2005 Minnesota Statutes

     256B.48 Conditions for participation. 

    Subdivision 1.    Prohibited practices.  A nursing 
 facility is not eligible to receive medical assistance payments 
 unless it refrains from all of the following: 

    (a) Charging private paying residents rates for similar 
 services which exceed those which are approved by the state 
 agency for medical assistance recipients as determined by the 
 prospective desk audit rate, except under the following 
 circumstances:  the nursing facility may (1) charge private 
 paying residents a higher rate for a private room, and (2) 
 charge for special services which are not included in the daily 
 rate if medical assistance residents are charged separately at 
 the same rate for the same services in addition to the daily 
 rate paid by the commissioner.  Services covered by the payment 
 rate must be the same regardless of payment source.  Special 
 services, if offered, must be available to all residents in all 
 areas of the nursing facility and charged separately at the same 
 rate.  Residents are free to select or decline special 
 services.  Special services must not include services which must 
 be provided by the nursing facility in order to comply with 
 licensure or certification standards and that if not provided 
 would result in a deficiency or violation by the nursing 
 facility.  Services beyond those required to comply with 
 licensure or certification standards must not be charged 
 separately as a special service if they were included in the 
 payment rate for the previous reporting year.  A nursing 
 facility that charges a private paying resident a rate in 
 violation of this clause is subject to an action by the state of 
 Minnesota or any of its subdivisions or agencies for civil 
 damages.  A private paying resident or the resident's legal 
 representative has a cause of action for civil damages against a 
 nursing facility that charges the resident rates in violation of 
 this clause.  The damages awarded shall include three times the 
 payments that result from the violation, together with costs and 
 disbursements, including reasonable attorneys' fees or their 
 equivalent.  A private paying resident or the resident's legal 
 representative, the state, subdivision or agency, or a nursing 
 facility may request a hearing to determine the allowed rate or 
 rates at issue in the cause of action.  Within 15 calendar days 
 after receiving a request for such a hearing, the commissioner 
 shall request assignment of an administrative law judge under 
 sections 14.48 to 14.56 to conduct the hearing as soon as 
 possible or according to agreement by the parties.  The 
 administrative law judge shall issue a report within 15 calendar 
 days following the close of the hearing.  The prohibition set 
 forth in this clause shall not apply to facilities licensed as 
 boarding care facilities which are not certified as skilled or 
 intermediate care facilities level I or II for reimbursement 
 through medical assistance. 

    (b)(1) Charging, soliciting, accepting, or receiving from 
 an applicant for admission to the facility, or from anyone 
 acting in behalf of the applicant, as a condition of admission, 
 expediting the admission, or as a requirement for the 
 individual's continued stay, any fee, deposit, gift, money, 
 donation, or other consideration not otherwise required as 
 payment under the state plan; 

    (2) requiring an individual, or anyone acting in behalf of 
 the individual, to loan any money to the nursing facility; 

    (3) requiring an individual, or anyone acting in behalf of 
 the individual, to promise to leave all or part of the 
 individual's estate to the facility; or 

    (4) requiring a third-party guarantee of payment to the 
 facility as a condition of admission, expedited admission, or 
 continued stay in the facility.  

 Nothing in this paragraph would prohibit discharge for 
 nonpayment of services in accordance with state and federal 
 regulations. 

    (c) Requiring any resident of the nursing facility to 
 utilize a vendor of health care services chosen by the nursing 
 facility.  A nursing facility may require a resident to use 
 pharmacies that utilize unit dose packing systems approved by 
 the Minnesota Board of Pharmacy, and may require a resident to 
 use pharmacies that are able to meet the federal regulations for 
 safe and timely administration of medications such as systems 
 with specific number of doses, prompt delivery of medications, 
 or access to medications on a 24-hour basis.  Notwithstanding 
 the provisions of this paragraph, nursing facilities shall not 
 restrict a resident's choice of pharmacy because the pharmacy 
 utilizes a specific system of unit dose drug packing. 

