2005 Minnesota Statutes

     256B.0652 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.  
 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 sections 256B.0651 and 256B.0653 to 256B.0656 
 with the following exceptions: 

    (a) Upon request for home care services and subsequent 
 assessment by the public health nurse under sections 256B.0651 
 and 256B.0653 to 256B.0656, 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