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Minnesota Legislature

Office of the Revisor of Statutes

CHAPTER 256B. MEDICAL ASSISTANCE FOR NEEDY PERSONS

Table of Sections
SectionHeadnote
256B.001APPLICATION OF LAWS 2005, CHAPTER 56, TERMINOLOGY CHANGES.
256B.01POLICY.
256B.011POLICY FOR CHILDBIRTH AND ABORTION FUNDING.
256B.0185REQUIRED REPORT.
256B.02DEFINITIONS.
256B.03PAYMENTS TO VENDORS.
256B.031PREPAID HEALTH PLANS.
256B.035MANAGED CARE.
256B.037PROSPECTIVE PAYMENT OF DENTAL SERVICES.
256B.038PROVIDER RATE INCREASES AFTER JUNE 30, 1999.
256B.039REPORTING OF SUPPLEMENTAL NURSING SERVICES AGENCY USE.
256B.04DUTIES OF STATE AGENCY.
256B.041CENTRALIZED DISBURSEMENT OF MEDICAL ASSISTANCE PAYMENTS.
256B.042THIRD PARTY LIABILITY.
256B.043256B.043 COST-CONTAINMENT EFFORTS.
256B.05ADMINISTRATION BY COUNTY AGENCIES.
256B.055ELIGIBILITY CATEGORIES.
256B.056ELIGIBILITY REQUIREMENTS FOR MEDICAL ASSISTANCE.
256B.057ELIGIBILITY REQUIREMENTS FOR SPECIAL CATEGORIES.
256B.0571LONG-TERM CARE PARTNERSHIP PROGRAM.
256B.0575AVAILABILITY OF INCOME FOR INSTITUTIONALIZED PERSONS.
256B.058TREATMENT OF INCOME OF INSTITUTIONALIZED SPOUSE.
256B.059TREATMENT OF ASSETS WHEN A SPOUSE IS INSTITUTIONALIZED.
256B.0594256B.0594 PAYMENT OF BENEFITS FROM AN ANNUITY.
256B.0595PROHIBITIONS ON TRANSFER; EXCEPTIONS.
256B.0596MENTAL HEALTH CASE MANAGEMENT.
256B.06ELIGIBILITY; MIGRANT WORKERS; CITIZENSHIP.
256B.061ELIGIBILITY; RETROACTIVE EFFECT; RESTRICTIONS.
256B.062Repealed, 1998 c 407 art 6 s 12,118
256B.0621COVERED SERVICES: TARGETED CASE MANAGEMENT SERVICES.
256B.0622INTENSIVE REHABILITATIVE MENTAL HEALTH SERVICES.
256B.0623ADULT REHABILITATIVE MENTAL HEALTH SERVICES COVERED.
256B.0624ADULT CRISIS RESPONSE SERVICES COVERED.
256B.0625COVERED SERVICES.
256B.0626ESTIMATION OF 50TH PERCENTILE OF PREVAILING CHARGES.
256B.0627
256B.0628Renumbered 256B.0652
256B.0629
256B.063COST SHARING.
256B.0631MEDICAL ASSISTANCE CO-PAYMENTS.
256B.0635CONTINUED ELIGIBILITY IN SPECIAL CIRCUMSTANCES.
256B.0637PRESUMPTIVE ELIGIBILITY; TREATMENT FOR BREAST OR CERVICAL CANCER.
256B.064SANCTIONS; MONETARY RECOVERY.
256B.0641RECOVERY OF OVERPAYMENTS.
256B.0642FEDERAL FINANCIAL PARTICIPATION.
256B.0643VENDOR REQUEST FOR CONTESTED CASE PROCEEDING.
256B.0644REIMBURSEMENT UNDER OTHER STATE HEALTH CARE PROGRAMS.
256B.0645PROVIDER PAYMENTS; RETROACTIVE CHANGES IN ELIGIBILITY.
256B.065SOCIAL SECURITY AMENDMENTS.
256B.0651HOME CARE SERVICES.
256B.0652PRIOR AUTHORIZATION AND REVIEW OF HOME CARE SERVICES.
256B.0653HOME HEALTH AGENCY SERVICES.
256B.0654PRIVATE DUTY NURSING.
256B.0655PERSONAL CARE ASSISTANT SERVICES.
256B.0656CONSUMER DIRECTED HOME CARE PROJECT.
256B.07Repealed, 1987 c 403 art 2 s 164
256B.071MEDICARE MAXIMIZATION PROGRAM.
256B.072PERFORMANCE REPORTING AND QUALITY IMPROVEMENT SYSTEM.
256B.075DISEASE MANAGEMENT PROGRAMS.
256B.08APPLICATION.
256B.09INVESTIGATIONS.
256B.091Repealed, 1991 c 292 art 7 s 26
256B.0911LONG-TERM CARE CONSULTATION SERVICES.
256B.0912Repealed, 1Sp2001 c 9 art 3 s 76
256B.0913ALTERNATIVE CARE PROGRAM.
256B.0914CONFLICTS OF INTEREST RELATED TO MEDICAID EXPENDITURES.
256B.0915MEDICAID WAIVER FOR ELDERLY SERVICES.
256B.0916EXPANSION OF HOME AND COMMUNITY-BASED SERVICES.
256B.0917SENIORS' AGENDA FOR INDEPENDENT LIVING (SAIL) PROJECTS.
256B.0918EMPLOYEE SCHOLARSHIP COSTS.
256B.0919ADULT FOSTER CARE AND FAMILY ADULT DAY CARE.
256B.092SERVICES FOR PERSONS WITH DEVELOPMENTAL DISABILITIES.
256B.0924TARGETED CASE MANAGEMENT SERVICES.
256B.0925Repealed, 1995 c 186 s 51
256B.0926ADMISSION REVIEW TEAM; INTERMEDIATE CARE FACILITIES.
256B.0928STATEWIDE CAREGIVER SUPPORT AND RESPITE CARE PROJECT.
256B.093SERVICES FOR PERSONS WITH TRAUMATIC BRAIN INJURIES.
256B.094CHILD WELFARE TARGETED CASE MANAGEMENT SERVICES.
256B.0943CHILDREN'S THERAPEUTIC SERVICES AND SUPPORTS.
256B.0944CHILDREN'S MENTAL HEALTH CRISIS RESPONSE SERVICES.
256B.0945SERVICES FOR CHILDREN WITH SEVERE EMOTIONAL DISTURBANCE.
256B.0946TREATMENT FOSTER CARE.
256B.0947INTENSIVE REHABILITATIVE MENTAL HEALTH SERVICES.

QUALITY ASSURANCE

256B.095QUALITY ASSURANCE SYSTEM ESTABLISHED.
256B.0951QUALITY ASSURANCE COMMISSION.
256B.0952COUNTY DUTIES; QUALITY ASSURANCE TEAMS.
256B.0953QUALITY ASSURANCE PROCESS.
256B.0954CERTAIN PERSONS DEFINED AS MANDATED REPORTERS.
256B.0955DUTIES OF THE COMMISSIONER OF HUMAN SERVICES.
256B.10Repealed, 1976 c 131 s 2
256B.11Repealed, 1976 c 131 s 2
256B.12LEGAL REPRESENTATION.
256B.121TREBLE DAMAGES.
256B.13SUBPOENAS.
256B.14RELATIVE'S RESPONSIBILITY.
256B.15CLAIMS AGAINST ESTATES.
256B.16Repealed, 1971 c 550 s 2
256B.17TRANSFERS OF PROPERTY.
256B.18METHODS OF ADMINISTRATION.
256B.19DIVISION OF COST.
256B.195INTERGOVERNMENTAL TRANSFERS; HOSPITAL PAYMENTS.
256B.199PAYMENTS REPORTED BY GOVERNMENTAL ENTITIES.
256B.20COUNTY APPROPRIATIONS.
256B.21CHANGE OF RESIDENCE.
256B.22COMPLIANCE WITH SOCIAL SECURITY ACT.
256B.23USE OF FEDERAL FUNDS.
256B.24PROHIBITIONS.
256B.25PAYMENTS TO CERTIFIED FACILITIES.
256B.26AGREEMENTS WITH OTHER STATE DEPARTMENTS.
256B.27MEDICAL ASSISTANCE; COST REPORTS.
256B.30HEALTH CARE FACILITY REPORT.
256B.31CONTINUED HOSPITAL CARE FOR LONG-TERM POLIO PATIENT.
256B.32FACILITY FEE PAYMENT.
256B.35PERSONAL NEEDS ALLOWANCE; PERSONS IN CERTAIN FACILITIES.
256B.36SPECIAL PERSONAL ALLOWANCE FOR CERTAIN INDIVIDUALS.
256B.37PRIVATE INSURANCE POLICIES, CAUSES OF ACTION.
256B.39AVOIDANCE OF DUPLICATE PAYMENTS.
256B.40SUBSIDY FOR ABORTIONS PROHIBITED.

NURSING FACILITY RATES

256B.41INTENT.
256B.411COMPLIANCE WITH STATE STATUTES.
256B.42Repealed, 1983 c 199 s 19
256B.421DEFINITIONS.
256B.43Repealed, 1983 c 199 s 19
256B.431RATE DETERMINATION.
256B.432LONG-TERM CARE FACILITIES; OFFICE COSTS.
256B.433ANCILLARY SERVICES.
256B.434ALTERNATIVE PAYMENT DEMONSTRATION PROJECT.
256B.435JULY 1, 2001, NURSING FACILITY REIMBURSEMENT SYSTEM.
256B.436VOLUNTARY CLOSURES; PLANNING.
256B.437NURSING FACILITY VOLUNTARY CLOSURE; ALTERNATIVES.
256B.438IMPLEMENTATION OF A CASE MIX SYSTEM.
256B.439LONG-TERM CARE QUALITY PROFILES.
256B.44
256B.440RECOMMENDATION FOR A NEW REIMBURSEMENT SYSTEM.
256B.441VALUE-BASED NURSING FACILITY REIMBURSEMENT SYSTEM.
256B.45Repealed, 1983 c 199 s 19
256B.46Repealed, 1983 c 199 s 19
256B.47NONALLOWABLE COSTS; NOTICE OF INCREASES.
256B.48CONDITIONS FOR PARTICIPATION.
256B.49HOME AND COMMUNITY-BASED SERVICE WAIVERS FOR DISABLED.
256B.491WAIVERED SERVICES.
256B.495NURSING FACILITY RECEIVERSHIP FEES.
256B.50APPEALS.
256B.501RATES FOR COMMUNITY-BASED SERVICES FOR DISABLED.
256B.5011ICF/MR REIMBURSEMENT SYSTEM EFFECTIVE OCTOBER 1, 2000.
256B.5012ICF/MR PAYMENT SYSTEM IMPLEMENTATION.
256B.5013PAYMENT RATE ADJUSTMENTS.
256B.5014FINANCIAL REPORTING.
256B.5015PASS-THROUGH OF OTHER SERVICES COSTS.
256B.5016ICF/MR MANAGED CARE OPTION.
256B.502RULES.
256B.503RULES.
256B.504Repealed, 1995 c 248 art 2 s 8
256B.51NURSING HOMES; COST OF HOME CARE.