    (d) Providing differential treatment on the basis of status 
 with regard to public assistance.  

    (e) Discriminating in admissions, services offered, or room 
 assignment on the basis of status with regard to public 
 assistance or refusal to purchase special services.  Admissions 
 discrimination shall include, but is not limited to:  

    (1) basing admissions decisions upon assurance by the 
 applicant to the nursing facility, or the applicant's guardian 
 or conservator, that the applicant is neither eligible for nor 
 will seek public assistance for payment of nursing facility care 
 costs; and 

    (2) engaging in preferential selection from waiting lists 
 based on an applicant's ability to pay privately or an 
 applicant's refusal to pay for a special service. 

    The collection and use by a nursing facility of financial 
 information of any applicant pursuant to a preadmission 
 screening program established by law shall not raise an 
 inference that the nursing facility is utilizing that 
 information for any purpose prohibited by this paragraph.  

    (f) Requiring any vendor of medical care as defined by 
 section 256B.02, subdivision 7, who is reimbursed by medical 
 assistance under a separate fee schedule, to pay any amount 
 based on utilization or service levels or any portion of the 
 vendor's fee to the nursing facility except as payment for 
 renting or leasing space or equipment or purchasing support 
 services from the nursing facility as limited by section 
 256B.433.  All agreements must be disclosed to the commissioner 
 upon request of the commissioner.  Nursing facilities and 
 vendors of ancillary services that are found to be in violation 
 of this provision shall each be subject to an action by the 
 state of Minnesota or any of its subdivisions or agencies for 
 treble civil damages on the portion of the fee in excess of that 
 allowed by this provision and section 256B.433.  Damages awarded 
 must include three times the excess payments together with costs 
 and disbursements including reasonable attorney's fees or their 
 equivalent.  

    (g) Refusing, for more than 24 hours, to accept a resident 
 returning to the same bed or a bed certified for the same level 
 of care, in accordance with a physician's order authorizing 
 transfer, after receiving inpatient hospital services. 

    For a period not to exceed 180 days, the commissioner may 
 continue to make medical assistance payments to a nursing 
 facility or boarding care home which is in violation of this 
 section if extreme hardship to the residents would result.  In 
 these cases the commissioner shall issue an order requiring the 
 nursing facility to correct the violation.  The nursing facility 
 shall have 20 days from its receipt of the order to correct the 
 violation.  If the violation is not corrected within the 20-day 
 period the commissioner may reduce the payment rate to the 
 nursing facility by up to 20 percent.  The amount of the payment 
 rate reduction shall be related to the severity of the violation 
 and shall remain in effect until the violation is corrected.  
 The nursing facility or boarding care home may appeal the 
 commissioner's action pursuant to the provisions of chapter 14 
 pertaining to contested cases.  An appeal shall be considered 
 timely if written notice of appeal is received by the 
 commissioner within 20 days of notice of the commissioner's 
 proposed action.  

    In the event that the commissioner determines that a 
 nursing facility is not eligible for reimbursement for a 
 resident who is eligible for medical assistance, the 
 commissioner may authorize the nursing facility to receive 
 reimbursement on a temporary basis until the resident can be 
 relocated to a participating nursing facility.  

    Certified beds in facilities which do not allow medical 
 assistance intake on July 1, 1984, or after shall be deemed to 
 be decertified for purposes of section 144A.071 only.  

    Subd. 1a.    Termination.  If a nursing facility 
 terminates its participation in the medical assistance program, 
 whether voluntarily or involuntarily, the commissioner may 
 authorize the nursing facility to receive continued medical 
 assistance reimbursement until medical assistance residents can 
 be relocated to nursing facilities participating in the medical 
 assistance program. 

