2005 Minnesota Statutes

     256L.03 Covered health services. 

    Subdivision 1.    Covered health services.  For 
 individuals under section 256L.04, subdivision 7, with income no 
 greater than 75 percent of the federal poverty guidelines or for 
 families with children under section 256L.04, subdivision 1, all 
 subdivisions of this section apply.  "Covered health services" 
 means the health services reimbursed under chapter 256B, with 
 the exception of inpatient hospital services, special education 
 services, private duty nursing services, adult dental care 
 services other than services covered under section 256B.0625, 
 subdivision 9, orthodontic services, nonemergency medical 
 transportation services, personal care assistant and case 
 management services, nursing home or intermediate care 
 facilities services, inpatient mental health services, and 
 chemical dependency services.  Outpatient mental health services 
 covered under the MinnesotaCare program are limited to 
 diagnostic assessments, psychological testing, explanation of 
 findings, mental health telemedicine, psychiatric consultation, 
 medication management by a physician, day treatment, partial 
 hospitalization, and individual, family, and group psychotherapy.

    No public funds shall be used for coverage of abortion 
 under MinnesotaCare except where the life of the female would be 
 endangered or substantial and irreversible impairment of a major 
 bodily function would result if the fetus were carried to term; 
 or where the pregnancy is the result of rape or incest. 

    Covered health services shall be expanded as provided in 
 this section. 

    Subd. 1a.    Covered services for pregnant women and 
 children under MinnesotaCare health care reform waiver.  
 Beginning January 1, 1999, children and pregnant women are 
 eligible for coverage of all services that are eligible for 
 reimbursement under the medical assistance program according to 
 chapter 256B, except that abortion services under MinnesotaCare 
 shall be limited as provided under subdivision 1.  Pregnant 
 women and children are exempt from the provisions of subdivision 
 5, regarding co-payments.  Pregnant women and children who are 
 lawfully residing in the United States but who are not 
 "qualified noncitizens" under title IV of the Personal 
 Responsibility and Work Opportunity Reconciliation Act of 1996, 
 Public Law 104-193, Statutes at Large, volume 110, page 2105, 
 are eligible for coverage of all services provided under the 
 medical assistance program according to chapter 256B. 

    Subd. 1b.    Pregnant women; eligibility for full medical 
 assistance services.  A pregnant woman enrolled in 
 MinnesotaCare is eligible for coverage of all services provided 
 under the medical assistance program according to chapter 256B 
 retroactive to the date of conception.  Co-payments totaling $30 
 or more, paid after the date of conception, shall be refunded. 

    Subd. 2.    Alcohol and drug dependency.  Beginning July 
 1, 1993, covered health services shall include individual 
 outpatient treatment of alcohol or drug dependency by a 
 qualified health professional or outpatient program.  

    Persons who may need chemical dependency services under the 
 provisions of this chapter shall be assessed by a local agency 
 as defined under section 254B.01, and under the assessment 
 provisions of section 254A.03, subdivision 3.  A local agency or 
 managed care plan under contract with the Department of Human 
 Services must place a person in need of chemical dependency 
 services as provided in Minnesota Rules, parts 9530.6600 to 
 9530.6660.  Persons who are recipients of medical benefits under 
 the provisions of this chapter and who are financially eligible 
 for consolidated chemical dependency treatment fund services 
 provided under the provisions of chapter 254B shall receive 
 chemical dependency treatment services under the provisions of 
 chapter 254B only if: 

    (1) they have exhausted the chemical dependency benefits 
 offered under this chapter; or 

    (2) an assessment indicates that they need a level of care 
 not provided under the provisions of this chapter. 

    Recipients of covered health services under the children's 
 health plan, as provided in Minnesota Statutes 1990, section 
 256.936, and as amended by Laws 1991, chapter 292, article 4, 
 section 17, and recipients of covered health services enrolled 
 in the children's health plan or the MinnesotaCare program after 
 October 1, 1992, pursuant to Laws 1992, chapter 549, article 4, 
 sections 5 and 17, are eligible to receive alcohol and drug 
 dependency benefits under this subdivision. 

    Subd. 3.    Inpatient hospital services.  (a) Covered 
 health services shall include inpatient hospital services, 
 including inpatient hospital mental health services and 
 inpatient hospital and residential chemical dependency 
 treatment, subject to those limitations necessary to coordinate 
 the provision of these services with eligibility under the 
 medical assistance spenddown.  Prior to July 1, 1997, the 
 inpatient hospital benefit for adult enrollees is subject to an 
 annual benefit limit of $10,000.  The inpatient hospital benefit 
 for adult enrollees who qualify under section 256L.04, 
 subdivision 7, or who qualify under section 256L.04, 
 subdivisions 1 and 2, with family gross income that exceeds 175 
 percent of the federal poverty guidelines and who are not 
 pregnant, is subject to an annual limit of $10,000.  