DENTAL ACCESS GRANTS

256B.53DENTAL ACCESS GRANTS.
256B.55DENTAL ACCESS ADVISORY COMMITTEE.
256B.56Repealed, 1996 c 310 s 1
256B.57Repealed, 1996 c 310 s 1
256B.58Repealed, 1996 c 310 s 1
256B.59Repealed, 1996 c 310 s 1
256B.60Repealed, 1996 c 310 s 1
256B.61Repealed, 1996 c 310 s 1
256B.62Repealed, 1996 c 310 s 1
256B.63Repealed, 1996 c 310 s 1
256B.64ATTENDANTS TO VENTILATOR-DEPENDENT RECIPIENTS.
256B.69PREPAYMENT DEMONSTRATION PROJECT.
256B.691RISK-BASED TRANSPORTATION PAYMENTS.
256B.692COUNTY-BASED PURCHASING.
256B.693STATE-OPERATED SERVICES; MANAGED CARE.
256B.70DEMONSTRATION PROJECT WAIVER.
256B.71SOCIAL HEALTH MAINTENANCE ORGANIZATION DEMONSTRATION.
256B.72RIGHT OF APPEAL.
256B.73DEMONSTRATION PROJECT FOR UNINSURED LOW-INCOME PERSONS.
256B.74SPECIAL PAYMENTS.
256B.75HOSPITAL OUTPATIENT REIMBURSEMENT.
256B.76PHYSICIAN AND DENTAL REIMBURSEMENT.
256B.761REIMBURSEMENT FOR MENTAL HEALTH SERVICES.
256B.762REIMBURSEMENT FOR HEALTH CARE SERVICES.
256B.763256B.763 CRITICAL ACCESS MENTAL HEALTH RATE INCREASE.
256B.765PROVIDER RATE INCREASES.
256B.77COORDINATED SERVICE DELIVERY SYSTEM FOR DISABLED.
256B.78DEMONSTRATION PROJECT FOR FAMILY PLANNING SERVICES.
256B.81MENTAL HEALTH PROVIDER APPEAL PROCESS.
256B.82PREPAID PLANS AND MENTAL HEALTH REHABILITATIVE SERVICES.
256B.83Repealed, 2006 c 282 art 16 s 17
256B.84AMERICAN INDIAN CONTRACTING PROVISIONS.
256B.001 APPLICATION OF LAWS 2005, CHAPTER 56, TERMINOLOGY CHANGES.
State agencies shall use the terminology changes specified in Laws 2005, chapter 56, section
1, when printed material and signage are replaced and new printed material and signage are
obtained. State agencies do not have to replace existing printed material and signage to comply
with Laws 2005, chapter 56, sections 1 and 2. Language changes made according to Laws 2005,
chapter 56, sections 1 and 2, shall not expand or exclude eligibility to services.
History: 2005 c 56 s 3
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.
History: 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.
History: 1978 c 508 s 1
256B.0185 REQUIRED REPORT.
    Subdivision 1. Pending application. By December 15 of both 2005 and 2006, the
commissioner must deliver to the legislature a report that identifies:
(1) each county in which an application for medical assistance from a person identified
as residing in a long-term care facility is or was pending, at any time between January 1 and
December 1 of the calendar year to which the report relates, for more than 60 days in the case of a
person who is disabled, or for more than 45 days in the case of a person who is age 65 or older; and
(2) for each of the identified counties: the number of applications described in clause (1), the
average number of days the applications were pending, the distribution of days for applications
that were pending, and what percentage of the applications, respectively, the county approved
and denied.
    Subd. 2. Time to process application. The report must include specific recommendations
for how counties, as a group, could shorten the time it takes to act on the applications described in
subdivision 1, clause (1).
History: 1Sp2005 c 4 art 7 s 3
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. "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. "State agency" means the commissioner of human services.
    Subd. 6. County agency. "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, ambulatory surgical center services, 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. "Private health care coverage" means any plan
regulated by chapter 62A, 62C or 64B. Private health care coverage also includes any self-insured
plan providing health care benefits, pharmacy benefit manager, service benefit plan, managed
care organization, and other parties that are by contract legally responsible for payment of a
claim for a health care item or service for an individual receiving medical benefits under chapter
256B, 256D, or 256L.
    Subd. 10. Automobile accident coverage. "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. "Related condition" means that condition defined in section
252.27, subdivision 1a.
    Subd. 12. Third-party payer. "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. Third-party payer includes an entity under contract with the
recipient to cover all or part of the recipient's medical costs.
    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.
History: 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; 2004 c 198 s 17; 1Sp2005 c 4 art 8 s 17; 2006 c 282 art 17 s 24
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 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.
History: 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 chapter 518A, 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. Reimbursement limitation; providers not with 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.
History: 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;
2005 c 164 s 29; 1Sp2005 c 7 s 28
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.
History: 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 co-payments 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.
History: 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 developmental disabilities 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 developmental disabilities 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.
History: 1998 c 407 art 4 s 12; 2005 c 56 s 1
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.
History: 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. 4a. Medicare prescription drug subsidy. The commissioner shall perform all duties
necessary to administer eligibility determinations for the Medicare Part D prescription drug
subsidy and facilitate the enrollment of eligible medical assistance recipients into Medicare
prescription drug plans as required by the Medicare Prescription Drug, Improvement, and
Modernization Act of 2003 (MMA), Public Law 108-173, and Code of Federal Regulations, title
42, sections 423.30 to 423.56 and 423.771 to 423.800.
    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 disabled 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. (a) 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:
(i) hospital beds;
(ii) commodes;
(iii) glide-about chairs;
(iv) patient lift apparatus;
(v) wheelchairs and accessories;
(vi) oxygen administration equipment;
(vii) respiratory therapy equipment;
(viii) electronic diagnostic, therapeutic and life support systems;
(5) special transportation services; and
(6) drugs.
(b) Rate changes under this chapter and chapters 256D and 256L do not affect contract
payments under this subdivision unless specifically identified.
    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 Minnesota Statutes 1992, 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.
History: 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; 2005 c 56 s 1; 2005 c
98 art 2 s 1; 1Sp2005 c 4 art 8 s 18
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 commissioner of finance. If required by federal law or
rules promulgated thereunder, or by authorized rule of the state agency, each county shall pay
to the commissioner of finance 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.
History: 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; 2003 c 112 art 2 s 50
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 (c), 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 (c), 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.
History: 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; 2004 c 228 art 1 s 75
256B.043 COST-CONTAINMENT EFFORTS.
    Subdivision 1. Alternative and complementary health care. The commissioner of human
services, through the medical director and in consultation with the Health Services Policy
Committee established under section 256B.0625, subdivision 3c, as part of the commissioner's
ongoing duties, shall consider the potential for improving quality and obtaining cost savings
through greater use of alternative and complementary treatment methods and clinical practice;
shall incorporate these methods into the medical assistance, MinnesotaCare, and general
assistance medical care programs; and shall make related legislative recommendations as
appropriate. The commissioner shall post the recommendations required under this subdivision on
agency Web sites according to section 144.0506, subdivision 1.
    Subd. 2. Access to care. (a) The commissioners of human services and health, as part of
their ongoing duties, shall consider the adequacy of the current system of community health
clinics and centers both statewide and in urban areas with significant disparities in health status
and access to services across racial and ethnic groups, including:
(1) methods to provide 24-hour availability of care through the clinics and centers;
(2) methods to expand the availability of care through the clinics and centers;
(3) the use of grants to expand the number of clinics and centers, the services provided, and
the availability of care; and
(4) the extent to which increased use of physician assistants, nurse practitioners, medical
residents and interns, and other allied health professionals in clinics and centers would increase
the availability of services.
(b) The commissioners shall make departmental modifications and legislative
recommendations as appropriate on the basis of their considerations under paragraph (a).
History: 2006 c 267 art 1 s 9
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]
History: 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 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 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 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 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.[Repealed, 1Sp2003 c 14 art 12 s 101]
    Subd. 10b. Children. This subdivision supersedes subdivision 10 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. Medical
assistance may be paid for a child less than two years of age with countable family income as
established for infants 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 developmental disabilities, 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.0655, subdivision 4, clause (3), adjusted to address age-appropriate standards
for children age 18 and under, pursuant to section 256B.0655, subdivision 3.
(d) For purposes of this subdivision, "intermediate care facility for persons with
developmental disabilities" or "ICF/MR" means a program licensed to provide services to
persons with developmental disabilities 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
developmental disabilities 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 a developmental disability
in accordance with section 256B.092, is in need of a 24-hour plan of care and active treatment
similar to persons with developmental disabilities, 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 ICF's/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.
    Subd. 13. Residents of institutions for mental diseases. Beginning October 1, 2003,
persons who would be eligible for medical assistance under this chapter but for residing in a
facility that is determined by the commissioner or the federal Centers for Medicare and Medicaid
Services to be an institution for mental diseases are eligible for medical assistance without federal
financial participation, except that coverage shall not include payment for a nursing facility
determined to be an institution for mental diseases.
    Subd. 14. Persons detained by law. (a) Medical assistance may be paid for an inmate of a
correctional facility who is conditionally released as authorized under section 241.26, 244.065, or
631.425, if the individual does not require the security of a public detention facility and is housed
in a halfway house or community correction center, or under house arrest and monitored by
electronic surveillance in a residence approved by the commissioner of corrections, and if the
individual meets the other eligibility requirements of this chapter.
(b) An individual, regardless of age, who is considered an inmate of a public institution as
defined in Code of Federal Regulations, title 42, section 435.1009, is not eligible for medical
assistance.
History: 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; 1Sp2003 c 14 art 12
s 15; 2004 c 288 art 3 s 21; 2005 c 10 art 1 s 47; 2005 c 56 s 1; 1Sp2005 c 4 art 8 s 19
256B.056 ELIGIBILITY REQUIREMENTS FOR MEDICAL ASSISTANCE.
    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 104-193, shall be used, except that effective October 1, 2003,
the earned income disregards and deductions are limited to those in subdivision 1c. 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)(1) [Expired, 1Sp2003 c 14
art 12 s 17]
(2) For applications processed within one calendar month prior to July 1, 2003, eligibility
shall be determined by applying the income standards and methodologies in effect prior to July 1,
2003, for any months in the six-month budget period before July 1, 2003, and the income standards
and methodologies in effect on July 1, 2003, for any months in the six-month budget period on or
after that date. The income standards for each month shall be added together and compared to the
applicant's total countable income for the six-month budget period to determine eligibility.
(3) For children ages one through 18 whose eligibility is determined under section 256B.057,
subdivision 2
, the following deductions shall be applied to income counted toward the child's
eligibility as allowed under the state's AFDC plan in effect as of July 16, 1996: $90 work expense,
dependent care, and child support paid under court order. This clause is effective October 1, 2003.
(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 and the following deductions shall be applied to each
individual's income counted toward eligibility as allowed under the state's AFDC plan in effect as
of July 16, 1996: dependent care and child support paid under court order.
(c) If the four-month disregard in paragraph (b) 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.
(d) The commissioner shall adjust the income standards under this section each July 1 by
the annual update of the federal poverty guidelines following publication by the United States
Department of Health and Human Services.
    Subd. 2. Homestead exclusion and homestead equity limit for institutionalized persons.
(a) 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:
(1) the spouse;
(2) a child under age 21;
(3) a child of any age who is blind or permanently and totally disabled as defined in the
supplemental security income program;
(4) 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
(5) 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.
(b) Effective for applications filed on or after July 1, 2006, and for renewals after July 1,
2006, for persons who first applied for payment of long-term care services on or after January 2,
2006, the equity interest in the homestead of an individual whose eligibility for long-term care
services is determined on or after January 1, 2006, shall not exceed $500,000, unless it is the
lawful residence of the individual's spouse or child who is under age 21, blind, or disabled. The
amount specified in this paragraph shall be increased beginning in year 2011, from year to year
based on the percentage increase in the Consumer Price Index for all urban consumers (all items;
United States city average), rounded to the nearest $1,000. This provision may be waived in the
case of demonstrated hardship by a process to be determined by the secretary of health and human
services pursuant to section 6014 of the Deficit Reduction Act of 2005, Public Law 109-171.
    Subd. 3. Asset limitations for individuals and families. 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 a developmental disability living in an intermediate care facility for
persons with developmental disabilities; 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 103-66.
    Subd. 3c. Asset limitations for families and children. A household of two or more persons
must not own more than $20,000 in total net assets, and a household of one person must not
own more than $10,000 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
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. 3d. Reduction of excess assets. Assets in excess of the limits in subdivisions 3 to 3c
may be reduced to allowable limits as follows:
(a) Assets may be reduced in any of the three calendar months before the month of
application in which the applicant seeks coverage by:
(1) designating burial funds up to $1,500 for each applicant, spouse, and MA-eligible
dependent child; and
(2) paying health service bills incurred in the retroactive period for which the applicant seeks
eligibility, starting with the oldest bill. After assets are reduced to allowable limits, eligibility
begins with the next dollar of MA-covered health services incurred in the retroactive period.
Applicants reducing assets under this subdivision who also have excess income shall first spend
excess assets to pay health service bills and may meet the income spenddown on remaining bills.
(b) Assets may be reduced beginning the month of application by:
(1) paying bills for health services that would otherwise be paid by medical assistance; and
(2) using any means other than a transfer of assets for less than fair market value as defined
in section 256B.0595, subdivision 1, paragraph (b).
    Subd. 3e. Continuing care retirement and life care community entrance fees. An
entrance fee paid by an individual to a continuing care retirement or life care community shall be
treated as an available asset to the extent that:
(1) the individual has the ability to use the entrance fee, or the contract provides that the
entrance fee may be used, to pay for care should other resources or income of the individual be
insufficient to pay for care;
(2) the individual is eligible for a refund of any remaining entrance fees when the individual
dies or terminates the continuing care retirement or life care community contract and leaves
the community; and
(3) the entrance fee does not confer an ownership interest in the continuing care retirement or
life care community.
    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 last
business day 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 noon on the last business day 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 every 12 months. The 12-month period begins with the month of application.
    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 every six months. The six-month
period begins the month of application.
    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
legal representative from any third party liable for the costs of medical care. By accepting
or receiving assistance, the person is deemed to have assigned the person's rights to medical
support and third party payments as required by title 19 of the Social Security Act. Persons must
cooperate with the state in establishing paternity and obtaining third party payments. By accepting
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. For the
purposes of this section, "the Department of Human Services or the state" includes prepaid health
plans under contract with the commissioner according to sections 256B.031, 256B.69, 256D.03,
subdivision 4
, paragraph (c), 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 the
county-based purchasing entities under section 256B.692.
    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. Eligibility
for months prior to application is determined independently from eligibility for the month of
application and future months. A redetermination of eligibility must occur every 12 months. The
12-month period begins with the month of application.
    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.
    Subd. 9. Notice. The state agency must be given notice of monetary claims against a person,
entity, or corporation that may be liable to pay all or part of the cost of medical care when the
state agency has paid or becomes liable for the cost of that care. Notice must be given according
to paragraphs (a) to (d).
(a) An applicant for medical assistance shall notify the state or local agency of any possible
claims when the applicant submits the application. A recipient 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 that may be assigned to the state agency under this section shall notify
the state agency of its potential assignment claim in writing 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.
(d) 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 for 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 the 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 assignment claim.
    Subd. 10. Eligibility verification. (a) The commissioner shall require women who are
applying for the continuation of medical assistance coverage following the end of the 60-day
postpartum period to update their income and asset information and to submit any required
income or asset verification.
(b) The commissioner shall determine the eligibility of private-sector health care coverage
for infants less than one year of age eligible under section 256B.055, subdivision 10, or 256B.057,
subdivision 1
, paragraph (d), and shall pay for private-sector coverage if this is determined to be
cost-effective.
(c) The commissioner shall modify the application for Minnesota health care programs to
require more detailed information related to verification of assets and income, and shall verify
assets and income for all applicants, and for all recipients upon renewal.
(d) The commissioner shall require Minnesota health care program recipients to report new
or an increase in earned income within ten days of the change, and to verify new or an increase in
earned income that affects eligibility within ten days of notification by the agency that the new
or increased earned income affects eligibility. Recipients who fail to verify new or an increase
in earned income that affects eligibility shall be disenrolled.
    Subd. 11. Treatment of annuities. (a) Any individual applying for or seeking recertification
of eligibility for medical assistance payment of long-term care services shall provide a complete
description of any interest either the individual or the individual's spouse has in annuities. The
individual and the individual's spouse shall furnish the agency responsible for determining
eligibility with complete current copies of their annuities and related documents for review as
part of the application process on disclosure forms provided by the department as part of their
application.
(b) The disclosure form shall include a statement that the department becomes the remainder
beneficiary under the annuity or similar financial instrument by virtue of the receipt of medical
assistance. The disclosure form shall include a notice to the issuer of the department's right under
this section as a preferred remainder beneficiary under the annuity or similar financial instrument
for medical assistance furnished to the individual or the individual's spouse, and require the
issuer to provide confirmation that a remainder beneficiary designation has been made and to
notify the county agency when there is a change in the amount of the income or principal being
withdrawn from the annuity or other similar financial instrument at the time of the most recent
disclosure required under this section. The individual and the individual's spouse shall execute
separate disclosure forms for each annuity or similar financial instrument that they are required to
disclose under this section and in which they have an interest.
(c) An issuer of an annuity or similar financial instrument who receives notice on a disclosure
form as described in paragraph (b) shall provide confirmation to the requesting agency that a
remainder beneficiary designating the state has been made and shall notify the county agency
when there is a change in the amount of income or principal being withdrawn from the annuity
or other similar financial instrument. The county agency shall provide the issuer with the name,
address, and telephone number of a unit within the department that the issuer can contact to
comply with this paragraph.
History: 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; 1Sp2003 c 14 art 2 s 16; art 12 s 16-18; 2004 c 228 art 1 s 75; 2005 c 56 s 1; 2005 c 98 art
2 s 2; 1Sp2005 c 4 art 8 s 20-26; 2006 c 282 art 17 s 25-27

NOTE: The amendments to subdivisions 5, 5a, 5b, and 7, by Laws 2005, First Special
Session chapter 4, article 8, sections 21 to 24, are effective August 1, 2007, or upon HealthMatch
implementation, whichever is later. Laws 2005, First Special Session chapter 4, article 8, sections
21 to 24, the effective dates.

256B.057 ELIGIBILITY REQUIREMENTS FOR SPECIAL CATEGORIES.
    Subdivision 1. Infants and pregnant women. (a)(1) An infant less than one year of age 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. 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 200 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
104-193, except for the earned income disregard and employment deductions.
(2) For applications processed within one calendar month prior to the effective date,
eligibility shall be determined by applying the income standards and methodologies in effect
prior to the effective date for any months in the six-month budget period before that date and
the income standards and methodologies in effect on the effective date for any months in the
six-month budget period on or after that date. The income standards for each month shall be
added together and compared to the applicant's total countable income for the six-month budget
period to determine eligibility.
(b)(1) [Expired, 1Sp2003 c 14 art 12 s 19]
(2) For applications processed within one calendar month prior to July 1, 2003, eligibility
shall be determined by applying the income standards and methodologies in effect prior to July
1, 2003, for any months in the six-month budget period before July 1, 2003, and the income
standards and methodologies in effect on the expiration date for any months in the six-month
budget period on or after July 1, 2003. The income standards for each month shall be added
together and compared to the applicant's total countable income for the six-month budget period
to determine eligibility.
(c) Dependent care and child support paid under court order shall be deducted from the
countable income of pregnant women.
(d) 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.[Repealed, 1Sp2003 c 14 art 12 s 101]
    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. (a) Except as specified in subdivision 1b, effective October 1, 2003, a
child one through 18 years of age in a family whose countable income is no greater than 150
percent of the federal poverty guidelines for the same family size, is eligible for medical assistance.
(b) For applications processed within one calendar month prior to the effective date,
eligibility shall be determined by applying the income standards and methodologies in effect
prior to the effective date for any months in the six-month budget period before that date and
the income standards and methodologies in effect on the effective date for any months in the
six-month budget period on or after that date. The income standards for each month shall be
added together and compared to the applicant's total countable income for the six-month budget
period to determine eligibility.
    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, contingent upon federal funding,
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 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 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 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) effective November 1, 2003, pays a premium and other obligations under paragraph (d).
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:
(1) 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; or
(2) effective January 1, 2004, loses employment for reasons not attributable to the enrollee,
may retain eligibility for up to four consecutive months after the month of job loss. To receive
a four-month extension, enrollees must verify the medical condition or provide notification of
job loss. All other eligibility requirements must be met and the enrollee must pay all calculated
premium costs for continued eligibility.
(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)(1) Effective January 1, 2004, for purposes of eligibility, there will be a $65 earned income
disregard. To be eligible, a person applying for medical assistance under this subdivision must
have earned income above the disregard level.
(2) Effective January 1, 2004, to be considered earned income, Medicare, Social Security,
and applicable state and federal income taxes must be withheld. To be eligible, a person must
document earned income tax withholding.
(d)(1) 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.
(2) Effective January 1, 2004, all enrollees must pay a premium to be eligible for medical
assistance under this subdivision. An enrollee shall pay the greater of a $35 premium or the
premium calculated in clause (1).
(3) Effective November 1, 2003, all enrollees who receive unearned income must pay
one-half of one percent of unearned income in addition to the premium amount.
(4) Effective November 1, 2003, for enrollees whose income does not exceed 200 percent of
the federal poverty guidelines and who are also enrolled in Medicare, the commissioner must
reimburse the enrollee for Medicare Part B premiums under section 256B.0625, subdivision 15,
paragraph (a).
(5) 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.
(e) 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.
(f) Any required premium shall be determined at application and redetermined at the
enrollee's six-month income review or when a change in income or household size is reported.
Enrollees must report any change in income or household size within ten days of when the change
occurs. A decreased premium resulting from a reported change in income or household size shall
be effective the first day of the next available billing month after the change is reported. Except
for changes occurring from annual cost-of-living increases, a change resulting in an increased
premium shall not affect the premium amount until the next six-month review.
(g) 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.
(h) 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. Except when an
installment agreement is accepted by the commissioner, all persons disenrolled for nonpayment
of a premium must pay any past due premiums as well as current premiums due prior to being
reenrolled. 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
1396a(a)(10)(A)(i); and
(6) is not otherwise covered under creditable coverage, as defined under United States
Code, title 42, section 1396a(aa).
(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
.
History: 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; 1Sp2003 c 14 art
12 s 19-23; 1Sp2005 c 4 art 7 s 4

NOTE: The amendment to subdivision 1 by Laws 2003, First Special Session chapter 14,
article 12, section 19, is effective February 1, 2004, or upon federal approval, whichever is later,
except where a different date is specified in the text. Laws 2003, First Special Session chapter
14, article 12, section 19, the effective date.

