coordinated network of 
 volunteer and paid respite care services and assign workers to 
 clients; 

    (2) recruit and train volunteer providers; 

    (3) train caregivers; 

    (4) ensure the development of support groups for 
 caregivers; 

    (5) advertise the availability of the caregiver support and 
 respite care project; and 

    (6) purchase equipment to maintain a system of assigning 
 workers to clients. 

    (f) Project funds may not be used to supplant existing 
 funding sources. 

    Subd. 7.    Contract.  (a) The commissioner of human 
 services shall execute a contract with Living at Home/Block 
 Nurse Program, Inc. (LAH/BN, Inc.).  The contract shall require 
 LAH/BN, Inc. to: 

    (1) develop criteria for and award grants to establish 
 community-based organizations that will implement 
 living-at-home/block nurse programs throughout the state; 

    (2) award grants to enable living-at-home/block nurse 
 programs to continue to implement the combined 
 living-at-home/block nurse program model; 

    (3) serve as a state technical assistance center to assist 
 and coordinate the living-at-home/block nurse programs 
 established; and 

    (4) manage contracts with individual living-at-home/block 
 nurse programs. 

    (b) The contract shall be effective July 1, 1997, and 
 section 16B.17 shall not apply. 

    Subd. 8.    Living-at-home/block nurse program grant.  
 (a) The organization awarded the contract under subdivision 7, 
 shall develop and administer a grant program to establish or 
 expand up to 33 community-based organizations that will 
 implement living-at-home/block nurse programs that are designed 
 to enable senior citizens to live as independently as possible 
 in their homes and in their communities.  At least one-half of 
 the programs must be in counties outside the seven-county 
 metropolitan area.  Nonprofit organizations and units of local 
 government are eligible to apply for grants to establish the 
 community organizations that will implement living-at-home/block 
 nurse programs.  In awarding grants, the organization awarded 
 the contract under subdivision 7 shall give preference to 
 nonprofit organizations and units of local government from 
 communities that: 

    (1) have high nursing home occupancy rates; 

    (2) have a shortage of health care professionals; 

    (3) are located in counties adjacent to, or are located in, 
 counties with existing living-at-home/block nurse programs; and 

    (4) meet other criteria established by LAH/BN, Inc., in 
 consultation with the commissioner. 

    (b) Grant applicants must also meet the following criteria: 

    (1) the local community demonstrates a readiness to 
 establish a community model of care, including the formation of 
 a board of directors, advisory committee, or similar group, of 
 which at least two-thirds is comprised of community citizens 
 interested in community-based care for older persons; 

    (2) the program has sponsorship by a credible, 
 representative organization within the community; 

    (3) the program has defined specific geographic boundaries 
 and defined its organization, staffing and coordination/delivery 
 of services; 

    (4) the program demonstrates a team approach to 
 coordination and care, ensuring that the older adult 
 participants, their families, the formal and informal providers 
 are all part of the effort to plan and provide services; and 

    (5) the program provides assurances that all community 
 resources and funding will be coordinated and that other funding 
 sources will be maximized, including a person's own resources. 

    (c) Grant applicants must provide a minimum of five percent 
 of total estimated development costs from local community 
 funding.  Grants shall be awarded for four-year periods, and the 
 base amount shall not exceed $80,000 per applicant for the grant 
 period.  The organization under contract may increase the grant 
 amount for applicants from communities that have socioeconomic 
 characteristics that indicate a higher level of need for 
 assistance.  Subject to the availability of funding, grants and 
 grant renewals awarded or entered into on or after July 1, 1997, 
 shall be renewed by LAH/BN, Inc. every four years, unless 
 LAH/BN, Inc. determines that the grant recipient has not 
 satisfactorily operated the living-at-home/block nurse program 
 in compliance with the requirements of paragraphs (b) and (d).  
 Grants provided to living-at-home/block nurse programs under 
 this paragraph may be used for both program development and the 
 delivery of services. 

    (d) Each living-at-home/block nurse program shall be 
 designed by representatives of the communities being served to 
 ensure that the program addresses the specific needs of the 
 community residents.  The programs must be designed to: 

    (1) incorporate the basic community, organizational, and 
 service delivery principles of the living-at-home/block nurse 
 program model; 

    (2) provide senior citizens with registered nurse directed 
 assessment, provision and coordination of health and personal 
 care services on a sliding fee basis as an alternative to 
 expensive nursing home care; 

    (3) provide information, support services, homemaking 
 services, counseling, and training for the client and family 
 caregivers; 

    (4) encourage the development and use of respite care, 
 caregiver support, and in-home support programs, such as adult 
 foster care and in-home adult day care; 

    (5) encourage neighborhood residents and local 
 organizations to collaborate in meeting the needs of senior 
 citizens in their communities; 

    (6) recruit, train, and direct the use of volunteers to 
 provide informal services and other appropriate support to 
 senior citizens and their caregivers; and 

    (7) provide coordination and management of formal and 
 informal services to senior citizens and their families using 
 less expensive alternatives. 

    Subd. 9.    State technical assistance center.  The 
 organization under contract shall be the state technical 
 assistance center to provide orientation and technical 
 assistance, and to coordinate the living-at-home/block nurse 
 programs established.  The state resource center shall: 

    (1) provide communities with criteria in planning and 
 designing their living-at-home/block nurse programs; 

    (2) provide general orientation and technical assistance to 
 communities who desire to establish living-at-home/block nurse 
 programs; 

    (3) provide ongoing analysis and data collection of 
 existing and newly established living-at-home/block nurse 
 programs and provide data to the organization performing the 
 independent assessment; and 

    (4) serve as the living-at-home/block nurse programs' 
 liaison to the legislature and other state agencies. 

    Subd. 10.    Implementation plan.  The organization 
 under contract shall develop a plan that specifies a strategy 
 for implementing living-at-home/block nurse programs statewide.  
 The plan must also analyze the data collected by the state 
 technical assistance center and describe the effectiveness of 
 services provided by living-at-home/block nurse programs, 
 including the program's impact on acute care costs.  The 
 organization shall report to the commissioner of human services 
 and to the legislature by January 1, 1993.  

    Subd. 11.    SAIL evaluation and expansion.  The 
 commissioner shall evaluate the success of the SAIL projects 
 against the objective stated in subdivision 1, paragraph (b), 
 and recommend to the legislature the continuation or expansion 
 of the long-term care strategy by February 15, 1995. 

    Subd. 12.    Public awareness campaign.  The 
 commissioner, with assistance from the commissioner of health 
 and with the advice of the long-term care planning committee, 
 shall contract for a public awareness campaign to educate the 
 general public, seniors, consumers, caregivers, and 
 professionals about the aging process, the long-term care 
 system, and alternatives available including alternative care 
 and residential alternatives.  Particular emphasis will be given 
 to informing consumers on how to access the alternatives and 
 obtain information on the long-term care system.  The 
 commissioner shall pursue the development of new names for 
 preadmission screening, alternative care, foster care, and other 
 services as deemed necessary for the public awareness campaign. 

    Subd. 13.    Community service grants.  The commissioner 
 shall award contracts for grants to public and private nonprofit 
 agencies to establish services that strengthen a community's 
 ability to provide a system of home and community-based services 
 for elderly persons.  The commissioner shall use a request for 
 proposal process.  The commissioner shall give preference when 
 awarding grants under this section to areas where nursing 
 facility closures have occurred or are occurring.  The 
 commissioner shall consider grants for: 

    (1) caregiver support and respite care projects under 
 subdivision 6; 

    (2) on-site coordination under section 256.9731; 

    (3) the living-at-home/block nurse grant under subdivisions 
 7 to 10; and 

    (4) services identified as needed for community transition. 

    HIST: 1991 c 292 art 7 s 17; 1992 c 513 art 7 s 65-72; 1Sp1993 
 c 1 art 5 s 73-79; 1994 c 625 art 8 s 63; 1997 c 203 art 4 s 
 44,45; 1999 c 245 art 4 s 62; 2000 c 488 art 9 s 36; 2001 c 161 
 s 46,47; 1Sp2001 c 9 art 4 s 31,32; 2002 c 379 art 1 s 113 

     256B.0919 Adult foster care and family adult day care. 

    Subdivision 1.    Adult foster care licensure capacity.  
 Notwithstanding contrary provisions of the Human Services 
 Licensing Act and rules adopted under it, an adult foster care 
 license holder may care for five adults age 60 years or older 
 who do not have serious and persistent mental illness or a 
 developmental disability.  

    Subd. 2.    Adult foster care; family adult day care.  
 An adult foster care license holder who is not providing care to 
 persons with serious and persistent mental illness or 
 developmental disabilities may also provide family adult day 
 care for adults age 60 years or older who do not have serious 
 and persistent mental illness or a developmental disability.  
 The maximum combined license capacity for adult foster care and 
 family adult day care is five adults.  A separate license is not 
 required to provide family adult day care under this 
 subdivision.  Foster care homes providing services to five 
 adults shall not be subject to licensure by the commissioner of 
 health under the provisions of chapter 144, 144A, 157, or any 
 other law requiring facility licensure by the commissioner of 
 health. 

    Subd. 3.    County certification of persons providing 
 adult foster care to related persons.  A person exempt from 
 licensure under section 245A.03, subdivision 2, who provides 
 adult foster care to a related individual age 65 and older, and 
 who meets the requirements in Minnesota Rules, parts 9555.5105 
 to 9555.6265, may be certified by the county to provide adult 
 foster care.  A person certified by the county to provide adult 
 foster care may be reimbursed for services provided and eligible 
 for funding under sections 256B.0913 and 256B.0915, if the 
 relative would suffer a financial hardship as a result of 
 providing care.  For purposes of this subdivision, financial 
 hardship refers to a situation in which a relative incurs a 
 substantial reduction in income as a result of resigning from a 
 full-time job or taking a leave of absence without pay from a 
 full-time job to care for the client. 

    HIST: 1986 c 444; 1991 c 292 art 7 s 18; 1992 c 513 art 7 s 73 

     256B.092 Case management of persons with mental 
  retardation or related conditions. 

    Subdivision 1.    County of financial responsibility; 
 duties.  Before any services shall be rendered to persons with 
 mental retardation or related conditions who are in need of 
 social service and medical assistance, the county of financial 
 responsibility shall conduct or arrange for a diagnostic 
 evaluation in order to determine whether the person has or may 
 have mental retardation or has or may have a related condition.  
 If the county of financial responsibility determines that the 
 person has mental retardation or a related condition, the county 
 shall inform the person of case management services available 
 under this section.  Except as provided in subdivision 1g or 4b, 
 if a person is diagnosed as having mental retardation or a 
 related condition, the county of financial responsibility shall 
 conduct or arrange for a needs assessment, develop or arrange 
 for an individual service plan, provide or arrange for ongoing 
 case management services at the level identified in the 
 individual service plan, provide or arrange for case management 
 administration, and authorize services identified in the 
 person's individual service plan developed according to 
 subdivision 1b.  Diagnostic information, obtained by other 
 providers or agencies, may be used by the county agency in 
 determining eligibility for case management.  Nothing in this 
 section shall be construed as requiring:  (1) assessment in 
 areas agreed to as unnecessary by the case manager and the 
 person, or the person's legal guardian or conservator, or the 
 parent if the person is a minor, or (2) assessments in areas 
 where there has been a functional assessment completed in the 
 previous 12 months for which the case manager and the person or 
 person's guardian or conservator, or the parent if the person is 
 a minor, agree that further assessment is not necessary.  For 
 persons under state guardianship, the case manager shall seek 
 authorization from the public guardianship office for waiving 
 any assessment requirements.  Assessments related to health, 
 safety, and protection of the person for the purpose of 
 identifying service type, amount, and frequency or assessments 
 required to authorize services may not be waived.  To the extent 
 possible, for wards of the commissioner the county shall 
 consider the opinions of the parent of the person with mental 
 retardation or a related condition when developing the person's 
 individual service plan.  

    Subd. 1a.    Case management administration and services. 
  (a) The administrative functions of case management provided 
 to or arranged for a person include: 

    (1) intake; 

    (2) diagnosis; 

    (3) screening; 

    (4) service authorization; 

    (5) review of eligibility for services; and 

    (6) responding to requests for conciliation conferences and 
 appeals according to section 256.045 made by the person, the 
 person's legal guardian or conservator, or the parent if the 
 person is a minor. 

    (b) Case management service activities provided to or 
 arranged for a person include: 

    (1) development of the individual service plan; 

    (2) informing the individual or the individual's legal 
 guardian or conservator, or parent if the person is a minor, of 
 service options; 

    (3) assisting the person in the identification of potential 
 providers; 

    (4) assisting the person to access services; 

    (5) coordination of services; 

    (6) evaluation and monitoring of the services identified in 
 the plan; and 

    (7) annual reviews of service plans. 

    (c) Case management administration and service activities 
 that are provided to the person with mental retardation or a 
 related condition shall be provided directly by county agencies 
 or under contract.  

    Subd. 1b.    Individual service plan.  The individual 
 service plan must: 

    (1) include the results of the assessment information on 
 the person's need for service, including identification of 
 service needs that will be or that are met by the person's 
 relatives, friends, and others, as well as community services 
 used by the general public; 

    (2) identify the person's preferences for services as 
 stated by the person, the person's legal guardian or 
 conservator, or the parent if the person is a minor; 

    (3) identify long- and short-range goals for the person; 

    (4) identify specific services and the amount and frequency 
 of the services to be provided to the person based on assessed 
 needs, preferences, and available resources.  The individual 
 service plan shall also specify other services the person needs 
 that are not available; 

    (5) identify the need for an individual program plan to be 
 developed by the provider according to the respective state and 
 federal licensing and certification standards, and additional 
 assessments to be completed or arranged by the provider after 
 service initiation; 

    (6) identify provider responsibilities to implement and 
 make recommendations for modification to the individual service 
 plan; 

    (7) include notice of the right to request a conciliation 
 conference or a hearing under section 256.045; 

    (8) be agreed upon and signed by the person, the person's 
 legal guardian or conservator, or the parent if the person is a 
 minor, and the authorized county representative; and 

    (9) be reviewed by a health professional if the person has 
 overriding medical needs that impact the delivery of services. 

    Service planning formats developed for interagency planning 
 such as transition, vocational, and individual family service 
 plans may be substituted for service planning formats developed 
 by county agencies. 

    Subd. 1c. Repealed, 1991 c 94 s 25; c 292 art 6 s 47 

    Subd. 1d. Repealed, 1991 c 94 s 25; c 292 art 6 s 47 

    Subd. 1e. Renumbered subd 1f 

    Subd. 1e.    Coordination, evaluation, and monitoring of 
 services identified in the individual service plan.  (a) If 
 the individual service plan identifies the need for individual 
 program plans for authorized services, the case manager shall 
 assure that individual program plans are developed by the 
 providers according to clauses (2) to (5).  The providers shall 
 assure that the individual program plans:  

    (1) are developed according to the respective state and 
 federal licensing and certification requirements; 

    (2) are designed to achieve the goals of the individual 
 service plan; 

    (3) are consistent with other aspects of the individual 
 service plan; 

    (4) assure the health and safety of the person; and 

    (5) are developed with consistent and coordinated 
 approaches to services among the various service providers.  

    (b) The case manager shall monitor the provision of 
 services:  

    (1) to assure that the individual service plan is being 
 followed according to paragraph (a); 

    (2) to identify any changes or modifications that might be 
 needed in the individual service plan, including changes 
 resulting from recommendations of current service providers; 

    (3) to determine if the person's legal rights are 
 protected, and if not, notify the person's legal guardian or 
 conservator, or the parent if the person is a minor, protection 
 services, or licensing agencies as appropriate; and 

    (4) to determine if the person, the person's legal guardian 
 or conservator, or the parent if the person is a minor, is 
 satisfied with the services provided.  

    (c) If the provider fails to develop or carry out the 
 individual program plan according to paragraph (a), the case 
 manager shall notify the person's legal guardian or conservator, 
 or the parent if the person is a minor, the provider, the 
 respective licensing and certification agencies, and the county 
 board where the services are being provided.  In addition, the 
 case manager shall identify other steps needed to assure the 
 person receives the services identified in the individual 
 service plan. 

    Subd. 1f.    County waiting list.  The county agency 
 shall maintain a waiting list of persons with developmental 
 disabilities specifying the services needed but not provided.  
 This waiting list shall be used by county agencies to assist 
 them in developing needed services or amending their community 
 social services plan as required in section 256E.09, subdivision 
 1.  

    Subd. 1g.    Conditions not requiring development of 
 individual service plan.  Unless otherwise required by federal 
 law, the county agency is not required to complete an individual 
 service plan as defined in subdivision 1b for:  

    (1) persons whose families are requesting respite care for 
 their family member who resides with them, or whose families are 
 requesting a family support grant and are not requesting 
 purchase or arrangement of habilitative services; and 

    (2) persons with mental retardation or related conditions, 
 living independently without authorized services or receiving 
 funding for services at a rehabilitation facility as defined in 
 section 268A.01, subdivision 6, and not in need of or requesting 
 additional services.  

    Subd. 2.    Medical assistance.  To assure quality case 
 management to those persons who are eligible for medical 
 assistance, the commissioner shall, upon request: 

    (a) provide consultation on the case management process; 

    (b) assist county agencies in the screening and annual 
 reviews of clients review process to assure that appropriate 
 levels of service are provided to persons; 

    (c) provide consultation on service planning and 
 development of services with appropriate options; 

    (d) provide training and technical assistance to county 
 case managers; and 

    (e) authorize payment for medical assistance services 
 according to this chapter and rules implementing it.  

    Subd. 2a.    Medical assistance for case management 
 activities under the state plan Medicaid option.  Upon receipt 
 of federal approval, the commissioner shall make payments to 
 approved vendors of case management services participating in 
 the medical assistance program to reimburse costs for providing 
 case management service activities to medical assistance 
 eligible persons with mental retardation or a related condition, 
 in accordance with the state Medicaid plan and federal 
 requirements and limitations. 

    Subd. 3.    Authorization and termination of services.  
 County agency case managers, under rules of the commissioner, 
 shall authorize and terminate services of community and regional 
 treatment center providers according to individual service 
 plans.  Services provided to persons with mental retardation or 
 related conditions may only be authorized and terminated by case 
 managers according to (1) rules of the commissioner and (2) the 
 individual service plan as defined in subdivision 1b.  Medical 
 assistance services not needed shall not be authorized by county 
 agencies or funded by the commissioner.  When purchasing or 
 arranging for unlicensed respite care services for persons with 
 overriding health needs, the county agency shall seek the advice 
 of a health care professional in assessing provider staff 
 training needs and skills necessary to meet the medical needs of 
 the person.  

    Subd. 4.    Home and community-based services for persons 
 with mental retardation or related conditions.  (a) The 
 commissioner shall make payments to approved vendors 
 participating in the medical assistance program to pay costs of 
 providing home and community-based services, including case 
 management service activities provided as an approved home and 
 community-based service, to medical assistance eligible persons 
 with mental retardation or related conditions who have been 
 screened under subdivision 7 and according to federal 
 requirements.  Federal requirements include those services and 
 limitations included in the federally approved application for 
 home and community-based services for persons with mental 
 retardation or related conditions and subsequent amendments.  

    (b) Effective July 1, 1995, contingent upon federal 
 approval and state appropriations made available for this 
 purpose, and in conjunction with Laws 1995, chapter 207, article 
 8, section 40, the commissioner of human services shall allocate 
 resources to county agencies for home and community-based 
 waivered services for persons with mental retardation or related 
 conditions authorized but not receiving those services as of 
 June 30, 1995, based upon the average resource need of persons 
 with similar functional characteristics.  To ensure service 
 continuity for service recipients receiving home and 
 community-based waivered services for persons with mental 
 retardation or related conditions prior to July 1, 1995, the 
 commissioner shall make available to the county of financial 
 responsibility home and community-based waivered services 
 resources based upon fiscal year 1995 authorized levels. 

    (c) Home and community-based resources for all recipients 
 shall be managed by the county of financial responsibility 
 within an allowable reimbursement average established for each 
 county.  Payments for home and community-based services provided 
 to individual recipients shall not exceed amounts authorized by 
 the county of financial responsibility.  For specifically 
 identified former residents of nursing facilities, the 
 commissioner shall be responsible for authorizing payments and 
 payment limits under the appropriate home and community-based 
 service program.  Payment is available under this subdivision 
 only for persons who, if not provided these services, would 
 require the level of care provided in an intermediate care 
 facility for persons with mental retardation or related 
 conditions.  

    Subd. 4a.    Demonstration projects.  The commissioner 
 may waive state rules governing home and community-based 
 services in order to demonstrate other methods of administering 
 these services and to improve efficiency and responsiveness to 
 individual needs of persons with mental retardation or related 
 conditions, notwithstanding section 14.05, subdivision 4.  All 
 demonstration projects approved by the commissioner must comply 
 with state laws and federal regulations, must remain within the 
 fiscal limitations of the home and community-based services 
 program for persons with mental retardation or related 
 conditions, and must assure the health and safety of the persons 
 receiving services according to section 256E.08, subdivision 1.  

    Subd. 4b.    Case management for persons receiving home 
 and community-based services.  Persons authorized for and 
 receiving home and community-based services may select from 
 vendors of case management which have provider agreements with 
 the state to provide home and community-based case management 
 service activities.  This subdivision becomes effective July 1, 
 1992, only if the state agency is unable to secure federal 
 approval for limiting choice of case management vendors to the 
 county of financial responsibility.  

    Subd. 4c.    Living arrangements based on a 24-hour plan 
 of care.  (a) Notwithstanding the requirements for licensure 
 under Minnesota Rules, part 9525.1860, subpart 6, item D, and 
 upon federal approval of an amendment to the home and 
 community-based services waiver for persons with mental 
 retardation or related conditions, a person receiving home and 
 community-based services may choose to live in their own home 
 without requiring that the living arrangement be licensed under 
 Minnesota Rules, parts 9555.5050 to 9555.6265, provided the 
 following conditions are met: 

    (1) the person receiving home and community-based services 
 has chosen to live in their own home; 

    (2) home and community-based services are provided by a 
 qualified vendor who meets the provider standards as approved in 
 the Minnesota home and community-based services waiver plan for 
 persons with mental retardation or related conditions; 

    (3) the person, or their legal representative, individually 
 or with others has purchased or rents the home and the person's 
 service provider has no financial interest in the home; and 

    (4) the service planning team, as defined in Minnesota 
 Rules, part 9525.0004, subpart 24, has determined that the 
 planned services, the 24-hour plan of care, and the housing 
 arrangement are appropriate to address the health, safety, and 
 welfare of the person. 

    (b) The county agency may require safety inspections of the 
 selected housing as part of their determination of the adequacy 
 of the living arrangement. 

    Subd. 5.    Federal waivers.  (a) The commissioner shall 
 apply for any federal waivers necessary to secure, to the extent 
 allowed by law, federal financial participation under United 
 States Code, title 42, sections 1396 et seq., as amended, for 
 the provision of services to persons who, in the absence of the 
 services, would need the level of care provided in a regional 
 treatment center or a community intermediate care facility for 
 persons with mental retardation or related conditions.  The 
 commissioner may seek amendments to the waivers or apply for 
 additional waivers under United States Code, title 42, sections 
 1396 et seq., as amended, to contain costs.  The commissioner 
 shall ensure that payment for the cost of providing home and 
 community-based alternative services under the federal waiver 
 plan shall not exceed the cost of intermediate care services 
 including day training and habilitation services that would have 
 been provided without the waivered services.  

    (b) The commissioner, in administering home and 
 community-based waivers for persons with mental retardation and 
 related conditions, shall ensure that day services for eligible 
 persons are not provided by the person's residential service 
 provider, unless the person or the person's legal representative 
 is offered a choice of providers and agrees in writing to 
 provision of day services by the residential service provider.  
 The individual service plan for individuals who choose to have 
 their residential service provider provide their day services 
 must describe how health, safety, and protection needs will be 
 met by frequent and regular contact with persons other than the 
 residential service provider. 

    Subd. 6.    Rules.  The commissioner shall adopt rules 
 to establish required controls, documentation, and reporting of 
 services provided in order to assure proper administration of 
 the approved waiver plan, and to establish policy and procedures 
 to reduce duplicative efforts and unnecessary paperwork on the 
 part of case managers.  

    Subd. 7.    Screening teams.  For persons with mental 
 retardation or a related condition, screening teams shall be 
 established which shall evaluate the need for the level of care 
 provided by residential-based habilitation services, residential 
 services, training and habilitation services, and nursing 
 facility services.  The evaluation shall address whether home 
 and community-based services are appropriate for persons who are 
 at risk of placement in an intermediate care facility for 
 persons with mental retardation or related conditions, or for 
 whom there is reasonable indication that they might require this 
 level of care.  The screening team shall make an evaluation of 
 need within 60 working days of a request for service by a person 
 with mental retardation or related conditions, and within five 
 working days of an emergency admission of a person to an 
 intermediate care facility for persons with mental retardation 
 or related conditions.  The screening team shall consist of the 
 case manager for persons with mental retardation or related 
 conditions, the person, the person's legal guardian or 
 conservator, or the parent if the person is a minor, and a 
 qualified mental retardation professional, as defined in the 
 Code of Federal Regulations, title 42, section 483.430, as 
 amended through June 3, 1988.  The case manager may also act as 
 the qualified mental retardation professional if the case 
 manager meets the federal definition.  County social service 
 agencies may contract with a public or private agency or 
 individual who is not a service provider for the person for the 
 public guardianship representation required by the screening or 
 individual service planning process.  The contract shall be 
 limited to public guardianship representation for the screening 
 and individual service planning activities.  The contract shall 
 require compliance with the commissioner's instructions and may 
 be for paid or voluntary services.  For persons determined to 
 have overriding health care needs and are seeking admission to a 
 nursing facility or an ICF/MR, or seeking access to home and 
 community-based waivered services, a registered nurse must be 
 designated as either the case manager or the qualified mental 
 retardation professional.  For persons under the jurisdiction of 
 a correctional agency, the case manager must consult with the 
 corrections administrator regarding additional health, safety, 
 and supervision needs.  The case manager, with the concurrence 
 of the person, the person's legal guardian or conservator, or 
 the parent if the person is a minor, may invite other 
 individuals to attend meetings of the screening team.  No member 
 of the screening team shall have any direct or indirect service 
 provider interest in the case.  Nothing in this section shall be 
 construed as requiring the screening team meeting to be separate 
 from the service planning meeting. 

    Subd. 8.    Screening team duties.  The screening team 
 shall: 

    (a) review diagnostic data; 

    (b) review health, social, and developmental assessment 
 data using a uniform screening tool specified by the 
 commissioner; 

    (c) identify the level of services appropriate to maintain 
 the person in the most normal and least restrictive setting that 
 is consistent with the person's treatment needs; 

    (d) identify other noninstitutional public assistance or 
 social service that may prevent or delay long-term residential 
 placement; 

    (e) assess whether a person is in need of long-term 
 residential care; 

    (f) make recommendations regarding placement and payment 
 for:  (1) social service or public assistance support, or both, 
 to maintain a person in the person's own home or other place of 
 residence; (2) training and habilitation service, vocational 
 rehabilitation, and employment training activities; (3) 
 community residential placement; (4) regional treatment center 
 placement; or (5) a home and community-based service alternative 
 to community residential placement or regional treatment center 
 placement; 

    (g) evaluate the availability, location, and quality of the 
 services listed in paragraph (f), including the impact of 
 placement alternatives on the person's ability to maintain or 
 improve existing patterns of contact and involvement with 
 parents and other family members; 

    (h) identify the cost implications of recommendations in 
 paragraph (f); 

    (i) make recommendations to a court as may be needed to 
 assist the court in making decisions regarding commitment of 
 persons with mental retardation; and 

    (j) inform the person and the person's legal guardian or 
 conservator, or the parent if the person is a minor, that appeal 
 may be made to the commissioner pursuant to section 256.045. 

    Subd. 8a.    County concurrence.  (a) If the county of 
 financial responsibility wishes to place a person in another 
 county for services, the county of financial responsibility 
 shall seek concurrence from the proposed county of service and 
 the placement shall be made cooperatively between the two 
 counties.  Arrangements shall be made between the two counties 
 for ongoing social service, including annual reviews of the 
 person's individual service plan.  The county where services are 
 provided may not make changes in the person's service plan 
 without approval by the county of financial responsibility. 

    (b) When a person has been screened and authorized for 
 services in an intermediate care facility for persons with 
 mental retardation or related conditions or for home and 
 community-based services for persons with mental retardation or 
 related conditions, the case manager shall assist that person in 
 identifying a service provider who is able to meet the needs of 
 the person according to the person's individual service plan.  
 If the identified service is to be provided in a county other 
 than the county of financial responsibility, the county of 
 financial responsibility shall request concurrence of the county 
 where the person is requesting to receive the identified 
 services.  The county of service may refuse to concur if:  

    (1) it can demonstrate that the provider is unable to 
 provide the services identified in the person's individual 
 service plan as services that are needed and are to be provided; 

    (2) in the case of an intermediate care facility for 
 persons with mental retardation or related conditions, there has 
 been no authorization for admission by the admission review team 
 as required in section 256B.0926; or 

    (3) in the case of home and community-based services for 
 persons with mental retardation or related conditions, the 
 county of service can demonstrate that the prospective provider 
 has failed to substantially comply with the terms of a past 
 contract or has had a prior contract terminated within the last 
 12 months for failure to provide adequate services, or has 
 received a notice of intent to terminate the contract.  

