256L.03 COVERED HEALTH SERVICES.
Subdivision 1. Covered health services.
For individuals under section
, with income no greater than 75 percent of the federal poverty guidelines or for families
with children under section
256L.04, subdivision 1
, all subdivisions of this section apply.
"Covered health services" means the health services reimbursed under chapter 256B, with the
exception of inpatient hospital services, special education services, private duty nursing services,
adult dental care services other than services covered under section
256B.0625, subdivision 9
orthodontic services, nonemergency medical transportation services, personal care assistant
and case management services, nursing home or intermediate care facilities services, inpatient
mental health services, and chemical dependency services. Outpatient mental health services
covered under the MinnesotaCare program are limited to diagnostic assessments, psychological
testing, explanation of findings, mental health telemedicine, psychiatric consultation, medication
management by a physician, day treatment, partial hospitalization, and individual, family, and
No public funds shall be used for coverage of abortion under MinnesotaCare except where
the life of the female would be endangered or substantial and irreversible impairment of a
major bodily function would result if the fetus were carried to term; or where the pregnancy is
the result of rape or incest.
Covered health services shall be expanded as provided in this section.
Subd. 1a. Pregnant women and children; MinnesotaCare health care reform waiver.
Beginning January 1, 1999, children and pregnant women are eligible for coverage of all services
that are eligible for reimbursement under the medical assistance program according to chapter
256B, except that abortion services under MinnesotaCare shall be limited as provided under
subdivision 1. Pregnant women and children are exempt from the provisions of subdivision 5,
regarding co-payments. Pregnant women and children who are lawfully residing in the United
States but who are not "qualified noncitizens" under title IV of the Personal Responsibility and
Work Opportunity Reconciliation Act of 1996, Public Law 104-193, Statutes at Large, volume
110, page 2105, are eligible for coverage of all services provided under the medical assistance
program according to chapter 256B.
Subd. 1b. Pregnant women; eligibility for full medical assistance services.
woman enrolled in MinnesotaCare is eligible for coverage of all services provided under the
medical assistance program according to chapter 256B retroactive to the date of conception.
Co-payments totaling $30 or more, paid after the date of conception, shall be refunded.
Subd. 2. Alcohol and drug dependency.
Beginning July 1, 1993, covered health services
shall include individual outpatient treatment of alcohol or drug dependency by a qualified health
professional or outpatient program.
Persons who may need chemical dependency services under the provisions of this chapter
shall be assessed by a local agency as defined under section
, and under the assessment
provisions of section
254A.03, subdivision 3
. A local agency or managed care plan under contract
with the Department of Human Services must place a person in need of chemical dependency
services as provided in Minnesota Rules, parts 9530.6600
. Persons who are
recipients of medical benefits under the provisions of this chapter and who are financially eligible
for consolidated chemical dependency treatment fund services provided under the provisions of
chapter 254B shall receive chemical dependency treatment services under the provisions of
chapter 254B only if:
(1) they have exhausted the chemical dependency benefits offered under this chapter; or
(2) an assessment indicates that they need a level of care not provided under the provisions
of this chapter.
Recipients of covered health services under the children's health plan, as provided in
Minnesota Statutes 1990, section
, and as amended by Laws 1991, chapter 292, article
4, section 17, and recipients of covered health services enrolled in the children's health plan or
the MinnesotaCare program after October 1, 1992, pursuant to Laws 1992, chapter 549, article
4, sections 5 and 17, are eligible to receive alcohol and drug dependency benefits under this
Subd. 3. Inpatient hospital services.
(a) Covered health services shall include inpatient
hospital services, including inpatient hospital mental health services and inpatient hospital and
residential chemical dependency treatment, subject to those limitations necessary to coordinate
the provision of these services with eligibility under the medical assistance spenddown. Prior to
July 1, 1997, the inpatient hospital benefit for adult enrollees is subject to an annual benefit limit
of $10,000. The inpatient hospital benefit for adult enrollees who qualify under section
, or who qualify under section
256L.04, subdivisions 1 and 2
, with family gross
income that exceeds 175 percent of the federal poverty guidelines and who are not pregnant, is
subject to an annual limit of $10,000.