256B.0571 LONG-TERM CARE PARTNERSHIP PROGRAM.
    Subdivision 1. Definitions. For purposes of this section, the following terms have the
meanings given them.
    Subd. 2.[Repealed, 2006 c 282 art 17 s 37]
    Subd. 3. Long-term care insurance. "Long-term care insurance" means a policy described
in section 62S.01.
    Subd. 4. Medical assistance. "Medical assistance" means the program of medical assistance
established under section 256B.01.
    Subd. 5.[Repealed, 2006 c 282 art 17 s 37]
    Subd. 6. Partnership policy. "Partnership policy" means a long-term care insurance policy
that meets the requirements under subdivision 10 and was issued on or after the effective date of
the state plan amendment implementing the partnership program in Minnesota.
    Subd. 7. Partnership program. "Partnership program" means the Minnesota partnership for
long-term care program established under this section.
    Subd. 7a. Protected assets. "Protected assets" means assets or proceeds of assets that are
protected from recovery under subdivisions 13 and 15.
    Subd. 8. Program established. (a) The commissioner, in cooperation with the commissioner
of commerce, shall establish the Minnesota partnership for long-term care program to provide for
the financing of long-term care through a combination of private insurance and medical assistance.
(b) An individual who meets the requirements in this paragraph is eligible to participate in
the partnership program. The individual must:
(1) be a Minnesota resident at the time coverage first became effective under the partnership
policy;
(2) be a beneficiary of a partnership policy that (i) is issued on or after the effective date of
the state plan amendment implementing the partnership program in Minnesota, or (ii) qualifies as
a partnership policy under the provisions of subdivision 8a; and
(3) have exhausted all of the benefits under the partnership policy as described in this section.
Benefits received under a long-term care insurance policy before July 1, 2006, do not count
toward the exhaustion of benefits required in this subdivision.
    Subd. 8a. Exchange for long-term care partnership policy; addition of policy rider. (a)
If authorized by federal law or if federal approval is granted with respect to the partnership
program established in this section, a long-term care insurance policy that was issued before the
effective date of the state plan amendment implementing the partnership program in Minnesota
that was exchanged after the effective date of the state plan amendment for a long-term care
partnership policy that meets the requirements of Public Law 109-171, section 6021, qualifies
as a long-term care partnership policy under this section, unless the policy is paying benefits
on the date the policy is exchanged.
(b) If authorized by federal law or if federal approval is granted with respect to the
partnership program established in this section, a long-term care insurance policy that was issued
before the effective date of the state plan amendment implementing the partnership program in
Minnesota that has a rider added after the effective date of the state plan amendment that meets
the requirements of Public Law 109-171, section 6021, qualifies as a long-term care partnership
policy under this section, unless the policy is paying benefits on the date the rider is added.
    Subd. 9. Medical assistance eligibility. (a) Upon application for medical assistance program
payment of long-term care services by an individual who meets the requirements described in
subdivision 8, the commissioner shall determine the individual's eligibility for medical assistance
according to paragraphs (b) to (i).
(b) After determining assets subject to the asset limit under section 256B.056, subdivision 3
or 3c, or 256B.057, subdivision 9 or 10, the commissioner shall allow the individual to designate
assets to be protected from recovery under subdivisions 13 and 15 up to the dollar amount of the
benefits utilized under the partnership policy. Designated assets shall be disregarded for purposes
of determining eligibility for payment of long-term care services.
(c) The individual shall identify the designated assets and the full fair market value of those
assets and designate them as assets to be protected at the time of initial application for medical
assistance. The full fair market value of real property or interests in real property shall be based
on the most recent full assessed value for property tax purposes for the real property, unless the
individual provides a complete professional appraisal by a licensed appraiser to establish the full
fair market value. The extent of a life estate in real property shall be determined using the life
estate table in the health care program's manual. Ownership of any asset in joint tenancy shall
be treated as ownership as tenants in common for purposes of its designation as a disregarded
asset. The unprotected value of any protected asset is subject to estate recovery according
to subdivisions 13 and 15.
(d) The right to designate assets to be protected is personal to the individual and ends when
the individual dies, except as otherwise provided in subdivisions 13 and 15. It does not include
the increase in the value of the protected asset and the income, dividends, or profits from the
asset. It may be exercised by the individual or by anyone with the legal authority to do so on the
individual's behalf. It shall not be sold, assigned, transferred, or given away.
(e) If the dollar amount of the benefits utilized under a partnership policy is greater than the
full fair market value of all assets protected at the time of the application for medical assistance
long-term care services, the individual may designate additional assets that become available
during the individual's lifetime for protection under this section. The individual must make the
designation in writing to the county agency no later than the last date on which the individual
must report a change in circumstances to the county agency, as provided for under the medical
assistance program. Any excess used for this purpose shall not be available to the individual's
estate to protect assets in the estate from recovery under section 256B.15 or 524.3-1202, or
otherwise.
(f) This section applies only to estate recovery under United States Code, title 42, section
1396p, subsections (a) and (b), and does not apply to recovery authorized by other provisions of
federal law, including, but not limited to, recovery from trusts under United States Code, title
42, section 1396p, subsection (d)(4)(A) and (C), or to recovery from annuities, or similar legal
instruments, subject to section 6012, subsections (a) and (b), of the Deficit Reduction Act of
2005, Public Law 109-171.
(g) An individual's protected assets owned by the individual's spouse who applies for
payment of medical assistance long-term care services shall not be protected assets or disregarded
for purposes of eligibility of the individual's spouse solely because they were protected assets of
the individual.
(h) Assets designated under this subdivision shall not be subject to penalty under section
256B.0595.
(i) The commissioner shall otherwise determine the individual's eligibility for payment of
long-term care services according to medical assistance eligibility requirements.
    Subd. 10. Long-term care partnership policy inflation protection. A long-term care
partnership policy must provide the inflation protection described in this subdivision. If the
policy is sold to an individual who:
(1) has not attained age 61 as of the date of purchase, the policy must provide compound
annual inflation protection;
(2) has attained age 61, but has not attained age 76 as of such date, the policy must provide
some level of inflation protection; and
(3) has attained age 76 as of such date, the policy may, but is not required to, provide some
level of inflation protection.
    Subd. 11.[Repealed, 2006 c 282 art 17 s 37]
    Subd. 12. Compliance with federal law. An issuer of a partnership policy must comply
with Public Law 109-171, section 6021, including any federal regulations, as amended, adopted
under that law.
    Subd. 13. Limitations on estate recovery. (a) Protected assets of the individual shall not be
subject to recovery under section 256B.15 or 524.3-1201 for medical assistance or alternative care
paid on behalf of the individual. Protected assets of the individual in the estate of the individual's
surviving spouse shall not be liable to pay a claim for recovery of medical assistance paid for the
predeceased individual that is filed in the estate of the surviving spouse under section 256B.15.
Protected assets of the individual shall not be protected assets in the surviving spouse's estate
by reason of the preceding sentence and shall be subject to recovery under section 256B.15 or
524.3-1201 for medical assistance paid on behalf of the surviving spouse.
(b) The personal representative may protect the full fair market value of an individual's
unprotected assets in the individual's estate in an amount equal to the unused amount of asset
protection the individual had on the date of death. The personal representative shall apply the
asset protection so that the full fair market value of any unprotected asset in the estate is protected.
When or if the asset protection available to the personal representative is or becomes less than
the full fair market value of any remaining unprotected asset, it shall be applied to partially
protect one unprotected asset.
(c) The asset protection described in paragraph (a) terminates with respect to an asset
includable in the individual's estate under chapter 524 or section 256B.15:
(1) when the estate distributes the asset; or
(2) if the estate of the individual has not been probated within one year from the date of death.
(d) If an individual owns a protected asset on the date of death and the estate is opened for
probate more than one year after death, the state or a county agency may file and collect claims in
the estate under section 256B.15, and no statute of limitations in chapter 524 that would otherwise
limit or bar the claim shall apply.
(e) Except as otherwise provided, nothing in this section shall limit or prevent recovery
of medical assistance.
    Subd. 14. Implementation. (a) The commissioner, in cooperation with the commissioner of
commerce, may alter the requirements of this section so as to be in compliance with forthcoming
requirements of the federal Department of Health and Human Services and the National
Association of Insurance Commissioners necessary to implement the long-term care partnership
program requirements of Public Law 109-171, section 6021.
(b) The commissioner shall submit a state plan amendment to the federal government to
implement the long-term care partnership program in accordance with this section.
    Subd. 15. Limitation on liens. (a) An individual's interest in real property shall not be
subject to a medical assistance lien or a notice of potential claim while and to the extent it is
protected under subdivision 9.
(b) Medical assistance liens or liens arising under notices of potential claims against an
individual's interests in real property in the individual's estate that are designated as protected
under subdivision 13, paragraph (b), shall be released to the extent of the dollar value of the
protection applied to the interest.
(c) If an interest in real property is protected from a lien for recovery of medical assistance
paid on behalf of the individual under paragraph (a) or (b), no lien for recovery of medical
assistance paid on behalf of that individual shall be filed against the protected interest in real
property after it is distributed to the individual's heirs or devisees.
    Subd. 16. Burden of proof. Any individual or the personal representative of the individual's
estate who asserts that an asset is a disregarded or protected asset under this section in connection
with any determination of eligibility for benefits under the medical assistance program or any
appeal, case, controversy, or other proceedings, shall have the initial burden of:
(1) documenting and proving by clear and convincing evidence that the asset or source of
funds for the asset in question was designated as disregarded or protected;
(2) tracing the asset and the proceeds of the asset from that time forward; and
(3) documenting that the asset or proceeds of the asset remained disregarded or protected
at all relevant times.
History: 1Sp2005 c 4 art 7 s 5; 2006 c 255 s 74; 2006 c 282 art 17 s 28
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.
Reasonable expenses are limited to expenses that have not been previously used as a
deduction from income and are incurred during the enrollee's current period of eligibility,
including retroactive months associated with the current period of eligibility, for medical
assistance payment of long-term care services.
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.
History: 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; 1Sp2005 c 4 art 8 s 27
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.
History: 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 developmental
disabilities, 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 developmental disabilities, 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.
History: 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; 2005 c 56 s 1
256B.0594 PAYMENT OF BENEFITS FROM AN ANNUITY.
When payment becomes due under an annuity that names the department a remainder
beneficiary as described in section 256B.056, subdivision 11, the issuer shall request and the
department shall, within 45 days after receipt of the request, provide a written statement of the
total amount of the medical assistance paid. Upon timely receipt of the written statement of
the amount of medical assistance paid, the issuer shall pay the department an amount equal to
the lesser of the amount due the department under the annuity or the total amount of medical
assistance paid on behalf of the individual or the individual's spouse. Any amounts remaining
after the issuer's payment to the department shall be payable according to the terms of the annuity
or similar financial instrument. The county agency or the department shall provide the issuer with
the name, address, and telephone number of a unit within the department the issuer can contact to
comply with this section. The requirements of section 72A.201, subdivision 4, clause (3), shall not
apply to payments made under this section until the issuer has received final payment information
from the department, if the issuer has notified the beneficiary of the requirements of this section at
the time it initially requests payment information from the department.
History: 2006 c 282 art 17 s 29
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. This applies to all transfers,
including those made by a community spouse after the month in which the institutionalized
spouse is determined eligible for medical assistance. 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. In the case of payments from a trust or portions of a
trust that are considered transfers of assets under federal law, or in the case of any other disposal
of assets made on or after February 8, 2006, 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) Effective for transactions, including the purchase of an annuity, occurring on or after
February 8, 2006, the purchase of an annuity by or on behalf of an individual who has applied for
or is receiving long-term care services or the individual's spouse shall be treated as the disposal
of an asset for less than fair market value unless the department is named as the remainder
beneficiary in first position for an amount equal to at least the total amount of medical assistance
paid on behalf of the individual or the individual's spouse; or the department is named as the
remainder beneficiary in second position for an amount equal to at least the total amount of
medical assistance paid on behalf of the individual or the individual's spouse after the individual's
community spouse or minor or disabled child and is named as the remainder beneficiary in the
first position if the community spouse or a representative of the minor or disabled child disposes
of the remainder for less than fair market value. Any subsequent change to the designation of
the department as a remainder beneficiary shall result in the annuity being treated as a disposal
of assets for less than fair market value. The amount of such transfer shall be the maximum
amount the individual or the individual's spouse could receive from the annuity or similar
financial instrument. Any change in the amount of the income or principal being withdrawn from
the annuity or other similar financial instrument at the time of the most recent disclosure shall
be deemed to be a transfer of assets for less than fair market value unless the individual or the
individual's spouse demonstrates that the transaction was for fair market value.
(g) Effective for transactions, including the purchase of an annuity, occurring on or after
February 8, 2006, the purchase of an annuity by or on behalf of an individual applying for
or receiving long-term care services shall be treated as a disposal of assets for less than fair
market value unless it is:
(i) an annuity described in subsection (b) or (q) of section 408 of the Internal Revenue
Code of 1986; or
(ii) purchased with proceeds from:
(A) an account or trust described in subsection (a), (c), or (p) of section 408 of the Internal
Revenue Code;
(B) a simplified employee pension within the meaning of section 408(k) of the Internal
Revenue Code; or
(C) a Roth IRA described in section 408A of the Internal Revenue Code; or
(iii) an annuity that is irrevocable and nonassignable; is actuarially sound as determined in
accordance with actuarial publications of the Office of the Chief Actuary of the Social Security
Administration; and provides for payments in equal amounts during the term of the annuity, with
no deferral and no balloon payments made.
(h) 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 developmental disabilities,
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 developmental disabilities or who is receiving home
and community-based services under sections 256B.0915, 256B.092, and 256B.49.
(i) This section applies to funds used to purchase a promissory note, loan, or mortgage
unless the note, loan, or mortgage:
(1) has a repayment term that is actuarially sound;
(2) provides for payments to be made in equal amounts during the term of the loan, with no
deferral and no balloon payments made; and
(3) prohibits the cancellation of the balance upon the death of the lender.
In the case of a promissory note, loan, or mortgage that does not meet an exception in clauses
(1) to (3), the value of such note, loan, or mortgage shall be the outstanding balance due as of the
date of the individual's application for long-term care services.
(j) This section applies to the purchase of a life estate interest in another individual's home
unless the purchaser resides in the home for a period of at least one year after the date of purchase.
    Subd. 1a.[Repealed, 2001 c 203 s 19]
    Subd. 1b. Prohibited transfers. (a) Notwithstanding any contrary provisions of this section,
this subdivision applies to transfers involving recipients of medical assistance that are made on or
after July 1, 2003, and to all transfers involving persons who apply for medical assistance on or
after July 1, 2003, if the transfer occurred within 72 months before the person applies for medical
assistance, except that this subdivision does not apply to transfers made prior to July 1, 2003. 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, may not give away, sell, dispose of, or reduce ownership or control of any income, asset,
or interest therein for less than fair market value for the purpose of establishing or maintaining
medical assistance eligibility. This applies to all transfers, including those made by a community
spouse after the month in which the institutionalized spouse is determined eligible for medical
assistance. For purposes of determining eligibility for medical assistance services, any transfer of
such income or assets for less than fair market value within 72 months before or any time after a
person applies for medical assistance 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 medical assistance services for the period of time determined under
subdivision 2b, unless the person furnishes convincing evidence to establish that the transaction
was exclusively for another purpose or unless the transfer is permitted under subdivision 3b or 4b.
Convincing evidence of any one of the following facts shall establish that a gift that is a
charitable contribution to an organization described in section 170(c) of the Internal Revenue
Code of 1986, as amended, was made exclusively for a purpose other than establishing or
maintaining medical assistance eligibility, unless at the time of the gift the donor or donor's
spouse was receiving long-term care services, was advised by a medical professional of the need
for long-term care services, or was a medical assistance applicant or recipient:
(1) the donor made one or more gifts to the same donee organization more than 180 days
prior to the date of the gift in question; or
(2) the gift was made to an organization for which the donor had provided volunteer services,
acknowledged in writing by the organization, prior to the date of the gift.
A person may alternatively establish with other convincing evidence that a charitable gift was
made exclusively for a purpose other than establishing or maintaining medical assistance
eligibility.
(b) This section applies to transfers to trusts. The commissioner shall determine valid trust
purposes under this section. Assets placed into a trust that is not for a valid purpose shall always
be considered available for the purposes of medical assistance eligibility, regardless of when the
trust is established.
(c) This section applies to transfers of income or assets for less than fair market value,
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 that 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 income, asset, or interest therein 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 the
person's spouse while alive, based on estimated life expectancy, using the life expectancy tables
employed by the supplemental security income program, or based on a shorter life expectancy if
the annuitant had a medical condition that would shorten the annuitant's life expectancy and that
was diagnosed before funds were placed into the annuity. The agency may request and receive a
physician's statement to determine if the annuitant had a diagnosed medical condition that would
shorten the annuitant's life expectancy. If so, the agency shall determine the expected value of the
benefits based upon the physician's statement instead of using a life expectancy table. 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) Transfers under this section shall affect determinations of eligibility for all medical
assistance services or long-term care services, whichever receives federal approval.
    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 first day of the month after 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 on the first day of the month after the month in which the
first uncompensated transfer was made. If the transfer was reported to the local agency after the
date that advance notice of a period of ineligibility that affects the next month could be provided
to the recipient and the recipient received medical assistance services or the transfer was not
reported to the local agency, and the applicant or recipient 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) For uncompensated transfers made on or after February 8, 2006, the period of ineligibility
begins on the first day of the month in which advance notice can be given following the month
in which assets have been transferred for less than fair market value, or the date on which the
individual is eligible for medical assistance under the Medicaid state plan and would otherwise
be receiving long-term care services based on an approved application for such care but for
the application of the penalty period, whichever is later, and which does not occur during any
other period of ineligibility.
(d) 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.
(e) In the case of multiple fractional transfers of assets in more than one month for less
than fair market value on or after February 8, 2006, the period of ineligibility is calculated by
treating the total, cumulative, uncompensated value of all assets transferred during all months
on or after February 8, 2006, as one transfer.
    Subd. 2a.[Repealed, 2001 c 203 s 19]
    Subd. 2b. Period of ineligibility. (a) Notwithstanding any contrary provisions of this section,
this subdivision applies to transfers, including transfers to trusts, involving recipients of medical
assistance that are made on or after July 1, 2003, and to all transfers involving persons who
apply for medical assistance on or after July 1, 2003, regardless of when the transfer occurred,
except that this subdivision does not apply to transfers made prior to July 1, 2003. For any
uncompensated transfer occurring within 72 months prior to the date of application, at any time
after application, or while eligible, the number of months of cumulative ineligibility for medical
assistance services shall be the total uncompensated value of the assets and income transferred
divided by the statewide average per-person nursing facility payment made by the state in effect
at the time a penalty for a transfer is determined. The amount used to calculate the average
per-person nursing facility payment shall be adjusted each July 1 to reflect average payments for
the previous calendar year. For applicants, the period of ineligibility begins with the month in
which the person applied for medical assistance and satisfied all other requirements for eligibility,
or the first month the local agency becomes aware of the transfer and can give proper notice, if
later. For recipients, the period of ineligibility begins in the first month after the month the agency
becomes aware of the transfer and can give proper notice, except that penalty periods for transfers
made during a period of ineligibility as determined under this section shall begin in the month
following the existing period of ineligibility. If the transfer was not reported to the local agency,
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 that was not recovered from the transferor through the
implementation of a penalty period under this subdivision, whichever is less. Recovery shall
include the costs incurred due to the action. The action may be brought by the state or the local
agency responsible for providing medical assistance under this chapter. The total uncompensated
value is the fair market value of the income or asset at the time it was given away, sold, or disposed
of, less the amount of compensation received. 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.
(b) If a calculation of a penalty period results in a partial month, payments for medical
assistance 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.
(c) Ineligibility under this section shall apply to medical assistance services or long-term
care services, whichever receives federal approval.
    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. With the written consent of the individual or
the personal representative of the individual, a long-term care facility in which an individual is
residing may file an undue hardship waiver request, on behalf of the individual who is denied
eligibility for long-term care services on or after July 1, 2006, due to a period of ineligibility
resulting from a transfer on or after February 8, 2006. 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;
(3) 36 months if transferred in any other manner after August 10, 1993, but prior to February
8, 2006; or
(4) 60 months if the homestead was transferred on or after February 8, 2006,
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. 3b. Homestead exception to transfer prohibition. (a) This subdivision applies to
transfers involving recipients of medical assistance that are made on or after July 1, 2003, and
to all transfers involving persons who apply for medical assistance on or after July 1, 2003,
regardless of when the transfer occurred, except that this subdivision does not apply to transfers
made prior to July 1, 2003. A person is not ineligible for medical assistance services due to
a transfer of assets for less than fair market value as described in subdivision 1b, if the asset
transferred was a homestead, and:
(1) a satisfactory showing is made that the individual intended to dispose of the homestead at
fair market value or for other valuable consideration; or
(2) 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 and there
exists 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.
(b) When a waiver is granted under paragraph (a), clause (2), a cause of action exists against
the person to whom the homestead was transferred for that portion of medical assistance services
granted within 72 months of the date the transferor applied for medical assistance and satisfied
all other requirements for eligibility 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.
    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. With the written
consent of the individual or the personal representative of the individual, a long-term care facility
in which an individual is residing may file an undue hardship waiver request, on behalf of the
individual who is denied eligibility for long-term care services on or after July 1, 2006, due to
a period of ineligibility resulting from a transfer on or after February 8, 2006. 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, whether the individual has taken any action to prevent the designation
of the department as a remainder beneficiary on an annuity as described in section 256B.056,
subdivision 11, 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;
(iii) 36 months of a transfer if transferred in any other manner after August 10, 1993, but
prior to February 8, 2006; or
(iv) 60 months of any transfer made on or after February 8, 2006,
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. 4b. Other exceptions to transfer prohibition. This subdivision applies to transfers
involving recipients of medical assistance that are made on or after July 1, 2003, and to all
transfers involving persons who apply for medical assistance on or after July 1, 2003, regardless
of when the transfer occurred, except that this subdivision does not apply to transfers made prior
to July 1, 2003. A person or a person's spouse who made a transfer prohibited by subdivision 1b is
not ineligible for medical assistance services if one of the following conditions applies:
(1) the assets or income were transferred to the individual's spouse or to another for the sole
benefit of the spouse, except that after eligibility is established and the assets have been divided
between the spouses as part of the asset allowance under section 256B.059, no further transfers
between spouses may be made;
(2) the institutionalized spouse, prior to being institutionalized, transferred assets or income
to a spouse, provided that the spouse to whom the assets or income were transferred does not
then transfer those assets or income 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;
(3) the assets or income were transferred to a trust for the sole benefit of the individual's
child who is blind or permanently and totally disabled as determined in the supplemental security
income program and the trust reverts to the state upon the disabled child's death to the extent the
medical assistance has paid for services for the grantor or beneficiary of the trust. This clause
applies to a trust established after the commissioner publishes a notice in the State Register that
the commissioner has been authorized to implement this clause due to a change in federal law
or the approval of a federal waiver;
(4) a satisfactory showing is made that the individual intended to dispose of the assets or
income either at fair market value or for other valuable consideration; or
(5) the local agency determines that denial of eligibility for medical assistance services
would cause undue hardship and grants a waiver of a penalty resulting from a transfer for less
than fair market value because there exists 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 medical assistance services granted within 72 months
of the date the transferor applied for medical assistance and satisfied all other requirements for
eligibility, 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.
    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.
History: 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; 1Sp2003 c 14 art 12 s 24-29; 2004 c
266 s 1; 2005 c 56 s 1; 2005 c 155 art 3 s 1; 2006 c 282 art 17 s 30-33