    (c) The county of service shall notify the county of 
 financial responsibility of concurrence or refusal to concur no 
 later than 20 working days following receipt of the written 
 request.  Unless other mutually acceptable arrangements are made 
 by the involved county agencies, the county of financial 
 responsibility is responsible for costs of social services and 
 the costs associated with the development and maintenance of the 
 placement.  The county of service may request that the county of 
 financial responsibility purchase case management services from 
 the county of service or from a contracted provider of case 
 management when the county of financial responsibility is not 
 providing case management as defined in this section and rules 
 adopted under this section, unless other mutually acceptable 
 arrangements are made by the involved county agencies.  
 Standards for payment limits under this section may be 
 established by the commissioner.  Financial disputes between 
 counties shall be resolved as provided in section 256G.09.  

    Subd. 9.    Reimbursement.  Payment for services shall 
 not be provided to a service provider for any person placed in 
 an intermediate care facility for persons with mental 
 retardation or related conditions prior to the person being 
 screened by the screening team.  The commissioner shall not deny 
 reimbursement for:  (a) a person admitted to an intermediate 
 care facility for persons with mental retardation or related 
 conditions who is assessed to need long-term supportive 
 services, if long-term supportive services other than 
 intermediate care are not available in that community; (b) any 
 person admitted to an intermediate care facility for persons 
 with mental retardation or related conditions under emergency 
 circumstances; (c) any eligible person placed in the 
 intermediate care facility for persons with mental retardation 
 or related conditions pending an appeal of the screening team's 
 decision; or (d) any medical assistance recipient when, after 
 full discussion of all appropriate alternatives including those 
 that are expected to be less costly than intermediate care for 
 persons with mental retardation or related conditions, the 
 person or the person's legal guardian or conservator, or the 
 parent if the person is a minor, insists on intermediate care 
 placement.  The screening team shall provide documentation that 
 the most cost-effective alternatives available were offered to 
 this individual or the individual's legal guardian or 
 conservator. 

    Subd. 10.    Admission of persons to and discharge of 
 persons from regional treatment centers.  (a) Prior to the 
 admission of a person to a regional treatment center program for 
 persons with mental retardation, the case manager shall make 
 efforts to secure community-based alternatives.  If these 
 alternatives are rejected by the person, the person's legal 
 guardian or conservator, or the county agency in favor of a 
 regional treatment center placement, the case manager shall 
 document the reasons why the alternatives were rejected.  

    (b) When discharge of a person from a regional treatment 
 center to a community-based service is proposed, the case 
 manager shall convene the screening team and in addition to 
 members of the team identified in subdivision 7, the case 
 manager shall invite to the meeting the person's parents and 
 near relatives, and the ombudsman established under section 
 245.92 if the person is under public guardianship.  The meeting 
 shall be convened at a time and place that allows for 
 participation of all team members and invited individuals who 
 choose to attend.  The notice of the meeting shall inform the 
 person's parents and near relatives about the screening team 
 process, and their right to request a review if they object to 
 the discharge, and shall provide the names and functions of 
 advocacy organizations, and information relating to assistance 
 available to individuals interested in establishing private 
 guardianships under the provisions of section 252A.03.  The 
 screening team meeting shall be conducted according to 
 subdivisions 7 and 8.  Discharge of the person shall not go 
 forward without consensus of the screening team.  

    (c) The results of the screening team meeting and 
 individual service plan developed according to subdivision 1b 
 shall be used by the interdisciplinary team assembled in 
 accordance with Code of Federal Regulations, title 42, section 
 483.440, to evaluate and make recommended modifications to the 
 individual service plan as proposed.  The individual service 
 plan shall specify postplacement monitoring to be done by the 
 case manager according to section 253B.15, subdivision 1a.  

    (d) Notice of the meeting of the interdisciplinary team 
 assembled in accordance with Code of Federal Regulations, title 
 42, section 483.440, shall be sent to all team members 15 days 
 prior to the meeting, along with a copy of the proposed 
 individual service plan.  The case manager shall request that 
 proposed providers visit the person and observe the person's 
 program at the regional treatment center prior to the 
 discharge.  Whenever possible, preplacement visits by the person 
 to proposed service sites should also be scheduled in advance of 
 the meeting.  Members of the interdisciplinary team assembled 
 for the purpose of discharge planning shall include but not be 
 limited to the case manager, the person, the person's legal 
 guardian or conservator, parents and near relatives, the 
 person's advocate, representatives of proposed community service 
 providers, representatives of the regional treatment center 
 residential and training and habilitation services, a registered 
 nurse if the person has overriding medical needs that impact the 
 delivery of services, and a qualified mental retardation 
 professional specializing in behavior management if the person 
 to be discharged has behaviors that may result in injury to self 
 or others.  The case manager may also invite other service 
 providers who have expertise in an area related to specific 
 service needs of the person to be discharged.  

    (e) The interdisciplinary team shall review the proposed 
 plan to assure that it identifies service needs, availability of 
 services, including support services, and the proposed 
 providers' abilities to meet the service needs identified in the 
 person's individual service plan.  The interdisciplinary team 
 shall review the most recent licensing reports of the proposed 
 providers and corrective action taken by the proposed provider, 
 if required.  The interdisciplinary team shall review the 
 current individual program plans for the person and agree to an 
 interim individual program plan to be followed for the first 30 
 days in the person's new living arrangement.  The 
 interdisciplinary team may suggest revisions to the service 
 plan, and all team suggestions shall be documented.  If the 
 person is to be discharged to a community intermediate care 
 facility for persons with mental retardation or related 
 conditions, the team shall give preference to facilities with a 
 licensed capacity of 15 or fewer beds.  Thirty days prior to the 
 date of discharge, the case manager shall send a final copy of 
 the service plan to all invited members of the team, the 
 ombudsman, if the person is under public guardianship, and the 
 advocacy system established under United States Code, title 42, 
 section 6042.  

    (f) No discharge shall take place until disputes are 
 resolved under section 256.045, subdivision 4a, or until a 
 review by the commissioner is completed upon request of the 
 chief executive officer or program director of the regional 
 treatment center, or the county agency.  For persons under 
 public guardianship, the ombudsman may request a review or 
 hearing under section 256.045.  Notification schedules required 
 under this subdivision may be waived by members of the team when 
 judged urgent and with agreement of the parents or near 
 relatives participating as members of the interdisciplinary team.

    HIST: 1983 c 312 art 9 s 5; 1984 c 640 s 32; 1985 c 21 s 55; 
 1Sp1985 c 9 art 2 s 40-45; 1987 c 305 s 2; 1988 c 689 art 2 s 
 148,149; 1989 c 282 art 3 s 61; art 6 s 29,30; 1990 c 568 art 3 
 s 57-61; 1990 c 599 s 1; 1991 c 292 art 6 s 47; 1992 c 513 art 7 
 s 74; art 9 s 26,27; 1993 c 339 s 15-19; 1995 c 207 art 3 s 19; 
 art 8 s 34; 1997 c 7 art 5 s 30; 1Sp2001 c 9 art 3 s 46; 2002 c 
 379 art 1 s 113 

     256B.0924 Targeted case management services for 
  vulnerable adults and persons with developmental disabilities. 

    Subdivision 1.    Purpose.  The state recognizes that 
 targeted case management services can decrease the need for more 
 costly services such as multiple emergency room visits or 
 hospitalizations by linking eligible individuals with less 
 costly services available in the community. 

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

    (a) "Targeted case management" means services which will 
 assist medical assistance eligible persons to gain access to 
 needed medical, social, educational, and other services.  
 Targeted case management does not include therapy, treatment, 
 legal, or outreach services. 

    (b) "Targeted case management for adults" means activities 
 that coordinate and link social and other services designed to 
 help eligible persons gain access to needed protective services, 
 social, health care, mental health, habilitative, educational, 
 vocational, recreational, advocacy, legal, chemical, health, and 
 other related services. 

    Subd. 3.    Eligibility.  Persons are eligible to 
 receive targeted case management services under this section if 
 the requirements in paragraphs (a) and (b) are met. 

    (a) The person must be assessed and determined by the local 
 county agency to: 

    (1) be age 18 or older; 

    (2) be receiving medical assistance; 

    (3) have significant functional limitations; and 

    (4) be in need of service coordination to attain or 
 maintain living in an integrated community setting. 

    (b) The person must be a vulnerable adult in need of adult 
 protection as defined in section 626.5572, or is an adult with 
 mental retardation as defined in section 252A.02, subdivision 2, 
 or a related condition as defined in section 252.27, subdivision 
 1a, and is not receiving home and community-based waiver 
 services. 

    Subd. 4.    Targeted case management service activities. 
  (a) For persons with mental retardation or a related 
 condition, targeted case management services must meet the 
 provisions of section 256B.092. 

    (b) For persons not eligible as a person with mental 
 retardation or a related condition, targeted case management 
 service activities include: 

    (1) an assessment of the person's need for targeted case 
 management services; 

    (2) the development of a written personal service plan; 

    (3) a regular review and revision of the written personal 
 service plan with the recipient and the recipient's legal 
 representative, and others as identified by the recipient, to 
 ensure access to necessary services and supports identified in 
 the plan; 

    (4) effective communication with the recipient and the 
 recipient's legal representative and others identified by the 
 recipient; 

    (5) coordination of referrals for needed services with 
 qualified providers; 

    (6) coordination and monitoring of the overall service 
 delivery to ensure the quality and effectiveness of services; 

    (7) assistance to the recipient and the recipient's legal 
 representative to help make an informed choice of services; 

    (8) advocating on behalf of the recipient when service 
 barriers are encountered or referring the recipient and the 
 recipient's legal representative to an independent advocate; 

    (9) monitoring and evaluating services identified in the 
 personal service plan to ensure personal outcomes are met and to 
 ensure satisfaction with services and service delivery; 

    (10) conducting face-to-face monitoring with the recipient 
 at least twice a year; 

    (11) completing and maintaining necessary documentation 
 that supports and verifies the activities in this section; 

    (12) coordinating with the medical assistance facility 
 discharge planner in the 180-day period prior to the recipient's 
 discharge into the community; and 

    (13) a personal service plan developed and reviewed at 
 least annually with the recipient and the recipient's legal 
 representative.  The personal service plan must be revised when 
 there is a change in the recipient's status.  The personal 
 service plan must identify: 

    (i) the desired personal short and long-term outcomes; 

    (ii) the recipient's preferences for services and supports, 
 including development of a person-centered plan if requested; 
 and 

    (iii) formal and informal services and supports based on 
 areas of assessment, such as:  social, health, mental health, 
 residence, family, educational and vocational, safety, legal, 
 self-determination, financial, and chemical health as determined 
 by the recipient and the recipient's legal representative and 
 the recipient's support network. 

    Subd. 5.    Provider standards.  County boards or 
 providers who contract with the county are eligible to receive 
 medical assistance reimbursement for adult targeted case 
 management services.  To qualify as a provider of targeted case 
 management services the vendor must: 

    (1) have demonstrated the capacity and experience to 
 provide the activities of case management services defined in 
 subdivision 4; 

    (2) be able to coordinate and link community resources 
 needed by the recipient; 

    (3) have the administrative capacity and experience to 
 serve the eligible population in providing services and to 
 ensure quality of services under state and federal requirements; 

    (4) have a financial management system that provides 
 accurate documentation of services and costs under state and 
 federal requirements; 

    (5) have the capacity to document and maintain individual 
 case records complying with state and federal requirements; 

    (6) coordinate with county social service agencies 
 responsible for planning for community social services under 
 chapters 256E and 256F; conducting adult protective 
 investigations under section 626.557, and conducting prepetition 
 screenings for commitments under section 253B.07; 

    (7) coordinate with health care providers to ensure access 
 to necessary health care services; 

    (8) have a procedure in place that notifies the recipient 
 and the recipient's legal representative of any conflict of 
 interest if the contracted targeted case management service 
 provider also provides the recipient's services and supports and 
 provides information on all potential conflicts of interest and 
 obtains the recipient's informed consent and provides the 
 recipient with alternatives; and 

    (9) have demonstrated the capacity to achieve the following 
 performance outcomes:  access, quality, and consumer 
 satisfaction. 

    Subd. 6.    Payment for targeted case management.  (a) 
 Medical assistance and MinnesotaCare payment for targeted case 
 management shall be made on a monthly basis.  In order to 
 receive payment for an eligible adult, the provider must 
 document at least one contact per month and not more than two 
 consecutive months without a face-to-face contact with the adult 
 or the adult's legal representative, family, primary caregiver, 
 or other relevant persons identified as necessary to the 
 development or implementation of the goals of the personal 
 service plan. 

    (b) Payment for targeted case management provided by county 
 staff under this subdivision shall be based on the monthly rate 
 methodology under section 256B.094, subdivision 6, paragraph 
 (b), calculated as one combined average rate together with adult 
 mental health case management under section 256B.0625, 
 subdivision 20, except for calendar year 2002.  In calendar year 
 2002, the rate for case management under this section shall be 
 the same as the rate for adult mental health case management in 
 effect as of December 31, 2001.  Billing and payment must 
 identify the recipient's primary population group to allow 
 tracking of revenues. 

    (c) Payment for targeted case management provided by 
 county-contracted vendors shall be based on a monthly rate 
 negotiated by the host county.  The negotiated rate must not 
 exceed the rate charged by the vendor for the same service to 
 other payers.  If the service is provided by a team of 
 contracted vendors, the county may negotiate a team rate with a 
 vendor who is a member of the team.  The team shall determine 
 how to distribute the rate among its members.  No reimbursement 
 received by contracted vendors shall be returned to the county, 
 except to reimburse the county for advance funding provided by 
 the county to the vendor. 

    (d) If the service is provided by a team that includes 
 contracted vendors and county staff, the costs for county staff 
 participation on the team shall be included in the rate for 
 county-provided services.  In this case, the contracted vendor 
 and the county may each receive separate payment for services 
 provided by each entity in the same month.  In order to prevent 
 duplication of services, the county must document, in the 
 recipient's file, the need for team targeted case management and 
 a description of the different roles of the team members. 

    (e) Notwithstanding section 256B.19, subdivision 1, the 
 nonfederal share of costs for targeted case management shall be 
 provided by the recipient's county of responsibility, as defined 
 in sections 256G.01 to 256G.12, from sources other than federal 
 funds or funds used to match other federal funds. 

    (f) The commissioner may suspend, reduce, or terminate 
 reimbursement to a provider that does not meet the reporting or 
 other requirements of this section.  The county of 
 responsibility, as defined in sections 256G.01 to 256G.12, is 
 responsible for any federal disallowances.  The county may share 
 this responsibility with its contracted vendors. 

    (g) The commissioner shall set aside five percent of the 
 federal funds received under this section for use in reimbursing 
 the state for costs of developing and implementing this section. 

    (h) Payments to counties for targeted case management 
 expenditures under this section shall only be made from federal 
 earnings from services provided under this section.  Payments to 
 contracted vendors shall include both the federal earnings and 
 the county share. 

    (i) Notwithstanding section 256B.041, county payments for 
 the cost of case management services provided by county staff 
 shall not be made to the state treasurer.  For the purposes of 
 targeted case management services provided by county staff under 
 this section, the centralized disbursement of payments to 
 counties under section 256B.041 consists only of federal 
 earnings from services provided under this section. 

    (j) If the recipient is a resident of a nursing facility, 
 intermediate care facility, or hospital, and the recipient's 
 institutional care is paid by medical assistance, payment for 
 targeted case management services under this subdivision is 
 limited to the last 180 days of the recipient's residency in 
 that facility and may not exceed more than six months in a 
 calendar year. 

    (k) Payment for targeted case management services under 
 this subdivision shall not duplicate payments made under other 
 program authorities for the same purpose. 

    (l) Any growth in targeted case management services and 
 cost increases under this section shall be the responsibility of 
 the counties. 

    Subd. 7.    Implementation and evaluation.  The 
 commissioner of human services in consultation with county 
 boards shall establish a program to accomplish the provisions of 
 subdivisions 1 to 6.  The commissioner in consultation with 
 county boards shall establish performance measures to evaluate 
 the effectiveness of the targeted case management services.  If 
 a county fails to meet agreed upon performance measures, the 
 commissioner may authorize contracted providers other than the 
 county.  Providers contracted by the commissioner shall also be 
 subject to the standards in subdivision 6. 

    HIST: 1Sp2001 c 9 art 2 s 44; 2002 c 277 s 18; 2002 c 375 art 
 2 s 31; 2002 c 379 art 1 s 113 

  256B.0925 Repealed, 1995 c 186 s 51 

     256B.0926 Admission review team for admissions to 
  intermediate care facilities for persons with mental retardation 
  or related conditions. 

    Subdivision 1.    Definitions.  (a) For purposes of this 
 section, the following terms have the meanings given them in 
 this subdivision. 

    (b) "Provider" means a provider of community-based 
 intermediate care facility services for persons with mental 
 retardation or related conditions. 

    (c) "Facility" means a community-based intermediate care 
 facility for persons with mental retardation or related 
 conditions. 

    (d) "Person" means a person with mental retardation or 
 related conditions who is applying for admission to an 
 intermediate care facility for persons with mental retardation 
 or related conditions.  

    Subd. 2.    Admission review team; responsibilities; 
 composition.  (a) Before a person is admitted to a facility, 
 an admission review team must assure that the provider can meet 
 the needs of the person as identified in the person's individual 
 service plan required under section 256B.092, subdivision 1. 

    (b) The admission review team must be assembled pursuant to 
 Code of Federal Regulations, title 42, section 483.440(b)(2).  
 The composition of the admission review team must meet the 
 definition of an interdisciplinary team in Code of Federal 
 Regulations, title 42, section 483.440.  In addition, the 
 admission review team must meet any conditions agreed to by the 
 provider and the county where services are to be provided.  

    (c)  The county in which the facility is located may 
 establish an admission review team which includes at least the 
 following:  

    (1) a qualified mental retardation professional, as defined 
 in Code of Federal Regulations, title 42, section 483.440; 

    (2) a representative of the county in which the provider is 
 located; 

    (3) at least one professional representing one of the 
 following professions:  nursing, psychology, physical therapy, 
 or occupational therapy; and 

    (4) a representative of the provider.  

    If the county in which the facility is located does not 
 establish an admission review team, the provider shall establish 
 a team whose composition meets the definition of an 
 interdisciplinary team in Code of Federal Regulations, title 42, 
 section 483.440.  The provider shall invite a representative of 
 the county agency where the facility is located to be a member 
 of the admission review team.  

    Subd. 3.    Factors to be considered for admission.  (a) 
 The determination of the team to admit a person to the facility 
 must include, but is not limited to, consideration of the 
 following:  

    (1) the preferences of the person and the person's guardian 
 or family for services of an intermediate care facility for 
 persons with mental retardation or related conditions; 

    (2) the ability of the provider to meet the needs of the 
 person according to the person's individual service plan and the 
 admission criteria established by the provider; 

    (3) the availability of a bed in the facility and of 
 nonresidential services required by the person as specified in 
 the person's individual service plan; and 

    (4) the need of the person for the services in the facility 
 to prevent placement of the person in a more restrictive setting.

    (b) When there is more than one qualified person applying 
 for admission to the facility, the admission review team shall 
 determine which applicant shall be offered services first, using 
 the criteria established in this subdivision.  The admission 
 review team shall document the factors that resulted in the 
 decision to offer services to one qualified person over 
 another.  In cases of emergency, a review of the admission by 
 the admission review team must occur within the first 14 days of 
 placement.  

    Subd. 4.    Information from provider.  The provider 
 must establish admission criteria based on the level of service 
 that can be provided to persons seeking admission to that 
 facility and must provide the admission review team with the 
 following information:  

    (1) a copy of the admission and level of care criteria 
 adopted by the provider; and 

    (2) a written description of the services that are 
 available to the person seeking admission, including day 
 services, professional support services, emergency services, 
 available direct care staffing, supervisory and administrative 
 supports, quality assurance systems, and criteria established by 
 the provider for discharging persons from the facility. 

    Subd. 5.    Establishment of admission review team; notice 
 to provider.  When a county agency decides to establish 
 admission review teams for the intermediate care facilities for 
 persons with mental retardation or related conditions located in 
 the county, the county agency shall notify the providers of the 
 county agency's intent at least 60 days prior to establishing 
 the teams.  

    HIST: 1991 c 292 art 6 s 48 

     256B.0928 Statewide caregiver support and respite care 
  project. 

    The commissioner shall establish and maintain a statewide 
 caregiver support and respite care project.  The project shall: 

    (1) provide information, technical assistance, and training 
 statewide to county agencies and organizations on direct service 
 models of caregiver support and respite care services; 

    (2) identify and address issues, concerns, and gaps in the 
 statewide network for caregiver support and respite care; 

    (3) maintain a statewide caregiver support and respite care 
 resource center; 

    (4) educate caregivers on the availability and use of 
 caregiver and respite care services; 

    (5) promote and expand caregiver training and support 
 groups using existing networks when possible; and 

    (6) apply for and manage grants related to caregiver 
 support and respite care. 

    HIST: 1992 c 513 art 7 s 75; 1999 c 86 art 2 s 5 

     256B.093 Services for persons with traumatic brain 
  injuries. 

    Subdivision 1.    State traumatic brain injury program.  
 The commissioner of human services shall: 

    (1) maintain a statewide traumatic brain injury program; 

    (2) supervise and coordinate services and policies for 
 persons with traumatic brain injuries; 

    (3) contract with qualified agencies or employ staff to 
 provide statewide administrative case management and 
 consultation; 

    (4) maintain an advisory committee to provide 
 recommendations in reports to the commissioner regarding program 
 and service needs of persons with traumatic brain injuries; 

    (5) investigate the need for the development of rules or 
 statutes for the traumatic brain injury home and community-based 
 services waiver; 

    (6) investigate present and potential models of service 
 coordination which can be delivered at the local level; and 

    (7) the advisory committee required by clause (4) must 
 consist of no fewer than ten members and no more than 30 
 members.  The commissioner shall appoint all advisory committee 
 members to one- or two-year terms and appoint one member as 
 chair.  Notwithstanding section 15.059, subdivision 5, the 
 advisory committee does not terminate until June 30, 2005. 

    Subd. 2.    Eligibility.  Persons eligible for traumatic 
 brain injury administrative case management and consultation 
 must be eligible medical assistance recipients who have 
 traumatic or certain acquired brain injury and are at risk of 
 institutionalization.  

    Subd. 3.    Traumatic brain injury program duties.  The 
 department shall fund administrative case management under this 
 subdivision using medical assistance administrative funds.  The 
 traumatic brain injury program duties include: 

    (1) recommending to the commissioner in consultation with 
 the medical review agent according to Minnesota Rules, parts 
 9505.0500 to 9505.0540, the approval or denial of medical 
 assistance funds to pay for out-of-state placements for 
 traumatic brain injury services and in-state traumatic brain 
 injury services provided by designated Medicare long-term care 
 hospitals; 

    (2) coordinating the traumatic brain injury home and 
 community-based waiver; 

    (3) providing ongoing technical assistance and consultation 
 to county and facility case managers to facilitate care plan 
 development for appropriate, accessible, and cost-effective 
 medical assistance services; 

    (4) providing technical assistance to promote statewide 
 development of appropriate, accessible, and cost-effective 
 medical assistance services and related policy; 

    (5) providing training and outreach to facilitate access to 
 appropriate home and community-based services to prevent 
 institutionalization; 

    (6) facilitating appropriate admissions, continued stay 
 review, discharges, and utilization review for neurobehavioral 
 hospitals and other specialized institutions; 

    (7) providing technical assistance on the use of prior 
 authorization of home care services and coordination of these 
 services with other medical assistance services; 

    (8) developing a system for identification of nursing 
 facility and hospital residents with traumatic brain injury to 
 assist in long-term planning for medical assistance services.  
 Factors will include, but are not limited to, number of 
 individuals served, length of stay, services received, and 
 barriers to community placement; and 

    (9) providing information, referral, and case consultation 
 to access medical assistance services for recipients without a 
 county or facility case manager.  Direct access to this 
 assistance may be limited due to the structure of the program. 

    Subd. 3a.    Traumatic brain injury case management 
 services.  The annual appropriation established under section 
 171.29, subdivision 2, paragraph (b), clause (5), shall be used 
 for traumatic brain injury program services that include, but 
 are not limited to: 

    (1) collaborating with counties, providers, and other 
 public and private organizations to expand and strengthen local 
 capacity for delivering needed services and supports, including 
 efforts to increase access to supportive residential housing 
 options; 

    (2) participating in planning and accessing services not 
 otherwise covered in subdivision 3 to allow individuals to 
 attain and maintain community-based services; 

    (3) providing information, referral, and case consultation 
 to access health and human services for persons with traumatic 
 brain injury not eligible for medical assistance, though direct 
 access to this assistance may be limited due to the structure of 
 the program; and 

    (4) collaborating on injury prevention efforts. 

    Subd. 4.    Definitions.  For purposes of this section, 
 the following definitions apply: 

    (a) "Traumatic brain injury" means a sudden insult or 
 damage to the brain or its coverings, not of a degenerative or 
 congenital nature.  The insult or damage may produce an altered 
 state of consciousness and may result in a decrease in 
 cognitive, behavioral, emotional, or physical functioning 
 resulting in partial or total disability. 

    (b) "Home care services" means medical assistance home care 
 services defined under section 256B.0625, subdivisions 6a, 7, 
 and 19a. 

    HIST: 1989 c 282 art 3 s 62; 1991 c 292 art 7 s 19; 1992 c 513 
 art 7 s 76-78; 1Sp1993 c 1 art 5 s 80,81; 1995 c 207 art 6 s 
 75-78; 1996 c 451 art 5 s 25; 2001 c 161 s 48; 1Sp2001 c 9 art 3 
 s 47; 2002 c 379 art 1 s 113 

     256B.094 Child welfare targeted case management services.

    Subdivision 1.    Definition.  "Child welfare targeted 
 case management services" means activities that coordinate 
 social and other services designed to help the child under age 
 21 and the child's family gain access to needed social services, 
 mental health services, habilitative services, educational 
 services, health services, vocational services, recreational 
 services, and related services including, but not limited to, 
 the areas of volunteer services, advocacy, transportation, and 
 legal services.  Case management services include developing an 
 individual service plan and assisting the child and the child's 
 family in obtaining needed services through coordination with 
 other agencies and assuring continuity of care.  Case managers 
 must assess the delivery, appropriateness, and effectiveness of 
 services on a regular basis.  

    Subd. 2.    Eligible services.  Services eligible for 
 medical assistance reimbursement include:  

    (1) assessment of the recipient's need for case management 
 services to gain access to medical, social, educational, and 
 other related services; 

    (2) development, completion, and regular review of a 
 written individual service plan based on the assessment of need 
 for case management services to ensure access to medical, 
 social, educational, and other related services; 

    (3) routine contact or other communication with the client, 
 the client's family, primary caregiver, legal representative, 
 substitute care provider, service providers, or other relevant 
 persons identified as necessary to the development or 
 implementation of the goals of the individual service plan, 
 regarding the status of the client, the individual service plan, 
 or the goals for the client, exclusive of transportation of the 
 child; 

    (4) coordinating referrals for, and the provision of, case 
 management services for the client with appropriate service 
 providers, consistent with section 1902(a)(23) of the Social 
 Security Act; 

    (5) coordinating and monitoring the overall service 
 delivery to ensure quality of services; 

    (6) monitoring and evaluating services on a regular basis 
 to ensure appropriateness and continued need; 

    (7) completing and maintaining necessary documentation that 
 supports and verifies the activities in this subdivision; 

    (8) traveling to conduct a visit with the client or other 
 relevant person necessary to the development or implementation 
 of the goals of the individual service plan; and 

    (9) coordinating with the medical assistance facility 
 discharge planner in the 30-day period before the client's 
 discharge into the community.  This case management service 
 provided to patients or residents in a medical assistance 
 facility is limited to a maximum of two 30-day periods per 
 calendar year. 

    Subd. 3.    Coordination and provision of services.  (a) 
 In a county or reservation where a prepaid medical assistance 
 provider has contracted under section 256B.031 or 256B.69 to 
 provide mental health services, the case management provider 
 shall coordinate with the prepaid provider to ensure that all 
 necessary mental health services required under the contract are 
 provided to recipients of case management services. 

    (b) When the case management provider determines that a 
 prepaid provider is not providing mental health services as 
 required under the contract, the case management provider shall 
 assist the recipient to appeal the prepaid provider's denial 
 pursuant to section 256.045, and may make other arrangements for 
 provision of the covered services.  

    (c) The case management provider may bill the provider of 
 prepaid health care services for any mental health services 
 provided to a recipient of case management services which the 
 county or tribal social services arranges for or provides and 
 which are included in the prepaid provider's contract, and which 
 were determined to be medically necessary as a result of an 
 appeal pursuant to section 256.045.  The prepaid provider must 
 reimburse the mental health provider, at the prepaid provider's 
 standard rate for that service, for any services delivered under 
 this subdivision. 

    (d) If the county or tribal social services has not 
 obtained prior authorization for this service, or an appeal 
 results in a determination that the services were not medically 
 necessary, the county or tribal social services may not seek 
 reimbursement from the prepaid provider.  