    Subd. 1b.    Exception.  Notwithstanding any agreement 
 between a nursing facility and the Department of Human Services 
 or the provisions of this section or section 256B.411, other 
 than subdivision 1a, the commissioner may authorize continued 
 medical assistance payments to a nursing facility which ceased 
 intake of medical assistance recipients prior to July 1, 1983, 
 and which charges private paying residents rates that exceed 
 those permitted by subdivision 1, paragraph (a), for (i) 
 residents who resided in the nursing facility before July 1, 
 1983, or (ii)  residents for whom the commissioner or any 
 predecessors of the commissioner granted a permanent individual 
 waiver prior to October 1, 1983.  Nursing facilities seeking 
 continued medical assistance payments under this subdivision 
 shall make the reports required under subdivision 2, except that 
 on or after December 31, 1985, the financial statements required 
 need not be audited by or contain the opinion of a certified 
 public accountant or licensed public accountant, but need only 
 be reviewed by a certified public accountant or licensed public 
 accountant.  In the event that the state is determined by the 
 federal government to be no longer eligible for the federal 
 share of medical assistance payments made to a nursing facility 
 under this subdivision, the commissioner may cease medical 
 assistance payments, under this subdivision, to that nursing 
 facility.  

    Subd. 1c.    Case mix rate for provider with addendum to 
 provider agreement.  A nursing facility with an addendum to 
 its provider agreement effective beginning July 1, 1983, or 
 September 24, 1985, shall have its payment rates established by 
 the commissioner under this subdivision.  To save medical 
 assistance resources, for rate years beginning after July 1, 
 1991, the provider's payment rates shall be the payment rates 
 established by the commissioner July 1, 1990, multiplied by a 
 12-month inflation factor based on the forecasted inflation 
 between the midpoints of rate years using the inflation index 
 applied by the commissioner to other nursing facilities. 

    The provider and the Department of Health shall complete 
 case mix assessments under Minnesota Rules, chapter 4656, and 
 parts 9549.0058 and 9549.0059, on only those residents receiving 
 medical assistance.  The commissioner of health may audit and 
 verify the limited provider assessments at any time. 

    Subd. 2.    Reporting requirements.  No later than 
 December 31 of each year, a skilled nursing facility or 
 intermediate care facility, including boarding care facilities, 
 which receives medical assistance payments or other 
 reimbursements from the state agency shall:  

    (a) Provide the state agency with a copy of its audited 
 financial statements.  The audited financial statements must 
 include a balance sheet, income statement, statement of the rate 
 or rates charged to private paying residents, statement of 
 retained earnings, statement of cash flows, notes to the 
 financial statements, audited applicable supplemental 
 information, and the certified public accountant's or licensed 
 public accountant's opinion.  The examination by the certified 
 public accountant or licensed public accountant shall be 
 conducted in accordance with generally accepted auditing 
 standards as promulgated and adopted by the American Institute 
 of Certified Public Accountants.  Beginning with the reporting 
 year which begins October 1, 1992, a nursing facility is no 
 longer required to have a certified audit of its financial 
 statements.  The cost of a certified audit shall not be an 
 allowable cost in that reporting year, nor in subsequent 
 reporting years unless the nursing facility submits its 
 certified audited financial statements in the manner otherwise 
 specified in this subdivision.  A nursing facility which does 
 not submit a certified audit must submit its working trial 
 balance; 

    (b) Provide the state agency with a statement of ownership 
 for the facility; 

    (c) Provide the state agency with separate, audited 
 financial statements as specified in clause (a) for every other 
 facility owned in whole or part by an individual or entity which 
 has an ownership interest in the facility; 

    (d) Upon request, provide the state agency with separate, 
 audited financial statements as specified in clause (a) for 
 every organization with which the facility conducts business and 
 which is owned in whole or in part by an individual or entity 
 which has an ownership interest in the facility; 

    (e) Provide the state agency with copies of leases, 
 purchase agreements, and other documents related to the lease or 
 purchase of the nursing facility; 

    (f) Upon request, provide the state agency with copies of 
 leases, purchase agreements, and other documents related to the 
 acquisition of equipment, goods, and services which are claimed 
 as allowable costs; and 

    (g) Permit access by the state agency to the certified 
 public accountant's and licensed public accountant's audit 
 workpapers which support the audited financial statements 
 required in clauses (a), (c), and (d).  