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.

NOTE: Subdivisions 1b, 2b, 3b, and 4b, as added by Laws 2003, First Special Session
chapter 14, article 12, sections 25, 27, 28, and 29, are effective July 1, 2003, to the extent
permitted by law. If any provision is prohibited by federal law, the provision shall become
effective when federal law is changed to permit its application or a waiver is received. The
commissioner of human services shall notify the revisor of statutes when federal law is enacted
or a waiver or other federal approval is received and publish a notice in the first State Register
published after the federal change is effective. Laws 2003, First Special Session chapter 14, article
12, sections 25, 27, 28, and 29, the effective dates.

NOTE: The amendment to subdivision 1b by Laws 2004, chapter 266, section 1, is effective
upon publication in the State Register of receipt of federal approval for the 72-month lookback
period described in paragraph (a). Laws 2004, chapter 266, section 1, the effective date.

256B.0596 MENTAL HEALTH CASE MANAGEMENT.
Counties shall contract with eligible providers willing to provide mental health case
management services under section 256B.0625, subdivision 20. In order to be eligible, in addition
to general provider requirements under this chapter, the provider must:
(1) be willing to provide the mental health case management services; and
(2) have a minimum of at least one contact with the client per week. This section is not
intended to limit the ability of a county to provide its own mental health case management
services.
History: 1Sp2003 c 2 art 5 s 6; 1Sp2003 c 14 art 12 s 30; 2004 c 288 art 3 s 22
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. Citizens or nationals of the United States must
cooperate in obtaining satisfactory documentary evidence of citizenship or nationality according
to the requirements of the federal Deficit Reduction Act of 2005, Public Law 109-171.
(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 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 104-200; or
(9) determined to be a Cuban or Haitian entrant as defined in section 501(e) of Public Law
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 this chapter, 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 this chapter, 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 this chapter 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
this chapter, 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 this chapter 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 this chapter,
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, nonimmigrants, or eligible for medical
assistance as described in paragraph (j), and who are not covered by a group health plan or health
insurance coverage according to Code of Federal Regulations, title 42, section 457.310, and who
otherwise meet the eligibility requirements of this chapter, are eligible for medical assistance
through the period of pregnancy, including labor and delivery, to the extent federal funds are
available under title XXI of the Social Security Act, and the state children's health insurance
program, followed by 60 days postpartum without federal financial participation.
(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) Beginning October 1, 2003, persons who are receiving care and rehabilitation services
from a nonprofit center established to serve victims of torture and are otherwise ineligible
for medical assistance under this chapter are eligible for medical assistance without federal
financial participation. These individuals are eligible only for the period during which they are
receiving services from the center. Individuals eligible under this paragraph shall not be required
to participate in prepaid medical assistance.
    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 104-193, sections 421 and 422, and subsequently set out in federal rules. This section
is effective May 1, 1997.
History: 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; 1Sp2003 c 14 art 12 s 31; 2004 c
288 art 6 s 21; 1Sp2005 c 4 art 8 s 28; 2006 c 282 art 17 s 34
256B.061 ELIGIBILITY; RETROACTIVE EFFECT; RESTRICTIONS.
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.
History: 1973 c 717 s 3; 1983 c 312 art 5 s 16; 1986 c 444; 1999 c 245 art 4 s 36; 1Sp2003
c 14 art 12 s 32
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 sections 256B.0651 to 256B.0656: 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 developmental disabilities;
(4) "relocation targeted case management" includes the provision of both county targeted
case management and public or private vendor service coordination 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 July 1, 2005.
    Subd. 4. Relocation targeted county case management provider qualifications. (a) A
relocation targeted county 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.
(b) A provider of targeted case management under section 256B.0625, subdivision 20, may
be deemed a certified provider of relocation targeted case management.
(c) A relocation targeted county 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, and 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 provider also provides, or will provide, the
recipient's services and supports. Counties must require that contracted providers must provide
information on all conflicts of interest and obtain the recipient's informed consent or provide the
recipient with alternatives.
    Subd. 5. Specific provider qualifications. Providers of home care targeted case management
and relocation service coordination must meet the qualifications under subdivision 4 for county
vendors or the qualifications and certification standards under paragraphs (a) and (b) for private
vendors.
(a) The commissioner must certify each provider of home care targeted case management
and relocation service coordination 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) Both home care targeted case management providers and relocation service coordination
providers are enrolled medical assistance providers who have a minimum of a bachelor's degree
or a license in a health or human services field, comparable training and two years of experience
in human services, or who have been credentialed by an American Indian tribe under section
256B.02, subdivision 7, and have been 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;
(5) the capacity to coordinate with county administrative functions;
(6) have no financial interest in the provision of out-of-home residential services to persons
for whom home care targeted case management or relocation service coordination is provided; and
(7) if a provider has a financial interest in services other than out-of-home residential
services provided to persons for whom home care targeted case management or relocation service
coordination is also provided, the county must determine each year that:
(i) any possible conflict of interest is explained annually at a face-to-face meeting and in
writing and the person provides written informed consent consistent with section 256B.77,
subdivision 2
, paragraph (p); and
(ii) information on a range of other feasible service provider options has been provided.
(c) The state of Minnesota, a county board, or agency acting on behalf of a county board
shall not be liable for damages, injuries, or liabilities sustained because of services provided to a
client by a private service coordination vendor.
    Subd. 6. Eligible services. (a) Services eligible for medical assistance reimbursement as
targeted case management include:
(1) assessment of the recipient's need for targeted case management services and for persons
choosing to relocate, the county must provide service coordination provider options at the first
contact and upon request;
(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 and engaging in advocacy as
needed 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) assisting individuals in order to access needed services, including travel 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.
(b) Relocation targeted county case management includes services under paragraph (a),
clauses (1), (2), and (4). Relocation service coordination includes services under paragraph (a),
clauses (3) and (5) to (8). Home care targeted case management includes services under paragraph
(a), clauses (1) to (8).
    Subd. 7. Time lines. The following time lines must be met for assigning a case manager:
(a) For relocation targeted case management, an eligible recipient must be assigned a county
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.
(1) If a county agency, its contractor, or federally recognized tribe does not provide case
management services as required, the recipient may obtain relocation service coordination from a
provider qualified under subdivision 5.
(2) The commissioner may waive the provider requirements in subdivision 4, paragraph
(a), clauses (1) and (4), to ensure recipient access to the assistance necessary to move from an
institution to the community. The recipient or the recipient's legal guardian shall provide written
notice to the county or tribe of the decision to obtain services from an alternative provider.
(3) Providers of relocation targeted case management enrolled under this subdivision shall:
(i) meet the provider requirements under subdivision 4 that are not waived by the
commissioner;
(ii) be qualified to provide the services specified in subdivision 6;
(iii) coordinate efforts with local social service agencies and tribes; and
(iv) comply with the conflict of interest provisions established under subdivision 4,
paragraph (c).
(4) Local social service agencies and federally recognized tribes shall cooperate with
providers certified by the commissioner under this subdivision to facilitate the recipient's
successful relocation from an institution to the community.
(b) 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.
    Subd. 11. Data use agreement; notice of relocation assistance. The commissioner shall
execute a data use agreement with the Centers for Medicare and Medicaid Services to obtain the
long-term care minimum data set data to assist residents of nursing facilities who have indicated a
desire to live in the community. The commissioner shall in turn enter into agreements with the
Centers for Independent Living to provide information about assistance for persons who want to
move to the community. The commissioner shall work with the Centers for Independent Living
on both the content of the information to be provided and privacy protections for the individual
residents.
History: 1Sp2001 c 9 art 2 s 39; art 3 s 20-28; 1Sp2003 c 14 art 3 s 17,18; 2005 c 56 s
1; 1Sp2005 c 4 art 7 s 6-12
256B.0622 INTENSIVE REHABILITATIVE MENTAL HEALTH SERVICES.
    Subdivision 1. Scope. Subject to federal approval, medical assistance covers medically
necessary, intensive nonresidential and residential rehabilitative mental health services as defined
in subdivision 2, for recipients as defined in subdivision 3, when the services are provided by an
entity meeting the standards in this section.
    Subd. 2. Definitions. For purposes of this section, the following terms have the meanings
given them.
(a) "Intensive nonresidential rehabilitative mental health services" means adult rehabilitative
mental health services as defined in section 256B.0623, subdivision 2, paragraph (a), except that
these services are provided by a multidisciplinary staff using a total team approach consistent
with assertive community treatment, the Fairweather Lodge treatment model, as defined by the
standards established by the National Coalition for Community Living, and other evidence-based
practices, and directed to recipients with a serious mental illness who require intensive services.
(b) "Intensive residential rehabilitative mental health services" means short-term,
time-limited services provided in a residential setting to recipients who are in need of more
restrictive settings and are at risk of significant functional deterioration if they do not receive
these services. Services are designed to develop and enhance psychiatric stability, personal and
emotional adjustment, self-sufficiency, and skills to live in a more independent setting. Services
must be directed toward a targeted discharge date with specified client outcomes and must be
consistent with the Fairweather Lodge treatment model as defined in paragraph (a), and other
evidence-based practices.
(c) "Evidence-based practices" are nationally recognized mental health services that are
proven by substantial research to be effective in helping individuals with serious mental illness
obtain specific treatment goals.
(d) "Overnight staff" means a member of the intensive residential rehabilitative mental health
treatment team who is responsible during hours when recipients are typically asleep.
(e) "Treatment team" means all staff who provide services under this section to recipients.
At a minimum, this includes the clinical supervisor, mental health professionals, mental health
practitioners, and mental health rehabilitation workers.
    Subd. 3. Eligibility. An eligible recipient is an individual who:
(1) is age 18 or older;
(2) is eligible for medical assistance;
(3) is diagnosed with a mental illness;
(4) because of a mental illness, 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;
(5) has one or more of the following: a history of two or more inpatient hospitalizations in
the past year, significant independent living instability, homelessness, or very frequent use of
mental health and related services yielding poor outcomes; and
(6) in the written opinion of a licensed mental health professional, has the need for mental
health services that cannot be met with other available community-based services, or is likely to
experience a mental health crisis or require a more restrictive setting if intensive rehabilitative
mental health services are not provided.
    Subd. 4. Provider certification and contract requirements. (a) The intensive nonresidential
rehabilitative mental health services provider must:
(1) have a contract with the host county to provide intensive adult rehabilitative mental
health services; and
(2) be certified by the commissioner as being in compliance with this section and section
256B.0623.
(b) The intensive residential rehabilitative mental health services provider must:
(1) be licensed under Minnesota Rules, parts 9520.0500 to 9520.0670;
(2) not exceed 16 beds per site;
(3) comply with the additional standards in this section; and
(4) have a contract with the host county to provide these services.
(c) The commissioner shall develop procedures for counties and providers to submit
contracts and other documentation as needed to allow the commissioner to determine whether
the standards in this section are met.
    Subd. 5. Standards applicable to both nonresidential and residential providers. (a)
Services must be provided by qualified staff as defined in section 256B.0623, subdivision 5, who
are trained and supervised according to section 256B.0623, subdivision 6, except that mental
health rehabilitation workers acting as overnight staff are not required to comply with section
256B.0623, subdivision 5, clause (3)(iv).
(b) The clinical supervisor must be an active member of the treatment team. The treatment
team must meet with the clinical supervisor at least weekly to discuss recipients' progress and make
rapid adjustments to meet recipients' needs. The team meeting shall include recipient-specific case
reviews and general treatment discussions among team members. Recipient-specific case reviews
and planning must be documented in the individual recipient's treatment record.
(c) Treatment staff must have prompt access in person or by telephone to a mental health
practitioner or mental health professional. The provider must have the capacity to promptly and
appropriately respond to emergent needs and make any necessary staffing adjustments to assure
the health and safety of recipients.
(d) The initial functional assessment must be completed within ten days of intake and
updated at least every three months or prior to discharge from the service, whichever comes first.
(e) The initial individual treatment plan must be completed within ten days of intake and
reviewed and updated at least monthly with the recipient.
    Subd. 6. Standards for intensive residential rehabilitative mental health services. (a) The
provider of intensive residential services must have sufficient staff to provide 24-hour-per-day
coverage to deliver the rehabilitative services described in the treatment plan and to safely
supervise and direct the activities of recipients given the recipient's level of behavioral and
psychiatric stability, cultural needs, and vulnerability. The provider must have the capacity within
the facility to provide integrated services for chemical dependency, illness management services,
and family education when appropriate.
(b) At a minimum:
(1) staff must be available and provide direction and supervision whenever recipients are
present in the facility;
(2) staff must remain awake during all work hours;
(3) there must be a staffing ratio of at least one to nine recipients for each day and evening
shift. If more than nine recipients are present at the residential site, there must be a minimum
of two staff during day and evening shifts, one of whom must be a mental health practitioner or
mental health professional;
(4) if services are provided to recipients who need the services of a medical professional, the
provider shall assure that these services are provided either by the provider's own medical staff or
through referral to a medical professional; and
(5) the provider must assure the timely availability of a licensed registered nurse, either
directly employed or under contract, who is responsible for ensuring the effectiveness and safety
of medication administration in the facility and assessing patients for medication side effects
and drug interactions.
    Subd. 7. Additional standards for nonresidential services. The standards in this
subdivision apply to intensive nonresidential rehabilitative mental health services.
(1) The treatment team must use team treatment, not an individual treatment model.
(2) The clinical supervisor must function as a practicing clinician at least on a part-time basis.
(3) The staffing ratio must not exceed ten recipients to one full-time equivalent treatment
team position.
(4) Services must be available at times that meet client needs.
(5) The treatment team must actively and assertively engage and reach out to the recipient's
family members and significant others, after obtaining the recipient's permission.
(6) The treatment team must establish ongoing communication and collaboration between
the team, family, and significant others and educate the family and significant others about mental
illness, symptom management, and the family's role in treatment.
(7) The treatment team must provide interventions to promote positive interpersonal
relationships.
    Subd. 8. Medical assistance payment for intensive rehabilitative mental health services.
(a) Payment for residential and nonresidential services in this section shall be based on one
daily rate per provider inclusive of the following services received by an eligible recipient in a
given calendar day: all rehabilitative services under this section, staff travel time to provide
rehabilitative services under this section, and nonresidential crisis stabilization services under
section 256B.0624.
(b) Except as indicated in paragraph (c), payment will not be made to more than one entity
for each recipient for services provided under this section on a given day. If services under this
section are provided by a team that includes staff from more than one entity, the team must
determine how to distribute the payment among the members.
(c) The host county shall recommend to the commissioner one rate for each entity that
will bill medical assistance for residential services under this section and two rates for each
nonresidential provider. The first nonresidential rate is for recipients who are not receiving
residential services. The second nonresidential rate is for recipients who are temporarily receiving
residential services and need continued contact with the nonresidential team to assure timely
discharge from residential services. In developing these rates, the host county shall consider
and document:
(1) the cost for similar services in the local trade area;
(2) actual costs incurred by entities providing the services;
(3) the intensity and frequency of services to be provided to each recipient;
(4) the degree to which recipients will receive services other than services under this section;
(5) the costs of other services that will be separately reimbursed; and
(6) input from the local planning process authorized by the adult mental health initiative
under section 245.4661, regarding recipients' service needs.
(d) The rate for intensive rehabilitative mental health services must exclude room and board,
as defined in section 256I.03, subdivision 6, and services not covered under this section, such
as partial hospitalization, home care, and inpatient services. Physician services that are not
separately billed may be included in the rate to the extent that a psychiatrist is a member of the
treatment team. The county's recommendation shall specify the period for which the rate will be
applicable, not to exceed two years.
(e) When services under this section are provided by an assertive community team, case
management functions must be an integral part of the team.
(f) The rate for a provider must not exceed the rate charged by that provider for the same
service to other payors.
(g) The commissioner shall approve or reject the county's rate recommendation, based on the
commissioner's own analysis of the criteria in paragraph (c).
    Subd. 9. Provider enrollment; rate setting for county-operated entities. Counties
that employ their own staff to provide services under this section shall apply directly to the
commissioner for enrollment and rate setting. In this case, a county contract is not required
and the commissioner shall perform the program review and rate setting duties which would
otherwise be required of counties under this section.
    Subd. 10. Provider enrollment; rate setting for specialized program. A provider
proposing to serve a subpopulation of eligible recipients may bypass the county approval
procedures in this section and receive approval for provider enrollment and rate setting directly
from the commissioner under the following circumstances:
(1) the provider demonstrates that the subpopulation to be served requires a specialized
program which is not available from county-approved entities; and
(2) the subpopulation to be served is of such a low incidence that it is not feasible to develop
a program serving a single county or regional group of counties.
For providers meeting the criteria in clauses (1) and (2), the commissioner shall perform
the program review and rate setting duties which would otherwise be required of counties under
this section.
History: 1Sp2003 c 14 art 3 s 19; 2004 c 288 art 3 s 23; 1Sp2005 c 4 art 2 s 7
256B.0623 ADULT REHABILITATIVE MENTAL HEALTH SERVICES COVERED.
    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, physician's assistants,
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 certified by the state
following the certification process and procedures developed by the commissioner.
(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) A noncounty provider entity 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. A county-operated
entity must obtain this additional certification from any other county in which it will provide
services.
(d) Recertification must occur at least every three 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 and ongoing 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.
    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). If the recipient has a current diagnostic assessment by a licensed mental health professional
as defined in section 245.462, subdivision 18, clauses (1) to (5), recommending receipt of adult
mental health rehabilitative services, the definition of mental health professional for purposes of
this section includes a person who is qualified under section 245.462, subdivision 18, clause (6),
and who holds a current and valid national certification as a certified rehabilitation counselor or
certified psychosocial rehabilitation practitioner;
(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 20 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) Clinical supervision may be provided by a full- or part-time qualified professional
employed by or under contract with the provider entity. Clinical supervision may be provided by
interactive videoconferencing according to procedures developed by the commissioner. 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 monthly 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; and