    Subd. 4.    Case management provider.  To be eligible to 
 receive medical assistance reimbursement, the case management 
 provider must meet all provider qualification and certification 
 standards under section 256F.10.  

    Subd. 5.    Case manager.  To provide case management 
 services, a case manager must be employed or contracted by and 
 authorized by the case management provider to provide case 
 management services and meet all requirements under section 
 256F.10. 

    Subd. 6.    Medical assistance reimbursement of case 
 management services.  (a) Medical assistance reimbursement for 
 services under this section shall be made on a monthly basis.  
 Payment is based on face-to-face or telephone contacts between 
 the case manager and the client, client's family, primary 
 caregiver, legal representative, or other relevant person 
 identified as necessary to the development or implementation of 
 the goals of the individual service plan regarding the status of 
 the client, the individual service plan, or the goals for the 
 client.  These contacts must meet the minimum standards in 
 clauses (1) and (2):  

    (1) there must be a face-to-face contact at least once a 
 month except as provided in clause (2); and 

    (2) for a client placed outside of the county of financial 
 responsibility, or a client served by tribal social services 
 placed outside the reservation, in an excluded time facility 
 under section 256G.02, subdivision 6, or through the Interstate 
 Compact on the Placement of Children, section 260.851, and the 
 placement in either case is more than 60 miles beyond the county 
 or reservation boundaries, there must be at least one contact 
 per month and not more than two consecutive months without a 
 face-to-face contact. 

    (b) Except as provided under paragraph (c), the payment 
 rate is established using time study data on activities of 
 provider service staff and reports required under sections 
 245.482, 256.01, subdivision 2, paragraph (17), and 256E.08, 
 subdivision 8. 

    (c) Payments for tribes may be made according to section 
 256B.0625 or other relevant federally approved rate setting 
 methodology for child welfare targeted case management provided 
 by Indian health services and facilities operated by a tribe or 
 tribal organization. 

    (d) Payment for case management provided by county or 
 tribal social services contracted vendors shall be based on a 
 monthly rate negotiated by the host county or tribal social 
 services.  The negotiated rate must not exceed the rate charged 
 by the vendor for the same service to other payers.  If the 
 service is provided by a team of contracted vendors, the county 
 or tribal social services may negotiate a team rate with a 
 vendor who is a member of the team.  The team shall determine 
 how to distribute the rate among its members.  No reimbursement 
 received by contracted vendors shall be returned to the county 
 or tribal social services, except to reimburse the county or 
 tribal social services for advance funding provided by the 
 county or tribal social services to the vendor. 

    (e) If the service is provided by a team that includes 
 contracted vendors and county or tribal social services staff, 
 the costs for county or tribal social services staff 
 participation in the team shall be included in the rate for 
 county or tribal social services provided services.  In this 
 case, the contracted vendor and the county or tribal social 
 services may each receive separate payment for services provided 
 by each entity in the same month.  To prevent duplication of 
 services, each entity must document, in the recipient's file, 
 the need for team case management and a description of the roles 
 and services of the team members. 

    Separate payment rates may be established for different 
 groups of providers to maximize reimbursement as determined by 
 the commissioner.  The payment rate will be reviewed annually 
 and revised periodically to be consistent with the most recent 
 time study and other data.  Payment for services will be made 
 upon submission of a valid claim and verification of proper 
 documentation described in subdivision 7.  Federal 
 administrative revenue earned through the time study, or under 
 paragraph (c), shall be distributed according to earnings, to 
 counties, reservations, or groups of counties or reservations 
 which have the same payment rate under this subdivision, and to 
 the group of counties or reservations which are not certified 
 providers under section 256F.10.  The commissioner shall modify 
 the requirements set out in Minnesota Rules, parts 9550.0300 to 
 9550.0370, as necessary to accomplish this. 

    Subd. 7.    Documentation for case record and claim.  (a)
 The assessment, case finding, and individual service plan shall 
 be maintained in the individual case record under the Data 
 Practices Act, chapter 13.  The individual service plan must be 
 reviewed at least annually and updated as necessary.  Each 
 individual case record must maintain documentation of routine, 
 ongoing, contacts and services.  Each claim must be supported by 
 written documentation in the individual case record.  

    (b) Each claim must include:  

    (1) the name of the recipient; 

    (2) the date of the service; 

    (3) the name of the provider agency and the person 
 providing service; 

    (4) the nature and extent of services; and 

    (5) the place of the services. 

    Subd. 8.    Payment limitation.  Services that are not 
 eligible for payment as a child welfare targeted case management 
 service include, but are not limited to:  

    (1) assessments prior to opening a case; 

    (2) therapy and treatment services; 

    (3) legal services, including legal advocacy, for the 
 client; 

    (4) information and referral services that are part of a 
 county's community social services plan, that are not provided 
 to an eligible recipient; 

    (5) outreach services including outreach services provided 
 through the community support services program; 

    (6) services that are not documented as required under 
 subdivision 7 and Minnesota Rules, parts 9505.2165 and 
 9505.2175; 

    (7) services that are otherwise eligible for payment on a 
 separate schedule under rules of the department of human 
 services; 

    (8) services to a client that duplicate the same case 
 management service from another case manager; 

    (9) case management services provided to patients or 
 residents in a medical assistance facility except as described 
 under subdivision 2, clause (9); and 

    (10) for children in foster care, group homes, or 
 residential care, payment for case management services is 
 limited to case management services that focus on permanency 
 planning or return to the family home and that do not duplicate 
 the facility's discharge planning services. 

    HIST: 1Sp1993 c 1 art 3 s 24; 1999 c 139 art 4 s 2; 1999 c 245 
 art 8 s 6-8; 2000 c 488 art 9 s 17; 2001 c 203 s 11,12 

     256B.0945 Residential services for children with severe 
  emotional disturbance. 

    Subdivision 1.    Provider qualifications.  Counties 
 must arrange to provide residential services for children with 
 severe emotional disturbance according to sections 245.4882, 
 245.4885, and this section.  Services must be provided by a 
 facility that is licensed according to section 245.4882 and 
 administrative rules promulgated thereunder, and under contract 
 with the county.  Facilities providing services under 
 subdivision 2, paragraph (a), must be accredited as a 
 psychiatric facility by the Joint Commission on Accreditation of 
 Healthcare Organizations, the Commission on Accreditation of 
 Rehabilitation Facilities, or the Council on Accreditation.  
 Accreditation is not required for facilities providing services 
 under subdivision 2, paragraph (b). 

    Subd. 2.    Covered services.  All services must be 
 included in a child's individualized treatment or multiagency 
 plan of care as defined in chapter 245.  

    (a) For facilities that are institutions for mental 
 diseases according to statute and regulation or are not 
 institutions for mental diseases but are approved by the 
 commissioner to provide services under this paragraph, medical 
 assistance covers the full contract rate, including room and 
 board if the services meet the requirements of Code of Federal 
 Regulations, title 42, section 440.160.  

    (b) For facilities that are not institutions for mental 
 diseases according to federal statute and regulation and are not 
 providing services under paragraph (a), medical assistance 
 covers mental health related services that are required to be 
 provided by a residential facility under section 245.4882 and 
 administrative rules promulgated thereunder, except for room and 
 board. 

    Subd. 3.    Centralized disbursement of medical assistance 
 payments.  Notwithstanding section 256B.041, county payments 
 for the cost of residential services provided under this section 
 shall not be made to the state treasurer. 

    Subd. 4.    Payment rates.  (a) Notwithstanding sections 
 256B.19 and 256B.041, payments to counties for residential 
 services provided by a residential facility shall only be made 
 of federal earnings for services provided under this section, 
 and the nonfederal share of costs for services provided under 
 this section shall be paid by the county from sources other than 
 federal funds or funds used to match other federal funds.  
 Payment to counties for services provided according to 
 subdivision 2, paragraph (a), shall be the federal share of the 
 contract rate.  Payment to counties for services provided 
 according to subdivision 2, paragraph (b), shall be a proportion 
 of the per day contract rate that relates to rehabilitative 
 mental health services and shall not include payment for costs 
 or services that are billed to the IV-E program as room and 
 board.  

    (b) The commissioner shall set aside a portion not to 
 exceed five percent of the federal funds earned under this 
 section to cover the state costs of administering this section.  
 Any unexpended funds from the set-aside shall be distributed to 
 the counties in proportion to their earnings under this section. 

    Subd. 5.    Quality measures.  Counties must collect and 
 report to the commissioner information on outcomes for services 
 provided under this section using standardized tools that 
 measure the impact of residential treatment programs on child 
 functioning and/or behavior, living stability, and parent and 
 child satisfaction consistent with the goals of sections 
 245.4876, subdivision 1, and 256F.01.  The commissioner shall 
 designate standardized tools to be used and shall collect and 
 analyze individualized outcome data on a statewide basis and 
 report to the legislature by December 1, 2003.  The commissioner 
 shall provide standardized tools that measure child and 
 adolescent functionality, placement stability, and satisfaction 
 for youth and family members. 

    Subd. 6.    Federal earnings.  Use of new federal 
 funding earned from services provided under this section is 
 limited to:  

    (1) increasing prevention and early intervention and 
 supportive services to meet the mental health and child welfare 
 needs of the children and families in the system of care; 

    (2) replacing reductions in federal IV-E reimbursement 
 resulting from new medical assistance coverage; 

    (3) paying the nonfederal share of additional provider 
 costs due to accreditation and new program standards necessary 
 for Medicaid reimbursement; and 

    (4) paying for the costs of complying with the data 
 collection and reporting requirements contained in subdivision 5.

 For purposes of this section, prevention, early intervention, 
 and supportive services for children and families include 
 alternative responses to child maltreatment reports under 
 chapter 626 and nonresidential children's mental health services 
 outlined in section 245.4875, subdivision 2, and family 
 preservation services outlined in section 256F.05, subdivision 8.

    Subd. 7.    Maintenance of effort.  (a) Counties that 
 receive payment under this section must maintain a level of 
 expenditures such that each year's county expenditures for 
 prevention, early intervention, and supportive services for 
 children and families is at least equal to that county's average 
 expenditures for those services for calendar years 1998 and 1999.

    (b) The commissioner may waive the requirements in 
 paragraph (a) if any of the conditions specified in section 
 256F.13, subdivision 1, paragraph (a), clause (4), items (i) to 
 (iv), are met.  

    Subd. 8.    Reports.  The commissioner shall review 
 county expenditures annually using reports required under 
 sections 245.482; 256.01, subdivision 2, clause (17); and 
 256E.08, subdivision 8, to ensure that counties meet their 
 obligation under subdivision 7, and that the base level of 
 expenditures for prevention, early intervention, and supportive 
 services for children and families and children's mental health 
 residential treatment is continued from sources other than 
 federal funds earned under this section. 

    Subd. 9.    Sanctions.  The commissioner may suspend, 
 reduce, or terminate funds for prevention, early intervention, 
 and supportive services for children and families up to the 
 limit of federal revenue earned under this section to a county 
 that does not meet one or all of the requirements of this 
 section.  If the commissioner finds evidence of children placed 
 in residential treatment who do not meet the criteria outlined 
 in section 245.4885, subdivision 1, the commissioner may take 
 action to limit inappropriate placements in residential 
 treatment. 

    Subd. 10.    Recommendations.  The commissioner shall 
 provide recommendations to the legislature by January 15, 2000, 
 regarding any amendments to this section that may be necessary 
 or advisable prior to implementation. 

    HIST: 1999 c 245 art 8 s 9; 2000 c 340 s 4-11; 2002 c 277 s 19 

QUALITY ASSURANCE

     256B.095 Quality assurance project established. 

    Effective July 1, 1998, an alternative quality assurance 
 licensing system project for programs for persons with 
 developmental disabilities is established in Dodge, Fillmore, 
 Freeborn, Goodhue, Houston, Mower, Olmsted, Rice, Steele, 
 Wabasha, and Winona counties for the purpose of improving the 
 quality of services provided to persons with developmental 
 disabilities.  A county, at its option, may choose to have all 
 programs for persons with developmental disabilities located 
 within the county licensed under chapter 245A using standards 
 determined under the alternative quality assurance licensing 
 system project or may continue regulation of these programs 
 under the licensing system operated by the commissioner.  The 
 project expires on June 30, 2005. 

    HIST: 1997 c 203 art 7 s 18; 1Sp2001 c 9 art 3 s 48; 2002 c 
 379 art 1 s 113 

     256B.0951 Quality assurance commission. 

    Subdivision 1.    Membership.  The region 10 quality 
 assurance commission is established.  The commission consists of 
 at least 14 but not more than 21 members as follows:  at least 
 three but not more than five members representing advocacy 
 organizations; at least three but not more than five members 
 representing consumers, families, and their legal 
 representatives; at least three but not more than five members 
 representing service providers; at least three but not more than 
 five members representing counties; and the commissioner of 
 human services or the commissioner's designee.  Initial 
 membership of the commission shall be recruited and approved by 
 the region 10 stakeholders group.  Prior to approving the 
 commission's membership, the stakeholders group shall provide to 
 the commissioner a list of the membership in the stakeholders 
 group, as of February 1, 1997, a brief summary of meetings held 
 by the group since July 1, 1996, and copies of any materials 
 prepared by the group for public distribution.  The first 
 commission shall establish membership guidelines for the 
 transition and recruitment of membership for the commission's 
 ongoing existence.  Members of the commission who do not receive 
 a salary or wages from an employer for time spent on commission 
 duties may receive a per diem payment when performing commission 
 duties and functions.  All members may be reimbursed for 
 expenses related to commission activities.  Notwithstanding the 
 provisions of section 15.059, subdivision 5, the commission 
 expires on June 30, 2005. 

    Subd. 2.    Authority to hire staff.  The commission may 
 hire staff to perform the duties assigned in this section.  

    Subd. 3.    Commission duties.  (a) By October 1, 1997, 
 the commission, in cooperation with the commissioners of human 
 services and health, shall do the following:  (1) approve an 
 alternative quality assurance licensing system based on the 
 evaluation of outcomes; (2) approve measurable outcomes in the 
 areas of health and safety, consumer evaluation, education and 
 training, providers, and systems that shall be evaluated during 
 the alternative licensing process; and (3) establish variable 
 licensure periods not to exceed three years based on outcomes 
 achieved.  For purposes of this subdivision, "outcome" means the 
 behavior, action, or status of a person that can be observed or 
 measured and can be reliably and validly determined. 

    (b) By January 15, 1998, the commission shall approve, in 
 cooperation with the commissioner of human services, a training 
 program for members of the quality assurance teams established 
 under section 256B.0952, subdivision 4. 

    (c) The commission and the commissioner shall establish an 
 ongoing review process for the alternative quality assurance 
 licensing system.  The review shall take into account the 
 comprehensive nature of the alternative system, which is 
 designed to evaluate the broad spectrum of licensed and 
 unlicensed entities that provide services to clients, as 
 compared to the current licensing system.  

    (d) The commission shall contract with an independent 
 entity to conduct a financial review of the alternative quality 
 assurance project.  The review shall take into account the 
 comprehensive nature of the alternative system, which is 
 designed to evaluate the broad spectrum of licensed and 
 unlicensed entities that provide services to clients, as 
 compared to the current licensing system.  The review shall 
 include an evaluation of possible budgetary savings within the 
 department of human services as a result of implementation of 
 the alternative quality assurance project.  If a federal waiver 
 is approved under subdivision 7, the financial review shall also 
 evaluate possible savings within the department of health.  This 
 review must be completed by December 15, 2000. 

    (e) The commission shall submit a report to the legislature 
 by January 15, 2001, on the results of the review process for 
 the alternative quality assurance project, a summary of the 
 results of the independent financial review, and a 
 recommendation on whether the project should be extended beyond 
 June 30, 2001. 

    (f) The commissioner, in consultation with the commission, 
 shall examine the feasibility of expanding the project to other 
 populations or geographic areas and identify barriers to 
 expansion.  The commissioner shall report findings and 
 recommendations to the legislature by December 15, 2004. 

    Subd. 4.    Commission's authority to recommend variances 
 of licensing standards.  The commission may recommend to the 
 commissioners of human services and health variances from the 
 standards governing licensure of programs for persons with 
 developmental disabilities in order to improve the quality of 
 services by implementing an alternative developmental 
 disabilities licensing system if the commission determines that 
 the alternative licensing system does not adversely affect the 
 health or safety of persons being served by the licensed program 
 nor compromise the qualifications of staff to provide services. 

    Subd. 5.    Variance of certain standards prohibited.  
 The safety standards, rights, or procedural protections under 
 sections 245.825; 245.91 to 245.97; 245A.04, subdivisions 3, 3a, 
 3b, and 3c; 245A.09, subdivision 2, paragraph (c), clauses (2) 
 and (5); 245A.12; 245A.13; 252.41, subdivision 9; 256B.092, 
 subdivisions 1b, clause (7), and 10; 626.556; 626.557, and 
 procedures for the monitoring of psychotropic medications shall 
 not be varied under the alternative licensing system project.  
 The commission may make recommendations to the commissioners of 
 human services and health or to the legislature regarding 
 alternatives to or modifications of the rules and procedures 
 referenced in this subdivision. 

    Subd. 6. Repealed, 1Sp2001 c 9 art 3 s 76 

    Subd. 7.    Waiver of rules.  If a federal waiver is 
 approved under subdivision 8, the commissioner of health may 
 exempt residents of intermediate care facilities for persons 
 with mental retardation (ICFs/MR) who participate in the 
 alternative quality assurance project established in section 
 256B.095 from the requirements of Minnesota Rules, chapter 4665. 

    Subd. 8.    Federal waiver.  The commissioner of human 
 services shall seek a federal waiver to allow intermediate care 
 facilities for persons with mental retardation (ICFs/MR) in 
 region 10 of Minnesota to participate in the alternative 
 licensing system.  If it is necessary for purposes of 
 participation in this alternative licensing system for a 
 facility to be decertified as an ICF/MR facility according to 
 the terms of the federal waiver, when the facility seeks 
 recertification under the provisions of ICF/MR regulations at 
 the end of the demonstration project, it will not be considered 
 a new ICF/MR as defined under section 252.291 provided the 
 licensed capacity of the facility did not increase during its 
 participation in the alternative licensing system.  The 
 provisions of sections 252.82, 252.292, and 256B.5011 to 
 256B.5015 will remain applicable for counties in region 10 of 
 Minnesota and the ICFs/MR located within those counties 
 notwithstanding a county's participation in the alternative 
 licensing system. 

    Subd. 9.    Evaluation.  The commission, in consultation 
 with the commissioner of human services, shall conduct an 
 evaluation of the alternative quality assurance system, and 
 present a report to the commissioner by June 30, 2004. 

    HIST: 1997 c 203 art 7 s 19; 1998 c 407 art 4 s 40; 1999 c 245 
 art 4 s 63,64; 1Sp2001 c 9 art 3 s 49-55; 2002 c 375 art 2 s 
 32,33; 2002 c 379 art 1 s 113 

     256B.0952 County duties; quality assurance teams. 

    Subdivision 1.    Notification.  For each year of the 
 project, region 10 counties shall give notice to the commission 
 and commissioners of human services and health by March 15 of 
 intent to join the quality assurance alternative licensing 
 system, effective July 1 of that year.  A county choosing to 
 participate in the alternative licensing system commits to 
 participate until June 30, 2005.  Counties participating in the 
 quality assurance alternative licensing system as of January 1, 
 2001, shall notify the commission and the commissioners of human 
 services and health by March 15, 2001, of intent to continue 
 participation.  Counties that elect to continue participation 
 must participate in the alternative licensing system until June 
 30, 2005. 

    Subd. 2.    Appointment of review council; duties of 
 council.  A county or group of counties that chooses to 
 participate in the alternative licensing system shall appoint a 
 quality assurance review council comprised of advocates; 
 consumers, families, and their legal representatives; providers; 
 and county staff.  The council shall: 

    (1) review summary reports from quality assurance team 
 reviews and make recommendations to counties regarding program 
 licensure; 

    (2) make recommendations to the commission regarding the 
 alternative licensing system and quality assurance process; and 

    (3) resolve complaints between the quality assurance teams, 
 counties, providers, and consumers, families, and their legal 
 representatives. 

    Subd. 3.    Notice to commissioners.  The county, based 
 on reports from quality assurance managers and recommendations 
 from the quality assurance review council regarding the findings 
 of quality assurance teams, shall notify the commissioners of 
 human services and health regarding whether facilities, 
 programs, or services have met the outcome standards for 
 licensure and are eligible for payment. 

    Subd. 4.    Appointment of quality assurance manager.  
 (a) A county or group of counties that chooses to participate in 
 the alternative licensing system shall designate a quality 
 assurance manager and shall establish quality assurance teams in 
 accordance with subdivision 5.  The manager shall recruit, 
 train, and assign duties to the quality assurance team members.  
 In assigning team members to conduct the quality assurance 
 process at a facility, program, or service, the manager shall 
 take into account the size of the service provider, the number 
 of services to be reviewed, the skills necessary for team 
 members to complete the process, and other relevant factors.  
 The manager shall ensure that no team member has a financial, 
 personal, or family relationship with the facility, program, or 
 service being reviewed or with any clients of the facility, 
 program, or service. 

    (b) Quality assurance teams shall report the findings of 
 their quality assurance reviews to the quality assurance manager.
 The quality assurance manager shall provide the report from the 
 quality assurance team to the county and, upon request, to the 
 commissioners of human services and health, and shall provide a 
 summary of the report to the quality assurance review council.  

    Subd. 5.    Quality assurance teams.  Quality assurance 
 teams shall be comprised of county staff; providers; consumers, 
 families, and their legal representatives; members of advocacy 
 organizations; and other involved community members.  Team 
 members must satisfactorily complete the training program 
 approved by the commission and must demonstrate 
 performance-based competency.  Team members are not considered 
 to be county employees for purposes of workers' compensation, 
 unemployment compensation, or state retirement laws solely on 
 the basis of participation on a quality assurance team.  The 
 county may pay a per diem to team members who do not receive a 
 salary or wages from an employer for time spent on alternative 
 quality assurance process matters.  All team members may be 
 reimbursed for expenses related to their participation in the 
 alternative process. 

    Subd. 6.    Licensing functions.  Participating counties 
 shall perform licensing functions and activities as delegated by 
 the commissioner of human services in accordance with section 
 245A.16. 

    HIST: 1997 c 203 art 7 s 20; 1Sp2001 c 9 art 3 s 56,57; 2002 c 
 379 art 1 s 113 

     256B.0953 Quality assurance process. 

    Subdivision 1.    Process components.  (a) The quality 
 assurance licensing process consists of an evaluation by a 
 quality assurance team of the facility, program, or service 
 according to outcome-based measurements.  The process must 
 include an evaluation of a random sample of program consumers.  
 The sample must be representative of each service provided.  The 
 sample size must be at least five percent of consumers but not 
 less than three consumers.  

    (b) All consumers must be given the opportunity to be 
 included in the quality assurance process in addition to those 
 chosen for the random sample. 

    Subd. 2.    Licensure periods.  (a) In order to be 
 licensed under the alternative quality assurance process, a 
 facility, program, or service must satisfy the health and safety 
 outcomes approved for the pilot project. 

    (b) Licensure shall be approved for periods of one to three 
 years for a facility, program, or service that satisfies the 
 requirements of paragraph (a) and achieves the outcome 
 measurements in the categories of consumer evaluation, education 
 and training, providers, and systems. 

    Subd. 3.    Appeals process.  A facility, program, or 
 service may contest a licensing decision of the quality 
 assurance team as permitted under chapter 245A. 

    HIST: 1997 c 203 art 7 s 21 

     256B.0954 Certain persons defined as mandated reporters. 

    Members of the quality assurance commission established 
 under section 256B.0951, members of quality assurance review 
 councils established under section 256B.0952, quality assurance 
 managers appointed under section 256B.0952, and members of 
 quality assurance teams established under section 256B.0952 are 
 mandated reporters as that term is defined in sections 626.556, 
 subdivision 3, and 626.5572, subdivision 16. 

    HIST: 1997 c 203 art 7 s 22 

     256B.0955 Duties of the commissioner of human services. 

    (a) Effective July 1, 1998, the commissioner of human 
 services shall delegate authority to perform licensing functions 
 and activities, in accordance with section 245A.16, to counties 
 participating in the alternative licensing system.  The 
 commissioner shall not license or reimburse a facility, program, 
 or service for persons with developmental disabilities in a 
 county that participates in the alternative licensing system if 
 the commissioner has received from the appropriate county 
 notification that the facility, program, or service has been 
 reviewed by a quality assurance team and has failed to qualify 
 for licensure. 

    (b) The commissioner may conduct random licensing 
 inspections based on outcomes adopted under section 256B.0951 at 
 facilities, programs, and services governed by the alternative 
 licensing system.  The role of such random inspections shall be 
 to verify that the alternative licensing system protects the 
 safety and well-being of consumers and maintains the 
 availability of high-quality services for persons with 
 developmental disabilities.  

    (c) The commissioner shall provide technical assistance and 
 support or training to the alternative licensing system pilot 
 project. 

    HIST: 1997 c 203 art 7 s 23; 1999 c 245 art 4 s 65 

  256B.10 Repealed, 1976 c 131 s 2 

  256B.11 Repealed, 1976 c 131 s 2 

     256B.12 Legal representation. 

    The attorney general or the appropriate county attorney 
 appearing at the direction of the attorney general shall be the 
 attorney for the state agency, and the county attorney of the 
 appropriate county shall be the attorney for the local agency in 
 all matters pertaining hereto.  To prosecute under this chapter 
 or sections 609.466 and 609.52, subdivision 2, or to recover 
 payments wrongfully made under this chapter, the attorney 
 general or the appropriate county attorney, acting independently 
 or at the direction of the attorney general may institute a 
 criminal or civil action. 

    HIST: Ex1967 c 16 s 12; 1975 c 437 art 2 s 6; 1976 c 188 s 2 

     256B.121 Treble damages. 

    Any vendor of medical care who willfully submits a cost 
 report, rate application or claim for reimbursement for medical 
 care which the vendor knows is a false representation and which 
 results in the payment of public funds for which the vendor is 
 ineligible shall, in addition to other provisions of Minnesota 
 law, be subject to an action by the state of Minnesota or any of 
 its subdivisions or agencies for civil damages.  The damages 
 awarded shall include three times the payments which result from 
 the false representation, together with costs and disbursements, 
 including reasonable attorneys' fees or their equivalent. 

    HIST: 1976 c 188 s 4 

     256B.13 Subpoenas. 

    Each county agency and the state agency shall have the 
 power to issue subpoenas for witnesses and compel their 
 attendance and the production of papers and writing; and 
 officers and employees designated by any county agency or the 
 state agency may administer oaths and examine witnesses under 
 oath in connection with any application or proceedings hereunder.

    HIST: Ex1967 c 16 s 13 

     256B.14 Relative's responsibility. 

    Subdivision 1.    In general.  Subject to the provisions 
 of sections 256B.055, 256B.056, and 256B.06, responsible 
 relative means the parent of a minor recipient of medical 
 assistance or the spouse of a medical assistance recipient.  

    Subd. 2.    Actions to obtain payment.  The state agency 
 shall promulgate rules to determine the ability of responsible 
 relatives to contribute partial or complete payment or repayment 
 of medical assistance furnished to recipients for whom they are 
 responsible.  All medical assistance exclusions shall be 
 allowed, and a resource limit of $10,000 for nonexcluded 
 resources shall be implemented.  Above these limits, a 
 contribution of one-third of the excess resources shall be 
 required.  These rules shall not require payment or repayment 
 when payment would cause undue hardship to the responsible 
 relative or that relative's immediate family.  These rules shall 
 be consistent with the requirements of section 252.27 for 
 parents of children whose eligibility for medical assistance was 
 determined without deeming of the parents' resources and income. 
 The county agency shall give the responsible relative notice of 
 the amount of the payment or repayment.  If the state agency or 
 county agency finds that notice of the payment obligation was 
 given to the responsible relative, but that the relative failed 
 or refused to pay, a cause of action exists against the 
 responsible relative for that portion of medical assistance 
 granted after notice was given to the responsible relative, 
 which the relative was determined to be able to pay.  

    The action may be brought by the state agency or the county 
 agency in the county where assistance was granted, for the 
 assistance, together with the costs of disbursements incurred 
 due to the action.  

    In addition to granting the county or state agency a money 
 judgment, the court may, upon a motion or order to show cause, 
 order continuing contributions by a responsible relative found 
 able to repay the county or state agency.  The order shall be 
 effective only for the period of time during which the recipient 
 receives medical assistance from the county or state agency. 

    Subd. 3.    Community spouse contribution.  The 
 community spouse of an institutionalized person who receives 
 medical assistance under section 256B.059, subdivision 5, 
 paragraph (b), has an obligation to pay for the cost of care 
 equal to the dollar value of assets considered available under 
 section 256B.059, subdivision 5. 

    Subd. 4.    Appeals.  A responsible relative may appeal 
 the determination of an obligation to make a contribution under 
 this section according to section 256.045. 

    HIST: Ex1967 c 16 s 14; 1973 c 725 s 46; 1977 c 448 s 7; 1982 
 c 640 s 6; 1983 c 312 art 5 s 19; 1984 c 530 s 4; 1986 c 444; 
 1988 c 689 art 2 s 150,268,270; 1989 c 282 art 3 s 63; 1990 c 
 568 art 3 s 62; 1992 c 513 art 7 s 79 

     256B.15 Claims against estates. 