    (b) Admissions for inpatient hospital services paid for 
 under section 256L.11, subdivision 3, must be certified as 
 medically necessary in accordance with Minnesota Rules, parts 
 9505.0500 to 9505.0540, except as provided in clauses (1) and 
 (2): 

    (1) all admissions must be certified, except those 
 authorized under rules established under section 254A.03, 
 subdivision 3, or approved under Medicare; and 

    (2) payment under section 256L.11, subdivision 3, shall be 
 reduced by five percent for admissions for which certification 
 is requested more than 30 days after the day of admission.  The 
 hospital may not seek payment from the enrollee for the amount 
 of the payment reduction under this clause. 

    Subd. 3a.    Interpreter services.  Covered services 
 include sign and spoken language interpreter services that 
 assist an enrollee in obtaining covered health care services. 

    Subd. 4.    Coordination with medical assistance.  The 
 commissioner shall coordinate the provision of hospital 
 inpatient services under the MinnesotaCare program with enrollee 
 eligibility under the medical assistance spenddown. 

    Subd. 5.    Co-payments and coinsurance.  (a) Except as 
 provided in paragraphs (b) and (c), the MinnesotaCare benefit 
 plan shall include the following co-payments and coinsurance 
 requirements for all enrollees:  

    (1) ten percent of the paid charges for inpatient hospital 
 services for adult enrollees, subject to an annual inpatient 
 out-of-pocket maximum of $1,000 per individual and $3,000 per 
 family; 

    (2) $3 per prescription for adult enrollees; 

    (3) $25 for eyeglasses for adult enrollees; 

    (4) $3 per nonpreventive visit.  For purposes of this 
 subdivision, a "visit" means an episode of service which is 
 required because of a recipient's symptoms, diagnosis, or 
 established illness, and which is delivered in an ambulatory 
 setting by a physician or physician ancillary, chiropractor, 
 podiatrist, nurse midwife, advanced practice nurse, audiologist, 
 optician, or optometrist; 

    (5) $6 for nonemergency visits to a hospital-based 
 emergency room; and 

    (6) 50 percent of the fee-for-service rate for adult dental 
 care services other than preventive care services for persons 
 eligible under section 256L.04, subdivisions 1 to 7, with income 
 equal to or less than 175 percent of the federal poverty 
 guidelines. 

    (b) Paragraph (a), clause (1), does not apply to parents 
 and relative caretakers of children under the age of 21 in 
 households with family income equal to or less than 175 percent 
 of the federal poverty guidelines.  Paragraph (a), clause (1), 
 does not apply to parents and relative caretakers of children 
 under the age of 21 in households with family income greater 
 than 175 percent of the federal poverty guidelines for inpatient 
 hospital admissions occurring on or after January 1, 2001.  

    (c) Paragraph (a), clauses (1) to (4), do not apply to 
 pregnant women and children under the age of 21.  

    (d) Adult enrollees with family gross income that exceeds 
 175 percent of the federal poverty guidelines and who are not 
 pregnant shall be financially responsible for the coinsurance 
 amount, if applicable, and amounts which exceed the $10,000 
 inpatient hospital benefit limit. 

    (e) When a MinnesotaCare enrollee becomes a member of a 
 prepaid health plan, or changes from one prepaid health plan to 
 another during a calendar year, any charges submitted towards 
 the $10,000 annual inpatient benefit limit, and any 
 out-of-pocket expenses incurred by the enrollee for inpatient 
 services, that were submitted or incurred prior to enrollment, 
 or prior to the change in health plans, shall be disregarded. 

    Subd. 5a. Repealed, 2002 c 220 art 15 s 27 

    Subd. 6.    Lien.  When the state agency provides, pays 
 for, or becomes liable for covered health services, the agency 
 shall have a lien for the cost of the covered health services 
 upon any and all causes of action accruing to the enrollee, or 
 to the enrollee's legal representatives, as a result of the 
 occurrence that necessitated the payment for the covered health 
 services.  All liens under this section shall be subject to the 
 provisions of section 256.015.  For purposes of this 
 subdivision, "state agency" includes prepaid health plans under 
 contract with the commissioner according to sections 256B.69, 
 256D.03, subdivision 4, paragraph (c), and 256L.12; and 
 county-based purchasing entities under section 256B.692. 

    HIST: 1986 c 444; 1992 c 549 art 4 s 4,19; 1992 c 603 s 31; 
 1993 c 247 art 4 s 2-4,11; 1993 c 345 art 9 s 3; 1993 c 366 s 
 26; 1994 c 625 art 8 s 50,51,72; 1995 c 207 art 6 s 12; 1995 c 
 234 art 6 s 4,5; 1997 c 225 art 1 s 1-3; 1998 c 407 art 5 s 
 10-16; 1999 c 245 art 4 s 89,90; 2000 c 340 s 15; 1Sp2001 c 9 
 art 2 s 60; 2002 c 379 art 1 s 113; 1Sp2003 c 14 art 12 s 71; 
 2004 c 228 art 1 s 75; 1Sp2005 c 4 art 2 s 17; art 8 s 57-59