(6) be available for urgent consultation as the individual recipient needs or the situation
necessitates.
(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 a 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.
For initial implementation of adult rehabilitative mental health services, until June 30, 2005, a
diagnostic assessment that reflects the recipient's current status and has been completed within the
past three years preceding admission is acceptable.
    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.
History: 1Sp2001 c 9 art 9 s 39; 2002 c 277 s 11; 2002 c 379 art 1 s 113; 1Sp2003 c 14 art
3 s 20-24
256B.0624 ADULT CRISIS RESPONSE SERVICES COVERED.
    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. 4a. Alternative provider standards. If a county demonstrates that, due to geographic
or other barriers, it is not feasible to provide mobile crisis intervention services according to the
standards in subdivision 4, paragraph (b), clause (9), the commissioner may approve a crisis
response provider based on an alternative plan proposed by a county or group of counties. The
alternative plan must:
(1) result in increased access and a reduction in disparities in the availability of crisis services;
(2) provide mobile services outside of the usual nine-to-five office hours and on weekends
and holidays; and
(3) comply with standards for emergency mental health services in section 245.469.
    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. 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.
History: 1Sp2001 c 9 art 9 s 40; 2002 c 379 art 1 s 113; 2005 c 165 art 1 s 3
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. 1a. Services provided in a hospital emergency room. Medical assistance does
not cover visits to a hospital emergency room that are not for emergency and emergency
poststabilization care or urgent care, and does not pay for any services provided in a hospital
emergency room that are not for emergency and emergency poststabilization care or urgent care.
    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 developmental disabilities
who are residing in intermediate care facilities for persons with developmental disabilities.
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. The commissioner shall exempt a facility from compliance with the
sole community provider requirement in clause (a) if, as of January 1, 2004, the facility had an
agreement with the commissioner to provide medical assistance swing bed services. 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. 2a. Skilled nursing facility and hospice services for dual eligibles. Medical
assistance covers skilled nursing facility services for individuals eligible for both medical
assistance and Medicare who have waived the Medicare skilled nursing facility room and board
benefit and have enrolled in the Medicare hospice program. Medical assistance covers skilled
nursing facility services regardless of whether an individual enrolled in the Medicare hospice
program prior to, on, or after the date of the hospitalization that qualified the individual for
Medicare skilled nursing facility services.
    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. Sex reassignment surgery. Sex reassignment surgery is not covered.
    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. 3c. Health Services Policy Committee. The commissioner, after receiving
recommendations from professional physician associations, professional associations representing
licensed nonphysician health care professionals, and consumer groups, shall establish a
13-member Health Services Policy Committee, which consists of 12 voting members and one
nonvoting member. The Health Services Policy Committee shall advise the commissioner
regarding health services pertaining to the administration of health care benefits covered under the
medical assistance, general assistance medical care, and MinnesotaCare programs. The Health
Services Policy Committee shall meet at least quarterly. The Health Services Policy Committee
shall annually elect a physician chair from among its members, who shall work directly with the
commissioner's medical director, to establish the agenda for each meeting.
    Subd. 3d. Health Services Policy Committee members. The Health Services Policy
Committee consists of:
(1) seven voting members who are licensed physicians actively engaged in the practice
of medicine in Minnesota, one of whom must be actively engaged in the treatment of persons
with mental illness, and three of whom must represent health plans currently under contract to
serve medical assistance recipients;
(2) two voting members who are physician specialists actively practicing their specialty in
Minnesota;
(3) two voting members who are nonphysician health care professionals licensed or registered
in their profession and actively engaged in their practice of their profession in Minnesota;
(4) one consumer who shall serve as a voting member; and
(5) the commissioner's medical director who shall serve as a nonvoting member.
Members of the Health Services Policy Committee shall not be employed by the Department
of Human Services, except for the medical director.
    Subd. 3e. Health Services Policy Committee terms and compensation. Committee
members shall serve staggered three-year terms, with one-third of the voting members' terms
expiring annually. Members may be reappointed by the commissioner. The commissioner may
require more frequent Health Services Policy Committee meetings as needed. An honorarium of
$200 per meeting and reimbursement for mileage and parking shall be paid to each committee
member in attendance except the medical director. The Health Services Policy Committee does
not expire as provided in section 15.059, subdivision 6.
    Subd. 3f. Circumcision for newborns. Newborn circumcision is not covered, unless the
procedure is medically necessary or required because of a well-established religious practice.
    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 section
245.481, 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 developmental disability.
(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. Services for children with autism spectrum disorders. (a) Medical assistance
covers home-based intensive early intervention behavior therapy for children with autism
spectrum disorders, effective July 1, 2007. 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.
(b) 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.
(c) 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.
    Subd. 5b. 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.
    Subd. 5c. 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.
    Subd. 5d. 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 developmental disabilities;
(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.
    Subd. 5e. 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.
    Subd. 5f. 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.
    Subd. 5g. Supervision requirements. (a) 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.
(b) 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.
(c) 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.
    Subd. 5h. 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.
    Subd. 5i. 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.
    Subd. 5j. 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.
    Subd. 5k. 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, 2010.
    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 9505.0295. 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 developmental disabilities, 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 sections 256B.0651 to 256B.0656.
    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 sections 256B.0651 and 256B.0653
to 256B.0656. All private duty nursing services must be provided according to the limits
established under sections 256B.0651 and 256B.0653 to 256B.0656. 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.
(b) The dispensed quantity of a prescription drug must not exceed a 34-day supply, unless
authorized by the commissioner.
(c) Medical assistance covers the following over-the-counter drugs when prescribed by
a licensed practitioner or by a licensed pharmacist who meets standards established by the
commissioner, in consultation with the board of pharmacy: 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 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. A pharmacist may prescribe
over-the-counter medications as provided under this paragraph for purposes of receiving
reimbursement under Medicaid. When prescribing over-the-counter drugs under this paragraph,
licensed pharmacists must consult with the recipient to determine necessity, provide drug
counseling, review drug therapy for potential adverse interactions, and make referrals as needed
to other health care professionals.
(d) Effective January 1, 2006, medical assistance shall not cover drugs that are coverable
under Medicare Part D as defined in the Medicare Prescription Drug, Improvement, and
Modernization Act of 2003, Public Law 108-173, section 1860D-2(e), for individuals eligible for
drug coverage as defined in the Medicare Prescription Drug, Improvement, and Modernization
Act of 2003, Public Law 108-173, section 1860D-1(a)(3)(A). For these individuals, medical
assistance may cover drugs from the drug classes listed in United States Code, title 42, section
1396r-8(d)(2), subject to this subdivision and subdivisions 13a to 13g, except that drugs listed in
United States Code, title 42, section 1396r-8(d)(2)(E), shall not be covered.
    Subd. 13a. Drug Utilization Review Board. The commissioner, after receiving
recommendations from professional medical associations, professional pharmacy associations,
and consumer groups shall designate a nine-member Drug Utilization Review Board. The board
shall be 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 department's medical director shall also 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 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 by the commissioner. 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. 13c. Formulary committee. The commissioner, after receiving recommendations
from professional medical associations and professional pharmacy associations, and consumer
groups shall designate a Formulary Committee to carry out duties as described in subdivisions
13 to 13g. The Formulary Committee shall be comprised of four licensed physicians actively
engaged in the practice of medicine in Minnesota one of whom must be actively engaged in the
treatment of persons with mental illness; 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. Members of the Formulary Committee shall not be employed by the Department
of Human Services, but the committee shall be staffed by an employee of the department who
shall serve as an ex officio, nonvoting member of the board. The department's medical director
shall also serve as an ex officio, nonvoting member for the committee. Committee members shall
serve three-year terms and may be reappointed by the commissioner. The Formulary Committee
shall meet at least quarterly. The commissioner may require more frequent Formulary Committee
meetings as needed. An honorarium of $100 per meeting and reimbursement for mileage shall be
paid to each committee member in attendance.
    Subd. 13d. Drug formulary. 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:
(1) drugs or products for which there is no federal funding;
(2) over-the-counter drugs, except as provided in subdivision 13;
(3) drugs used for weight loss, except that medically necessary lipase inhibitors may be
covered for a recipient with type II diabetes;
(4) drugs when used for the treatment of impotence or erectile dysfunction;
(5) drugs for which medical value has not been established; and
(6) 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.
    Subd. 13e. Payment rates. (a) 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 12 percent. The actual acquisition cost of antihemophilic factor drugs shall be
estimated at the average wholesale price minus 30 percent. 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. Establishment of the amount of payment for drugs shall not be subject
to the requirements of the Administrative Procedure Act.
(b) 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.
(c) Whenever a generically equivalent product is available, payment shall be on the basis of
the actual acquisition cost of the generic drug, or on the maximum allowable cost established
by the commissioner.
(d) 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 or the amount
established for Medicare by the United States Department of Health and Human Services pursuant
to title XVIII, section 1847a of the federal Social Security Act.
(e) The commissioner may negotiate lower reimbursement rates for specialty pharmacy
products than the rates specified in paragraph (a). The commissioner may require individuals
enrolled in the health care programs administered by the department to obtain specialty pharmacy
products from providers with whom the commissioner has negotiated lower reimbursement
rates. Specialty pharmacy products are defined as those used by a small number of recipients
or recipients with complex and chronic diseases that require expensive and challenging drug
regimens. Examples of these conditions include, but are not limited to: multiple sclerosis,
HIV/AIDS, transplantation, hepatitis C, growth hormone deficiency, Crohn's Disease, rheumatoid
arthritis, and certain forms of cancer. Specialty pharmaceutical products include injectable and
infusion therapies, biotechnology drugs, high-cost therapies, and therapies that require complex
care. The commissioner shall consult with the formulary committee to develop a list of specialty
pharmacy products subject to this paragraph. In consulting with the formulary committee in
developing this list, the commissioner shall take into consideration the population served by
specialty pharmacy products, the current delivery system and standard of care in the state, and
access to care issues. The commissioner shall have the discretion to adjust the reimbursement
rate to prevent access to care issues.
    Subd. 13f. Prior authorization. (a) The Formulary Committee shall review and recommend
drugs which require prior authorization. The Formulary Committee shall establish general criteria
to be used for the prior authorization of brand-name drugs for which generically equivalent drugs
are available, but the committee is not required to review each brand-name drug for which a
generically equivalent drug is available.
(b) Prior authorization may be required by the commissioner before certain formulary drugs
are eligible for payment. The Formulary Committee may recommend drugs for prior authorization
directly to the commissioner. The commissioner may also request that the Formulary Committee
review a drug for prior authorization. Before the commissioner may require prior authorization
for a drug:
(1) the commissioner must provide information to the Formulary Committee on the impact
that placing the drug on prior authorization may have on the quality of patient care and on
program costs, information regarding whether the drug is subject to clinical abuse or misuse, and
relevant data from the state Medicaid program if such data is available;
(2) the Formulary Committee must review the drug, taking into account medical and clinical
data and the information provided by the commissioner; and
(3) the Formulary Committee must hold a public forum and receive public comment for
an additional 15 days.
The commissioner must provide a 15-day notice period before implementing the prior
authorization.
(c) Prior authorization shall not be required or utilized for any atypical antipsychotic drug
prescribed for the treatment of mental illness if:
(1) there is no generically equivalent drug available; and
(2) the drug was initially prescribed for the recipient prior to July 1, 2003; or
(3) the drug is part of the recipient's current course of treatment.
This paragraph applies to any multistate preferred drug list or supplemental drug rebate program
established or administered by the commissioner. Prior authorization shall automatically be
granted for 60 days for brand name drugs prescribed for treatment of mental illness within 60
days of when a generically equivalent drug becomes available, provided that the brand name
drug was part of the recipient's course of treatment at the time the generically equivalent drug
became available.
(d) 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 if the prior authorization is used in conjunction with any supplemental
drug rebate program or multistate preferred drug list established or administered by the
commissioner.
(e) The commissioner may require prior authorization for brand name drugs whenever a
generically equivalent product is available, even if the prescriber specifically indicates "dispense
as written-brand necessary" on the prescription as required by section 151.21, subdivision 2.
(f) Notwithstanding this subdivision, the commissioner may automatically require prior
authorization, for a period not to exceed 180 days, for any drug that is approved by the United
States Food and Drug Administration on or after July 1, 2005. The 180-day period begins no
later than the first day that a drug is available for shipment to pharmacies within the state. The
Formulary Committee shall recommend to the commissioner general criteria to be used for the
prior authorization of the drugs, but the committee is not required to review each individual drug.
In order to continue prior authorizations for a drug after the 180-day period has expired, the
commissioner must follow the provisions of this subdivision.
    Subd. 13g. Preferred drug list. (a) The commissioner shall adopt and implement a preferred
drug list by January 1, 2004. The commissioner may enter into a contract with a vendor or one or
more states for the purpose of participating in a multistate preferred drug list and supplemental
rebate program. The commissioner shall ensure that any contract meets all federal requirements
and maximizes federal financial participation. The commissioner shall publish the preferred
drug list annually in the State Register and shall maintain an accurate and up-to-date list on
the agency Web site.
(b) The commissioner may add to, delete from, and otherwise modify the preferred drug list,
after consulting with the Formulary Committee and appropriate medical specialists and providing
public notice and the opportunity for public comment.
(c) The commissioner shall adopt and administer the preferred drug list as part of the
administration of the supplemental drug rebate program. Reimbursement for prescription drugs
not on the preferred drug list may be subject to prior authorization, unless the drug manufacturer
signs a supplemental rebate contract.
(d) For purposes of this subdivision, "preferred drug list" means a list of prescription drugs
within designated therapeutic classes selected by the commissioner, for which prior authorization
based on the identity of the drug or class is not required.
(e) The commissioner shall seek any federal waivers or approvals necessary to implement
this subdivision.
    Subd. 13h. Medication therapy management services. (a) Medical assistance and general
assistance medical care cover medication therapy management services for a recipient taking four
or more prescriptions to treat or prevent two or more chronic medical conditions, or a recipient
with a drug therapy problem that is identified or prior authorized by the commissioner that has
resulted or is likely to result in significant nondrug program costs. The commissioner may cover
medical therapy management services under MinnesotaCare if the commissioner determines this
is cost-effective. For purposes of this subdivision, "medication therapy management" means the
provision of the following pharmaceutical care services by a licensed pharmacist to optimize the
therapeutic outcomes of the patient's medications:
(1) performing or obtaining necessary assessments of the patient's health status;
(2) formulating a medication treatment plan;
(3) monitoring and evaluating the patient's response to therapy, including safety and
effectiveness;
(4) performing a comprehensive medication review to identify, resolve, and prevent
medication-related problems, including adverse drug events;
(5) documenting the care delivered and communicating essential information to the patient's
other primary care providers;
(6) providing verbal education and training designed to enhance patient understanding and
appropriate use of the patient's medications;
(7) providing information, support services, and resources designed to enhance patient
adherence with the patient's therapeutic regimens; and
(8) coordinating and integrating medication therapy management services within the broader
health care management services being provided to the patient.
Nothing in this subdivision shall be construed to expand or modify the scope of practice of the
pharmacist as defined in section 151.01, subdivision 27.
(b) To be eligible for reimbursement for services under this subdivision, a pharmacist must
meet the following requirements:
(1) have a valid license issued under chapter 151;
(2) have graduated from an accredited college of pharmacy on or after May 1996, or
completed a structured and comprehensive education program approved by the Board of Pharmacy
and the American Council of Pharmaceutical Education for the provision and documentation of
pharmaceutical care management services that has both clinical and didactic elements;
(3) be practicing in an ambulatory care setting as part of a multidisciplinary team or have
developed a structured patient care process that is offered in a private or semiprivate patient care
area that is separate from the commercial business that also occurs in the setting; and
(4) make use of an electronic patient record system that meets state standards.
(c) For purposes of reimbursement for medication therapy management services, the
commissioner may enroll individual pharmacists as medical assistance and general assistance
medical care providers. The commissioner may also establish contact requirements between
the pharmacist and recipient, including limiting the number of reimbursable consultations per
recipient.
(d) The commissioner, after receiving recommendations from professional medical
associations, professional pharmacy associations, and consumer groups, shall convene an
11-member Medication Therapy Management Advisory Committee to advise the commissioner
on the implementation and administration of medication therapy management services. The
committee shall be comprised of: two licensed physicians; two licensed pharmacists; two
consumer representatives; two health plan company representatives; and three members with
expertise in the area of medication therapy management, who may be licensed physicians or
licensed pharmacists. The committee is governed by section 15.059, except that committee
members do not receive compensation or reimbursement for expenses. The advisory committee
expires on June 30, 2007.
(e) The commissioner shall evaluate the effect of medication therapy management on quality
of care, patient outcomes, and program costs, and shall include a description of any savings
generated in the medical assistance and general assistance medical care programs that can be
attributable to this coverage. The evaluation shall be submitted to the legislature by December 15,
2007. The commissioner may contract with a vendor or an academic institution that has expertise
in evaluating health care outcomes for the purpose of completing the evaluation.
    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 co-payments. (a) Medical assistance covers health
care prepayment plan premiums, insurance premiums, and co-payments if determined to be
cost-effective by the commissioner. For purposes of obtaining Medicare Part A and Part B, and
co-payments, 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 eligible persons
in obtaining emergency or nonemergency medical care when paid directly to an ambulance
company, common carrier, or other recognized providers of transportation services.
(b) Medical assistance covers special transportation, as defined in Minnesota Rules, part
9505.0315, subpart 1, item F, if 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.
The commissioner may use an order by the recipient's attending physician to certify that the
recipient requires special transportation services. 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. Special transportation providers must obtain written documentation from the health
care service provider who is serving the recipient being transported, identifying the time that the
recipient arrived. Special transportation providers may not bill for separate base rates for the
continuation of a trip beyond the original destination. Special transportation providers must take
recipients to the nearest appropriate health care provider, using the most direct route available.