    Subdivision 1.    Definition.  For purposes of this 
 section, "medical assistance" includes the medical assistance 
 program under this chapter and the general assistance medical 
 care program under chapter 256D, but does not include the 
 alternative care program for nonmedical assistance recipients 
 under section 256B.0913, subdivision 4. 

    Subd. 1a.    Estates subject to claims.  If a person 
 receives any medical assistance hereunder, on the person's 
 death, if single, or on the death of the survivor of a married 
 couple, either or both of whom received medical assistance, the 
 total amount paid for medical assistance rendered for the person 
 and spouse shall be filed as a claim against the estate of the 
 person or the estate of the surviving spouse in the court having 
 jurisdiction to probate the estate or to issue a decree of 
 descent according to sections 525.31 to 525.313.  

    A claim shall be filed if medical assistance was rendered 
 for either or both persons under one of the following 
 circumstances: 

    (a) the person was over 55 years of age, and received 
 services under this chapter, excluding alternative care; 

    (b) the person resided in a medical institution for six 
 months or longer, received services under this chapter excluding 
 alternative care, and, at the time of institutionalization or 
 application for medical assistance, whichever is later, the 
 person could not have reasonably been expected to be discharged 
 and returned home, as certified in writing by the person's 
 treating physician.  For purposes of this section only, a 
 "medical institution" means a skilled nursing facility, 
 intermediate care facility, intermediate care facility for 
 persons with mental retardation, nursing facility, or inpatient 
 hospital; or 

    (c) the person received general assistance medical care 
 services under chapter 256D.  

    The claim shall be considered an expense of the last 
 illness of the decedent for the purpose of section 524.3-805.  
 Any statute of limitations that purports to limit any county 
 agency or the state agency, or both, to recover for medical 
 assistance granted hereunder shall not apply to any claim made 
 hereunder for reimbursement for any medical assistance granted 
 hereunder.  Notice of the claim shall be given to all heirs and 
 devisees of the decedent whose identity can be ascertained with 
 reasonable diligence.  The notice must include procedures and 
 instructions for making an application for a hardship waiver 
 under subdivision 5; time frames for submitting an application 
 and determination; and information regarding appeal rights and 
 procedures.  Counties are entitled to one-half of the nonfederal 
 share of medical assistance collections from estates that are 
 directly attributable to county effort.  

    Subd. 1b. Repealed, 2001 c 203 s 19 

    Subd. 2.    Limitations on claims.  The claim shall 
 include only the total amount of medical assistance rendered 
 after age 55 or during a period of institutionalization 
 described in subdivision 1a, clause (b), and the total amount of 
 general assistance medical care rendered, and shall not include 
 interest.  Claims that have been allowed but not paid shall bear 
 interest according to section 524.3-806, paragraph (d).  A claim 
 against the estate of a surviving spouse who did not receive 
 medical assistance, for medical assistance rendered for the 
 predeceased spouse, is limited to the value of the assets of the 
 estate that were marital property or jointly owned property at 
 any time during the marriage. 

    Subd. 2a. Repealed, 2001 c 203 s 19 

    Subd. 3.    Minor, blind, or disabled children.  If a 
 decedent who was single, or who was the surviving spouse of a 
 married couple, is survived by a child who is under age 21 or 
 blind or permanently and totally disabled according to the 
 supplemental security income program criteria, no claim shall be 
 filed against the estate. 

    Subd. 4.    Other survivors.  If the decedent who was 
 single or the surviving spouse of a married couple is survived 
 by one of the following persons, a claim exists against the 
 estate in an amount not to exceed the value of the nonhomestead 
 property included in the estate: 

    (a) a sibling who resided in the decedent medical 
 assistance recipient's home at least one year before the 
 decedent's institutionalization and continuously since the date 
 of institutionalization; or 

    (b) a son or daughter or a grandchild who resided in the 
 decedent medical assistance recipient's home for at least two 
 years immediately before the parent's or grandparent's 
 institutionalization and continuously since the date of 
 institutionalization, and who establishes by a preponderance of 
 the evidence having provided care to the parent or grandparent 
 who received medical assistance, that the care was provided 
 before institutionalization, and that the care permitted the 
 parent or grandparent to reside at home rather than in an 
 institution. 

    Subd. 5.    Undue hardship.  Any person entitled to 
 notice in subdivision 1a has a right to apply for waiver of the 
 claim based upon undue hardship.  Any claim pursuant to this 
 section may be fully or partially waived because of undue 
 hardship.  Undue hardship does not include action taken by the 
 decedent which divested or diverted assets in order to avoid 
 estate recovery.  Any waiver of a claim must benefit the person 
 claiming undue hardship.  The commissioner shall have authority 
 to hear claimant appeals, pursuant to section 256.045, when an 
 application for a hardship waiver is denied in whole or part. 

    HIST: Ex1967 c 16 s 15; 1981 c 360 art 1 s 22; 1Sp1981 c 4 art 
 1 s 126; 1986 c 444; 1987 c 403 art 2 s 82; 1988 c 719 art 8 s 
 15; 1990 c 568 art 3 s 63; 1992 c 513 art 7 s 80,81; 1Sp1993 c 1 
 art 5 s 82,83; 1995 c 207 art 6 s 79-81; 1996 c 451 art 2 s 
 29,30,61,62; art 5 s 26; 2000 c 400 s 2,3; 2001 c 203 s 17 

*   NOTE:  The amendments to subdivisions 1a and 2 by Laws 
*1995, chapter 207, article 6, sections 79 and 80, relating only 
*to the age of a medical assistance recipient for purposes of 
*estate claims, are effective for persons who are between the 
*ages of 55 and 64 on or after July 1, 1995, for the total amount 
*of assistance on or after July 1, 1995.  See Laws 1995, chapter 
*207, article 6, section 125, subdivision 1.

  256B.16 Repealed, 1971 c 550 s 2 

     256B.17 Transfers of property. 

    Subdivision 1. Repealed, 1997 c 107 s 19 

    Subd. 2. Repealed, 1997 c 107 s 19 

    Subd. 3. Repealed, 1997 c 107 s 19 

    Subd. 4. Repealed, 1997 c 107 s 19 

    Subd. 5. Repealed, 1997 c 107 s 19 

    Subd. 6. Repealed, 1997 c 107 s 19 

    Subd. 7.    Exception for asset transfers.  An 
 institutionalized spouse, institutionalized before October 1, 
 1989, for a continuous period, who applies for medical 
 assistance on or after July 1, 1983, may transfer liquid assets 
 to a noninstitutionalized spouse if all of the following 
 conditions apply: 

    (a) The noninstitutionalized spouse is not applying for or 
 receiving assistance; 

    (b) Either (1) the noninstitutionalized spouse has less 
 than $10,000 in liquid assets, including assets singly owned and 
 50 percent of assets owned jointly with the institutionalized 
 spouse; or (2) the noninstitutionalized spouse has less than 50 
 percent of the total value of nonexempt assets owned by both 
 parties, jointly or individually; 

    (c) The amount transferred, together with the 
 noninstitutionalized spouse's own assets, totals no more than 
 one-half of the total value of the liquid assets of the parties 
 or $10,000 in liquid assets, whichever is greater; and 

    (d) The transfer may be effected only once, at the time of 
 initial medical assistance application. 

    Subd. 8. Repealed, 1997 c 107 s 19 

    HIST: Ex1967 c 16 s 17; 1981 c 360 art 2 s 30; 1983 c 312 art 
 5 s 20-24; 1984 c 534 s 23; 1985 c 252 s 23; 1986 c 444; 1987 c 
 403 art 2 s 83,84; 1988 c 689 art 2 s 151,268; 1989 c 282 art 3 
 s 98; 1990 c 568 art 3 s 95,96; 1997 c 107 s 7 

     256B.18 Methods of administration.  

    The state agency shall prescribe such methods of 
 administration as are necessary for compliance with requirements 
 of the Social Security Act, as amended, and for the proper and 
 efficient operation of the program of assistance hereunder.  The 
 state agency shall establish and maintain a system of personnel 
 standards on a merit basis for all such employees of the county 
 agencies and the examination thereof, and the administration 
 thereof shall be directed and controlled exclusively by the 
 state agency except in those counties in which such employees 
 are covered by a merit system that meets the requirements of the 
 state agency and the Social Security Act, as amended.  

    HIST: Ex1967 c 16 s 18 

     256B.19 Division of cost. 

    Subdivision 1.    Division of cost.  The state and 
 county share of medical assistance costs not paid by federal 
 funds shall be as follows:  

    (1) beginning January 1, 1992, 50 percent state funds and 
 50 percent county funds for the cost of placement of severely 
 emotionally disturbed children in regional treatment centers; 
 and 

    (2) beginning January 1, 2003, 80 percent state funds and 
 20 percent county funds for the costs of nursing facility 
 placements of persons with disabilities under the age of 65 that 
 have exceeded 90 days.  This clause shall be subject to chapter 
 256G and shall not apply to placements in facilities not 
 certified to participate in medical assistance. 

    For counties that participate in a Medicaid demonstration 
 project under sections 256B.69 and 256B.71, the division of the 
 nonfederal share of medical assistance expenses for payments 
 made to prepaid health plans or for payments made to health 
 maintenance organizations in the form of prepaid capitation 
 payments, this division of medical assistance expenses shall be 
 95 percent by the state and five percent by the county of 
 financial responsibility.  

    In counties where prepaid health plans are under contract 
 to the commissioner to provide services to medical assistance 
 recipients, the cost of court ordered treatment ordered without 
 consulting the prepaid health plan that does not include 
 diagnostic evaluation, recommendation, and referral for 
 treatment by the prepaid health plan is the responsibility of 
 the county of financial responsibility. 

    Subd. 1a. Repealed, 2002 c 277 s 34 

    Subd. 1b. Repealed, 1Sp2001 c 9 art 2 s 76 

    Subd. 1c.    Additional portion of nonfederal share.  (a)
 Hennepin county shall be responsible for a monthly transfer 
 payment of $1,500,000, due before noon on the 15th of each month 
 and the University of Minnesota shall be responsible for a 
 monthly transfer payment of $500,000 due before noon on the 15th 
 of each month, beginning July 15, 1995.  These sums shall be 
 part of the designated governmental unit's portion of the 
 nonfederal share of medical assistance costs. 

    (b) Beginning July 1, 2001, Hennepin county's payment under 
 paragraph (a) shall be $2,066,000 each month. 

    (c) Beginning July 1, 2001, the commissioner shall increase 
 annual capitation payments to the metropolitan health plan under 
 section 256B.69 for the prepaid medical assistance program by 
 approximately $3,400,000, plus any available federal matching 
 funds, to recognize higher than average medical education costs. 

    Subd. 1d.    Portion of nonfederal share to be paid by 
 certain counties.  (a) In addition to the percentage 
 contribution paid by a county under subdivision 1, the 
 governmental units designated in this subdivision shall be 
 responsible for an additional portion of the nonfederal share of 
 medical assistance cost.  For purposes of this subdivision, 
 "designated governmental unit" means the counties of Becker, 
 Beltrami, Clearwater, Cook, Dodge, Hubbard, Itasca, Lake, 
 Pennington, Pipestone, Ramsey, St. Louis, Steele, Todd, 
 Traverse, and Wadena. 

    (b) Beginning in 1994, each of the governmental units 
 designated in this subdivision shall transfer before noon on May 
 31 to the state Medicaid agency an amount equal to the number of 
 licensed beds in any nursing home owned and operated by the 
 county, with the county named as licensee, multiplied by $5,723. 
 If two or more counties own and operate a nursing home, the 
 payment shall be prorated.  These sums shall be part of the 
 designated governmental unit's portion of the nonfederal share 
 of medical assistance costs. 

    (c) Beginning in 2002, in addition to any transfer under 
 paragraph (b), each of the governmental units designated in this 
 subdivision shall transfer before noon on May 31 to the state 
 Medicaid agency an amount equal to the number of licensed beds 
 in any nursing home owned and operated by the county on that 
 date, with the county named as licensee, multiplied by $10,784.  
 The provisions of paragraph (b) apply to transfers under this 
 paragraph. 

    (d) The commissioner may reduce the intergovernmental 
 transfers under paragraph (c) based on the commissioner's 
 determination of the payment rate in section 256B.431, 
 subdivision 23, paragraphs (c) and (d).  Any adjustments must be 
 made on a per-bed basis and must result in an amount equivalent 
 to the total amount resulting from the rate adjustment in 
 section 256B.431, subdivision 23, paragraphs (c) and (d). 

    Subd. 2.    Distribution of federal funds.  Federal 
 funds available for administrative purposes shall be distributed 
 between the state and the county in the same proportion that 
 expenditures were made, except as provided for in section 
 256.017.  

    Subd. 2a.    Division of costs.  The county shall ensure 
 that only the least costly, most appropriate transportation and 
 travel expenses are used.  The state may enter into volume 
 purchase contracts, or use a competitive bidding process, 
 whenever feasible, to minimize the costs of transportation 
 services.  If the state has entered into a volume purchase 
 contract or used the competitive bidding procedures of chapter 
 16C to arrange for transportation services, the county may be 
 required to use such arrangements. 

    Subd. 2b.    Pilot project reimbursement.  In counties 
 where a pilot or demonstration project is operated under the 
 medical assistance program, the state may pay 100 percent of the 
 administrative costs for the pilot or demonstration project 
 after June 30, 1990.  

    Subd. 2c.    Obligation of local agency to investigate and 
 determine eligibility for medical assistance.  (a) When the 
 commissioner receives information that indicates that a general 
 assistance medical care recipient or MinnesotaCare program 
 enrollee may be eligible for medical assistance, the 
 commissioner may notify the appropriate local agency of that 
 fact.  The local agency must investigate eligibility for medical 
 assistance and take appropriate action and notify the 
 commissioner of that action within 90 days from the date notice 
 is issued.  If the person is eligible for medical assistance, 
 the local agency must find eligibility retroactively to the date 
 on which the person met all eligibility requirements. 

    (b) When a prepaid health plan under a contract with the 
 state to provide medical assistance services notifies the 
 commissioner that an infant has been or will be born to an 
 enrollee under the contract, the commissioner may notify the 
 appropriate local agency of that fact.  The local agency must 
 investigate eligibility for medical assistance for the infant, 
 take appropriate action, and notify the commissioner of that 
 action within 90 days from the date notice is issued.  If the 
 infant would have been eligible on the date of birth, the local 
 agency must establish eligibility retroactively to that month. 

    (c) For general assistance medical care recipients and 
 MinnesotaCare program enrollees, if the local agency fails to 
 comply with paragraph (a), the local agency is responsible for 
 the entire cost of general assistance medical care or 
 MinnesotaCare program services provided from the date the 
 commissioner issues the notice until the date the local agency 
 takes appropriate action on the case and notifies the 
 commissioner of the action.  For infants, if the local agency 
 fails to comply with paragraph (b), the commissioner may 
 determine eligibility for medical assistance for the infant for 
 a period of two months, and the local agency shall be 
 responsible for the entire cost of medical assistance services 
 provided for that infant, in addition to a fee of $100 for 
 processing the case.  The commissioner shall deduct any 
 obligation incurred under this paragraph from the amount due to 
 the local agency under subdivision 1. 

    Subd. 3.    Study of medical assistance financial 
 participation.  The commissioner shall study the feasibility 
 and outcomes of implementing a variable medical assistance 
 county financial participation rate for long-term care services 
 to mentally retarded persons in order to encourage the 
 utilization of alternative services to long-term intermediate 
 care for the mentally retarded.  The commissioner shall submit 
 findings and recommendations to the legislature by January 20, 
 1984.  

    HIST: Ex1967 c 16 s 19; 1971 c 547 s 1; 1975 c 437 art 2 s 7; 
 1982 c 640 s 7; 1983 c 312 art 9 s 6; 1984 c 534 s 24; 1Sp1985 c 
 9 art 2 s 46; 1986 c 444; 1987 c 403 art 2 s 85; 1988 c 719 art 
 8 s 16,17; 1Sp1989 c 1 art 16 s 8,9; 1990 c 568 art 3 s 64; 1991 
 c 292 art 4 s 51-53; 1992 c 513 art 7 s 82; 1993 c 13 art 1 s 
 32; 1Sp1993 c 1 art 5 s 84-86; 1995 c 207 art 6 s 82-84; 1995 c 
 234 art 8 s 56; 1997 c 203 art 11 s 7; 1998 c 386 art 2 s 80; 
 1Sp2001 c 9 art 2 s 45; 2002 c 220 art 14 s 7,8; 2002 c 277 s 
 20-23; 2002 c 375 art 2 s 34; 2002 c 379 art 1 s 113 

     256B.195 Additional intergovernmental transfers; 
  hospital payments. 

    Subdivision 1.    Federal approval required.  Sections 
 145.9268, 256.969, subdivision 26, and this section are 
 contingent on federal approval of the intergovernmental 
 transfers and payments to safety net hospitals and community 
 clinics authorized under this section.  These sections are also 
 contingent on current payment, by the government entities, of 
 intergovernmental transfers under section 256B.19 and this 
 section. 

    Subd. 2.    Payments from governmental entities.  (a) In 
 addition to any payment required under section 256B.19, 
 effective July 15, 2001, the following government entities shall 
 make the payments indicated before noon on the 15th of each 
 month: 

    (1) Hennepin county, $2,000,000; and 

    (2) Ramsey county, $1,000,000. 

    (b) These sums shall be part of the designated governmental 
 unit's portion of the nonfederal share of medical assistance 
 costs.  Of these payments, Hennepin county shall pay 71 percent 
 directly to Hennepin County Medical Center, and Ramsey county 
 shall pay 71 percent directly to Regions hospital.  The counties 
 must provide certification to the commissioner of payments to 
 hospitals under this subdivision. 

    Subd. 3.    Payments to certain safety net providers.  
 (a) Effective July 15, 2001, the commissioner shall make the 
 following payments to the hospitals indicated after noon on the 
 15th of each month: 

    (1) to Hennepin County Medical Center, any federal matching 
 funds available to match the payments received by the medical 
 center under subdivision 2, to increase payments for medical 
 assistance admissions and to recognize higher medical assistance 
 costs in institutions that provide high levels of charity care; 
 and 

    (2) to Regions hospital, any federal matching funds 
 available to match the payments received by the hospital under 
 subdivision 2, to increase payments for medical assistance 
 admissions and to recognize higher medical assistance costs in 
 institutions that provide high levels of charity care.  

    (b) Effective July 15, 2001, the following percentages of 
 the transfers under subdivision 2 shall be retained by the 
 commissioner for deposit each month into the general fund: 

    (1) 18 percent, plus any federal matching funds, shall be 
 allocated for the following purposes: 

    (i) during the fiscal year beginning July 1, 2001, of the 
 amount available under this clause, 39.7 percent shall be 
 allocated to make increased hospital payments under section 
 256.969, subdivision 26; 34.2 percent shall be allocated to fund 
 the amounts due from small rural hospitals, as defined in 
 section 144.148, for overpayments under section 256.969, 
 subdivision 5a, resulting from a determination that medical 
 assistance and general assistance payments exceeded the charge 
 limit during the period from 1994 to 1997; and 26.1 percent 
 shall be allocated to the commissioner of health for rural 
 hospital capital improvement grants under section 144.148; and 

    (ii) during fiscal years beginning on or after July 1, 
 2002, of the amount available under this clause, 55 percent 
 shall be allocated to make increased hospital payments under 
 section 256.969, subdivision 26, and 45 percent shall be 
 allocated to the commissioner of health for rural hospital 
 capital improvement grants under section 144.148; and 

    (2) 11 percent shall be allocated to the commissioner of 
 health to fund community clinic grants under section 145.9268. 

    (c) This subdivision shall apply to fee-for-service 
 payments only and shall not increase capitation payments or 
 payments made based on average rates. 

    (d) Medical assistance rate or payment changes, including 
 those required to obtain federal financial participation under 
 section 62J.692, subdivision 8, shall precede the determination 
 of intergovernmental transfer amounts determined in this 
 subdivision.  Participation in the intergovernmental transfer 
 program shall not result in the offset of any health care 
 provider's receipt of medical assistance payment increases other 
 than limits resulting from hospital-specific charge limits and 
 limits on disproportionate share hospital payments. 

    Subd. 4.    Adjustments permitted.  (a) The commissioner 
 may adjust the intergovernmental transfers under subdivision 2 
 and the payments under subdivision 3, and payments and transfers 
 under subdivision 5, based on the commissioner's determination 
 of Medicare upper payment limits, hospital-specific charge 
 limits, and hospital-specific limitations on disproportionate 
 share payments.  Any adjustments must be made on a proportional 
 basis.  If participation by a particular hospital under this 
 section is limited, the commissioner shall adjust the payments 
 that relate to that hospital under subdivisions 2, 3, and 5 on a 
 proportional basis in order to allow the hospital to participate 
 under this section to the fullest extent possible and shall 
 increase other payments under subdivisions 2, 3, and 5 to the 
 extent allowable to maintain the overall level of payments under 
 this section.  The commissioner may make adjustments under this 
 subdivision only after consultation with the counties and 
 hospitals identified in subdivisions 2 and 3, and, if 
 subdivision 5 receives federal approval, with the hospital and 
 educational institution identified in subdivision 5. 

    (b) The ratio of medical assistance payments specified in 
 subdivision 3 to the intergovernmental transfers specified in 
 subdivision 2 shall not be reduced except as provided under 
 paragraph (a). 

    Subd. 5.    Inclusion of Fairview University Medical 
 Center.  (a) Upon federal approval of the inclusion of 
 Fairview University Medical Center in the nonstate government 
 category, the commissioner shall establish an intergovernmental 
 transfer with the University of Minnesota in an amount 
 determined by the commissioner based on the increase in the 
 Medicare upper payment limit due solely to the inclusion of 
 Fairview University Medical Center as a nonstate government 
 hospital and limited by hospital-specific charge limits and the 
 amount available under the hospital-specific disproportionate 
 share limit. 

    (b) The commissioner shall increase payments for medical 
 assistance admissions at Fairview University Medical Center by 
 71 percent of the transfer plus any federal matching payments on 
 that amount, to increase payments for medical assistance 
 admissions and to recognize higher medical assistance costs in 
 institutions that provide high levels of charity care.  From 
 this payment, Fairview University Medical Center shall pay to 
 the University of Minnesota the cost of the transfer, on the 
 same day the payment is received.  Eighteen percent of the 
 transfer plus any federal matching payments shall be used as 
 specified in subdivision 3, paragraph (b), clause (1).  Payments 
 under section 256.969, subdivision 26, may be increased above 
 the 90 percent level specified in that subdivision within the 
 limits of additional funding available under this subdivision.  
 Eleven percent of the transfer shall be used to increase the 
 grants under section 145.9268. 

    HIST: 1Sp2001 c 9 art 2 s 46; 2002 c 379 art 1 s 113 

     256B.20 County appropriations. 

    The providing of funds necessary to carry out the 
 provisions hereof on the part of the counties and the manner of 
 administering the funds of the counties and the state shall be 
 as follows: 

    (1) The board of county commissioners of each county shall 
 annually set up in its budget an item designated as the county 
 medical assistance fund and levy taxes and fix a rate therefor 
 sufficient to produce the full amount of such item, in addition 
 to all other tax levies and tax rate, however fixed or 
 determined, sufficient to carry out the provisions hereof and 
 sufficient to pay in full the county share of assistance and 
 administrative expense for the ensuing year; and annually on or 
 before October 10 shall certify the same to the county auditor 
 to be entered by the auditor on the tax rolls.  Such tax levy 
 and tax rate shall make proper allowance and provision for 
 shortage in tax collections.  

    (2) Any county may transfer surplus funds from any county 
 fund, except the sinking or ditch fund, to the general fund or 
 to the county medical assistance fund in order to provide money 
 necessary to pay medical assistance awarded hereunder.  The 
 money so transferred shall be used for no other purpose, but any 
 portion thereof no longer needed for such purpose shall be 
 transferred back to the fund from which taken.  

    (3) Upon the order of the county agency the county auditor 
 shall draw a warrant on the proper fund in accordance with the 
 order, and the county treasurer shall pay out the amounts 
 ordered to be paid out as medical assistance hereunder.  When 
 necessary by reason of failure to levy sufficient taxes for the 
 payment of the medical assistance in the county, the county 
 auditor shall carry any such payments as an overdraft on the 
 medical assistance funds of the county until sufficient tax 
 funds shall be provided for such assistance payments.  The board 
 of county commissioners shall include in the tax levy and tax 
 rate in the year following the year in which such overdraft 
 occurred, an amount sufficient to liquidate such overdraft in 
 full.  

    (4) Claims for reimbursement and reports shall be presented 
 to the state agency by the respective counties as required under 
 section 256.01, subdivision 2, paragraph (17).  The state agency 
 shall audit such claims and certify to the commissioner of 
 finance the amounts due the respective counties without delay.  
 The amounts so certified shall be paid within ten days after 
 such certification, from the state treasury upon warrant of the 
 commissioner of finance from any money available therefor.  The 
 money available to the state agency to carry out the provisions 
 hereof, including all federal funds available to the state, 
 shall be kept and deposited by the state treasurer in the 
 revenue fund and disbursed upon warrants in the same manner as 
 other state funds.  

    HIST: Ex1967 c 16 s 20; 1973 c 492 s 14; 1986 c 444; 1989 c 89 
 s 11 

     256B.21 Change of residence.  

    On changing residence, a recipient shall notify the county 
 agency through which the recipient's medical assistance 
 hereunder is paid.  On removing to another county, the recipient 
 shall declare whether such absence is temporary or for the 
 purpose of residing therein.  

    HIST: Ex1967 c 16 s 21; 1986 c 444 

     256B.22 Compliance with Social Security Act.  

    The various terms and provisions hereof, including the 
 amount of medical assistance paid hereunder, are intended to 
 comply with and give effect to the program set out in Title XIX 
 of the federal Social Security Act.  During any period when 
 federal funds shall not be available or shall be inadequate to 
 pay in full the federal share of medical assistance as defined 
 in Title XIX of the federal Social Security Act, as amended by 
 Public Law Number 92-603, the state may reduce by an amount 
 equal to such deficiency the payments it would otherwise be 
 obligated to make pursuant to section 256B.041.  

    HIST: Ex1967 c 16 s 22; 1973 c 717 s 20 

     256B.23 Use of federal funds.  

    All federal funds made available for the purposes hereof 
 are hereby appropriated to the state agency to be disbursed and 
 paid out in accordance with the provisions hereof.  

    HIST: Ex1967 c 16 s 23 

     256B.24 Prohibitions.  

    No enrollment fee, premium, or similar charge shall be 
 required as a condition of eligibility for medical assistance 
 hereunder. 

    HIST: Ex1967 c 16 s 24 

     256B.25 Payments to certified facilities. 

    Subdivision 1.    Licensing required.  Payments may not 
 be made hereunder for care in any private or public institution, 
 including but not limited to hospitals and nursing homes, unless 
 licensed by an appropriate licensing authority of this state, 
 any other state, or a Canadian province and if applicable, 
 certified by an appropriate authority under United States Code, 
 title 42, sections 1396-1396p. 

    Subd. 2.    Payment distribution.  The payment of state 
 or county funds to nursing homes, boarding care homes, and 
 supervised living facilities, except payments to state operated 
 institutions, for the care of persons who are eligible for 
 medical assistance, shall be made only through the medical 
 assistance program, except as provided in subdivision 3.  

    Subd. 3.    Payment exceptions.  The limitation in 
 subdivision 2 shall not apply to:  

    (a) payment of Minnesota supplemental assistance funds to 
 recipients who reside in facilities which are involved in 
 litigation contesting their designation as an institution for 
 treatment of mental disease; 

    (b) payment or grants to a boarding care home or supervised 
 living facility licensed by the department of human services 
 under Minnesota Rules, parts 9520.0500 to 9520.0690, 9530.2500 
 to 9530.4000, 9545.0900 to 9545.1090, or 9545.1400 to 9545.1500, 
 or payment to recipients who reside in these facilities; 

    (c) payments or grants to a boarding care home or 
 supervised living facility which are ineligible for 
 certification under United States Code, title 42, sections 
 1396-1396p; 

    (d) payments or grants otherwise specifically authorized by 
 statute or rule.  

    Subd. 4.    Payment during suspended admissions.  A 
 nursing home or boarding care home that has received a notice to 
 suspend admissions under section 144A.10, subdivision 4a, shall 
 be ineligible to receive payment for admissions that occur 
 during the effective dates of the suspension.  Upon termination 
 of the suspension by the commissioner of health, payments may be 
 made for eligible persons, beginning with the day after the 
 suspension ends. 

    HIST: Ex1967 c 16 s 25; 1969 c 395 s 2; 1984 c 641 s 13; 1984 
 c 654 art 5 s 58; 1985 c 248 s 69; 1989 c 282 art 3 s 64 

     256B.26 Agreements with other state departments.  

    The commissioner of the department of human services is 
 authorized to enter into cooperative agreements with other state 
 departments or divisions of this state or of other states 
 responsible for administering or supervising the administration 
 of health services and vocational rehabilitation services in the 
 state for maximum utilization of such service in the provision 
 of medical assistance under sections 256B.01 to 256B.26.  

    HIST: Ex1967 c 16 s 26; 1984 c 654 art 5 s 58 

     256B.27 Medical assistance; cost reports. 