    Documents or information provided to the state agency 
 pursuant to this subdivision shall be public.  If the 
 requirements of clauses (a) to (g) are not met, the 
 reimbursement rate may be reduced to 80 percent of the rate in 
 effect on the first day of the fourth calendar month after the 
 close of the reporting year, and the reduction shall continue 
 until the requirements are met.  

    Both nursing facilities and intermediate care facilities 
 for the mentally retarded must maintain statistical and 
 accounting records in sufficient detail to support information 
 contained in the facility's cost report for at least six years, 
 including the year following the submission of the cost report.  
 For computerized accounting systems, the records must include 
 copies of electronically generated media such as magnetic discs 
 and tapes. 

    Subd. 3.    Incomplete or inaccurate reports.  The 
 commissioner may reject any annual cost report filed by a 
 nursing facility pursuant to this chapter if the commissioner 
 determines that the report or the information required in 
 subdivision 2, clause (a) has been filed in a form that is 
 incomplete or inaccurate.  In the event that a report is 
 rejected pursuant to this subdivision, the commissioner shall 
 reduce the reimbursement rate to a nursing facility to 80 
 percent of its most recently established rate until the 
 information is completely and accurately filed.  The 
 reinstatement of the total reimbursement rate is retroactive. 

    Subd. 3a.    Audit adjustments.  If the commissioner 
 requests supporting documentation during an audit for an item of 
 cost reported by a long-term care facility, and the long-term 
 care facility's response does not adequately document the item 
 of cost, the commissioner may make reasoned assumptions 
 considered appropriate in the absence of the requested 
 documentation to reasonably establish a payment rate rather than 
 disallow the entire item of cost.  This provision shall not 
 diminish the long-term care facility's appeal rights. 

    Subd. 4.    Extensions.  The commissioner may grant up 
 to a 15-day extension of the reporting deadline to a nursing 
 facility for good cause.  To receive such an extension, a 
 nursing facility shall submit a written request by December 1.  
 The commissioner will notify the nursing facility of the 
 decision by December 15.  Between December 1 and December 31, 
 the nursing facility may request a reporting extension for good 
 cause by telephone and followed by a written request. 

    Subd. 5.    False reports.  If a nursing facility 
 knowingly supplies inaccurate or false information in a required 
 report that results in an overpayment, the commissioner shall: 

    (a) immediately adjust the nursing facility's payment rate 
 to recover the entire overpayment within the rate year; or 

    (b) terminate the commissioner's agreement with the nursing 
 facility; or 

    (c) prosecute under applicable state or federal law; or 

    (d) use any combination of the foregoing actions.  

    Subd. 6.    Medicare certification.  (a)    Definition. 
  For purposes of this subdivision, "nursing facility" means a 
 nursing facility that is certified as a skilled nursing facility 
 or, after September 30, 1990, a nursing facility licensed under 
 chapter 144A that is certified as a nursing facility.  

    (b)    Medicare participation required.  All nursing 
 facilities shall participate in Medicare Part A and Part B 
 unless, after submitting an application, Medicare certification 
 is denied by the federal Centers for Medicare and Medicaid 
 Services.  Medicare review shall be conducted at the time of the 
 annual medical assistance review.  Charges for Medicare-covered 
 services provided to residents who are simultaneously eligible 
 for medical assistance and Medicare must be billed to Medicare 
 Part A or Part B before billing medical assistance.  Medical 
 assistance may be billed only for charges not reimbursed by 
 Medicare.  