The maximum medical assistance reimbursement rates for special transportation services are:
(1) $17 for the base rate and $1.35 per mile for services to eligible persons who need a
wheelchair-accessible van;
(2) $11.50 for the base rate and $1.30 per mile for services to eligible persons who do not
need a wheelchair-accessible van; and
(3) $60 for the base rate and $2.40 per mile, and an attendant rate of $9 per trip, for services
to eligible persons who need a 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
sections 256B.0651 and 256B.0653 to 256B.0656. 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 sections 256B.0651 and
256B.0653 to 256B.0656. 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 sections 256B.0651 and 256B.0653 to
256B.0656. Notwithstanding the provisions of section 256B.0655, subdivision 2, 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
sections 256B.0651 and 256B.0653 to 256B.0656, 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 sections 256B.0651 and 256B.0653 to 256B.0656, where the services have a statement of
need by a physician, provided in accordance with a plan, and are supervised by the recipient or a
qualified professional. The physician's statement of need for personal care assistant services shall
be documented on a form approved by the commissioner and include the diagnosis or condition
of the person that results in a need for personal care assistant services and be updated when
the person's medical condition requires a change, but at least annually if the need for personal
care assistant services is ongoing.
"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, or a licensed social worker as defined in section 148B.21. 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 245.4887, 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 section 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) 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.
(j) 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.
(k) 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.
(l) 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.
(m) 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 commissioner
of finance. 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.
(n) Case management services under this subdivision do not include therapy, treatment,
legal, or outreach services.
(o) 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.
(p) Payment for case management services under this subdivision shall not duplicate
payments made under other program authorities for the same purpose.
(q) 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.
(r) 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.
(s) 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.
(t) The adjustments in paragraphs (s) and (t) shall be calculated separately for children
and adults.
    Subd. 20a. Case management; developmental disabilities. To the extent defined in the state
Medicaid plan, case management service activities for persons with developmental disabilities
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
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. Notwithstanding Minnesota Rules, part 9505.0323, subpart
15, the commissioner may set authorization thresholds for day treatment for adults according
to section 256B.0625, subdivision 25. Effective July 1, 2004, medical assistance covers day
treatment services for children as specified under section 256B.0943.
    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. 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.
    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 developmentally disabled. 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 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.[Repealed, 1Sp2003 c 14 art 4 s 24]
    Subd. 35a. Children's mental health crisis response services. Medical assistance covers
children's mental health crisis response services according to section 256B.0944.
    Subd. 35b. Children's therapeutic services and supports. Medical assistance covers
children's therapeutic services and supports according to section 256B.0943.
    Subd. 36.[Repealed, 1Sp2003 c 14 art 4 s 24]
    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 chapter
148D; 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.
    Subd. 45. Subacute psychiatric care for persons under 21 years of age. Medical assistance
covers subacute psychiatric care for person under 21 years of age when:
(1) the services meet the requirements of Code of Federal Regulations, title 42, section
440.160;
(2) the facility is accredited as a psychiatric treatment facility by the Joint Commission on
Accreditation of Healthcare Organizations, the Commission on Accreditation of Rehabilitation
Facilities, or the Council on Accreditation; and
(3) the facility is licensed by the commissioner of health under section 144.50.
    Subd. 46. Mental health telemedicine. Effective January 1, 2006, and subject to federal
approval, mental health services that are otherwise covered by medical assistance as direct
face-to-face services may be provided via two-way interactive video. Use of two-way interactive
video must be medically appropriate to the condition and needs of the person being served.
Reimbursement is at the same rates and under the same conditions that would otherwise apply
to the service. The interactive video equipment and connection must comply with Medicare
standards in effect at the time the service is provided.
    Subd. 47. Treatment foster care services. Effective July 1, 2006, and subject to federal
approval, medical assistance covers treatment foster care services according to section 256B.0946.
    Subd. 48. Psychiatric consultation to primary care practitioners. Effective January 1,
2006, medical assistance covers consultation provided by a psychiatrist via telephone, e-mail,
facsimile, or other means of communication to primary care practitioners, including pediatricians.
The need for consultation and the receipt of the consultation must be documented in the patient
record maintained by the primary care practitioner. If the patient consents, and subject to federal
limitations and data privacy provisions, the consultation may be provided without the patient
present.
History: 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; 2003
c 112 art 2 s 50; 1Sp2003 c 14 art 3 s 25; art 4 s 4-7; art 11 s 11; art 12 s 33-36; 2004 c 288 art 5
s 3; art 6 s 22; 2005 c 10 art 1 s 48; 2005 c 56 s 1; 2005 c 98 art 2 s 3,4; 2005 c 147 art 1 s 67;
2005 c 155 art 3 s 2-6; 1Sp2005 c 4 art 2 s 8-10; art 7 s 13,14; art 8 s 29-40; 2006 c 282 art 16 s 6
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.
History: 1Sp1993 c 1 art 5 s 50; 1997 c 203 art 4 s 27
    Subdivision 1.[Paragraph (a) renumbered 256B.0651, subdivision 1; 256B.0655,
subd 1a
]
[Paragraph (b) renumbered 256B.0651, subdivision 1, para (b); 256B.0654, subdivision 1,
para (a); 256B.0655, subd 1b]
[Paragraph (c) renumbered 256B.0655, subd 1c]
[Paragraph (d) renumbered 256B.0654, subdivision 1, para (b)]
[Paragraph (e) renumbered 256B.0655, subd 1d]
[Paragraph (f) renumbered 256B.0651, subdivision 1, para (c)]
Paragraph (g) renumbered 256B.0655, subd 1e
[Paragraph (h) renumbered 256B.0651, subdivision 1, para (d)]
[Paragraph (i) renumbered 256B.0655, subd 1f]
[Paragraph (j) renumbered 256B.0655, subd 1g]
[Paragraph (k) renumbered 256B.0655, subd 1h]
[Paragraph (l) renumbered 256B.0655, subd 1i]
[Paragraph (m) renumbered 256B.0653, subdivision 1, para (a)]
[Paragraph (n) renumbered 256B.0651, subdivision 1, para (e)]
    Subd. 2.[Renumbered 256B.0651, subd 2]
    Subd. 3.[Repealed, 1991 c 292 art 7 s 26]
    Subd. 4.[Renumbered 256B.0655, subd 2]
    Subd. 5.[Paragraph (a) renumbered 256B.0651, subds 10 and 11]
[Paragraph (b) renumbered 256B.0651, subd 4]
[Paragraph (c) renumbered 256B.0651, subd 5]
[Paragraph (d) renumbered 256B.0655, subd 3]
[Paragraph (e) renumbered 256B.0651, subd 6; 256B.0655, subd 4]
[Paragraph (e)(1) renumbered 256B.0651, subd 6]
[Paragraph (e)(2) renumbered 256B.0655, subd 4]
[Paragraph (e)(3) renumbered 256B.0654, subd 2]
[Paragraph (e)(4) renumbered 256B.0651, subd 6, para (b)]
[Paragraph (f) renumbered 256B.0651, subd 7]
[Paragraph (g) renumbered 256B.0651, subd 12]
[Paragraph (h) renumbered 256B.0651, subd 8]
[Paragraph (i) renumbered 256B.0651, subd 9]
    Subd. 6.[Renumbered 256B.0651, subd 13]
    Subd. 7.[Renumbered 256B.0651, subd 3]
    Subd. 8.[Renumbered 256B.0655, subd 5]
    Subd. 9.[Renumbered 256B.0655, subd 6]
    Subd. 10.[Renumbered 256B.0655, subd 7]
    Subd. 11.[Renumbered 256B.0654, subd 3]
    Subd. 12.[Renumbered 256B.0655, subd 8]
    Subd. 13.[Renumbered 256B.0656]
    Subd. 14.[Renumbered 256B.0653, subdivision 1, para (b)]
    Subd. 15.[Renumbered 256B.0653, subdivision 1, para (c)]
    Subd. 16.[Renumbered 256B.0654, subd 4]
    Subd. 17.[Renumbered 256B.0655, subd 9]
    Subd. 18.[Renumbered 256B.0655, subd 10]
256B.0628 [Renumbered 256B.0652]
    Subdivision 1.[Repealed, 2005 c 98 art 2 s 18]
    Subd. 2.[Repealed, 2005 c 98 art 2 s 18]
    Subd. 3.[Repealed, 1997 c 7 art 2 s 67]
    Subd. 4.[Repealed, 2005 c 98 art 2 s 18]
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.
History: 1973 c 717 s 5
256B.0631 MEDICAL ASSISTANCE CO-PAYMENTS.
    Subdivision 1. Co-payments. (a) Except as provided in subdivision 2, the medical assistance
benefit plan shall include the following co-payments for all recipients, effective for services
provided on or after October 1, 2003:
(1) $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;
(2) $3 for eyeglasses;
(3) $6 for nonemergency visits to a hospital-based emergency room; and
(4) $3 per brand-name drug prescription and $1 per generic drug prescription, subject to
a $12 per month maximum for prescription drug co-payments. No co-payments shall apply to
antipsychotic drugs when used for the treatment of mental illness.
(b) Recipients of medical assistance are responsible for all co-payments in this subdivision.
    Subd. 2. Exceptions. Co-payments shall be subject to the following exceptions:
(1) children under the age of 21;
(2) pregnant women for services that relate to the pregnancy or any other medical condition
that may complicate the pregnancy;
(3) recipients expected to reside for at least 30 days in a hospital, nursing home, or
intermediate care facility for the developmentally disabled;
(4) recipients receiving hospice care;
(5) 100 percent federally funded services provided by an Indian health service;
(6) emergency services;
(7) family planning services;
(8) services that are paid by Medicare, resulting in the medical assistance program paying for
the coinsurance and deductible; and
(9) co-payments that exceed one per day per provider for nonpreventive visits, eyeglasses,
and nonemergency visits to a hospital-based emergency room.
    Subd. 3. Collection. The medical assistance reimbursement to the provider shall be reduced
by the amount of the co-payment, except that reimbursement for prescription drugs shall not
be reduced once a recipient has reached the $12 per month maximum for prescription drug
co-payments. The provider collects the co-payment from the recipient. Providers may not deny
services to recipients who are unable to pay the co-payment, except as provided in subdivision 4.
    Subd. 4. Uncollected debt. If it is the routine business practice of a provider to refuse
service to an individual with uncollected debt, the provider may include uncollected co-payments
under this section. A provider must give advance notice to a recipient with uncollected debt
before services can be denied.
History: 1Sp2003 c 14 art 12 s 37; 2005 c 56 s 1; 1Sp2005 c 4 art 8 s 41,42
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 100-485.
(b) Beginning July 1, 2002, contingent upon federal funding, 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 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, contingent upon federal funding, 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]
History: 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; art 10 s 66; 2002 c 277 s 31,33; 2002 c 379 art 1 s 113; 1Sp2003 c 14 art 12 s 38,39
256B.0637 PRESUMPTIVE ELIGIBILITY; 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.
History: 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 270C.40.
    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 paragraphs (b) and (d), 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) The commissioner may suspend or terminate a vendor's participation in the program
without providing advance notice and an opportunity for a hearing when the suspension or
termination is required because of the vendor's exclusion from participation in Medicare.
Within five days of taking such action, the commissioner must send notice of the suspension or
termination. The notice must:
(1) state that suspension or termination is the result of the vendor's exclusion from Medicare;
(2) identify the effective date of the suspension or termination;
(3) inform the vendor of the need to be reinstated to Medicare before reapplying for
participation in the program; and
(4) inform the vendor of the right to submit written evidence for consideration by the
commissioner.
(e) 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.
History: 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; 1Sp2003 c 14 art 2 s
17; 2005 c 151 art 2 s 17
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 developmental disabilities 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.
History: 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; 2005 c 56 s 1
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.
History: 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.
History: 1990 c 568 art 3 s 53
256B.0644 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.
History: 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.
History: 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 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.
History: 1973 c 717 s 7
256B.0651 HOME CARE SERVICES.
    Subdivision 1. Definitions. (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 home health agency services shall be conducted by a home
health agency nurse. Assessments for medical assistance home care services for developmental
disability 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) "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.
(d) "Medically necessary" has the meaning given in Minnesota Rules, parts 9505.0170 to
9505.0475.
(e) "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 and sections
256B.0653 to 256B.0656 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 section 256B.0655, subdivision 7;
(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. 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. 4. Prior authorization; exceptions. All home care services above the limits in
subdivision 11 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.
    Subd. 5. Retroactive authorization. A request for retroactive authorization will be evaluated
according to the same criteria applied to prior authorization requests.
    Subd. 6. Prior authorization. The commissioner, or the commissioner's designee, shall
review the assessment, service update, request for temporary services, request for flexible use
option, 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:
(a) 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.
(b) 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 paragraph, 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.
    Subd. 7. Prior authorization; time limits. The commissioner or the commissioner's
designee shall determine the time period for which a prior authorization shall be effective and,
if flexible use has been requested, whether to allow the flexible use option. 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 subdivision 4, 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 subdivision 8, 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.
    Subd. 8. 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.
    Subd. 9. Prior authorization for 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 subdivision 11.
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. 10. Limitation on payments. Medical assistance payments for home care services
shall be limited according to subdivisions 4 to 12 and sections 256B.0654, subdivision 2, and
256B.0655, subdivisions 3 and 4.
    Subd. 11. 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.
    Subd. 12. 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 subdivisions 4 to 12 and
sections 256B.0654, subdivision 2, and 256B.0655, subdivisions 3 and 4, 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.
    Subd. 13. 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 and sections 256B.0653 to 256B.0656. 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.
History: 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; 2003 c 15 art 1 s 33; 1Sp2003 c 14 art 3 s 26-28; 2005 c 10 art 1 s
49,50; 2005 c 56 s 1; 1Sp2005 c 4 art 7 s 15-19
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
developmental disabilities 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 developmental disabilities.
(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.
History: 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; 2005 c 56 s 1
256B.0653 HOME HEALTH AGENCY SERVICES.
    Subdivision 1. Covered services. (a) Homecare; skilled nurse visits. "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.
(b) 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.
(c) Therapies through home health agencies. (1) 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.
(2) 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.
History: 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; 2003 c 15 art 1 s 33; 1Sp2003 c 14 art 3 s 26-28; 2005 c 10 art 1 s
49,50; 1Sp2005 c 4 art 7 s 15-19
256B.0654 PRIVATE DUTY NURSING.
    Subdivision 1. Definitions. (a) "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 medical assistance home care
services for developmental disabilities 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.
(b) "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.
    Subd. 2. 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 section 256B.0655, subdivision 4;
(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 and sections
256B.0651, 256B.0653, 256B.0655, and 256B.0656 than would otherwise be authorized under
section 256B.49.
    Subd. 3. 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 and sections 256B.0651, 256B.0653, 256B.0655,
and 256B.0656, "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 2.
    Subd. 4. 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 chapter 245C, 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.
History: 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; 2003 c 15 art 1 s 33; 1Sp2003 c 14 art 3 s 26-28; 2005 c 10 art 1 s
49,50; 2005 c 56 s 1; 1Sp2005 c 4 art 7 s 15-19
256B.0655 PERSONAL CARE ASSISTANT SERVICES.
    Subdivision 1. Definitions. For purposes of this section and sections 256B.0651, 256B.0653,
256B.0654, and 256B.0656, the terms defined in subdivisions 1a to 1i have the meanings given
them unless otherwise provided or indicated by the context.
    Subd. 1a. Activities of daily living. "Activities of daily living" includes eating, toileting,
grooming, dressing, bathing, transferring, mobility, and positioning.
    Subd. 1b. Assessment. "Assessment" means a review and evaluation of a recipient's need
for home care services conducted in person. 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 or sections 256B.0651, 256B.0653, 256B.0654, and 256B.0656,
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
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.
    Subd. 1c. Care plan. "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.
    Subd. 1d. Health-related functions. "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 assistant.
    Subd. 1e. Instrumental activities of daily living. "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.
    Subd. 1f. Personal care assistant. "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 E;
(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;
(6) maintains daily written records detailing:
(i) the actual services provided to the recipient; and
(ii) the amount of time spent providing the services; and
(7) is subject to criminal background checks and procedures specified in chapter 245C.
    Subd. 1g. Personal care provider organization. "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 chapter 245C. 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 chapter 245C, or a comparable
crime in another jurisdiction, unless the owner or managerial official meets the reconsideration
criteria specified in chapter 245C;
(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 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;
(3) the organization must maintain documentation and a recipient file and satisfy
communication requirements in section 256B.0655, subdivision 2, paragraph (f); and
(4) the organization must comply with all laws and rules governing the provision of personal
care assistant services.
    Subd. 1h. Responsible party. "Responsible party" means an individual who is capable of
providing the support necessary to assist the recipient to live in the community, is at least 18 years
old, actively participates in planning and directing of personal care assistant services, and is not
the personal care assistant. The responsible party must be accessible to the recipient and the
personal care assistant when personal care services are being provided and monitor the services at
least weekly according to the plan of care. The responsible party must be identified at the time
of assessment and listed on the recipient's service agreement and care plan. Responsible parties
who are parents of minors or guardians of minors or incapacitated persons may delegate the
responsibility to another adult who is not the personal care assistant 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. The delegated
responsible party is not required to reside with the recipient while serving as the responsible party
if competent supervision to ensure the health and safety of the recipient and monitoring of services
provided are stated as part of the person's individual service plan under a home care service or
home and community-based waiver program or in conjunction with a home care targeted case
management service provider or other case manager. The responsible party must assure that the
delegate performs the functions of the responsible party, is identified at the time of the assessment,
and is listed on the service agreement and the care plan. 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.
    Subd. 1i. Service plan. "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.
    Subd. 2. 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 subdivisions 3 and 4, and sections 256B.0651, subdivisions 4 to 12, and
256B.0654, subdivision 2.
(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 provided without a physician's statement of need as required by section
256B.0625, subdivision 19c, and included in the personal care provider agency's file for the
recipient;
(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) homemaker services that are not an integral part of a personal care assistant services;
(11) home maintenance or chore services;
(12) services not specified under paragraph (a); and
(13) 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.
(f) In order to be paid for personal care assistant services, personal care provider
organizations, and personal care assistant choice providers are required:
(1) to maintain a recipient file for each recipient for whom services are being billed that
contains:
(i) the current physician's statement of need as required by section 256B.0625, subdivision
19c
;
(ii) the service plan, including the monthly authorized hours, or flexible use plan;
(iii) the care plan, signed by the recipient and the qualified professional, if required or
designated, detailing the personal care assistant services to be provided;
(iv) documentation, on a form approved by the commissioner and signed by the personal care
assistant, specifying the day, month, year, arrival, and departure times, with AM and PM notation,
for all services provided to the recipient. The form must include a notice that it is a federal crime
to provide false information on personal care service billings for medical assistance payment; and
(v) all notices to the recipient regarding personal care service use exceeding authorized
hours; and
(2) to communicate, by telephone if available, and in writing, with the recipient or the
responsible party about the schedule for use of authorized hours and to notify the recipient and
the county public health nurse in advance and as soon as possible, on a form approved by the
commissioner, if the monthly number of hours authorized is likely to be exceeded for the month.
(g) The commissioner shall establish an ongoing audit process for potential fraud and abuse