    Subdivision 1.    Reports and audits.  In the interests 
 of efficient administration of the medical assistance to the 
 needy program and incident to the approval of rates and charges 
 therefor, the commissioner of human services may require any 
 reports, information, and audits of medical vendors which the 
 commissioner deems necessary. 

    Subd. 2.    Verification of report.  All reports as to 
 the costs of operations or of medical care provided which are 
 submitted by vendors of medical care for use in determining 
 their rates or reimbursement shall be submitted under oath as to 
 the truthfulness of their contents by the vendor or an officer 
 or authorized representative of the vendor. 

    Subd. 2a.    On-site audits.  Each year the commissioner 
 shall provide for the on-site audit of the cost reports of 
 nursing homes participating as vendors of medical assistance.  
 The commissioner shall select for audit at least 15 percent of 
 these nursing homes at random or using factors including, but 
 not limited to:  change in ownership; frequent changes in 
 administration in excess of normal turnover rates; complaints to 
 the commissioner of health about care, safety, or rights; where 
 previous inspections or reinspections under section 144A.10 have 
 resulted in correction orders related to care, safety, or 
 rights; or where persons involved in ownership or administration 
 of the facility have been indicted for alleged criminal activity.

    Subd. 3.    Access to medical records.  The commissioner 
 of human services, with the written consent of the recipient, on 
 file with the local welfare agency, shall be allowed access to 
 all personal medical records of medical assistance recipients 
 solely for the purposes of investigating whether or not:  (a) a 
 vendor of medical care has submitted a claim for reimbursement, 
 a cost report or a rate application which is duplicative, 
 erroneous, or false in whole or in part, or which results in the 
 vendor obtaining greater compensation than the vendor is legally 
 entitled to; or (b) the medical care was medically necessary.  
 The vendor of medical care shall receive notification from the 
 commissioner at least 24 hours before the commissioner gains 
 access to such records.  The determination of provision of 
 services not medically necessary shall be made by the 
 commissioner.  The commissioner may consult with an advisory 
 task force of vendors the commissioner may appoint, on the 
 recommendation of appropriate professional organizations.  The 
 task force expires as provided in section 15.059, subdivision 
 6.  Notwithstanding any other law to the contrary, a vendor of 
 medical care shall not be subject to any civil or criminal 
 liability for providing access to medical records to the 
 commissioner of human services pursuant to this section.  

    Subd. 4.    Authorization of commissioner to examine 
 records.  A person determined to be eligible for medical 
 assistance shall be deemed to have authorized the commissioner 
 of human services in writing to examine, for the investigative 
 purposes identified in subdivision 3, all personal medical 
 records developed while receiving medical assistance. 

    Subd. 5.    Private data.  Medical records obtained by 
 the commissioner of human services pursuant to this section are 
 private data, as defined in section 13.02, subdivision 12. 

    HIST: 1971 c 961 s 24; 1976 c 188 s 3; 1977 c 326 s 11; 1980 c 
 349 s 7,8; 1981 c 311 s 39; 1982 c 476 s 1; 1982 c 545 s 24; 
 1982 c 640 s 8; 1983 c 312 art 5 s 25,26; 1984 c 654 art 5 s 58; 
 1986 c 444; 1987 c 370 art 1 s 5,6; 1988 c 629 s 53; 1995 c 207 
 art 11 s 6 

     256B.30 Health care facility report. 

    Every facility required to be licensed under the provisions 
 of sections 144.50 to 144.58, or 144A.02, shall provide annually 
 to the commissioner of human services the reports as may be 
 required under law and under rules adopted by the commissioner 
 of human services under the Administrative Procedure Act.  The 
 rules shall provide for the submission of a full and complete 
 financial report of a facility's operations including: 

    (1) An annual statement of income and expenditures; 

    (2) A complete statement of fees and charges; 

    (3) The names of all persons other than mortgage companies 
 owning any interest in the facility including stockholders with 
 an ownership interest of ten percent or more of the facility. 

    The financial reports and supporting data of the facility 
 shall be available for inspection and audit by the commissioner 
 of human services. 

    HIST: 1973 c 688 s 8; 1976 c 173 c 57; 1984 c 654 art 5 s 58 

     256B.31 Continued hospital care for long-term polio 
  patient. 

    A medical assistance recipient who has been a polio patient 
 in an acute care hospital for a period of not less than 25 
 consecutive years is eligible to continue receiving hospital 
 care, whether or not the care is medically necessary for 
 purposes of federal reimbursement.  The cost of continued 
 hospital care not reimbursable by the federal government must be 
 paid with state money allocated for the medical assistance 
 program.  The rate paid to the hospital is the rate per day 
 established using Medicare principles for the hospital's fiscal 
 year ending December 31, 1981, adjusted each year by the annual 
 hospital cost index established under section 256.969, 
 subdivision 1, or by other limits in effect at the time of the 
 adjustment.  This section does not prohibit a voluntary move to 
 another living arrangement by a recipient whose care is 
 reimbursed under this section. 

    HIST: 1988 c 689 art 2 s 152 

     256B.32 Facility fee for outpatient hospital emergency 
  room and clinic visits. 

    Subdivision 1.    Facility fee payment.  (a) The 
 commissioner shall establish a facility fee payment mechanism 
 that will pay a facility fee to all enrolled outpatient 
 hospitals for each emergency room or outpatient clinic visit 
 provided on or after July 1, 1989.  This payment mechanism may 
 not result in an overall increase in outpatient payment rates.  
 This section does not apply to federally mandated maximum 
 payment limits, department approved program packages, or 
 services billed using a nonoutpatient hospital provider number. 

    (b) For fee-for-service services provided on or after July 
 1, 2002, the total payment, before third-party liability and 
 spenddown, made to hospitals for outpatient hospital facility 
 services is reduced by .5 percent from the current statutory 
 rates. 

    Subd. 2.    Prospective payment system.  Effective for 
 services provided on or after July 1, 2003, rates that are based 
 on the Medicare outpatient prospective payment system shall be 
 replaced by a budget-neutral prospective payment system that is 
 derived using medical assistance data. 

    HIST: 1989 c 285 s 4; 2002 c 220 art 15 s 14; 2002 c 275 s 4 

     256B.35 Personal allowance, persons in skilled nursing 
  homes or intermediate care facilities. 

    Subdivision 1.    Personal needs allowance.  (a) 
 Notwithstanding any law to the contrary, welfare allowances for 
 clothing and personal needs for individuals receiving medical 
 assistance while residing in any skilled nursing home, 
 intermediate care facility, or medical institution including 
 recipients of supplemental security income, in this state shall 
 not be less than $45 per month from all sources.  When benefit 
 amounts for social security or supplemental security income 
 recipients are increased pursuant to United States Code, title 
 42, sections 415(i) and 1382f, the commissioner shall, effective 
 in the month in which the increase takes effect, increase by the 
 same percentage to the nearest whole dollar the clothing and 
 personal needs allowance for individuals receiving medical 
 assistance while residing in any skilled nursing home, medical 
 institution, or intermediate care facility.  The commissioner 
 shall provide timely notice to local agencies, providers, and 
 recipients of increases under this provision. 

    (b) The personal needs allowance may be paid as part of the 
 Minnesota supplemental aid program, notwithstanding the 
 provisions of section 256D.37, subdivision 2, and payments to 
 recipients of Minnesota supplemental aid may be made once each 
 three months covering liabilities that accrued during the 
 preceding three months. 

    (c) The personal needs allowance shall be increased to 
 include income garnished for child support under a court order, 
 up to a maximum of $250 per month but only to the extent that 
 the amount garnished is not deducted as a monthly allowance for 
 children under section 256B.0575, paragraph (a), clause (5). 

    Subd. 2.    Purpose for allowance.  Neither the skilled 
 nursing home, the intermediate care facility, the medical 
 institution, nor the department of human services shall withhold 
 or deduct any amount of this allowance for any purpose contrary 
 to this section. 

    Subd. 3.    Prohibition on commingling of funds.  The 
 nursing home may not commingle the patient's funds with nursing 
 home funds or in any way use the funds for nursing home purposes.

    Subd. 4.    Field audits required.  The commissioner of 
 human services shall conduct field audits at the same time as 
 cost report audits required under section 256B.27, subdivision 
 2a, and at any other time but at least once every four years, 
 without notice, to determine whether this section was complied 
 with and that the funds provided residents for their personal 
 needs were actually expended for that purpose. 

    Subd. 5.    Designation on use of funds.  The nursing 
 home may transfer the personal allowance to someone other than 
 the recipient only when the recipient or the recipient's 
 guardian or conservator designates that person in writing to 
 receive or expend funds on behalf of the recipient and that 
 person certifies in writing that the allowance is spent for the 
 well-being of the recipient.  Persons, other than the recipient, 
 in possession of the personal allowance, may use the allowance 
 only for the well-being of the recipient.  Any person, other 
 than the recipient, who, with intent to defraud, uses the 
 personal needs allowance for purposes other than the well-being 
 of the recipient shall be guilty of theft and shall be sentenced 
 pursuant to section 609.52, subdivision 3, clauses (2), (3)(a) 
 and (c), (4), and (5).  To prosecute under this subdivision, the 
 attorney general or the appropriate county attorney, acting 
 independently or at the direction of the attorney general, may 
 institute a criminal action.  A nursing home that transfers 
 personal needs allowance funds to a person other than the 
 recipient in good faith and in compliance with this section 
 shall not be held liable under this subdivision.  

    Subd. 6.    Civil action to recover damages.  In 
 addition to the remedies otherwise provided by law, any person 
 injured by a violation of any of the provisions of this section, 
 may bring a civil action and recover damages, together with 
 costs and disbursements, including costs of investigation and 
 reasonable attorney's fees, and receive other equitable relief 
 as determined by the court.  

    HIST: 1974 c 575 s 15; 1977 c 271 s 1,2; 1980 c 563 s 1; 1982 
 c 476 s 2; 1984 c 534 s 25; 1984 c 654 art 5 s 58; 1986 c 444; 
 1987 c 254 s 7; 1987 c 403 art 2 s 86,87; 1988 c 689 art 2 s 
 153; 1990 c 566 s 7; 1996 c 451 art 2 s 31 

     256B.36 Personal allowance for certain recipients of 
  medical assistance. 

    In addition to the personal allowance established in 
 section 256B.35, any disabled recipient of medical assistance 
 who is a resident of a nursing facility or intermediate care 
 facility for the mentally retarded, shall also be permitted a 
 special personal allowance drawn solely from earnings from any 
 employment under an individual plan of rehabilitation.  This 
 special personal allowance shall consist of the sum of the 
 following amounts, deducted from earnings in the following order:

    (1) $80 for the costs of meals and miscellaneous work 
 expenses; 

    (2) Federal Insurance Contributions Act payments withheld 
 from the person's earned income; 

    (3) actual employment related transportation expenses; 

    (4) other actual employment related expenses; and 

    (5) state and federal income taxes withheld from the 
 person's earned income, if the person cannot be claimed as 
 exempt from federal income tax withholding. 

    The maximum special personal allowance from earnings is the 
 sum of items (1) to (5). 

    HIST: 1974 c 575 s 16; 1985 c 21 s 56; 1986 c 444; 1992 c 513 
 art 7 s 83 

     256B.37 Private insurance policies, causes of action. 

    Subdivision 1.    Subrogation.  Upon furnishing medical 
 assistance to any person who has private accident or health care 
 coverage, or receives or has a right to receive health or 
 medical care from any type of organization or entity, or has a 
 cause of action arising out of an occurrence that necessitated 
 the payment of medical assistance, the state agency or the state 
 agency's agent shall be subrogated, to the extent of the cost of 
 medical care furnished, to any rights the person may have under 
 the terms of the coverage, or against the organization or entity 
 providing or liable to provide health or medical care, or under 
 the cause of action.  

    The right of subrogation created in this section includes 
 all portions of the cause of action, notwithstanding any 
 settlement allocation or apportionment that purports to dispose 
 of portions of the cause of action not subject to subrogation.  

    Subd. 2.    Civil action for recovery.  To recover under 
 this section, the attorney general may institute or join a civil 
 action to enforce the subrogation rights of the commissioner 
 established under this section.  

    Any prepaid health plan providing services under sections 
 256B.69, 256D.03, subdivision 4, paragraph (d), and 256L.12; 
 children's mental health collaboratives under section 245.493; 
 demonstration projects for persons with disabilities under 
 section 256B.77; nursing homes under the alternative payment 
 demonstration project under section 256B.434; or the 
 county-based purchasing entity providing services under section 
 256B.692 may retain legal representation to enforce the 
 subrogation rights created under this section or, if no action 
 has been brought, may initiate and prosecute an independent 
 action on their behalf against a person, firm, or corporation 
 that may be liable to the person to whom the care or payment was 
 furnished.  

    Subd. 3.    Notice.  The state agency must be given 
 notice of monetary claims against a person, firm, or corporation 
 that may be liable in damages, or otherwise obligated to pay 
 part or all of the cost of medical care when the state agency 
 has paid or become liable for the cost of care.  Notice must be 
 given as follows:  

    (a) Applicants for medical assistance shall notify the 
 state or local agency of any possible claims when they submit 
 the application.  Recipients of medical assistance shall notify 
 the state or local agency of any possible claims when those 
 claims arise.  

    (b) A person providing medical care services to a recipient 
 of medical assistance shall notify the state agency when the 
 person has reason to believe that a third party may be liable 
 for payment of the cost of medical care.  

    (c) A person who is party to a claim upon which the state 
 agency may be entitled to subrogation under this section shall 
 notify the state agency of its potential subrogation claim 
 before filing a claim, commencing an action, or negotiating a 
 settlement.  A person who is a party to a claim includes the 
 plaintiff, the defendants, and any other party to the cause of 
 action.  

    Notice given to the local agency is not sufficient to meet 
 the requirements of paragraphs (b) and (c).  

    Subd. 4.    Recovery.  Upon any judgment, award, or 
 settlement of a cause of action, or any part of it, upon which 
 the state agency has a subrogation right, including compensation 
 for liquidated, unliquidated, or other damages, reasonable costs 
 of collection, including attorney fees, must be deducted first.  
 The full amount of medical assistance paid to or on behalf of 
 the person as a result of the injury must be deducted next and 
 paid to the state agency.  The rest must be paid to the medical 
 assistance recipient or other plaintiff.  The plaintiff, 
 however, must receive at least one-third of the net recovery 
 after attorney fees and collection costs.  

    Subd. 5.    Private benefits to be used first.  Private 
 accident and health care coverage including Medicare for medical 
 services is primary coverage and must be exhausted before 
 medical assistance is paid for medical services including home 
 health care, personal care assistant services, hospice, or 
 services covered under a Centers for Medicare and Medicaid 
 Services waiver.  When a person who is otherwise eligible for 
 medical assistance has private accident or health care coverage, 
 including Medicare or a prepaid health plan, the private health 
 care benefits available to the person must be used first and to 
 the fullest extent. 

    Subd. 5a.    Supplemental payment by medical assistance. 
  Medical assistance payment will not be made when either 
 covered charges are paid in full by a third party or the 
 provider has an agreement to accept payment for less than 
 charges as payment in full.  Payment for patients that are 
 simultaneously covered by medical assistance and a liable third 
 party other than Medicare will be determined as the lesser of 
 clauses (1) to (3): 

    (1) the patient liability according to the provider/insurer 
 agreement; 

    (2) covered charges minus the third party payment amount; 
 or 

    (3) the medical assistance rate minus the third party 
 payment amount. 

 A negative difference will not be implemented. 

    All providers must reduce their submitted charge to medical 
 assistance programs to reflect all discount amounts applied to 
 the charge by any provider/insurer agreement or contract.  The 
 net submitted charge may not be greater than the patient 
 liability for the service. 

    Subd. 6.    Parent's or obligee's health plan.  When a 
 parent or a person with an obligation of support has enrolled in 
 a prepaid health care plan under section 518.171, subdivision 1, 
 the commissioner of human services shall limit the recipient of 
 medical assistance to the benefits payable under that prepaid 
 health care plan to the extent that services available under 
 medical assistance are also available under the prepaid health 
 care plan. 

    HIST: 1975 c 247 s 7; 1987 c 370 art 2 s 9-14; 1987 c 403 art 
 3 s 26; 1Sp1993 c 1 art 5 s 87-89; 1996 c 451 art 2 s 32; 1997 c 
 217 art 2 s 8; 1999 c 245 art 4 s 66,68; 2002 c 277 s 24,32 

     256B.39 Avoidance of duplicate payments.  

    Billing statements forwarded to recipients of medical 
 assistance by vendors seeking payment for medical care rendered 
 shall clearly state that reimbursement from the state agency is 
 contemplated.  

    HIST: 1975 c 247 s 8 

     256B.40 Subsidy for abortions prohibited. 

    No medical assistance funds of this state or any agency, 
 county, municipality or any other subdivision thereof and no 
 federal funds passing through the state treasury or the state 
 agency shall be authorized or paid pursuant to this chapter to 
 any person or entity for or in connection with any abortion that 
 is not eligible for funding pursuant to sections 256B.02, 
 subdivision 8, and 256B.0625. 

    HIST: 1978 c 508 s 3; 1988 c 689 art 2 s 268 

NURSING FACILITY RATES

     256B.41 Intent. 

    Subdivision 1.    Authority.  The commissioner shall 
 establish, by rule, procedures for determining rates for care of 
 residents of nursing facilities which qualify as vendors of 
 medical assistance, and for implementing the provisions of this 
 section and sections 256B.421, 256B.431, 256B.432, 256B.433, 
 256B.47, 256B.48, 256B.50, and 256B.502.  The procedures shall 
 specify the costs that are allowable for establishing payment 
 rates through medical assistance. 

    Subd. 2.    Federal requirements.  If any provision of 
 this section and sections 256B.421, 256B.431, 256B.432, 
 256B.433, 256B.47, 256B.48, 256B.50, and 256B.502, is determined 
 by the United States government to be in conflict with existing 
 or future requirements of the United States government with 
 respect to federal participation in medical assistance, the 
 federal requirements shall prevail. 

    Subd. 3.    Payment rates.  Payment rates paid to any 
 nursing facility receiving medical assistance payments must be 
 those rates established pursuant to this chapter and rules 
 adopted under it.  

    HIST: 1976 c 282 s 1; 1983 c 199 s 10; 1Sp1985 c 9 art 2 s 47; 
 1992 c 513 art 7 s 84,85,136; 1998 c 407 art 4 s 41 

     256B.411 Compliance with state statutes. 

    Subdivision 1.    Funding.  Subject to exceptions in 
 section 256B.25, subdivision 3, no nursing facility may receive 
 any state or local payment for providing care to a person 
 eligible for medical assistance, except under the medical 
 assistance program. 

    Subd. 2.    Requirements.  No medical assistance 
 payments shall be made to any nursing facility unless the 
 nursing facility is certified to participate in the medical 
 assistance program under title XIX of the federal Social 
 Security Act and has in effect a provider agreement with the 
 commissioner meeting the requirements of state and federal 
 statutes and rules.  No medical assistance payments shall be 
 made to any nursing facility unless the nursing facility 
 complies with all requirements of Minnesota Statutes including, 
 but not limited to, this chapter and rules adopted under it that 
 govern participation in the program.  This section applies 
 whether the nursing facility participates fully in the medical 
 assistance program or is withdrawing from the medical assistance 
 program.  No future payments may be made to any nursing facility 
 which has withdrawn or is withdrawing from the medical 
 assistance program except as provided in section 256B.48, 
 subdivision 1a, or federal law.  Payments may also be made under 
 a court order entered on or before June 7, 1985, unless the 
 court order is reversed on appeal. 

    HIST: 1Sp1985 c 9 art 2 s 48; 1992 c 513 art 7 s 136; 2000 c 
 449 s 2 

  256B.42 Repealed, 1983 c 199 s 19 

     256B.421 Definitions. 

    Subdivision 1.    Scope.  For the purposes of this 
 section and sections 256B.41, 256B.411, 256B.431, 256B.432, 
 256B.433, 256B.434, 256B.47, 256B.48, 256B.50, and 256B.502, the 
 following terms and phrases shall have the meaning given to them.

    Subd. 2.    Actual allowable historical operating cost per 
 diem.  "Actual allowable historical operating cost per diem" 
 means the per diem operating costs allowed by the commissioner 
 for the most recent reporting year. 

    Subd. 3.    Commissioner.  "Commissioner" means the 
 commissioner of human services.  

    Subd. 4.    Final rate.  "Final rate" means the rate 
 established after any adjustment by the commissioner, including 
 but not limited to adjustments resulting from cost report 
 reviews and field audits.  

    Subd. 5.    General and administrative costs.  "General 
 and administrative costs" means all allowable costs for 
 administering the facility, including but not limited to: 
 salaries of administrators, assistant administrators, accounting 
 personnel, data processing personnel, and all clerical 
 personnel; board of directors fees; business office functions 
 and supplies; travel, except as necessary for training programs 
 for nursing personnel and dietitians required to maintain 
 licensure, certification, or professional standards 
 requirements; telephone and telegraph; advertising; membership 
 dues and subscriptions; postage; insurance, except as included 
 as a fringe benefit under subdivision 14; professional services 
 such as legal, accounting and data processing services; central 
 or home office costs; management fees; management consultants; 
 employee training, for any top management personnel and for 
 other than direct resident care related personnel; and business 
 meetings and seminars.  

    Subd. 6.    Historical operating costs.  "Historical 
 operating costs" means the allowable operating costs incurred by 
 the facility during the reporting year immediately preceding the 
 rate year for which the payment rate becomes effective, after 
 the commissioner has reviewed those costs and determined them to 
 be allowable costs under the medical assistance program, and 
 after the commissioner has applied appropriate limitations such 
 as the limit on administrative costs.  

    Subd. 7.    Nursing facility.  "Nursing facility" means 
 a facility licensed under chapter 144A or a boarding care 
 facility licensed under sections 144.50 to 144.56.  

    Subd. 8.    Operating costs.  "Operating costs" means 
 the day-to-day costs of operating the facility in compliance 
 with licensure and certification standards.  Operating cost 
 categories are:  nursing, including nurses and nursing 
 assistants training; dietary; laundry and linen; housekeeping; 
 plant operation and maintenance; other care-related services; 
 medical directors; licenses, other than license fees required by 
 the Minnesota department of health; permits; general and 
 administration; payroll taxes; real estate taxes, license fees 
 required by the Minnesota department of health, and actual 
 special assessments paid; and fringe benefits, including 
 clerical training; and travel necessary for training programs 
 for nursing personnel and dietitians required to maintain 
 licensure, certification, or professional standards requirements.

    Subd. 9.    Payment rate.  "Payment rate" means the rate 
 determined under section 256B.431. 

    Subd. 10.    Private paying resident.  "Private paying 
 resident" means a nursing facility resident who is not a medical 
 assistance recipient and whose payment rate is not established 
 by another third party, including the veterans administration or 
 medicare.  

    Subd. 11.    Rate year.  "Rate year" means the fiscal 
 year for which a payment rate determined under section 256B.431 
 is effective, from July 1 to the next June 30.  

    Subd. 12.    Reporting year.  "Reporting year" means the 
 period from October 1 to September 30, immediately preceding the 
 rate year, for which the nursing facility submits reports 
 required under section 256B.48, subdivision 2.  

    Subd. 13.    Actual resident day.  "Actual resident day" 
 means a billable, countable day as defined by the commissioner.  

    Subd. 14.    Fringe benefits.  "Fringe benefits" means 
 workers' compensation insurance, group health or dental 
 insurance, group life insurance, retirement benefits or plans, 
 except for Public Employee Retirement Act contributions, and 
 uniform allowances.  

    Subd. 15.    Payroll taxes.  "Payroll taxes" means the 
 employer's share of FICA taxes, governmentally required 
 retirement contributions, and state and federal unemployment 
 compensation taxes.  

    Subd. 16.    Capital assets.  "Capital assets," for 
 purposes of section 256B.431, subdivisions 13 to 21, means a 
 nursing facility's buildings, attached fixtures, land 
 improvements, leasehold improvements, and all additions to or 
 replacements of those assets used directly for resident care. 

    HIST: 1983 c 199 s 11; 1984 c 641 s 14-16; 1984 c 654 art 5 s 
 58; 1985 c 267 s 2; 1Sp1985 c 3 s 26; 1Sp1985 c 9 art 2 s 49; 
 1987 c 403 art 2 s 88; 1989 c 282 art 3 s 65; 1992 c 513 art 7 s 
 86,87,136; 1997 c 203 art 3 s 6 

  256B.43 Repealed, 1983 c 199 s 19 

     256B.431 Rate determination. 

    Subdivision 1.    In general.  The commissioner shall 
 determine prospective payment rates for resident care costs.  
 For rates established on or after July 1, 1985, the commissioner 
 shall develop procedures for determining operating cost payment 
 rates that take into account the mix of resident needs, 
 geographic location, and other factors as determined by the 
 commissioner.  The commissioner shall consider whether the fact 
 that a facility is attached to a hospital or has an average 
 length of stay of 180 days or less should be taken into account 
 in determining rates.  The commissioner shall consider the use 
 of the standard metropolitan statistical areas when developing 
 groups by geographic location.  The commissioner shall provide 
 notice to each nursing facility on or before May 1 of the rates 
 effective for the following rate year except that if legislation 
 is pending on May 1 that may affect rates for nursing 
 facilities, the commissioner shall set the rates after the 
 legislation is enacted and provide notice to each facility as 
 soon as possible. 

    Compensation for top management personnel shall continue to 
 be categorized as a general and administrative cost and is 
 subject to any limits imposed on that cost category. 

    Subd. 2. Repealed, 2000 c 449 s 15 

    Subd. 2a. Repealed, 2000 c 449 s 15 

    Subd. 2b.    Operating costs, after July 1, 1985.  (a) 
 For rate years beginning on or after July 1, 1985, the 
 commissioner shall establish procedures for determining per diem 
 reimbursement for operating costs.  

    (b) The commissioner shall contract with an econometric 
 firm with recognized expertise in and access to national 
 economic change indices that can be applied to the appropriate 
 cost categories when determining the operating cost payment rate.

    (c) The commissioner shall analyze and evaluate each 
 nursing facility's cost report of allowable operating costs 
 incurred by the nursing facility during the reporting year 
 immediately preceding the rate year for which the payment rate 
 becomes effective.  

    (d) The commissioner shall establish limits on actual 
 allowable historical operating cost per diems based on cost 
 reports of allowable operating costs for the reporting year that 
 begins October 1, 1983, taking into consideration relevant 
 factors including resident needs, geographic location, and size 
 of the nursing facility.  In developing the geographic groups 
 for purposes of reimbursement under this section, the 
 commissioner shall ensure that nursing facilities in any county 
 contiguous to the Minneapolis-St. Paul seven-county metropolitan 
 area are included in the same geographic group.  The limits 
 established by the commissioner shall not be less, in the 
 aggregate, than the 60th percentile of total actual allowable 
 historical operating cost per diems for each group of nursing 
 facilities established under subdivision 1 based on cost reports 
 of allowable operating costs in the previous reporting year.  
 For rate years beginning on or after July 1, 1989, facilities 
 located in geographic group I as described in Minnesota Rules, 
 part 9549.0052, on January 1, 1989, may choose to have the 
 commissioner apply either the care related limits or the other 
 operating cost limits calculated for facilities located in 
 geographic group II, or both, if either of the limits calculated 
 for the group II facilities is higher.  The efficiency incentive 
 for geographic group I nursing facilities must be calculated 
 based on geographic group I limits.  The phase-in must be 
 established utilizing the chosen limits.  For purposes of these 
 exceptions to the geographic grouping requirements, the 
 definitions in Minnesota Rules, parts 9549.0050 to 9549.0059 
 (Emergency), and 9549.0010 to 9549.0080, apply.  The limits 
 established under this paragraph remain in effect until the 
 commissioner establishes a new base period.  Until the new base 
 period is established, the commissioner shall adjust the limits 
 annually using the appropriate economic change indices 
 established in paragraph (e).  In determining allowable 
 historical operating cost per diems for purposes of setting 
 limits and nursing facility payment rates, the commissioner 
 shall divide the allowable historical operating costs by the 
 actual number of resident days, except that where a nursing 
 facility is occupied at less than 90 percent of licensed 
 capacity days, the commissioner may establish procedures to 
 adjust the computation of the per diem to an imputed occupancy 
 level at or below 90 percent.  The commissioner shall establish 
 efficiency incentives as appropriate.  The commissioner may 
 establish efficiency incentives for different operating cost 
 categories.  The commissioner shall consider establishing 
 efficiency incentives in care related cost categories.  The 
 commissioner may combine one or more operating cost categories 
 and may use different methods for calculating payment rates for 
 each operating cost category or combination of operating cost 
 categories.  For the rate year beginning on July 1, 1985, the 
 commissioner shall: 

    (1) allow nursing facilities that have an average length of 
 stay of 180 days or less in their skilled nursing level of care, 
 125 percent of the care related limit and 105 percent of the 
 other operating cost limit established by rule; and 

    (2) exempt nursing facilities licensed on July 1, 1983, by 
 the commissioner to provide residential services for the 
 physically handicapped under Minnesota Rules, parts 9570.2000 to 
 9570.3600, from the care related limits and allow 105 percent of 
 the other operating cost limit established by rule. 

    For the purpose of calculating the other operating cost 
 efficiency incentive for nursing facilities referred to in 
 clause (1)  or (2), the commissioner shall use the other 
 operating cost limit established by rule before application of 
 the 105 percent. 