    (c)    After September 30, 1990.  After September 30, 
 1990, a nursing facility satisfies the requirements of paragraph 
 (b) if at least 50 percent of the facility's beds certified as 
 nursing facility beds under the medical assistance program are 
 Medicare certified. 

    (d)    Conflict with Medicare distinct part requirements. 
  At the request of a facility, the commissioner of human 
 services may reduce the 50 percent Medicare participation 
 requirement in paragraph (c) to no less than 20 percent if the 
 commissioner of health determines that, due to the facility's 
 physical plant configuration, the facility cannot satisfy 
 Medicare distinct part requirements at the 50 percent 
 certification level.  To receive a reduction in the 
 participation requirement, a facility must demonstrate that the 
 reduction will not adversely affect access of Medicare-eligible 
 residents to Medicare-certified beds. 

    (e)    Institutions for mental disease.  The 
 commissioner may grant exceptions to the requirements of 
 paragraph (b) for nursing facilities that are designated as 
 institutions for mental disease. 

    (f)    Notice of rights.  The commissioner shall inform 
 recipients of their rights under this subdivision and section 
 144.651, subdivision 29. 

    Subd. 7.    Refund of excess charges.  Any nursing 
 facility which has charged a resident a rate for a case-mix 
 classification upon admission which is in excess of the rate for 
 the case-mix classification established by the commissioner of 
 health and effective on the date of admission, must refund the 
 amount of charge in excess of the rate for the case-mix 
 classification established by the commissioner of health and 
 effective on the date of admission.  Refunds must be credited to 
 the next monthly billing or refunded within 15 days of receipt 
 of the classification notice from the Department of Health.  
 Failure to refund the excess charge shall be considered to be a 
 violation of this section. 

    Subd. 8.    Notification to a spouse.  When a private 
 pay resident who has not yet been screened by the preadmission 
 screening team is admitted to a nursing facility or boarding 
 care facility, the nursing facility or boarding care facility 
 must notify the resident and the resident's spouse of the 
 following:  

    (1) their right to retain certain resources under sections 
 256B.0575, 256B.058, 256B.059, 256B.0595, and 256B.14, 
 subdivision 2; and 

    (2) that the federal Medicare hospital insurance benefits 
 program covers posthospital extended care services in a 
 qualified skilled nursing facility for up to 150 days and that 
 there are several limitations on this benefit.  The resident and 
 the resident's family must be informed about all mechanisms to 
 appeal limitations imposed under this federal benefit program.  

    This notice may be included in the nursing facility's or 
 boarding care facility's admission agreement and must clearly 
 explain what resources the resident and spouse may retain if the 
 resident applies for medical assistance.  The Department of 
 Human Services must notify nursing facilities and boarding care 
 facilities of changes in the determination of medical assistance 
 eligibility that relate to resources retained by a resident and 
 the resident's spouse. 

    The preadmission screening team has primary responsibility 
 for informing all private pay applicants to a nursing facility 
 or boarding care facility of the resources the resident and 
 spouse may retain. 

    Subd. 9. Repealed, 2000 c 449 s 15 

    HIST: 1976 c 282 s 8; 1977 c 309 s 1; 1977 c 326 s 17; 1978 c 
 674 s 28; 1983 c 199 s 14; 1984 c 640 s 32; 1984 c 641 s 23; 
 1Sp1985 c 3 s 31; 1Sp1985 c 9 art 2 s 50-52; 1986 c 420 s 11,12; 
 1986 c 444; 1987 c 364 s 1; 1987 c 403 art 2 s 94; 1989 c 282 
 art 3 s 80-82; 1990 c 568 art 3 s 74,75; 1990 c 599 s 2; 1991 c 
 199 art 2 s 1; 1991 c 292 art 7 s 6; 1992 c 513 art 7 s 
 108-113,136; 1993 c 339 s 21; 1Sp1993 c 1 art 5 s 103,104; 1999 
 c 245 art 3 s 26-29; art 4 s 67; 2002 c 277 s 32