for personal care assistant services. The audit process must include, at a minimum, a requirement
that the documentation of hours of care provided be on a form approved by the commissioner and
include the personal care assistant's signature attesting that the hours shown on each bill were
provided by the personal care assistant on the dates and the times specified.
    Subd. 3. Assessment and service plan. Assessments under subdivision 1b and sections
256B.0651, subdivision 1, paragraph (b), and 256B.0654, 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 subdivision 8, 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 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. If the change in service need is due to a change
in medical condition, a new physician's statement of need required by section 256B.0625,
subdivision 19c
, must be obtained.
(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 subdivisions
1a to 1i and sections 256B.0651, subdivision 1; 256B.0653, subdivision 1; and 256B.0654,
subdivision 1
.
    Subd. 4. Prior authorization. The commissioner, or the commissioner's designee, shall
review the assessment, service update, request for temporary services, request for flexible use
option, 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) 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 section 256B.0651, subdivision 11. 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.
(2) 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.
(3) 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 sections 256B.0651, 256B.0653,
256B.0654, and 256B.0656 and shall use an advisory group, including representatives of
recipients, providers, and counties, for consultation in establishing and revising the forms and
protocols.
(4) 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.
(5) 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.
(6) Time authorized for personal care relating to Level I behavior in paragraph (5), clauses
(A) to (C), shall be based on the predictability, frequency, and amount of intervention required.
(7) 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 2, paragraph (a):
(A) unusual or repetitive habits;
(B) withdrawn behavior; or
(C) offensive behavior.
(8) A recipient with a home care rating of Level II behavior in paragraph (7), clauses (A) to
(C), shall be rated as comparable to a recipient with complex medical needs under paragraph (4).
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 paragraph (1), clause (B).
    Subd. 5. 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. 6. Flexible use option. (a) "Flexible use option" means the scheduled use of authorized
hours of personal care assistant services, which vary within a service authorization period
covering no more than six months, in order to more effectively meet the needs and schedule of
the recipient. Authorized hours not used within the six-month period may not be carried over to
another time period. The flexible use of personal care assistant hours for a six-month period must
be prior authorized by the commissioner, based on a request submitted on a form approved by
the commissioner. The request must include the assessment and the annual service plan prepared
by the county public health nurse.
(b) The recipient or responsible party, together with the case manager, if the recipient has
case management services, and the county public health nurse, shall determine whether flexible
use is an appropriate option based on the needs, abilities, preferences, and history of service use
of the recipient or responsible party, and if appropriate, must ensure that the allocation of hours
covers the ongoing needs of the recipient over an entire year divided into two six-month periods
of flexible use. A recipient who has terminated personal care assistant services before the end of
the 12-month authorization period shall not receive additional hours upon reapplying during the
same 12-month authorization period, except if a change in condition is documented. Services shall
be prorated for the remainder of the 12-month authorization period based on earlier assessment.
(c) If prior authorized, recipients may use their approved hours flexibly within the service
authorization period for medically necessary covered services specified in the assessment required
in subdivision 1b and section 256B.0651, subdivision 1, paragraph (b). The flexible use of
authorized hours does not increase the total amount of authorized hours available to a recipient as
determined under subdivision 4. 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.
(d) The personal care provider organization and the recipient or responsible party or the
personal care assistance choice provider must develop a written month-to-month plan of the
projected use of personal care assistant services that is part of the care plan and ensures:
(1) that the health and safety needs of the recipient will be met;
(2) that the total annual authorization will not be used before the end of the authorization
period; and
(3) monthly monitoring will be conducted of hours used as a percentage of the authorized
amount.
(e) The provider shall notify the recipient or responsible party, any case manager for the
recipient, and the county public health nurse in advance and as soon as possible, on a form
approved by the commissioner, if the monthly amount of hours authorized is likely to be exceeded
for the month.
(f) The commissioner shall provide written notice to the provider, the recipient or responsible
party, any case manager for the recipient, and the county public health nurse, when a flexible use
recipient exceeds the personal care assistant service authorization for the month by an amount
determined by the commissioner. If the use of hours exceeds the monthly service authorization by
the amount determined by the commissioner for two months during any three-month period, the
commissioner shall notify the recipient and the county public health nurse that the flexible use
authorization will be revoked beginning the following month. The revocation will not become
effective if, within ten working days of the commissioner's notice of flexible use revocation, the
county public health nurse requests prior authorization for an increase in the service authorization
or continuation of the flexible use option, or the recipient appeals and assistance pending appeal
is ordered. The commissioner shall determine whether to approve the increase and continued
flexible use.
(g) The recipient or responsible party may stop the flexible use of hours by notifying the
personal care provider organization or the personal care assistance choice provider and county
public health nurse in writing.
(h) The recipient or responsible party may appeal the commissioner's action according to
section 256.045. The denial or revocation of the flexible use option shall not affect the recipient's
authorized level of personal care assistant services as determined under subdivision 4.
    Subd. 7. Fiscal intermediary option. (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 2 and within the payment parameters of subdivision 4. 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 chapter 245C;
(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 and sections 256B.0651, 256B.0653,
256B.0654, and 256B.0656.
The fiscal intermediary or owners of the entity that provides fiscal intermediary services
under this subdivision must pass a criminal background check.
(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 section
256B.0651, 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 1b, 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 5 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 4.
    Subd. 8. 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. 9. Quality assurance plan. 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.
    Subd. 10. Oversight of enrolled providers. The commissioner may request from providers
documentation of compliance with laws, rules, and policies governing the provision of personal
care assistant services. A personal care assistant service provider must provide the requested
documentation to the commissioner within ten business days of the request. Failure to provide
information to demonstrate substantial compliance with laws, rules, or policies may result in
suspension, denial, or termination of the provider agreement.
History: 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; 2003 c 15 art 1 s 33; 1Sp2003 c 14 art 3 s 26-28; 2005 c 10 art 1 s
49,50; 1Sp2005 c 4 art 7 s 15-19
256B.0656 CONSUMER DIRECTED HOME CARE 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.
History: 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; 2003 c 15 art 1 s 33; 1Sp2003 c 14 art 3 s 26-28; 2005 c 10 art 1 s
49,50; 1Sp2005 c 4 art 7 s 15-19
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]
History: 1996 c 451 art 2 s 22; 1997 c 195 s 2-4; 2001 c 203 s 10
256B.072 PERFORMANCE REPORTING AND QUALITY IMPROVEMENT SYSTEM.
(a) The commissioner of human services shall establish a performance reporting system for
health care providers who provide health care services to public program recipients covered
under chapters 256B, 256D, and 256L, reporting separately for managed care and fee-for-service
recipients.
(b) The measures used for the performance reporting system for medical groups shall
include measures of care for asthma, diabetes, hypertension, and coronary artery disease and
measures of preventive care services. The measures used for the performance reporting system
for inpatient hospitals shall include measures of care for acute myocardial infarction, heart
failure, and pneumonia, and measures of care and prevention of surgical infections. In the
case of a medical group, the measures used shall be consistent with measures published by
nonprofit Minnesota or national organizations that produce and disseminate health care quality
measures or evidence-based health care guidelines. In the case of inpatient hospital measures,
the commissioner shall appoint the Minnesota Hospital Association and Stratis Health to advise
on the development of the performance measures to be used for hospital reporting. To enable
a consistent measurement process across the community, the commissioner may use measures
of care provided for patients in addition to those identified in paragraph (a). The commissioner
shall ensure collaboration with other health care reporting organizations so that the measures
described in this section are consistent with those reported by those organizations and used
by other purchasers in Minnesota.
(c) The commissioner may require providers to submit information in a required format to
a health care reporting organization or to cooperate with the information collection procedures
of that organization. The commissioner may collaborate with a reporting organization to collect
information reported and to prevent duplication of reporting.
(d) By October 1, 2007, and annually thereafter, the commissioner shall report through a
public Web site the results by medical groups and hospitals, where possible, of the measures
under this section, and shall compare the results by medical groups and hospitals for patients
enrolled in public programs to patients enrolled in private health plans. To achieve this reporting,
the commissioner may collaborate with a health care reporting organization that operates a Web
site suitable for this purpose.
History: 1Sp2005 c 4 art 8 s 43
256B.075 DISEASE MANAGEMENT PROGRAMS.
    Subdivision 1. General. The commissioner shall implement disease management initiatives
that seek to improve patient care and health outcomes and reduce health care costs by managing
the care provided to recipients with chronic conditions.
    Subd. 2. Fee-for-service. (a) The commissioner shall develop and implement a disease
management program for medical assistance and general assistance medical care recipients who
are not enrolled in the prepaid medical assistance or prepaid general assistance medical care
programs and who are receiving services on a fee-for-service basis. The commissioner may
contract with an outside organization to provide these services.
(b) The commissioner shall seek any federal approval necessary to implement this section
and to obtain federal matching funds.
(c) The commissioner shall develop and implement a pilot intensive care management
program for medical assistance children with complex and chronic medical issues who are not
able to participate in the metro-based U Special Kids program due to geographic distance.
    Subd. 3. Prepaid managed care programs. For the prepaid medical assistance, prepaid
general assistance medical care, and MinnesotaCare programs, the commissioner shall ensure
that contracting health plans implement disease management programs that are appropriate for
Minnesota health care program recipients and have been designed by the health plan to improve
patient care and health outcomes and reduce health care costs by managing the care provided to
recipients with chronic conditions.
    Subd. 4. Report. The commissioner of human services shall report to the legislature
by January 15, 2005, on the status of disease management initiatives, and shall present
recommendations to the legislature on any statutory changes needed to increase the effectiveness
of these initiatives.
    Subd. 5.[Repealed, 1Sp2005 c 4 art 8 s 88]
History: 2004 c 288 art 7 s 6; 1Sp2005 c 4 art 8 s 44
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.
History: 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.
History: 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 section 256.975,
subdivision 7
, 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 and the alternative care program under section 256B.0913.
    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 developmental disabilities 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 developmental disability as outlined in
paragraph (b).
(b) A person who has a diagnosis or possible diagnosis of mental illness or developmental
disability 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 101-508.
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 developmental disability professional, for persons with a primary or
secondary diagnosis of developmental disability. For purposes of this requirement, a qualified
developmental disability professional must meet the standards for a qualified developmental
disability professional under Code of Federal Regulations, title 42, section 483.430.
(c) The local county mental health authority or the state developmental disability 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 developmental disability 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 40 calendar 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 40 calendar
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 biennial home and community-based services quality assurance plan on a form provided
by the commissioner.
(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 developmental disability is approved by the state developmental disability 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]
History: 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; 1Sp2003 c 14 art 2 s 56; art 3 s 29; 2004 c 288 art 5 s
4; 2005 c 56 s 1; 2005 c 98 art 2 s 5; 1Sp2005 c 4 art 8 s 45
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 would be eligible for medical assistance within 135 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 135 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;
(6) the monthly cost of the alternative care services funded by the program for this person
does not exceed 75 percent of the monthly limit described under section 256B.0915, subdivision
3a
. 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; and
(7) the person is making timely payments of the assessed monthly fee.
A person is ineligible if payment of the fee is over 60 days past due, unless the person agrees to:
(i) the appointment of a representative payee;
(ii) automatic payment from a financial account;
(iii) the establishment of greater family involvement in the financial management of
payments; or
(iv) another method acceptable to the county to ensure prompt fee payments.
The county shall extend the client's eligibility as necessary while making arrangements to
facilitate payment of past-due amounts and future premium payments. Following disenrollment
due to nonpayment of a monthly fee, eligibility shall not be reinstated for a period of 30 days.
(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 and the elderly
waiver program 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, alternative care funds may not be used to pay for
any service the cost of which: (i) is payable by medical assistance; (ii) is used by a recipient to
meet a waiver obligation; or (iii) is used to pay a medical assistance income spenddown for a
person who is eligible to participate in the federally approved elderly waiver program under the
special income standard provision.
(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 for a
nursing home resident or certified boarding care home resident to assist with a relocation process
to a community-based setting.
(d) Alternative care funding is not available for a person whose income is greater than the
maintenance needs allowance under section 256B.0915, subdivision 1d, but equal to or less than
120 percent of the federal poverty guideline effective July 1 in the year for which alternative care
eligibility is determined, who would be eligible for the elderly waiver with a waiver obligation.
    Subd. 5. Services covered under alternative care. Alternative care funding may be used for
payment of costs of:
(1) adult day care;
(2) home health aide;
(3) homemaker services;
(4) personal care;
(5) case management;
(6) respite care;
(7) care-related supplies and equipment;
(8) meals delivered to the home;
(9) transportation;
(10) nursing services;
(11) chore services;
(12) companion services;
(13) nutrition services;
(14) training for direct informal caregivers;
(15) telehome care to provide services in their own homes in conjunction with in-home visits;
(16) discretionary services, for which counties may make payment from their alternative
care program allocation or services not otherwise defined in this section or section 256B.0625,
following approval by the commissioner;
(17) environmental modifications; and
(18) direct cash payments for which counties may make payment from their alternative care
program allocation to clients for the purpose of purchasing services, following approval by the
commissioner, and subject to the provisions of subdivision 5h, until approval and implementation
of consumer-directed services through the federally approved elderly waiver plan. Upon
implementation, consumer-directed services under the alternative care program are available
statewide and limited to the average monthly expenditures representative of all alternative care
program participants for the same case mix resident class assigned in the most recent fiscal year
for which complete expenditure data is available.
Total annual payments for discretionary services and direct cash payments, until the
federally approved consumer-directed service option is implemented statewide, for all clients
within a county may not exceed 25 percent of that county's annual alternative care program base
allocation. Thereafter, discretionary services are limited to 25 percent of the county's annual
alternative care program base allocation.
    Subd. 5a. Services; service definitions; service standards. (a) 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 transitional support services, assisted living services, adult foster care services,
and residential care services.
(b) The county agency must ensure that the funds are not used to supplant services available
through other public assistance or services programs. 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.
(c) 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 requirements or a relative who meets the criteria and is also the
responsible party under an individual service plan that ensures the client's health and safety
and supervision of the personal care services by a qualified professional as defined in section
256B.0625, subdivision 19c. Relative hardship is established by the county when the client's care
causes a relative caregiver to do any of the following: resign from a paying job, reduce work
hours resulting in lost wages, obtain a leave of absence resulting in lost wages, incur substantial
client-related expenses, provide services to address authorized, unstaffed direct care time, or meet
special needs of the client unmet in the formal service plan.
    Subd. 5b. Adult foster care rate. 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).
    Subd. 5c. Residential care services; supportive services; health-related services. 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 under section 157.16, and are registered with the Department of Health as
providing special services under section 157.17 except settings that are currently registered under
chapter 144D. Residential care services are defined as "supportive services" and "health-related
services." "Supportive services" means services as defined in section 157.17, subdivision 1,
paragraph (a). "Health-related services" means services covered in section 157.17, subdivision
1
, paragraph (b). Individuals receiving residential care services cannot receive homemaking
services funded under this section.
    Subd. 5d. Assisted living services. 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, oversight, and
supportive services as defined in section 157.17, subdivision 1, paragraph (a), individualized
home care aide tasks as defined in Minnesota Rules, part 4668.0110, and individualized home
management tasks as defined in Minnesota Rules, part 4668.0120, 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.
    Subd. 5e. Further assisted living requirements. (a) 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.
(b) For establishments registered under chapter 144D, assisted living services under this
section means either the services described in subdivision 5d 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.
    Subd. 5f. Payment rates for assisted living services and residential care. (a) 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.
(b) The individualized monthly negotiated payment for assisted living services as described
in subdivision 5d or 5e, paragraph (b), and residential care services as described in subdivision 5c,
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
according to subdivision 4, paragraph (a), clause (6).
(c) 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).
    Subd. 5g. Provisions governing direct cash payments. A county agency may make payment
from their alternative care program allocation for direct cash payments to the client for the purpose
of purchasing the services. The following provisions apply to payments under this subdivision:
(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); and
(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.
    Subd. 5h. Cash payments to persons. (a) 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:
(1) they must be over and above the normal cost of caring for the person if the person
did not have functional limitations;
(2) they must be directly attributable to the person's functional limitations;
(3) they must have the potential to be effective at meeting the goals of the program; and
(4) 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.
(b) 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.
(c) Persons receiving grants under this section shall have the following responsibilities:
(1) spend the grant money in a manner consistent with their individualized service plan
with the local agency;
(2) notify the local agency of any necessary changes in the grant expenditures;
(3) arrange and pay for supports; and
(4) inform the local agency of areas where they have experienced difficulty securing or
maintaining supports.
(d) The county shall report client outcomes, services, and costs under this paragraph in a
manner prescribed by the commissioner.
    Subd. 5i. Immunity. 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).
    Subd. 6. Alternative care program administration. (a) 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.
(b) Alternative care pilot projects operate according to this section and the provisions of
Laws 1993, First Special Session chapter 1, article 5, section 133, under agreement with the
commissioner. Each pilot project agreement period shall begin no later than the first payment
cycle of the state fiscal year and continue through the last payment cycle of the state fiscal year.
    Subd. 7. Case management. 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).
    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 county of service 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, including qualified case