    (e) The commissioner shall establish a composite index or 
 indices by determining the appropriate economic change 
 indicators to be applied to specific operating cost categories 
 or combination of operating cost categories.  

    (f) Each nursing facility shall receive an operating cost 
 payment rate equal to the sum of the nursing facility's 
 operating cost payment rates for each operating cost category.  
 The operating cost payment rate for an operating cost category 
 shall be the lesser of the nursing facility's historical 
 operating cost in the category increased by the appropriate 
 index established in paragraph (e) for the operating cost 
 category plus an efficiency incentive established pursuant to 
 paragraph (d) or the limit for the operating cost category 
 increased by the same index.  If a nursing facility's actual 
 historic operating costs are greater than the prospective 
 payment rate for that rate year, there shall be no retroactive 
 cost settle-up.  In establishing payment rates for one or more 
 operating cost categories, the commissioner may establish 
 separate rates for different classes of residents based on their 
 relative care needs.  

    (g) The commissioner shall include the reported actual real 
 estate tax liability or payments in lieu of real estate tax of 
 each nursing facility as an operating cost of that nursing 
 facility.  Allowable costs under this subdivision for payments 
 made by a nonprofit nursing facility that are in lieu of real 
 estate taxes shall not exceed the amount which the nursing 
 facility would have paid to a city or township and county for 
 fire, police, sanitation services, and road maintenance costs 
 had real estate taxes been levied on that property for those 
 purposes.  For rate years beginning on or after July 1, 1987, 
 the reported actual real estate tax liability or payments in 
 lieu of real estate tax of nursing facilities shall be adjusted 
 to include an amount equal to one-half of the dollar change in 
 real estate taxes from the prior year.  The commissioner shall 
 include a reported actual special assessment, and reported 
 actual license fees required by the Minnesota department of 
 health, for each nursing facility as an operating cost of that 
 nursing facility.  For rate years beginning on or after July 1, 
 1989, the commissioner shall include a nursing facility's 
 reported Public Employee Retirement Act contribution for the 
 reporting year as apportioned to the care-related operating cost 
 categories and other operating cost categories multiplied by the 
 appropriate composite index or indices established pursuant to 
 paragraph (e) as costs under this paragraph.  Total adjusted 
 real estate tax liability, payments in lieu of real estate tax, 
 actual special assessments paid, the indexed Public Employee 
 Retirement Act contribution, and license fees paid as required 
 by the Minnesota department of health, for each nursing facility 
 (1) shall be divided by actual resident days in order to compute 
 the operating cost payment rate for this operating cost 
 category, (2) shall not be used to compute the care-related 
 operating cost limits or other operating cost limits established 
 by the commissioner, and (3) shall not be increased by the 
 composite index or indices established pursuant to paragraph 
 (e), unless otherwise indicated in this paragraph. 

    (h) For rate years beginning on or after July 1, 1987, the 
 commissioner shall adjust the rates of a nursing facility that 
 meets the criteria for the special dietary needs of its 
 residents and the requirements in section 31.651.  The 
 adjustment for raw food cost shall be the difference between the 
 nursing facility's allowable historical raw food cost per diem 
 and 115 percent of the median historical allowable raw food cost 
 per diem of the corresponding geographic group. 

    The rate adjustment shall be reduced by the applicable 
 phase-in percentage as provided under subdivision 2h. 

    Subd. 2c.    Operating costs after July 1, 1986.  For 
 rate years beginning on or after July 1, 1986, the commissioner 
 may allow a one time adjustment to historical operating costs of 
 a nursing facility that has been found by the commissioner of 
 health to be significantly below care related minimum standards 
 appropriate to the mix of resident needs in that nursing 
 facility when it is determined by the commissioners of health 
 and human services that the nursing facility is unable to meet 
 minimum standards through reallocation of nursing facility costs 
 and efficiency incentives or allowances.  In developing 
 procedures to allow adjustments, the commissioner shall specify 
 the terms and conditions governing any additional payments made 
 to a nursing facility as a result of the adjustment.  The 
 commissioner shall establish procedures to recover amounts paid 
 under this subdivision, in whole or in part, and to adjust 
 current and future rates, for nursing facilities that fail to 
 use the adjustment to satisfy care related minimum standards.  

    Subd. 2d.  If an annual cost report or field audit 
 indicates that expenditures for direct resident care have been 
 reduced in amounts large enough to indicate a possible 
 detrimental effect on the quality of care, the commissioner 
 shall notify the commissioner of health and the interagency 
 long-term care planning committee.  If a field audit reveals 
 that unallowable expenditures have been included in the nursing 
 facility's historical operating costs, the commissioner shall 
 disallow the expenditures and recover the entire overpayment. 
 The commissioner shall establish, by rule, procedures for 
 assessing an interest charge at the rate determined for unpaid 
 taxes or penalties under section 270.75 on any outstanding 
 balance resulting from an overpayment or underpayment. 

    Subd. 2e.    Contracts for services for 
 ventilator-dependent persons.  The commissioner may negotiate 
 with a nursing facility eligible to receive medical assistance 
 payments to provide services to a ventilator-dependent person 
 identified by the commissioner according to criteria developed 
 by the commissioner, including:  

    (1) nursing facility care has been recommended for the 
 person by a preadmission screening team; 

    (2) the person has been hospitalized and no longer requires 
 inpatient acute care hospital services; and 

    (3) the commissioner has determined that necessary services 
 for the person cannot be provided under existing nursing 
 facility rates.  

    The commissioner may negotiate an adjustment to the 
 operating cost payment rate for a nursing facility with a 
 resident who is ventilator-dependent, for that resident.  The 
 negotiated adjustment must reflect only the actual additional 
 cost of meeting the specialized care needs of a 
 ventilator-dependent person identified by the commissioner for 
 whom necessary services cannot be provided under existing 
 nursing facility rates and which are not otherwise covered under 
 Minnesota Rules, parts 9549.0010 to 9549.0080 or 9505.0170 to 
 9505.0475.  For persons who are initially admitted to a nursing 
 facility before July 1, 2001, and have their payment rate under 
 this subdivision negotiated after July 1, 2001, the negotiated 
 payment rate must not exceed 200 percent of the highest multiple 
 bedroom payment rate for the facility, as initially established 
 by the commissioner for the rate year for case mix 
 classification K; or, upon implementation of the RUGs-based case 
 mix system, 200 percent of the highest RUGs rate.  For persons 
 initially admitted to a nursing facility on or after July 1, 
 2001, the negotiated payment rate must not exceed 300 percent of 
 the facility's multiple bedroom payment rate for case mix 
 classification K; or, upon implementation of the RUGs-based case 
 mix system, 300 percent of the highest RUGs rate.  The 
 negotiated adjustment shall not affect the payment rate charged 
 to private paying residents under the provisions of section 
 256B.48, subdivision 1.  

    Subd. 2f. Repealed, 2000 c 449 s 15 

    Subd. 2g.    Required consultants.  Costs considered 
 general and administrative costs under section 256B.421 must be 
 included in general and administrative costs in total, without 
 direct or indirect allocation to other cost categories.  In a 
 nursing facility of 60 or fewer beds, part of an administrator's 
 salary may be allocated to other cost categories to the extent 
 justified in records kept by the nursing facility.  Central or 
 home office costs representing services of required consultants 
 in areas including, but not limited to, dietary, pharmacy, 
 social services, or activities may be allocated to the 
 appropriate department, but only if those costs are directly 
 identified by the nursing facility.  Central, affiliated, or 
 corporate office costs representing services of consultants not 
 required by law in the areas of nursing, quality assurance, 
 medical records, dietary, other care related services, and plant 
 operations may be allocated to the appropriate operating cost 
 category of a nursing facility according to paragraphs (a) to 
 (e).  

    (a) Only the salaries, fringe benefits, and payroll taxes 
 associated with the individual performing the service may be 
 allocated.  No other costs may be allocated. 

    (b) The allocation must be based on direct identification 
 and only to the extent justified in time distribution records 
 that show the actual time spent by the consultant performing the 
 services in the nursing facility.  

    (c) The cost in paragraph (a) for each consultant must not 
 be allocated to more than one operating cost category in the 
 nursing facility.  If more than one nursing facility is served 
 by a consultant, all nursing facilities shall allocate the 
 consultant's cost to the same operating category. 

    (d) Top management personnel must not be considered 
 consultants. 

    (e) The consultant's full-time responsibilities shall be to 
 provide the services identified in this item. 

    Subd. 2h. Repealed, 2000 c 449 s 15 

    Subd. 2i.    Operating costs after July 1, 1988.  (a)  
   Other operating cost limits.  For rate years beginning on 
 or after July 1, 1989, the adjusted other operating cost limits 
 must be indexed as in Minnesota Rules, part 9549.0056, subparts 
 3 and 4.  For the rate period beginning October 1, 1992, and for 
 rate years beginning after June 30, 1993, the amount of the 
 surcharge under section 256.9657, subdivision 1, shall be 
 included in the plant operations and maintenance operating cost 
 category.  The surcharge shall be an allowable cost for the 
 purpose of establishing the payment rate. 

    (b)    Care-related operating cost limits.  For rate 
 years beginning on or after July 1, 1989, the adjusted 
 care-related limits must be indexed as in Minnesota Rules, part 
 9549.0056, subparts 1 and 2. 

    (c)    Salary adjustment per diem.  Effective July 1, 
 1998, to June 30, 2000, the commissioner shall make available 
 the salary adjustment per diem calculated in clause (1) or (2) 
 to the total operating cost payment rate of each nursing 
 facility reimbursed under this section or section 256B.434.  The 
 salary adjustment per diem for each nursing facility must be 
 determined as follows:  

    (1) For each nursing facility that reports salaries for 
 registered nurses, licensed practical nurses, and aides, 
 orderlies and attendants separately, the commissioner shall 
 determine the salary adjustment per diem by multiplying the 
 total salaries, payroll taxes, and fringe benefits allowed in 
 each operating cost category, except management fees and 
 administrator and central office salaries and the related 
 payroll taxes and fringe benefits, by 3.0 percent and then 
 dividing the resulting amount by the nursing facility's actual 
 resident days. 

    (2) For each nursing facility that does not report salaries 
 for registered nurses, licensed practical nurses, aides, 
 orderlies, and attendants separately, the salary adjustment per 
 diem is the weighted average salary adjustment per diem increase 
 determined under clause (1).  

    (3) A nursing facility may apply for the salary adjustment 
 per diem calculated under clauses (1) and (2).  The application 
 must be made to the commissioner and contain a plan by which the 
 nursing facility will distribute the salary adjustment to 
 employees of the nursing facility.  In order to apply for a 
 salary adjustment, a nursing facility reimbursed under section 
 256B.434, must report the information required by clause (1) or 
 (2) in the application, in the manner specified by the 
 commissioner.  For nursing facilities in which the employees are 
 represented by an exclusive bargaining representative, an 
 agreement negotiated and agreed to by the employer and the 
 exclusive bargaining representative, after July 1, 1998, may 
 constitute the plan for the salary distribution.  The 
 commissioner shall review the plan to ensure that the salary 
 adjustment per diem is used solely to increase the compensation 
 of nursing home facility employees.  To be eligible, a facility 
 must submit its plan for the salary distribution by December 31, 
 1998.  If a facility's plan for salary distribution is effective 
 for its employees after July 1, 1998, the salary adjustment cost 
 per diem shall be effective the same date as its plan. 

    (4) Additional costs incurred by nursing facilities as a 
 result of this salary adjustment are not allowable costs for 
 purposes of the September 30, 1998, cost report. 

    (d)    New base year.  The commissioner shall establish 
 a new base year for the reporting years ending September 30, 
 1991, and September 30, 1992.  In establishing a new base year, 
 the commissioner must take into account:  

    (1) statutory changes made in geographic groups; 

    (2) redefinitions of cost categories; and 

    (3) reclassification, pass-through, or exemption of certain 
 costs. 

    Subd. 2j.    Hospital-attached nursing facility status.  
 (a) For the purpose of setting rates under Minnesota Rules, 
 parts 9549.0010 to 9549.0080, for rate years beginning after 
 June 30, 1989, a hospital-attached nursing facility means a 
 nursing facility which meets the requirements of clauses (1) to 
 (3): 

    (1) the nursing facility is recognized by the federal 
 Medicare program to be a hospital-based nursing facility for 
 purposes of being subject to higher cost limits accorded 
 hospital-based nursing facilities under the Medicare program, 
 or, prior to June 30, 1983, was classified as a 
 hospital-attached nursing facility under Minnesota Rules, parts 
 9510.0010 to 9510.0480; 

    (2) the nursing facility's cost report filed under 
 Minnesota Rules, parts 9549.0010 to 9549.0080, shall use the 
 same cost allocation principles and methods used in the reports 
 filed for the Medicare program except as provided in clause (3); 
 and 

    (3) direct identification of costs to the nursing facility 
 cost center will be permitted only when the comparable hospital 
 costs have also been directly identified to a cost center which 
 is not allocated to the nursing facility.  

    (b) For rate years beginning after June 30, 1989, a nursing 
 facility and hospital, which have applied for hospital-based 
 nursing facility status under the federal Medicare program 
 during the reporting year or the nine-month period following the 
 nursing facility's reporting year, shall be considered a 
 hospital-attached nursing facility for purposes of setting 
 payment rates under Minnesota Rules, parts 9549.0010 to 
 9549.0080, for the rate year following the reporting year or the 
 nine-month period in which the facility made its Medicare 
 application.  The nursing facility must file its cost report or 
 an amended cost report for that reporting year before the 
 following rate year using Medicare principles and Medicare's 
 recommended cost allocation methods had the Medicare program's 
 hospital-based nursing facility status been granted to the 
 nursing facility.  For each subsequent rate year, the nursing 
 facility must meet the definition requirements in paragraph 
 (a).  If the nursing facility is denied hospital-based nursing 
 facility status under the Medicare program, the nursing 
 facility's payment rates for the rate years the nursing facility 
 was considered to be a hospital-attached nursing facility 
 pursuant to this paragraph shall be recalculated treating the 
 nursing facility as a non-hospital-attached nursing facility. 

    (c) For rate years beginning on or after July 1, 1995, a 
 nursing facility shall be considered a hospital attached nursing 
 facility for purposes of setting payment rates under Minnesota 
 Rules, parts 9549.0010 to 9549.0080 and this section if it meets 
 the requirements of paragraphs (a) and (b), and 

    (1) the hospital and nursing facility are physically 
 attached or connected by a tunnel or skyway; or 

    (2) the nursing facility was recognized by the Medicare 
 program as hospital attached as of January 1, 1995, and this 
 status has been maintained continuously. 

    Subd. 2k.    Operating costs after July 1, 1989.  For 
 rate years beginning on or after July 1, 1989, a nursing 
 facility that is exempt under subdivision 2b, paragraph (d), 
 clause (2); whose total number of licensed beds are licensed 
 under Minnesota Rules, parts 9570.2000 to 9570.3600; and that 
 maintains an average length of stay of less than 365 days during 
 each reporting year, is limited to 140 percent of the 
 other-operating-cost limit for hospital-attached nursing 
 facilities as established by Minnesota Rules, part 9549.0055, 
 subpart 2, item E, subitem (2), as modified by subdivision 2i, 
 paragraph (a).  For purposes of this subdivision, the nursing 
 facility's average length of stay must be computed by dividing 
 the nursing facility's actual resident days for the reporting 
 year by the nursing facility's total discharges for that 
 reporting year.  

    Subd. 2l.    Inflation adjustments after July 1, 1990.  
 (a) For rate years beginning on or after July 1, 1990, the 
 forecasted composite price index for a nursing facility's 
 allowable operating cost per diems shall be determined using 
 Data Resources, Inc., forecast for change in the Nursing Home 
 Market Basket.  The commissioner of human services shall use the 
 indices as forecasted by Data Resources, Inc., in the fourth 
 quarter of the calendar year preceding the rate year. 

    (b) For rate years beginning on or after July 1, 1992, the 
 commissioner shall index the prior year's operating cost limits 
 by the percentage change in the Data Resources, Inc., Nursing 
 Home Market Basket between the midpoint of the current reporting 
 year and the midpoint of the previous reporting year.  The 
 commissioner shall use the indices as forecasted by Data 
 Resources, Inc., in the fourth quarter of the calendar year 
 preceding the rate year.  

    (c) For rate years beginning on or after July 1, 1993, the 
 commissioner shall not provide automatic annual inflation 
 adjustments for nursing facilities.  The commissioner of finance 
 shall include annual adjustments in operating costs for nursing 
 facilities as a budget change request in each biennial detailed 
 expenditure budget submitted to the legislature under section 
 16A.11.  

    Subd. 2m. Repealed, 2000 c 449 s 15 

    Subd. 2n.    Efficiency incentive reductions for 
 substandard care.  For rate years beginning on or after July 
 1, 1991, the efficiency incentive established under subdivision 
 2b, paragraph (d), shall be reduced or eliminated for nursing 
 facilities determined by the commissioner of health under 
 section 144A.10, subdivision 4, to have uncorrected or repeated 
 violations which create a risk to resident care, safety, or 
 rights, except for uncorrected or repeated violations relating 
 to a facility's physical plant.  Upon being notified by the 
 commissioner of health of uncorrected or repeated violations, 
 the commissioner of human services shall require the nursing 
 facility to use efficiency incentive payments to correct the 
 violations.  The commissioner of human services shall require 
 the nursing facility to forfeit efficiency incentive payments 
 for failure to correct the violations.  Any forfeiture shall be 
 limited to the amount necessary to correct the violation.  

    Subd. 2o.    Special payment rates for short-stay nursing 
 facilities.  Notwithstanding contrary provisions of this 
 section and rules adopted by the commissioner, for the rate 
 years beginning on or after July 1, 1993, a nursing facility 
 whose average length of stay for the preceding reporting year is 
 (1) less than 180 days; or (2) less than 225 days in a nursing 
 facility with more than 315 licensed beds must be reimbursed for 
 allowable costs up to 125 percent of the total care-related 
 limit and 105 percent of the other-operating-cost limit for 
 hospital-attached nursing facilities.  A nursing facility that 
 received the benefit of this limit during the rate year 
 beginning July 1, 1992, continues to receive this rate during 
 the rate year beginning July 1, 1993, even if the facility's 
 average length of stay is more than 180 days in the rate years 
 subsequent to the rate year beginning July 1, 1991.  For 
 purposes of this subdivision, a nursing facility shall compute 
 its average length of stay by dividing the nursing facility's 
 actual resident days for the reporting year by the nursing 
 facility's total resident discharges for that reporting year. 

    Subd. 2p. Repealed, 2000 c 449 s 15 

    Subd. 2q. Repealed, 2000 c 449 s 15 

    Subd. 2r.    Payment restrictions on leave days.  
 Effective July 1, 1993, the commissioner shall limit payment for 
 leave days in a nursing facility to 79 percent of that nursing 
 facility's total payment rate for the involved resident. 

    Subd. 2s.    Nonallowable cost.  Costs incurred for any 
 activities which are directed at or are intended to influence or 
 dissuade employees in the exercise of their legal rights to 
 freely engage in the process of selecting an exclusive 
 representative for the purpose of collective bargaining with 
 their employer shall not be allowable for purposes of setting 
 payment rates. 

    Subd. 3. Repealed, 2000 c 449 s 15 

    Subd. 3a.    Property-related costs after July 1, 1985.  
 (a) For rate years beginning on or after July 1, 1985, the 
 commissioner, by permanent rule, shall reimburse nursing 
 facility providers that are vendors in the medical assistance 
 program for the rental use of real estate and depreciable 
 equipment.  "Real estate" means land improvements, buildings, 
 and attached fixtures used directly for resident care.  
 "Depreciable equipment" means the standard movable resident care 
 equipment and support service equipment generally used in 
 long-term care facilities.  

    (b) In developing the method for determining payment rates 
 for the rental use of nursing facilities, the commissioner shall 
 consider factors designed to:  

    (1) simplify the administrative procedures for determining 
 payment rates for property-related costs; 

    (2) minimize discretionary or appealable decisions; 

    (3) eliminate any incentives to sell nursing facilities; 

    (4) recognize legitimate costs of preserving and replacing 
 property; 

    (5) recognize the existing costs of outstanding 
 indebtedness allowable under the statutes and rules in effect on 
 May 1, 1983; 

    (6) address the current value of, if used directly for 
 patient care, land improvements, buildings, attached fixtures, 
 and equipment; 

    (7) establish an investment per bed limitation; 

    (8) reward efficient management of capital assets; 

    (9) provide equitable treatment of facilities; 

    (10) consider a variable rate; and 

    (11) phase-in implementation of the rental reimbursement 
 method.  

    (c) For rate years beginning on or after July 1, 1987, a 
 nursing facility which has reduced licensed bed capacity after 
 January 1, 1986, shall be allowed to: 

    (1) aggregate the applicable investment per bed limits 
 based on the number of beds licensed prior to the reduction; and 

    (2) establish capacity days for each rate year following 
 the licensure reduction based on the number of beds licensed on 
 the previous April 1 if the commissioner is notified of the 
 change by April 4.  The notification must include a copy of the 
 delicensure request that has been submitted to the commissioner 
 of health. 

    (d) For rate years beginning on or after July 1, 1989, the 
 interest expense that results from a refinancing of a nursing 
 facility's demand call loan, when the loan that must be 
 refinanced was incurred before May 22, 1983, is an allowable 
 interest expense if: 

    (1) the demand call loan or any part of it was in the form 
 of a loan that was callable at the demand of the lender; 

    (2) the demand call loan or any part of it was called by 
 the lender through no fault of the nursing facility; 

    (3) the demand call loan or any part of it was made by a 
 government agency operating under a statutory or regulatory loan 
 program; 

    (4) the refinanced debt does not exceed the sum of the 
 allowable remaining balance of the demand call loan at the time 
 of payment on the demand call loan and refinancing costs; 

    (5) the term of the refinanced debt does not exceed the 
 remaining term of the demand call loan, had the debt not been 
 subject to an on-call payment demand; and 

    (6) the refinanced debt is not a debt between related 
 organizations as defined in Minnesota Rules, part 9549.0020, 
 subpart 38. 

    Subd. 3b. Repealed, 2000 c 449 s 15 

    Subd. 3c.    Plant and maintenance costs.  For the rate 
 years beginning on or after July 1, 1987, the commissioner shall 
 allow as an expense in the reporting year of occurrence the 
 lesser of the actual allowable plant and maintenance costs for 
 supplies, minor equipment, equipment repairs, building repairs, 
 purchased services and service contracts, except for 
 arm's-length service contracts whose primary purpose is 
 supervision, or $325 per licensed bed. 

    Subd. 3d. Repealed, 2000 c 449 s 15 

    Subd. 3e.    Hospital-attached convalescent and nursing 
 care facilities.  If a nonprofit or community-operated 
 hospital and attached convalescent and nursing care facility 
 suspend operation of the hospital, the surviving nursing care 
 facility must be allowed to continue its status as a 
 hospital-attached convalescent and nursing care facility for 
 reimbursement purposes in five subsequent rate years.  In the 
 fourth year the facility shall receive 60 percent of the 
 difference between the hospital-attached limit and the 
 freestanding nursing facility limit, and in the fifth year the 
 facility shall receive 30 percent of the difference.  

    Subd. 3f.    Property costs after July 1, 1988.  (a)    
 Investment per bed limit.  For the rate year beginning July 1, 
 1988, the replacement-cost-new per bed limit must be $32,571 per 
 licensed bed in multiple bedrooms and $48,857 per licensed bed 
 in a single bedroom.  For the rate year beginning July 1, 1989, 
 the replacement-cost-new per bed limit for a single bedroom must 
 be $49,907 adjusted according to Minnesota Rules, part 
 9549.0060, subpart 4, item A, subitem (1).  Beginning January 1, 
 1990, the replacement-cost-new per bed limits must be adjusted 
 annually as specified in Minnesota Rules, part 9549.0060, 
 subpart 4, item A, subitem (1).  Beginning January 1, 1991, the 
 replacement-cost-new per bed limits will be adjusted annually as 
 specified in Minnesota Rules, part 9549.0060, subpart 4, item A, 
 subitem (1), except that the index utilized will be the Bureau 
 of the Census:  Composite fixed-weighted price index as 
 published in the C30 Report, Value of New Construction Put in 
 Place. 

    (b)    Rental factor.  For the rate year beginning July 
 1, 1988, the commissioner shall increase the rental factor as 
 established in Minnesota Rules, part 9549.0060, subpart 8, item 
 A, by 6.2 percent rounded to the nearest 100th percent for the 
 purpose of reimbursing nursing facilities for soft costs and 
 entrepreneurial profits not included in the cost valuation 
 services used by the state's contracted appraisers.  For rate 
 years beginning on or after July 1, 1989, the rental factor is 
 the amount determined under this paragraph for the rate year 
 beginning July 1, 1988. 

    (c)    Occupancy factor.  For rate years beginning on or 
 after July 1, 1988, in order to determine property-related 
 payment rates under Minnesota Rules, part 9549.0060, for all 
 nursing facilities except those whose average length of stay in 
 a skilled level of care within a nursing facility is 180 days or 
 less, the commissioner shall use 95 percent of capacity days.  
 For a nursing facility whose average length of stay in a skilled 
 level of care within a nursing facility is 180 days or less, the 
 commissioner shall use the greater of resident days or 80 
 percent of capacity days but in no event shall the divisor 
 exceed 95 percent of capacity days. 

    (d)    Equipment allowance.  For rate years beginning on 
 July 1, 1988, and July 1, 1989, the commissioner shall add ten 
 cents per resident per day to each nursing facility's 
 property-related payment rate.  The ten-cent property-related 
 payment rate increase is not cumulative from rate year to rate 
 year.  For the rate year beginning July 1, 1990, the 
 commissioner shall increase each nursing facility's equipment 
 allowance as established in Minnesota Rules, part 9549.0060, 
 subpart 10, by ten cents per resident per day.  For rate years 
 beginning on or after July 1, 1991, the adjusted equipment 
 allowance must be adjusted annually for inflation as in 
 Minnesota Rules, part 9549.0060, subpart 10, item E.  For the 
 rate period beginning October 1, 1992, the equipment allowance 
 for each nursing facility shall be increased by 28 percent.  For 
 rate years beginning after June 30, 1993, the allowance must be 
 adjusted annually for inflation. 

    (e)    Post chapter 199 related-organization debts and 
 interest expense.  For rate years beginning on or after July 
 1, 1990, Minnesota Rules, part 9549.0060, subpart 5, item E, 
 shall not apply to outstanding related organization debt 
 incurred prior to May 23, 1983, provided that the debt was an 
 allowable debt under Minnesota Rules, parts 9510.0010 to 
 9510.0480, the debt is subject to repayment through annual 
 principal payments, and the nursing facility demonstrates to the 
 commissioner's satisfaction that the interest rate on the debt 
 was less than market interest rates for similar arm's-length 
 transactions at the time the debt was incurred.  If the debt was 
 incurred due to a sale between family members, the nursing 
 facility must also demonstrate that the seller no longer 
 participates in the management or operation of the nursing 
 facility.  Debts meeting the conditions of this paragraph are 
 subject to all other provisions of Minnesota Rules, parts 
 9549.0010 to 9549.0080. 

    (f)    Building capital allowance for nursing facilities 
 with operating leases.  For rate years beginning on or after 
 July 1, 1990, a nursing facility with operating lease costs 
 incurred for the nursing facility's buildings shall receive its 
 building capital allowance computed in accordance with Minnesota 
 Rules, part 9549.0060, subpart 8.  If an operating lease 
 provides that the lessee's rent is adjusted to recognize 
 improvements made by the lessor and related debt, the costs for 
 capital improvements and related debt shall be allowed in the 
 computation of the lessee's building capital allowance, provided 
 that reimbursement for these costs under an operating lease 
 shall not exceed the rate otherwise paid. 

    Subd. 3g.    Property costs after July 1, 1990, for 
 certain facilities.  (a) For rate years beginning on or after 
 July 1, 1990, nursing facilities that, on or after January 1, 
 1976, but prior to January 1, 1987, were newly licensed after 
 new construction, or increased their licensed beds by a minimum 
 of 35 percent through new construction, and whose building 
 capital allowance is less than their allowable annual principal 
 and interest on allowable debt prior to the application of the 
 replacement-cost-new per bed limit and whose remaining weighted 
 average debt amortization schedule as of January 1, 1988, 
 exceeded 15 years, must receive a property-related payment rate 
 equal to the greater of their rental per diem or their annual 
 allowable principal and allowable interest without application 
 of the replacement-cost-new per bed limit, divided by their 
 capacity days as determined under Minnesota Rules, part 
 9549.0060, subpart 11, as modified by subdivision 3f, paragraph 
 (c), for the preceding reporting year, plus their equipment 
 allowance.  A nursing facility that is eligible for a 
 property-related payment rate under this subdivision and whose 
 property-related payment rate in a subsequent rate year is its 
 rental per diem must continue to have its property-related 
 payment rates established for all future rate years based on the 
 rental reimbursement method in Minnesota Rules, part 9549.0060.  

 The commissioner may require the nursing facility to apply for 
 refinancing as a condition of receiving special rate treatment 
 under this subdivision. 

    (b) If a nursing facility is eligible for a 
 property-related payment rate under this subdivision, and the 
 nursing facility's debt is refinanced after October 1, 1988, the 
 provisions in paragraphs (1) to (7) also apply to the 
 property-related payment rate for rate years beginning on or 
 after July 1, 1990. 

    (1) A nursing facility's refinancing must not include debts 
 with balloon payments. 

    (2) If the issuance costs, including issuance costs on the 
 debt refinanced, are financed as part of the refinancing, the 
 historical cost of capital assets limit in Minnesota Rules, part 
 9549.0060, subpart 5, item A, subitem (6), includes issuance 
 costs that do not exceed seven percent of the debt refinanced, 
 plus the related issuance costs.  For purposes of this 
 paragraph, issuance costs means the fees charged by the 
 underwriter, issuer, attorneys, bond raters, appraisers, and 
 trustees, and includes the cost of printing, title insurance, 
 registration tax, and a feasibility study for the refinancing of 
 a nursing facility's debt.  Issuance costs do not include bond 
 premiums or discounts when bonds are sold at other than their 
 par value, points, or a bond reserve fund.  To the extent 
 otherwise allowed under this paragraph, the straight-line 
 amortization of the refinancing issuance costs is not an 
 allowable cost. 

    (3) The annual principal and interest expense payments and 
 any required annual municipal fees on the nursing facility's 
 refinancing replace those of the refinanced debt and, together 
 with annual principal and interest payments on other allowable 
 debts, are allowable costs subject to the limitation on 
 historical cost of capital assets plus issuance costs as limited 
 in paragraph (2), if any. 

    (4) If the nursing facility's refinancing includes zero 
 coupon bonds, the commissioner shall establish a monthly debt 
 service payment schedule based on an annuity that will produce 
 an amount equal to the zero coupon bonds at maturity.  The term 
 and interest rate is the term and interest rate of the zero 
 coupon bonds.  Any refinancing to repay the zero coupon bonds is 
 not an allowable cost. 

    (5) The annual amount of annuity payments is added to the 
 nursing facility's allowable annual principal and interest 
 payment computed in paragraph (3). 

    (6) The property-related payment rate is equal to the 
 amount in paragraph (5), divided by the nursing facility's 
 capacity days as determined under Minnesota Rules, part 
 9549.0060, subpart 11, as modified by subdivision 3f, paragraph 
 (c), for the preceding reporting year plus an equipment 
 allowance. 

    (7) Except as provided in this subdivision, the provisions 
 of Minnesota Rules, part 9549.0060 apply. 

    Subd. 3h. Repealed, 2000 c 449 s 15 

    Subd. 3i.    Property costs for the rate year beginning 
 July 1, 1990.  Notwithstanding Minnesota Rules, part 
 9549.0060, subpart 13, item H, the commissioner shall determine 
 property-related payment rates for nursing facilities for the 
 rate year beginning July 1, 1990, as follows:  

    (a) The property-related payment rate for a nursing 
 facility that qualifies under subdivision 3g is the greater of 
 the rate determined under that subdivision or the rate 
 determined under paragraph (c), (d), or (e), whichever is 
 applicable. 

    (b) Nursing facilities shall be grouped according to the 
 type of property-related payment rate the commissioner 
 determined for the rate year beginning July 1, 1989.  A nursing 
 facility whose property-related payment rate was determined 
 under Minnesota Rules, part 9549.0060, subpart 13, item A (full 
 rental reimbursement), shall be considered group A.  A nursing 
 facility whose property-related payment rate was determined 
 under Minnesota Rules, part 9549.0060, subpart 13, item B 
 (phase-down to full rental reimbursement), shall be considered 
 group B.  A nursing facility whose property-related payment rate 
 was determined under Minnesota Rules, part 9549.0060, subpart 
 13, item C or D (phase-up to full rental reimbursement), shall 
 be considered group C. 

    (c) For the rate year beginning July 1, 1990, a group A 
 nursing facility shall receive its property-related payment rate 
 determined under Minnesota Rules, parts 9549.0010 to 9549.0080, 
 and this section. 

    (d) For the rate year beginning July 1, 1990, a Group B 
 nursing facility shall receive the greater of 87 percent of the 
 property-related payment rate in effect on July 1, 1989; or the 
 rental per diem rate determined under Minnesota Rules, parts 
 9549.0010 to 9549.0080, and this section in effect on July 1, 
 1990; or the sum of 100 percent of the nursing facility's 
 allowable principal and interest expense, plus its equipment 
 allowance multiplied by the resident days for the reporting year 
 ending September 30, 1989, divided by the nursing facility's 
 capacity days as determined under Minnesota Rules, part 
 9549.0060, subpart 11, as modified by subdivision 3f, paragraph 
 (c); except that the nursing facility's property-related payment 
 rate must not exceed its property-related payment rate in effect 
 on July 1, 1989. 

    (e) For the rate year beginning July 1, 1990, a group C 
 nursing facility shall receive its property-related payment rate 
 determined under Minnesota Rules, parts 9549.0010 to 9549.0080, 
 and this section, except the rate must not exceed the lesser of 
 its property-related payment rate determined for the rate year 
 beginning July 1, 1989, multiplied by 116 percent or its rental 
 per diem rate determined effective July 1, 1990. 

    (f) The property-related payment rate for a nursing 
 facility that qualifies for a rate adjustment under Minnesota 
 Rules, part 9549.0060, subpart 13, item G (special 
 reappraisals), shall have the property-related payment rate 
 determined in paragraphs (a) to (e) adjusted according to the 
 provisions in that rule. 

    (g) Except as provided in subdivision 4, paragraph (f), and 
 subdivision 11, a nursing facility that has a change in 
 ownership or a reorganization of provider entity is subject to 
 the provisions of Minnesota Rules, part 9549.0060, subpart 13, 
 item F. 

    Subd. 3j. Repealed, 2000 c 449 s 15 

    Subd. 4. Repealed, 2000 c 449 s 15 

    Subd. 5. Repealed, 2000 c 449 s 15 

    Subd. 6. Repealed, 1991 c 292 art 7 s 26 

    Subd. 7. Repealed, 2000 c 449 s 15 

    Subd. 8. Repealed, 2000 c 449 s 15 

    Subd. 9. Repealed, 2000 c 449 s 15 

    Subd. 9a. Repealed, 2000 c 449 s 15 

    Subd. 10.    Property rate adjustments and construction 
 projects.  A nursing facility's request for a property-related 
 payment rate adjustment and the related supporting documentation 
 of project construction cost information must be submitted to 
 the commissioner within 60 days after the construction project's 
 completion date to be considered eligible for a property-related 
 payment rate adjustment.  Construction projects with completion 
 dates within one year of the completion date associated with the 
 property rate adjustment request and phased projects with 
 project completion dates within three years of the last phase of 
 the phased project must be aggregated for purposes of the 
 minimum thresholds in subdivisions 16 and 17, and the maximum 
 threshold in section 144A.071, subdivision 2.  "Construction 
 project" and "project construction costs" have the meanings 
 given them in Minnesota Statutes, section 144A.071, subdivision 
 1a. 

    Subd. 11.    Special property rate setting procedures for 
 certain nursing facilities.  (a) Notwithstanding Minnesota 
 Rules, part 9549.0060, subpart 13, item H, to the contrary, for 
 the rate year beginning July 1, 1990, a nursing facility leased 
 prior to January 1, 1986, and currently subject to adverse 
 licensure action under section 144A.04, subdivision 4, paragraph 
 (a), or section 144A.11, subdivision 2, and whose ownership 
 changes prior to July 1, 1990, shall be allowed a 
 property-related payment equal to the lesser of its current 
 lease obligation divided by its capacity days as determined in 
 Minnesota Rules, part 9549.0060, subpart 11, as modified by 
 subdivision 3f, paragraph (c), or the frozen property-related 
 payment rate in effect for the rate year beginning July 1, 
 1989.  For rate years beginning on or after July 1, 1991, the 
 property-related payment rate shall be its rental rate computed 
 using the previous owner's allowable principal and interest 
 expense as allowed by the department prior to that prior owner's 
 sale and lease-back transaction of December 1985. 

    (b) Notwithstanding other provisions of applicable law, a 
 nursing facility licensed for 122 beds on January 1, 1998, and 
 located in Columbia Heights shall have its property-related 
 payment rate set under this subdivision.  The commissioner shall 
 make a rate adjustment by adding $2.41 to the facility's July 1, 
 1997, property-related payment rate.  The adjusted 
 property-related payment rate shall be effective for rate years 
 beginning on or after July 1, 1998.  The adjustment in this 
 paragraph shall remain in effect so long as the facility's rates 
 are set under this section.  If the facility participates in the 
 alternative payment system under section 256B.434, the 
 adjustment in this paragraph shall be included in the facility's 
 contract payment rate.  If historical rates or property costs 
 recognized under this section become the basis for future 
 medical assistance payments to the facility under a managed 
 care, capitation, or other alternative payment system, the 
 adjustment in this paragraph shall be included in the 
 computation of the facility's payments. 

    Subd. 12. Repealed, 2000 c 449 s 15 

    Subd. 13.    Hold-harmless property-related rates.  (a) 
 Terms used in subdivisions 13 to 21 shall be as defined in 
 Minnesota Rules, parts 9549.0010 to 9549.0080, and this section. 

    (b) Except as provided in this subdivision, for rate 
 periods beginning on October 1, 1992, and for rate years 
 beginning after June 30, 1993, the property-related rate for a 
 nursing facility shall be the greater of $4 or the 
 property-related payment rate in effect on September 30, 1992.  
 In addition, the incremental increase in the nursing facility's 
 rental rate will be determined under Minnesota Rules, parts 
 9549.0010 to 9549.0080, and this section. 

    (c) Notwithstanding Minnesota Rules, part 9549.0060, 
 subpart 13, item F, a nursing facility that has a sale permitted 
 under subdivision 14 after June 30, 1992, shall receive the 
 property-related payment rate in effect at the time of the sale 
 or reorganization.  For rate periods beginning after October 1, 
 1992, and for rate years beginning after June 30, 1993, a 
 nursing facility shall receive, in addition to its 
 property-related payment rate in effect at the time of the sale, 
 the incremental increase allowed under subdivision 14. 

    (d) For rate years beginning after June 30, 1993, the 
 property-related rate for a nursing facility licensed after July 
 1, 1989, after relocating its beds from a separate nursing home 
 to a building formerly used as a hospital and sold during the 
 cost reporting year ending September 30, 1991, shall be its 
 property-related rate prior to the sale in addition to the 
 incremental increases provided under this section effective on 
 October 1, 1992, of 29 cents per day, and any incremental 
 increases after October 1, 1992, calculated by using its rental 
 rate under Minnesota Rules, parts 9549.0010 to 9549.0080, and 
 this section, recognizing the current appraised value of the 
 facility at the new location, and including as allowable debt 
 otherwise allowable debt incurred to remodel the facility in the 
 new location prior to the relocation of beds. 

    Subd. 14.    Limitations on sales of nursing facilities. 
  (a) For rate periods beginning on October 1, 1992, and for 
 rate years beginning after June 30, 1993, a nursing facility's 
 property-related payment rate as established under subdivision 
 13 shall be adjusted by either paragraph (b) or (c) for the sale 
 of the nursing facility, including sales occurring after June 
 30, 1992, as provided in this subdivision. 

    (b) If the nursing facility's property-related payment rate 
 under subdivision 13 prior to sale is greater than the nursing 
 facility's rental rate under Minnesota Rules, parts 9549.0010 to 
 9549.0080, and this section prior to sale, the nursing 
 facility's property-related payment rate after sale shall be the 
 greater of its property-related payment rate under subdivision 
 13 prior to sale or its rental rate under Minnesota Rules, parts 
 9549.0010 to 9549.0080, and this section calculated after sale. 

    (c) If the nursing facility's property-related payment rate 
 under subdivision 13 prior to sale is equal to or less than the 
 nursing facility's rental rate under Minnesota Rules, parts 
 9549.0010 to 9549.0080, and this section prior to sale, the 
 nursing facility's property-related payment rate after sale 
 shall be the nursing facility's property-related payment rate 
 under subdivision 13 plus the difference between its rental rate 
 calculated under Minnesota Rules, parts 9549.0010 to 9549.0080, 
 and this section prior to sale and its rental rate calculated 
 under Minnesota Rules, parts 9549.0010 to 9549.0080, and this 
 section calculated after sale. 

    (d) For purposes of this subdivision, "sale" means the 
 purchase of a nursing facility's capital assets with cash or 
 debt.  The term sale does not include a stock purchase of a 
 nursing facility or any of the following transactions:  

    (1) a sale and leaseback to the same licensee that does not 
 constitute a change in facility license; 

    (2) a transfer of an interest to a trust; 

    (3) gifts or other transfers for no consideration; 

    (4) a merger of two or more related organizations; 

    (5) a change in the legal form of doing business, other 
 than a publicly held organization that becomes privately held or 
 vice versa; 

    (6) the addition of a new partner, owner, or shareholder 
 who owns less than 20 percent of the nursing facility or the 
 issuance of stock; and 

    (7) a sale, merger, reorganization, or any other transfer 
 of interest between related organizations other than those 
 permitted in this section.  

    (e) For purposes of this subdivision, "sale" includes the 
 sale or transfer of a nursing facility to a close relative as 
 defined in Minnesota Rules, part 9549.0020, subpart 38, item C, 
 upon the death of an owner, due to serious illness or 
 disability, as defined under the Social Security Act, under 
 United States Code, title 42, section 423(d)(1)(A), or upon 
 retirement of an owner from the business of owning or operating 
 a nursing home at 62 years of age or older.  For sales to a 
 close relative allowed under this paragraph, otherwise 
 nonallowable debt resulting from seller financing of all or a 
 portion of the debt resulting from the sale shall be allowed and 
 shall not be subject to Minnesota Rules, part 9549.0060, subpart 
 5, item E, provided that in addition to existing requirements 
 for allowance of debt and interest, the debt is subject to 
 repayment through annual principal payments and the interest 
 rate on the related organization debt does not exceed three 
 percentage points above the posted yield for standard 
 conventional fixed rate mortgages of the Federal Home Loan 
 Mortgage Corporation for delivery in 60 days in effect on the 
 day of sale.  If at any time, the seller forgives the related 
 organization debt allowed under this paragraph for other than 
 equal amount of payment on that debt, then the buyer shall pay 
 to the state the total revenue received by the nursing facility 
 after the sale attributable to the amount of allowable debt 
 which has been forgiven.  Any assignment, sale, or transfer of 
 the debt instrument entered into by the close relatives, either 
 directly or indirectly, which grants to the close relative buyer 
 the right to receive all or a portion of the payments under the 
 debt instrument shall, effective on the date of the transfer, 
 result in the prospective reduction in the corresponding portion 
 of the allowable debt and interest expense.  Upon the death of 
 the close relative seller, any remaining balance of the close 
 relative debt must be refinanced and such refinancing shall be 
 subject to the provisions of Minnesota Rules, part 9549.0060, 
 subpart 7, item G.  This paragraph shall not apply to sales 
 occurring on or after June 30, 1997.  

    (f) For purposes of this subdivision, "effective date of 
 sale" means the later of either the date on which legal title to 
 the capital assets is transferred or the date on which closing 
 for the sale occurred.  

    (g) The effective day for the property-related payment rate 
 determined under this subdivision shall be the first day of the 
 month following the month in which the effective date of sale 
 occurs or October 1, 1992, whichever is later, provided that the 
 notice requirements under section 256B.47, subdivision 2, have 
 been met. 

    (h) Notwithstanding Minnesota Rules, part 9549.0060, 
 subparts 5, item A, subitems (3) and (4), and 7, items E and F, 
 the commissioner shall limit the total allowable debt and 
 related interest for sales occurring after June 30, 1992, to the 
 sum of clauses (1) to (3):  

    (1) the historical cost of capital assets, as of the 
 nursing facility's most recent previous effective date of sale 
 or, if there has been no previous sale, the nursing facility's 
 initial historical cost of constructing capital assets; 

    (2) the average annual capital asset additions after 
 deduction for capital asset deletions, not including 
 depreciations; and 

    (3) one-half of the allowed inflation on the nursing 
 facility's capital assets.  The commissioner shall compute the 
 allowed inflation as described in paragraph (i). 

    (i) For purposes of computing the amount of allowed 
 inflation, the commissioner must apply the following principles: 

    (1) the lesser of the Consumer Price Index for all urban 
 consumers or the Dodge Construction Systems Costs for Nursing 
 Homes for any time periods during which both are available must 
 be used.  If the Dodge Construction Systems Costs for Nursing 
 Homes becomes unavailable, the commissioner shall substitute the 
 index in subdivision 3f, or such other index as the secretary of 
 the Centers for Medicare and Medicaid Services may designate; 

    (2) the amount of allowed inflation to be applied to the 
 capital assets in paragraph (g), clauses (1) and (2), must be 
 computed separately; 

    (3) the amount of allowed inflation must be determined on 
 an annual basis, prorated on a monthly basis for partial years 
 and if the initial month of use is not determinable for a 
 capital asset, then one-half of that calendar year shall be used 
 for purposes of prorating; 

    (4) the amount of allowed inflation to be applied to the 
 capital assets in paragraph (g), clauses (1) and (2), must not 
 exceed 300 percent of the total capital assets in any one of 
 those clauses; and 

    (5) the allowed inflation must be computed starting with 
 the month following the nursing facility's most recent previous 
 effective date of sale or, if there has been no previous sale, 
 the month following the date of the nursing facility's initial 
 occupancy, and ending with the month preceding the effective 
 date of sale. 

    (j) If the historical cost of a capital asset is not 
 readily available for the date of the nursing facility's most 
 recent previous sale or if there has been no previous sale for 
 the date of the nursing facility's initial occupancy, then the 
 commissioner shall limit the total allowable debt and related 
 interest after sale to the extent recognized by the Medicare 
 intermediary after the sale.  For a nursing facility that has no 
 historical capital asset cost data available and does not have 
 allowable debt and interest calculated by the Medicare 
 intermediary, the commissioner shall use the historical cost of 
 capital asset data from the point in time for which capital 
 asset data is recorded in the nursing facility's audited 
 financial statements. 

    (k) The limitations in this subdivision apply only to debt 
 resulting from a sale of a nursing facility occurring after June 
 30, 1992, including debt assumed by the purchaser of the nursing 
 facility. 

    Subd. 15.    Capital repair and replacement cost reporting 
 and rate calculation.  For rate years beginning after June 30, 
 1993, a nursing facility's capital repair and replacement 
 payment rate shall be established annually as provided in 
 paragraphs (a) to (e).  

    (a) Notwithstanding Minnesota Rules, part 9549.0060, 
 subpart 12, the costs of any of the following items not included 
 in the equity incentive computations under subdivision 16 or 
 reported as a capital asset addition under subdivision 18, 
 paragraph (b), including cash payment for equity investment and 
 principal and interest expense for debt financing, must be 
 reported in the capital repair and replacement cost category: 

    (1) wall coverings; 

    (2) paint; 

    (3) floor coverings; 

    (4) window coverings; 

    (5) roof repair; and 

    (6) window repair or replacement. 

    (b) Notwithstanding Minnesota Rules, part 9549.0060, 
 subpart 12, the repair or replacement of a capital asset not 
 included in the equity incentive computations under subdivision 
 16 or reported as a capital asset addition under subdivision 18, 
 paragraph (b), must be reported under this subdivision when the 
 cost of the item exceeds $500, or in the plant operations and 
 maintenance cost category when the cost of the item is equal to 
 or less than $500. 

    (c) To compute the capital repair and replacement payment 
 rate, the allowable annual repair and replacement costs for the 
 reporting year must be divided by actual resident days for the 
 reporting year.  The annual allowable capital repair and 
 replacement costs shall not exceed $150 per licensed bed.  The 
 excess of the allowed capital repair and replacement costs over 
 the capital repair and replacement limit shall be a cost 
 carryover to succeeding cost reporting periods, except that sale 
 of a facility, under subdivision 14, shall terminate the 
 carryover of all costs except those incurred in the most recent 
 cost reporting year.  The termination of the carryover shall 
 have effect on the capital repair and replacement rate on the 
 same date as provided in subdivision 14, paragraph (f), for the 
 sale.  For rate years beginning after June 30, 1994, the capital 
 repair and replacement limit shall be subject to the index 
 provided in subdivision 3f, paragraph (a).  For purposes of this 
 subdivision, the number of licensed beds shall be the number 
 used to calculate the nursing facility's capacity days.  The 
 capital repair and replacement rate must be added to the nursing 
 facility's total payment rate. 

    (d) Capital repair and replacement costs under this 
 subdivision shall not be counted as either care-related or other 
 operating costs, nor subject to care-related or other operating 
 limits. 

    (e) If costs otherwise allowable under this subdivision are 
 incurred as the result of a project approved under the 
 moratorium exception process in section 144A.073, or in 
 connection with an addition to or replacement of buildings, 
 attached fixtures, or land improvements for which the total 
 historical cost of these assets exceeds the lesser of $150,000 
 or ten percent of the nursing facility's appraised value, these 
 costs must be claimed under subdivision 16 or 17, as appropriate.

    Subd. 16.    Major additions and replacements; equity 
 incentive.  For rate years beginning after June 30, 1993, if a 
 nursing facility acquires capital assets in connection with a 
 project approved under the moratorium exception process in 
 section 144A.073 or in connection with an addition to or 
 replacement of buildings, attached fixtures, or land 
 improvements for which the total historical cost of those 
 capital asset additions exceeds the lesser of $150,000 or ten 
 percent of the most recent appraised value, the nursing facility 
 shall be eligible for an equity incentive payment rate as in 
 paragraphs (a) to (d).  This computation is separate from the 
 determination of the nursing facility's rental rate.  An equity 
 incentive payment rate as computed under this subdivision is 
 limited to one in a 12-month period. 

    (a) An eligible nursing facility shall receive an equity 
 incentive payment rate equal to the allowable historical cost of 
 the capital asset acquired, minus the allowable debt directly 
 identified to that capital asset, multiplied by the equity 
 incentive factor as described in paragraphs (b) and (c), and 
 divided by the nursing facility's occupancy factor under 
 subdivision 3f, paragraph (c).  This amount shall be added to 
 the nursing facility's total payment rate and shall be effective 
 the same day as the incremental increase in paragraph (d) or 
 subdivision 17.  The allowable historical cost of the capital 
 assets and the allowable debt shall be determined as provided in 
 Minnesota Rules, parts 9549.0010 to 9549.0080, and this section. 

    (b) The equity incentive factor shall be determined under 
 clauses (1) to (4):  

    (1) divide the initial allowable debt in paragraph (a) by 
 the initial historical cost of the capital asset additions 
 referred to in paragraph (a), then cube the quotient, 

    (2) subtract the amount calculated in clause (1) from the 
 number one, 

    (3) determine the difference between the rental factor and 
 the lesser of two percentage points above the posted yield for 
 standard conventional fixed rate mortgages of the Federal Home 
 Loan Mortgage Corporation as published in the Wall Street 
 Journal and in effect on the first day of the month the debt or 
 cost is incurred, or 16 percent, 

    (4) multiply the amount calculated in clause (2) by the 
 amount calculated in clause (3). 

    (c) The equity incentive payment rate shall be limited to 
 the term of the allowable debt in paragraph (a), not greater 
 than 20 years nor less than ten years.  If no debt is incurred 
 in acquiring the capital asset, the equity incentive payment 
 rate shall be paid for ten years.  The sale of a nursing 
 facility under subdivision 14 shall terminate application of the 
 equity incentive payment rate effective on the date provided in 
 subdivision 14, paragraph (f), for the sale. 

    (d) A nursing facility with an addition to or a renovation 
 of its buildings, attached fixtures, or land improvements 
 meeting the criteria in this subdivision and not receiving the 
 property-related payment rate adjustment in subdivision 17, 
 shall receive the incremental increase in the nursing facility's 
 rental rate as determined under Minnesota Rules, parts 9549.0010 
 to 9549.0080, and this section.  The incremental increase shall 
 be added to the nursing facility's property-related payment rate.
 The effective date of this incremental increase shall be the 
 first day of the month following the month in which the addition 
 or replacement is completed. 

    Subd. 17.    Special provisions for moratorium exceptions. 
  (a) Notwithstanding Minnesota Rules, part 9549.0060, subpart 
 3, for rate periods beginning on October 1, 1992, and for rate 
 years beginning after June 30, 1993, a nursing facility that (1) 
 has completed a construction project approved under section 
 144A.071, subdivision 4a, clause (m); (2) has completed a 
 construction project approved under section 144A.071, 
 subdivision 4a, and effective after June 30, 1995; or (3) has 
 completed a renovation, replacement, or upgrading project 
 approved under the moratorium exception process in section 
 144A.073 shall be reimbursed for costs directly identified to 
 that project as provided in subdivision 16 and this subdivision. 

    (b) Notwithstanding Minnesota Rules, part 9549.0060, 
 subparts 5, item A, subitems (1) and (3), and 7, item D, 
 allowable interest expense on debt shall include: 

    (1) interest expense on debt related to the cost of 
 purchasing or replacing depreciable equipment, excluding 
 vehicles, not to exceed six percent of the total historical cost 
 of the project; and 

    (2) interest expense on debt related to financing or 
 refinancing costs, including costs related to points, loan 
 origination fees, financing charges, legal fees, and title 
 searches; and issuance costs including bond discounts, bond 
 counsel, underwriter's counsel, corporate counsel, printing, and 
 financial forecasts.  Allowable debt related to items in this 
 clause shall not exceed seven percent of the total historical 
 cost of the project.  To the extent these costs are financed, 
 the straight-line amortization of the costs in this clause is 
 not an allowable cost; and 

    (3) interest on debt incurred for the establishment of a 
 debt reserve fund, net of the interest earned on the debt 
 reserve fund. 

    (c) Debt incurred for costs under paragraph (b) is not 
 subject to Minnesota Rules, part 9549.0060, subpart 5, item A, 
 subitem (5) or (6). 

    (d) The incremental increase in a nursing facility's rental 
 rate, determined under Minnesota Rules, parts 9549.0010 to 
 9549.0080, and this section, resulting from the acquisition of 
 allowable capital assets, and allowable debt and interest 
 expense under this subdivision shall be added to its 
 property-related payment rate and shall be effective on the 
 first day of the month following the month in which the 
 moratorium project was completed. 

    (e) Notwithstanding subdivision 3f, paragraph (a), for rate 
 periods beginning on October 1, 1992, and for rate years 
 beginning after June 30, 1993, the replacement-costs-new per bed 
 limit to be used in Minnesota Rules, part 9549.0060, subpart 4, 
 item B, for a nursing facility that has completed a renovation, 
 replacement, or upgrading project that has been approved under 
 the moratorium exception process in section 144A.073, or that 
 has completed an addition to or replacement of buildings, 
 attached fixtures, or land improvements for which the total 
 historical cost exceeds the lesser of $150,000 or ten percent of 
 the most recent appraised value, must be $47,500 per licensed 
 bed in multiple-bed rooms and $71,250 per licensed bed in a 
 single-bed room.  These amounts must be adjusted annually as 
 specified in subdivision 3f, paragraph (a), beginning January 1, 
 1993. 

    (f) For purposes of this paragraph, a total replacement 
 means the complete replacement of the nursing facility's 
 physical plant through the construction of a new physical plant, 
 the transfer of the nursing facility's license from one physical 
 plant location to another, or a new building addition to 
 relocate beds from three- and four-bed wards.  For total 
 replacement projects completed on or after July 1, 1992, the 
 commissioner shall compute the incremental change in the nursing 
 facility's rental per diem, for rate years beginning on or after 
 July 1, 1995, by replacing its appraised value, including the 
 historical capital asset costs, and the capital debt and 
 interest costs with the new nursing facility's allowable capital 
 asset costs and the related allowable capital debt and interest 
 costs.  If the new nursing facility has decreased its licensed 
 capacity, the aggregate investment per bed limit in subdivision 
 3a, paragraph (c), shall apply.  If the new nursing facility has 
 retained a portion of the original physical plant for nursing 
 facility usage, then a portion of the appraised value prior to 
 the replacement must be retained and included in the calculation 
 of the incremental change in the nursing facility's rental per 
 diem.  For purposes of this part, the original nursing facility 
 means the nursing facility prior to the total replacement 
 project.  The portion of the appraised value to be retained 
 shall be calculated according to clauses (1) to (3): 

    (1) The numerator of the allocation ratio shall be the 
 square footage of the area in the original physical plant which 
 is being retained for nursing facility usage. 

    (2) The denominator of the allocation ratio shall be the 
 total square footage of the original nursing facility physical 
 plant. 

    (3) Each component of the nursing facility's allowable 
 appraised value prior to the total replacement project shall be 
 multiplied by the allocation ratio developed by dividing clause 
 (1) by clause (2). 

    In the case of either type of total replacement as 
 authorized under section 144A.071 or 144A.073, the provisions of 
 this subdivision shall also apply.  For purposes of the 
 moratorium exception authorized under section 144A.071, 
 subdivision 4a, paragraph (s), if the total replacement involves 
 the renovation and use of an existing health care facility 
 physical plant, the new allowable capital asset costs and 
 related debt and interest costs shall include first the 
 allowable capital asset costs and related debt and interest 
 costs of the renovation, to which shall be added the allowable 
 capital asset costs of the existing physical plant prior to the 
 renovation, and if reported by the facility, the related 
 allowable capital debt and interest costs. 