management or service coordination providers other than those employed by any county;
however, the county or tribe maintains responsibility for prior authorizing services in accordance
with statutory and administrative requirements. The case manager must give the individual a
ten-day written notice of any denial, termination, or reduction of alternative care services.
(b) The county of service must provide access to and arrange for case management services,
including assuring implementation of the plan. The county of service must notify the county of
financial responsibility of the approved care plan and the amount of encumbered funds.
    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).
(f) On agreement between the commissioner and the lead agency, the commissioner may
have discretion to reallocate alternative care base allocations distributed to lead agencies in which
the base amount exceeds program expenditures.
    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 fees. (a) A fee is required for all alternative care eligible clients to help
pay for the cost of participating in the program. The amount of the fee 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 less than 100 percent of the federal poverty guideline effective on July 1 of the state fiscal year
in which the fee 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 equal to or greater than 100 percent but less than 150 percent of the federal poverty guideline
effective on July 1 of the state fiscal year in which the fee is being computed, and total assets are
less than $10,000, the fee is five percent of the cost of alternative care services;
(3) when the alternative care client's income less recurring and predictable medical expenses
is equal to or greater than 150 percent but less than 200 percent of the federal poverty guidelines
effective on July 1 of the state fiscal year in which the fee is being computed and assets are less
than $10,000, the fee is 15 percent of the cost of alternative care services;
(4) when the alternative care client's income less recurring and predictable medical expenses
is equal to or greater than 200 percent of the federal poverty guidelines effective on July 1 of the
state fiscal year in which the fee is being computed and assets are less than $10,000, the fee is 30
percent of the cost of alternative care services; and
(5) when the alternative care client's assets are equal to or greater than $10,000, the fee is 30
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 shall be included in the estimated costs for the purpose of
determining the fee.
Fees are due and payable each month alternative care services are received unless the actual
cost of the services is less than the fee, in which case the fee is the lesser amount.
(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 married couple is requesting an asset assessment under the spousal impoverishment
provisions;
(3) a person is found eligible for alternative care, but is not yet receiving alternative care
services; or
(4) a person has chosen to participate in a consumer-directed service plan for which the cost
is no greater than the total cost of the person's alternative care service plan less the monthly
fee amount that would otherwise be assessed.
(c) The county agency must record in the state's receivable system the client's assessed fee
amount or the reason the fee has been waived. The commissioner will bill and collect the fee 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
fee from the client. The commissioner shall collect unpaid fees 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 fee 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 fees billed to clients;
(2) total collections of fees billed; and
(3) balance of fees 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 submitted by the lead agency as the home and
community-based services quality assurance plan on a form provided by the commissioner.
    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]
History: 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; 1Sp2003 c 14 art 2 s 18-25; 2005
c 68 art 2 s 1; 2005 c 98 art 2 s 6; 1Sp2005 c 4 art 7 s 20-23
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 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.
History: 1986 c 444; 1999 c 245 art 4 s 60
256B.0915 MEDICAID WAIVER FOR ELDERLY SERVICES.
    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. (a) 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.
(b) The county of service or tribe must provide access to and arrange for 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. 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.
    Subd. 3a.[Repealed, 1Sp2001 c 9 art 3 s 76; art 4 s 34]
    Subd. 3a. Elderly waiver cost limits. (a) 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 percentage rate increase or the average statewide
percentage increase in nursing facility payment rates.
(b) 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 (a), 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 (a).
    Subd. 3b.[Repealed, 1Sp2001 c 9 art 3 s 76; art 4 s 34]
    Subd. 3b. Cost limits for elderly waiver applicants who reside in a nursing facility.
(a) 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 percentage rate
increase or the average statewide percentage increase in nursing facility payment rates. The limit
under this subdivision 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.
(b) 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.
    Subd. 3c.[Repealed, 1Sp2001 c 9 art 3 s 76; art 4 s 34]
    Subd. 3c. Service approval and contracting provisions. (a) 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.
(b) 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.
    Subd. 3d. Adult foster care rate. 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 subdivision 3a, paragraph (a).
    Subd. 3e. Assisted living service rate. (a) 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.
(b) The individualized monthly negotiated payment for assisted living services as described
in section 256B.0913, subdivisions 5d to 5f, and residential care services as described in section
256B.0913, subdivision 5c, 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.
(c) 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 subdivision 3a.
    Subd. 3f. Individual service rates; expenditure forecasts. (a) 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.
(b) 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.
    Subd. 3g. Service rate limits; state assumption of costs. (a) 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.
(b) Effective July 1, 2001, for service rate limits, except those described or defined in
subdivisions 3d and 3e, the rate limit for each service shall be the greater of the alternative care
statewide maximum rate or the elderly waiver statewide maximum rate.
(c) Counties may negotiate individual service rates with vendors for actual costs up to the
statewide maximum service rate limit.
    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.
The care plan must be implemented by the county administering waivered services when it is
different than the county of financial responsibility. The county administering waivered services
must notify the county of financial responsibility of the approved care plan.
    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).
    Subd. 9. Tribal management of elderly waiver. Notwithstanding contrary provisions of this
section, or those in other state laws or rules, the commissioner may develop a model for tribal
management of the elderly waiver program and implement this model through a contract between
the state and any of the state's federally recognized tribal governments. The model shall include
the provision of tribal waiver case management, assessment for personal care assistance, and
administrative requirements otherwise carried out by counties but shall not include tribal financial
eligibility determination for medical assistance.
History: 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; 1Sp2003 c 14 art 2 s
26; art 3 s 30; 2004 c 288 art 5 s 5,6; 2005 c 68 art 2 s 2-4
256B.0916 EXPANSION OF HOME AND COMMUNITY-BASED SERVICES.
    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 developmental disabilities 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;
(4) the need to serve persons affected by private sector ICF/MR closures; and
(5) the need to serve persons whose consumer support grant exception amount was
eliminated in 2004.
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
developmental disabilities. (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 developmental
disabilities 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 developmental disabilities, 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 developmental
disabilities. 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 developmental disabilities,
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 developmental disabilities 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.
    Subd. 10. Transitional supports allowance. A transitional supports allowance shall be
available to all persons under a home and community-based waiver who are moving from a
licensed setting to a community setting. "Transitional supports allowance" means a onetime
payment of up to $3,000, to cover the costs, not covered by other sources, associated with moving
from a licensed setting to a community setting. Covered costs include:
(1) lease or rent deposits;
(2) security deposits;
(3) utilities set-up costs, including telephone;
(4) essential furnishings and supplies; and
(5) personal supports and transports needed to locate and transition to community settings.
History: 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; 2004 c 288 art 3
s 24; 2005 c 56 s 1; 1Sp2005 c 4 art 8 s 46
256B.0917 SENIORS' AGENDA FOR INDEPENDENT LIVING (SAIL) PROJECTS.
    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, 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. 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, 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 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 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;
(4) one or more caregiver support and respite care projects, as described in subdivision 6; and
(5) 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 (4), and grant funds for paragraph (a), clause
(5), 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) the living-at-home/block nurse grant under subdivisions 7 to 10; and
(3) services identified as needed for community transition.
History: 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; 2005 c 10 art 1 s 51,52; 2005 c
98 art 3 s 24; 2006 c 212 art 3 s 19
256B.0918 EMPLOYEE SCHOLARSHIP COSTS.
    Subdivision 1. Program criteria. Beginning on or after October 1, 2005, within the limits of
appropriations specifically available for this purpose, the commissioner shall provide funding to
qualified provider applicants for employee scholarships for education in nursing and other health
care fields. Employee scholarships must be for a course of study that is expected to lead to career
advancement with the provider or in the field of long-term care, including home care or care of
persons with disabilities, or nursing. Providers that secure this funding must use it to award
scholarships to employees who work an average of at least 20 hours per week for the provider.
Executive management staff without direct care duties, registered nurses, and therapists are not
eligible to receive scholarships under this section.
    Subd. 2. Participating providers. The commissioner shall publish a request for proposals
in the State Register by August 15, 2005, specifying provider eligibility requirements, provider
selection criteria, program specifics, funding mechanism, and methods of evaluation. The
commissioner may publish additional requests for proposals in subsequent years. Providers
who provide services funded through the following programs are eligible to apply to participate
in the scholarship program: home and community-based waivered services for persons with
developmental disabilities under section 256B.501; home and community-based waivered
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 developmental disabilities under sections 252.40 to 252.46; and
intermediate care facilities for persons with developmental disabilities under section 256B.5012.
    Subd. 3. Provider selection criteria. To be considered for scholarship funding, the provider
shall submit a completed application within the time frame specified by the commissioner. In
awarding funding, the commissioner shall consider the following:
(1) the size of the provider as measured in annual billing to the medical assistance program.
To be eligible, a provider must receive at least $300,000 annually in medical assistance payments;
(2) the percentage of employees meeting the scholarship program recipient requirements;
(3) staff retention rates for paraprofessionals; and
(4) other criteria determined by the commissioner.
    Subd. 4. Funding specifics. Within the limits of appropriations specifically available for this
purpose, for the rate period beginning on or after October 1, 2005, to September 30, 2007, the
commissioner shall provide to each provider listed in subdivision 2 and awarded funds under
subdivision 3 a medical assistance rate increase to fund scholarships up to three-tenths percent of
the medical assistance reimbursement rate. The commissioner shall require providers to repay any
portion of funds awarded under subdivision 3 that is not used to fund scholarships. If applications
exceed available funding, funding shall be targeted to providers that employ a higher percentage
of paraprofessional staff or have lower rates of turnover of paraprofessional staff. During the
subsequent years of the program, the rate adjustment may be recalculated, at the discretion of the
commissioner. In making a recalculation the commissioner may consider the provider's success at
granting scholarships based on the amount spent during the previous year and the availability of
appropriations to continue the program.
    Subd. 5. Reporting requirements. Participating providers shall report to the commissioner
on a schedule determined by the commissioner and on a form supplied by the commissioner for a
scholarship rate for rate periods beginning October 1, 2007. The report shall include the amount
spent during the reporting period on eligible scholarships, and, for each scholarship recipient,
the name of the recipient, the amount awarded, the educational institution attended, the nature of
the educational program, the expected or actual program completion date, and a determination
of the amount spent as a percentage of the provider's reimbursement. The commissioner shall
require providers to repay all of the funds awarded under subdivision 3 if the report required in
this subdivision is not filled according to the schedule determined by the commissioner.
    Subd. 6. Evaluation. The commissioner shall report to the legislature annually, beginning
March 15, 2007, on the use of these funds.
History: 2005 c 56 s 1; 1Sp2005 c 4 art 8 s 47; 2006 c 282 art 20 s 17-19
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.
History: 1986 c 444; 1991 c 292 art 7 s 18; 1992 c 513 art 7 s 73
256B.092 SERVICES FOR PERSONS WITH DEVELOPMENTAL DISABILITIES.
    Subdivision 1. County of financial responsibility; duties. Before any services shall be
rendered to persons with developmental disabilities 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 a developmental disability
or has or may have a related condition. If the county of financial responsibility determines
that the person has a developmental disability, 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 a developmental disability, 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 a
developmental disability 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) review of eligibility for services;
(2) screening;
(3) intake;
(4) diagnosis;
(5) the review and authorization of services based upon an individualized service plan; 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) consulting with relevant medical experts or service providers;
(4) assisting the person in the identification of potential providers;
(5) assisting the person to access services;
(6) coordination of services, if coordination is not provided by another service provider;
(7) evaluation and monitoring of the services identified in the plan; and
(8) annual reviews of service plans and services provided.
(c) Case management administration and service activities that are provided to the person
with a developmental disability shall be provided directly by county agencies or under contract.
(d) Case managers are responsible for the administrative duties and service provisions
listed in paragraphs (a) and (b). Case managers shall collaborate with consumers, families, legal
representatives, and relevant medical experts and service providers in the development and annual
review of the individualized service and habilitation plans.
(e) The Department of Human Services shall offer ongoing education in case management to
case managers. Case managers shall receive no less than ten hours of case management education
and disability-related training each year.
    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. (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
children and community service agreements.
    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 developmental disabilities, 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 developmental disabilities, 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 developmental disabilities 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 developmental disabilities. (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 developmental disabilities 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 developmental disabilities 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 developmental disabilities 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 developmental disabilities 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
developmental disabilities.
    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
developmental disabilities, 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 developmental disabilities, and must assure the health and safety of the persons
receiving services.
    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 developmental disabilities, 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 developmental disabilities;
(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 developmental disabilities. 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.
The commissioner shall seek an amendment to the 1915c home and community-based
waiver to allow properly licensed adult foster care homes to provide residential services to up
to five individuals with developmental disabilities. If the amendment to the waiver is approved,
adult foster care providers that can accommodate five individuals shall increase their capacity to
five beds, provided the providers continue to meet all applicable licensing requirements.
(b) The commissioner, in administering home and community-based waivers for persons
with developmental disabilities, 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, protection, and
habilitation needs will be met, including how frequent and regular contact with persons other
than the residential service provider will occur. The individualized service plan must address the
provision of services during the day outside the residence on weekdays.
(c) When a county is evaluating denials, reductions, or terminations of home and
community-based services under section 256B.0916 for an individual, the case manager shall
offer to meet with the individual or the individual's guardian in order to discuss the prioritization
of service needs within the individualized service plan. The reduction in the authorized services
for an individual due to changes in funding for waivered services may not exceed the amount
needed to ensure medically necessary services to meet the individual's health, safety, and welfare.
    Subd. 5a. Increasing adult foster care capacity to serve five persons. (a) When an adult
foster care provider increases the capacity of an existing home licensed to serve four persons to
serve a fifth person under this section, the county agency shall reduce the contracted per diem cost
for room and board and the developmental disability waiver services of the existing foster care
home by an average of 14 percent for all individuals living in that home. A county agency may
average the required per diem rate reductions across several adult foster care homes that expand
capacity under this section to achieve the necessary overall per diem reduction.
(b) Following the contract changes in paragraph (a), the commissioner shall adjust:
(1) individual county allocations for developmental disability waivered services by the
amount of savings that results from the changes made for developmental disability waiver
recipients for whom the county is financially responsible; and
(2) group residential housing rate payments to the adult foster care home by the amount of
savings that results from the changes made.
(c) Effective July 1, 2003, when a new five-person adult foster care home is licensed under
this section, county agencies shall not establish group residential housing room and board rates
and developmental disability waiver service rates for the new home that exceed 86 percent of
the average per diem room and board and developmental disability waiver services costs of
four-person homes serving persons with comparable needs and in the same geographic area. A
county agency developing more than one new five-person adult foster care home may average the
required per diem rates across the homes to achieve the necessary overall per diem reductions.
(d) The commissioner shall reduce the individual county allocations for developmental
disability waivered services by the savings resulting from the per diem limits on adult foster care
recipients for whom the county is financially responsible, and shall limit the group residential
housing rate for a new five-person adult foster care home.
    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 developmental disabilities, 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 developmental disabilities, 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 a developmental disability, and within
five working days of an emergency admission of a person to an intermediate care facility for
persons with developmental disabilities. The screening team shall consist of the case manager for
persons with developmental disabilities, the person, the person's legal guardian or conservator,
or the parent if the person is a minor, and a qualified developmental disability 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 developmental disability 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 developmental disability 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 developmental disabilities; 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 developmental disabilities or for home and community-based services for
persons with developmental disabilities, 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 developmental disabilities,
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 developmental
disabilities, 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 developmental disabilities
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
developmental disabilities 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 developmental disabilities under
emergency circumstances; (c) any eligible person placed in the intermediate care facility for
persons with developmental disabilities 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
developmental disabilities, 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 developmental disabilities, 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 developmental disability 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 developmental disabilities, 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.
History: 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; 1Sp2003 c 14 art 3 s 31,32; art 6 s 50,51; art 11 s 11; 2005 c 56 s 1; 2005 c 98 art 2 s 7
256B.0924 TARGETED CASE MANAGEMENT SERVICES.
    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 a developmental disability 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, or is an adult who lacks a permanent residence and who
has been without a permanent residence for at least one year or on at least four occasions in
the last three years.
    Subd. 4. Targeted case management service activities. (a) For persons with developmental
disabilities, targeted case management services must meet the provisions of section 256B.092.
(b) For persons not eligible as a person with a developmental disability, 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