    (g) Notwithstanding Minnesota Rules, part 9549.0060, 
 subpart 11, item C, subitem (2), for a total replacement, as 
 defined in paragraph (f), authorized under section 144A.071 or 
 144A.073 after July 1, 1999, or any building project that is a 
 relocation, renovation, upgrading, or conversion completed on or 
 after July 1, 2001, the replacement-costs-new per bed limit 
 shall be $74,280 per licensed bed in multiple-bed rooms, $92,850 
 per licensed bed in semiprivate rooms with a fixed partition 
 separating the resident beds, and $111,420 per licensed bed in 
 single rooms.  Minnesota Rules, part 9549.0060, subpart 11, item 
 C, subitem (2), does not apply.  These amounts must be adjusted 
 annually as specified in subdivision 3f, paragraph (a), 
 beginning January 1, 2000.  

    (h) For a total replacement, as defined in paragraph (f), 
 authorized under section 144A.073 for a 96-bed nursing home in 
 Carlton county, the replacement-costs-new per bed limit shall be 
 $74,280 per licensed bed in multiple-bed rooms, $92,850 per 
 licensed bed in semiprivate rooms with a fixed partition 
 separating the resident's beds, and $111,420 per licensed bed in 
 a single room.  Minnesota Rules, part 9549.0060, subpart 11, 
 item C, subitem (2), does not apply.  The resulting maximum 
 allowable replacement-costs-new multiplied by 1.25 shall 
 constitute the project's dollar threshold for purposes of 
 application of the limit set forth in section 144A.071, 
 subdivision 2.  The commissioner of health may waive the 
 requirements of section 144A.073, subdivision 3b, paragraph (b), 
 clause (2), on the condition that the other requirements of that 
 paragraph are met. 

    (i) For a renovation authorized under section 144A.073 for 
 a 65-bed nursing home in St. Louis county, the incremental 
 increase in rental rate for purposes of paragraph (d) shall be 
 $8.16, and the total replacement cost, allowable appraised 
 value, allowable debt, and allowable interest shall be increased 
 according to the incremental increase. 

    (j) For a total replacement, as defined in paragraph (f), 
 authorized under section 144A.073 involving a new building 
 addition that relocates beds from three-bed wards for an 80-bed 
 nursing home in Redwood county, the replacement-costs-new per 
 bed limit shall be $74,280 per licensed bed for multiple-bed 
 rooms; $92,850 per licensed bed for semiprivate rooms with a 
 fixed partition separating the beds; and $111,420 per licensed 
 bed for single rooms.  These amounts shall be adjusted annually, 
 beginning January 1, 2001.  Minnesota Rules, part 9549.0060, 
 subpart 11, item C, subitem (2), does not apply.  The resulting 
 maximum allowable replacement-costs-new multiplied by 1.25 shall 
 constitute the project's dollar threshold for purposes of 
 application of the limit set forth in section 144A.071, 
 subdivision 2.  The commissioner of health may waive the 
 requirements of section 144A.073, subdivision 3b, paragraph (b), 
 clause (2), on the condition that the other requirements of that 
 paragraph are met. 

    Subd. 18.    Updating appraisals, additions, and 
 replacements.  (a) Notwithstanding Minnesota Rules, part 
 9549.0060, subparts 1 to 3, the appraised value, routine 
 updating of the appraised value, and special reappraisals are 
 subject to this subdivision. 

    For all rate years after June 30, 1993, the commissioner 
 shall no longer conduct any appraisals under Minnesota Rules, 
 part 9549.0060, for the purpose of determining property-related 
 payment rates. 

    (b) Notwithstanding Minnesota Rules, part 9549.0060, 
 subpart 2, for rate years beginning after June 30, 1993, the 
 commissioner shall routinely update the appraised value of each 
 nursing facility by adding the cost of capital asset 
 acquisitions to its allowable appraised value.  

    The commissioner shall also annually index each nursing 
 facility's allowable appraised value by the inflation index 
 referenced in subdivision 3f, paragraph (a), for the purpose of 
 computing the nursing facility's annual rental rate.  In 
 annually adjusting the nursing facility's appraised value, the 
 commissioner must not include the historical cost of capital 
 assets acquired during the reporting year in the nursing 
 facility's appraised value. 

    In addition, the nursing facility's appraised value must be 
 reduced by the historical cost of capital asset disposals or 
 applicable credits such as public grants and insurance 
 proceeds.  Capital asset additions and disposals must be 
 reported on the nursing facility's annual cost report in the 
 reporting year of acquisition or disposal.  The incremental 
 increase in the nursing facility's rental rate resulting from 
 this annual adjustment as determined under Minnesota Rules, 
 parts 9549.0010 to 9549.0080, and this section shall be added to 
 the nursing facility's property-related payment rate for the 
 rate year following the reporting year.  

    Subd. 19.    Refinancing incentive.  (a) A nursing 
 facility that refinances debt after May 30, 1992, in order to 
 save in interest expense payments as determined in clauses (1) 
 to (5) may be eligible for the refinancing incentive under this 
 subdivision.  To be eligible for the refinancing incentive, a 
 nursing facility must notify the commissioner in writing of such 
 a refinancing within 60 days following the date on which the 
 refinancing occurs.  If the nursing facility meets these 
 conditions, the commissioner shall determine the refinancing 
 incentive as in clauses (1) to (5).  

    (1) Compute the aggregate amount of interest expense, 
 including amortized issuance and financing costs, remaining on 
 the debt to be refinanced, and divide this amount by the number 
 of years remaining for the term of that debt. 

    (2) Compute the aggregate amount of interest expense, 
 including amortized issuance and financing costs, for the new 
 debt, and divide this amount by the number of years for the term 
 of that debt. 

    (3) Subtract the amount in clause (2) from the amount in 
 clause (1), and multiply the amount, if positive, by .5. 

    (4) The amount in clause (3) shall be divided by the 
 nursing facility's occupancy factor under subdivision 3f, 
 paragraph (c). 

    (5) The per diem amount in clause (4) shall be deducted 
 from the nursing facility's property-related payment rate for 
 three full rate years following the rate year in which the 
 refinancing occurs.  For the fourth full rate year following the 
 rate year in which the refinancing occurs, and each rate year 
 thereafter, the per diem amount in clause (4) shall again be 
 deducted from the nursing facility's property-related payment 
 rate. 

    (b) An increase in a nursing facility's debt for costs in 
 subdivision 17, paragraph (b), clause (2), including the cost of 
 refinancing the issuance or financing costs of the debt 
 refinanced resulting from refinancing that meets the conditions 
 of this section shall be allowed, notwithstanding Minnesota 
 Rules, part 9549.0060, subpart 5, item A, subitem (6).  

    (c) The proceeds of refinancing may not be used for the 
 purpose of withdrawing equity from the nursing facility. 

    (d) Sale of a nursing facility under subdivision 14 shall 
 terminate the payment of the incentive payments under this 
 subdivision effective the date provided in subdivision 14, 
 paragraph (f), for the sale, and the full amount of the 
 refinancing incentive in paragraph (a) shall be implemented. 

    (e) If a nursing facility eligible under this subdivision 
 fails to notify the commissioner as required, the commissioner 
 shall determine the full amount of the refinancing incentive in 
 paragraph (a), and shall deduct one-half that amount from the 
 nursing facility's property-related payment rate effective the 
 first day of the month following the month in which the 
 refinancing is completed.  For the next three full rate years, 
 the commissioner shall deduct one-half the amount in paragraph 
 (a), clause (5).  The remaining per diem amount shall be 
 deducted in each rate year thereafter. 

    (f) The commissioner shall reestablish the nursing 
 facility's rental rate under Minnesota Rules, parts 9549.0010 to 
 9549.0080, and this section following the refinancing using the 
 new debt and interest expense information for the purpose of 
 measuring future incremental rental increases. 

    Subd. 20.    Special property rate setting.  For rate 
 periods beginning on October 1, 1992, and for rate years 
 beginning after June 30, 1993, the property-related payment rate 
 for a nursing facility approved for total replacement under the 
 moratorium exception process in section 144A.073 through an 
 addition to another nursing facility shall have its 
 property-related rate under subdivision 13 recalculated using 
 the greater of actual resident days or 80 percent of capacity 
 days.  This rate shall apply until the nursing facility is 
 replaced or until the moratorium exception authority lapses, 
 whichever is sooner. 

    Subd. 21.    Indexing thresholds.  Beginning January 1, 
 1993, and each January 1 thereafter, the commissioner shall 
 annually update the dollar thresholds in subdivisions 15, 
 paragraph (e), 16, and 17, and in section 144A.071, subdivisions 
 2 and 4a, clauses (b) and (e), by the inflation index referenced 
 in subdivision 3f, paragraph (a). 

    Subd. 22.    Changes to nursing facility reimbursement.  
 The nursing facility reimbursement changes in paragraphs (a) to 
 (d) apply to Minnesota Rules, parts 9549.0010 to 9549.0080, and 
 this section, and are effective for rate years beginning on or 
 after July 1, 1993, unless otherwise indicated. 

    (a) In addition to the approved pension or profit sharing 
 plans allowed by the reimbursement rule, the commissioner shall 
 allow those plans specified in Internal Revenue Code, sections 
 403(b) and 408(k). 

    (b) The commissioner shall allow as workers' compensation 
 insurance costs under section 256B.421, subdivision 14, the 
 costs of workers' compensation coverage obtained under the 
 following conditions: 

    (1) a plan approved by the commissioner of commerce as a 
 Minnesota group or individual self-insurance plan as provided in 
 section 79A.03; 

    (2) a plan in which: 

    (i) the nursing facility, directly or indirectly, purchases 
 workers' compensation coverage in compliance with section 
 176.181, subdivision 2, from an authorized insurance carrier; 

    (ii) a related organization to the nursing facility 
 reinsures the workers' compensation coverage purchased, directly 
 or indirectly, by the nursing facility; and 

    (iii) all of the conditions in clause (4) are met; 

    (3) a plan in which: 

    (i) the nursing facility, directly or indirectly, purchases 
 workers' compensation coverage in compliance with section 
 176.181, subdivision 2, from an authorized insurance carrier; 

    (ii) the insurance premium is calculated retrospectively, 
 including a maximum premium limit, and paid using the paid loss 
 retro method; and 

    (iii) all of the conditions in clause (4) are met; 

    (4) additional conditions are: 

    (i) the costs of the plan are allowable under the federal 
 Medicare program; 

    (ii) the reserves for the plan are maintained in an account 
 controlled and administered by a person which is not a related 
 organization to the nursing facility; 

    (iii) the reserves for the plan cannot be used, directly or 
 indirectly, as collateral for debts incurred or other 
 obligations of the nursing facility or related organizations to 
 the nursing facility; 

    (iv) if the plan provides workers' compensation coverage 
 for non-Minnesota nursing facilities, the plan's cost 
 methodology must be consistent among all nursing facilities 
 covered by the plan, and if reasonable, is allowed 
 notwithstanding any reimbursement laws regarding cost allocation 
 to the contrary; 

    (v) central, affiliated, corporate, or nursing facility 
 costs related to their administration of the plan are costs 
 which must remain in the nursing facility's administrative cost 
 category and must not be allocated to other cost categories; 

    (vi) required security deposits, whether in the form of 
 cash, investments, securities, assets, letters of credit, or in 
 any other form are not allowable costs for purposes of 
 establishing the facilities payment rate; and 

    (vii) for the rate year beginning on July 1, 1998, a group 
 of nursing facilities related by common ownership that 
 self-insures workers' compensation may allocate its directly 
 identified costs of self-insuring its Minnesota nursing facility 
 workers among those nursing facilities in the group that are 
 reimbursed under this section or section 256B.434.  The method 
 of cost allocation shall be based on the ratio of each nursing 
 facility's total allowable salaries and wages to that of the 
 nursing facility group's total allowable salaries and wages, 
 then similarly allocated within each nursing facility's 
 operating cost categories.  The costs associated with the 
 administration of the group's self-insurance plan must remain 
 classified in the nursing facility's administrative cost 
 category.  A written request of the nursing facility group's 
 election to use this alternate method of allocation of 
 self-insurance costs must be received by the commissioner no 
 later than May 1, 1998, to take effect July 1, 1998, or such 
 costs shall continue to be allocated under the existing cost 
 allocation methods.  Once a nursing facility group elects this 
 method of cost allocation for its workers' compensation 
 self-insurance costs, it shall remain in effect until such time 
 as the group no longer self-insures these costs; 

    (5) any costs allowed pursuant to clauses (1) to (3) are 
 subject to the following requirements: 

    (i) if the nursing facility is sold or otherwise ceases 
 operations, the plan's reserves must be subject to an 
 actuarially based settle-up after 36 months from the date of 
 sale or the date on which operations ceased.  The facility's 
 medical assistance portion of the total excess plan reserves 
 must be paid to the state within 30 days following the date on 
 which excess plan reserves are determined; 

    (ii) any distribution of excess plan reserves made to or 
 withdrawals made by the nursing facility or a related 
 organization are applicable credits and must be used to reduce 
 the nursing facility's workers' compensation insurance costs in 
 the reporting period in which a distribution or withdrawal is 
 received; 

    (iii) if reimbursement for the plan is sought under the 
 federal Medicare program, and is audited pursuant to the 
 Medicare program, the nursing facility must provide a copy of 
 Medicare's final audit report, including attachments and 
 exhibits, to the commissioner within 30 days of receipt by the 
 nursing facility or any related organization.  The commissioner 
 shall implement the audit findings associated with the plan upon 
 receipt of Medicare's final audit report.  The department's 
 authority to implement the audit findings is independent of its 
 authority to conduct a field audit. 

    (c) In the determination of incremental increases in the 
 nursing facility's rental rate as required in subdivisions 14 to 
 21, except for a refinancing permitted under subdivision 19, the 
 commissioner must adjust the nursing facility's property-related 
 payment rate for both incremental increases and decreases in 
 recomputations of its rental rate; 

    (d) A nursing facility's administrative cost limitation 
 must be modified as follows: 

    (1) if the nursing facility's licensed beds exceed 195 
 licensed beds, the general and administrative cost category 
 limitation shall be 13 percent; 

    (2) if the nursing facility's licensed beds are more than 
 150 licensed beds, but less than 196 licensed beds, the general 
 and administrative cost category limitation shall be 14 percent; 
 or 

    (3) if the nursing facility's licensed beds is less than 
 151 licensed beds, the general and administrative cost category 
 limitation shall remain at 15 percent. 

    (e) For the rate year beginning on July 1, 1998, a group of 
 nursing facilities related by common ownership that self-insures 
 group health, dental, or life insurance may allocate its 
 directly identified costs of self-insuring its Minnesota nursing 
 facility workers among those nursing facilities in the group 
 that are reimbursed under this section or section 256B.434.  The 
 method of cost allocation shall be based on the ratio of each 
 nursing facility's total allowable salaries and wages to that of 
 the nursing facility group's total allowable salaries and wages, 
 then similarly allocated within each nursing facility's 
 operating cost categories.  The costs associated with the 
 administration of the group's self-insurance plan must remain 
 classified in the nursing facility's administrative cost 
 category.  A written request of the nursing facility group's 
 election to use this alternate method of allocation of 
 self-insurance costs must be received by the commissioner no 
 later than May 1, 1998, to take effect July 1, 1998, or those 
 self-insurance costs shall continue to be allocated under the 
 existing cost allocation methods.  Once a nursing facility group 
 elects this method of cost allocation for its group health, 
 dental, or life insurance self-insurance costs, it shall remain 
 in effect until such time as the group no longer self-insures 
 these costs. 

    Subd. 23.    County nursing home payment adjustments.  
 (a) Beginning in 1994, the commissioner shall pay a nursing home 
 payment adjustment on May 31 after noon to a county in which is 
 located a nursing home that, on that date, was county-owned and 
 operated, with the county named as licensee by the commissioner 
 of health, and had over 40 beds and medical assistance occupancy 
 in excess of 50 percent during the reporting year ending 
 September 30, 1991.  The adjustment shall be an amount equal to 
 $16 per calendar day multiplied by the number of beds licensed 
 in the facility as of September 30, 1991. 

    (b) Payments under paragraph (a) are excluded from medical 
 assistance per diem rate calculations.  These payments are 
 required notwithstanding any rule prohibiting medical assistance 
 payments from exceeding payments from private pay residents.  A 
 facility receiving a payment under paragraph (a) may not 
 increase charges to private pay residents by an amount 
 equivalent to the per diem amount payments under paragraph (a) 
 would equal if converted to a per diem. 

    (c) Beginning in 2002, in addition to any payment under 
 paragraph (a), the commissioner shall pay to a nursing facility 
 described in paragraph (a) an adjustment in an amount equal to 
 $29.55 per calendar day multiplied by the number of beds 
 licensed in the facility on that date.  The provisions of 
 paragraphs (a) and (b) apply to payments under this paragraph.  

    (d) The commissioner may reduce payments under paragraph (c)
 based on the commissioner's determination of Medicare upper 
 payment limits.  Any adjustments must be proportional to 
 adjustments made under section 256B.19, subdivision 1d, 
 paragraph (d). 

    Subd. 24. Repealed, 2000 c 449 s 15 

    Subd. 25.    Changes to nursing facility reimbursement 
 beginning July 1, 1995.  A nursing facility licensed for 302 
 beds on September 30, 1993, that was approved under the 
 moratorium exception process in section 144A.073 for a partial 
 replacement, and completed the replacement project in December 
 1994, is exempt from Minnesota Statutes 1998, section 256B.431, 
 subdivision 25, paragraphs (b) to (d) for rate years beginning 
 on or after July 1, 1995. 

    For the rate year beginning July 1, 1997, after computing 
 this nursing facility's payment rate according to section 
 256B.434, the commissioner shall make a one-year rate adjustment 
 of $8.62 to the facility's contract payment rate for the rate 
 effect of operating cost changes associated with the facility's 
 1994 downsizing project. 

    For rate years beginning on or after July 1, 1997, the 
 commissioner shall add 35 cents to the facility's base property 
 related payment rate for the rate effect of reducing its 
 licensed capacity to 290 beds from 302 beds and shall add 83 
 cents to the facility's real estate tax and special assessment 
 payment rate for payments in lieu of real estate taxes.  The 
 adjustments in this clause shall remain in effect for the 
 duration of the facility's contract under section 256B.434. 

    Subd. 26.    Changes to nursing facility reimbursement 
 beginning July 1, 1997.  The nursing facility reimbursement 
 changes in paragraphs (a) to (e) shall apply in the sequence 
 specified in Minnesota Rules, parts 9549.0010 to 9549.0080, and 
 this section, beginning July 1, 1997. 

    (a) For rate years beginning on or after July 1, 1997, the 
 commissioner shall limit a nursing facility's allowable 
 operating per diem for each case mix category for each rate year.
 The commissioner shall group nursing facilities into two groups, 
 freestanding and nonfreestanding, within each geographic group, 
 using their operating cost per diem for the case mix A 
 classification.  A nonfreestanding nursing facility is a nursing 
 facility whose other operating cost per diem is subject to the 
 hospital attached, short length of stay, or the rule 80 limits.  
 All other nursing facilities shall be considered freestanding 
 nursing facilities.  The commissioner shall then array all 
 nursing facilities in each grouping by their allowable case mix 
 A operating cost per diem.  In calculating a nursing facility's 
 operating cost per diem for this purpose, the commissioner shall 
 exclude the raw food cost per diem related to providing special 
 diets that are based on religious beliefs, as determined in 
 subdivision 2b, paragraph (h).  For those nursing facilities in 
 each grouping whose case mix A operating cost per diem: 

    (1) is at or below the median of the array, the 
 commissioner shall limit the nursing facility's allowable 
 operating cost per diem for each case mix category to the lesser 
 of the prior reporting year's allowable operating cost per diem 
 as specified in Laws 1996, chapter 451, article 3, section 11, 
 paragraph (h), plus the inflation factor as established in 
 paragraph (d), clause (2), increased by two percentage points, 
 or the current reporting year's corresponding allowable 
 operating cost per diem; or 

    (2) is above the median of the array, the commissioner 
 shall limit the nursing facility's allowable operating cost per 
 diem for each case mix category to the lesser of the prior 
 reporting year's allowable operating cost per diem as specified 
 in Laws 1996, chapter 451, article 3, section 11, paragraph (h), 
 plus the inflation factor as established in paragraph (d), 
 clause (2), increased by one percentage point, or the current 
 reporting year's corresponding allowable operating cost per diem.

    For purposes of paragraph (a), if a nursing facility 
 reports on its cost report a reduction in cost due to a refund 
 or credit for a rate year beginning on or after July 1, 1998, 
 the commissioner shall increase that facility's spend-up limit 
 for the rate year following the current rate year by the amount 
 of the cost reduction divided by its resident days for the 
 reporting year preceding the rate year in which the adjustment 
 is to be made. 

    (b) For rate years beginning on or after July 1, 1997, the 
 commissioner shall limit the allowable operating cost per diem 
 for high cost nursing facilities.  After application of the 
 limits in paragraph (a) to each nursing facility's operating 
 cost per diem, the commissioner shall group nursing facilities 
 into two groups, freestanding or nonfreestanding, within each 
 geographic group.  A nonfreestanding nursing facility is a 
 nursing facility whose other operating cost per diem are subject 
 to hospital attached, short length of stay, or rule 80 limits.  
 All other nursing facilities shall be considered freestanding 
 nursing facilities.  The commissioner shall then array all 
 nursing facilities within each grouping by their allowable case 
 mix A operating cost per diem.  In calculating a nursing 
 facility's operating cost per diem for this purpose, the 
 commissioner shall exclude the raw food cost per diem related to 
 providing special diets that are based on religious beliefs, as 
 determined in subdivision 2b, paragraph (h).  For those nursing 
 facilities in each grouping whose case mix A operating cost per 
 diem exceeds 1.0 standard deviation above the median, the 
 commissioner shall reduce their allowable operating cost per 
 diem by three percent.  For those nursing facilities in each 
 grouping whose case mix A operating cost per diem exceeds 0.5 
 standard deviation above the median but is less than or equal to 
 1.0 standard deviation above the median, the commissioner shall 
 reduce their allowable operating cost per diem by two percent.  
 However, in no case shall a nursing facility's operating cost 
 per diem be reduced below its grouping's limit established at 
 0.5 standard deviations above the median. 

    (c) For rate years beginning on or after July 1, 1997, the 
 commissioner shall determine a nursing facility's efficiency 
 incentive by first computing the allowable difference, which is 
 the lesser of $4.50 or the amount by which the facility's other 
 operating cost limit exceeds its nonadjusted other operating 
 cost per diem for that rate year.  The commissioner shall 
 compute the efficiency incentive by: 

    (1) subtracting the allowable difference from $4.50 and 
 dividing the result by $4.50; 

    (2) multiplying 0.20 by the ratio resulting from clause 
 (1), and then; 

    (3) adding 0.50 to the result from clause (2); and 

    (4) multiplying the result from clause (3) times the 
 allowable difference. 

    The nursing facility's efficiency incentive payment shall 
 be the lesser of $2.25 or the product obtained in clause (4). 

    (d) For rate years beginning on or after July 1, 1997, the 
 forecasted price index for a nursing facility's allowable 
 operating cost per diem shall be determined under clauses (1) 
 and (2) using the change in the Consumer Price Index-All Items 
 (United States city average) (CPI-U) as forecasted by Data 
 Resources, Inc.  The commissioner shall use the indices as 
 forecasted in the fourth quarter of the calendar year preceding 
 the rate year, subject to subdivision 2l, paragraph (c).  

    (1) The CPI-U forecasted index for allowable operating cost 
 per diem shall be based on the 21-month period from the midpoint 
 of the nursing facility's reporting year to the midpoint of the 
 rate year following the reporting year. 

    (2) For rate years beginning on or after July 1, 1997, the 
 forecasted index for operating cost limits referred to in 
 subdivision 21, paragraph (b), shall be based on the CPI-U for 
 the 12-month period between the midpoints of the two reporting 
 years preceding the rate year. 

    (e) After applying these provisions for the respective rate 
 years, the commissioner shall index these allowable operating 
 cost per diem by the inflation factor provided for in paragraph 
 (d), clause (1), and add the nursing facility's efficiency 
 incentive as computed in paragraph (c). 

    (f) For the rate years beginning on July 1, 1997, July 1, 
 1998, and July 1, 1999, a nursing facility licensed for 40 beds 
 effective May 1, 1992, with a subsequent increase of 20 
 Medicare/Medicaid certified beds, effective January 26, 1993, in 
 accordance with an increase in licensure is exempt from 
 paragraphs (a) and (b). 

    (g) For a nursing facility whose construction project was 
 authorized according to section 144A.073, subdivision 5, 
 paragraph (g), the operating cost payment rates for the new 
 location shall be determined based on Minnesota Rules, part 
 9549.0057.  The relocation allowed under section 144A.073, 
 subdivision 5, paragraph (g), and the rate determination allowed 
 under this paragraph must meet the cost neutrality requirements 
 of section 144A.073, subdivision 3c.  Paragraphs (a) and (b) 
 shall not apply until the second rate year after the settle-up 
 cost report is filed.  Notwithstanding subdivision 2b, paragraph 
 (g), real estate taxes and special assessments payable by the 
 new location, a 501(c)(3) nonprofit corporation, shall be 
 included in the payment rates determined under this subdivision 
 for all subsequent rate years. 

    (h) For the rate year beginning July 1, 1997, the 
 commissioner shall compute the payment rate for a nursing 
 facility licensed for 94 beds on September 30, 1996, that 
 applied in October 1993 for approval of a total replacement 
 under the moratorium exception process in section 144A.073, and 
 completed the approved replacement in June 1995, with other 
 operating cost spend-up limit under paragraph (a), increased by 
 $3.98, and after computing the facility's payment rate according 
 to this section, the commissioner shall make a one-year positive 
 rate adjustment of $3.19 for operating costs related to the 
 newly constructed total replacement, without application of 
 paragraphs (a) and (b).  The facility's per diem, before the 
 $3.19 adjustment, shall be used as the prior reporting year's 
 allowable operating cost per diem for payment rate calculation 
 for the rate year beginning July 1, 1998.  A facility described 
 in this paragraph is exempt from paragraph (b) for the rate 
 years beginning July 1, 1997, and July 1, 1998. 

    (i) For the purpose of applying the limit stated in 
 paragraph (a), a nursing facility in Kandiyohi county licensed 
 for 86 beds that was granted hospital-attached status on 
 December 1, 1994, shall have the prior year's allowable 
 care-related per diem increased by $3.207 and the prior year's 
 other operating cost per diem increased by $4.777 before adding 
 the inflation in paragraph (d), clause (2), for the rate year 
 beginning on July 1, 1997. 

    (j) For the purpose of applying the limit stated in 
 paragraph (a), a 117 bed nursing facility located in Pine county 
 shall have the prior year's allowable other operating cost per 
 diem increased by $1.50 before adding the inflation in paragraph 
 (d), clause (2), for the rate year beginning on July 1, 1997. 

    (k) For the purpose of applying the limit under paragraph 
 (a), a nursing facility in Hibbing licensed for 192 beds shall 
 have the prior year's allowable other operating cost per diem 
 increased by $2.67 before adding the inflation in paragraph (d), 
 clause (2), for the rate year beginning July 1, 1997. 

    Subd. 27.    Changes to nursing facility reimbursement 
 beginning July 1, 1998.  (a) For the purpose of applying the 
 limit stated in subdivision 26, paragraph (a), a nursing 
 facility in Hennepin county licensed for 181 beds on September 
 30, 1996, shall have the prior year's allowable care-related per 
 diem increased by $1.455 and the prior year's other operating 
 cost per diem increased by $0.439 before adding the inflation in 
 subdivision 26, paragraph (d), clause (2), for the rate year 
 beginning on July 1, 1998. 

    (b) For the purpose of applying the limit stated in 
 subdivision 26, paragraph (a), a nursing facility in Hennepin 
 county licensed for 161 beds on September 30, 1996, shall have 
 the prior year's allowable care-related per diem increased by 
 $1.154 and the prior year's other operating cost per diem 
 increased by $0.256 before adding the inflation in subdivision 
 26, paragraph (d), clause (2), for the rate year beginning on 
 July 1, 1998. 

    (c) For the purpose of applying the limit stated in 
 subdivision 26, paragraph (a), a nursing facility in Ramsey 
 county licensed for 176 beds on September 30, 1996, shall have 
 the prior year's allowable care-related per diem increased by 
 $0.803 and the prior year's other operating cost per diem 
 increased by $0.272 before adding the inflation in subdivision 
 26, paragraph (d), clause (2), for the rate year beginning on 
 July 1, 1998. 

    (d) For the purpose of applying the limit stated in 
 subdivision 26, paragraph (a), a nursing facility in Brown 
 county licensed for 86 beds on September 30, 1996, shall have 
 the prior year's allowable care-related per diem increased by 
 $0.850 and the prior year's other operating cost per diem 
 increased by $0.275 before adding the inflation in subdivision 
 26, paragraph (d), clause (2), for the rate year beginning on 
 July 1, 1998. 

    (e) For the rate year beginning July 1, 1998, the 
 commissioner shall compute the payment rate for a nursing 
 facility, which was licensed for 110 beds on May 1, 1997, was 
 granted approval in January 1994 for a replacement and 
 remodeling project under the moratorium exception process in 
 section 144A.073, and completed the approved replacement and 
 remodeling project on March 14, 1997, by increasing the other 
 operatin