(b) Admissions for inpatient hospital services paid for under section
256L.11, subdivision 3
must be certified as medically necessary in accordance with Minnesota Rules, parts 9505.0500
, except as provided in clauses (1) and (2):
(1) all admissions must be certified, except those authorized under rules established under
254A.03, subdivision 3
, or approved under Medicare; and
(2) payment under section
256L.11, subdivision 3
, shall be reduced by five percent for
admissions for which certification is requested more than 30 days after the day of admission.
The hospital may not seek payment from the enrollee for the amount of the payment reduction
under this clause.
Subd. 3a. Interpreter services.
Covered services include sign and spoken language
interpreter services that assist an enrollee in obtaining covered health care services.
Subd. 4. Coordination with medical assistance.
The commissioner shall coordinate the
provision of hospital inpatient services under the MinnesotaCare program with enrollee eligibility
under the medical assistance spenddown.
Subd. 5. Co-payments and coinsurance.
(a) Except as provided in paragraphs (b) and
(c), the MinnesotaCare benefit plan shall include the following co-payments and coinsurance
requirements for all enrollees:
(1) ten percent of the paid charges for inpatient hospital services for adult enrollees, subject
to an annual inpatient out-of-pocket maximum of $1,000 per individual and $3,000 per family;
(2) $3 per prescription for adult enrollees;
(3) $25 for eyeglasses for adult enrollees;
(4) $3 per nonpreventive visit. For purposes of this subdivision, a "visit" means an episode of
service which is required because of a recipient's symptoms, diagnosis, or established illness, and
which is delivered in an ambulatory setting by a physician or physician ancillary, chiropractor,
podiatrist, nurse midwife, advanced practice nurse, audiologist, optician, or optometrist; and
(5) $6 for nonemergency visits to a hospital-based emergency room.
(b) Paragraph (a), clause (1), does not apply to parents and relative caretakers of children
under the age of 21 in households with family income equal to or less than 175 percent of the
federal poverty guidelines. Paragraph (a), clause (1), does not apply to parents and relative
caretakers of children under the age of 21 in households with family income greater than 175
percent of the federal poverty guidelines for inpatient hospital admissions occurring on or after
January 1, 2001.
(c) Paragraph (a), clauses (1) to (4), do not apply to pregnant women and children under the
age of 21.
(d) Adult enrollees with family gross income that exceeds 175 percent of the federal poverty
guidelines and who are not pregnant shall be financially responsible for the coinsurance amount,
if applicable, and amounts which exceed the $10,000 inpatient hospital benefit limit.
(e) When a MinnesotaCare enrollee becomes a member of a prepaid health plan, or changes
from one prepaid health plan to another during a calendar year, any charges submitted towards the
$10,000 annual inpatient benefit limit, and any out-of-pocket expenses incurred by the enrollee
for inpatient services, that were submitted or incurred prior to enrollment, or prior to the change
in health plans, shall be disregarded.
Subd. 5a.[Repealed, 2002 c 220 art 15 s 27
Subd. 6. Lien.
When the state agency provides, pays for, or becomes liable for covered health
services, the agency shall have a lien for the cost of the covered health services upon any and all
causes of action accruing to the enrollee, or to the enrollee's legal representatives, as a result of
the occurrence that necessitated the payment for the covered health services. All liens under this
section shall be subject to the provisions of section
. For purposes of this subdivision,
"state agency" includes prepaid health plans under contract with the commissioner according
256D.03, subdivision 4
, paragraph (c), and
; and county-based
purchasing entities under section
History: 1986 c 444; 1992 c 549 art 4 s 4,19; 1992 c 603 s 31; 1993 c 247 art 4 s 2-4,11;
1993 c 345 art 9 s 3; 1993 c 366 s 26; 1994 c 625 art 8 s 50,51,72; 1995 c 207 art 6 s 12; 1995 c
234 art 6 s 4,5; 1997 c 225 art 1 s 1-3; 1998 c 407 art 5 s 10-16; 1999 c 245 art 4 s 89,90; 2000 c
340 s 15; 1Sp2001 c 9 art 2 s 60; 2002 c 379 art 1 s 113; 1Sp2003 c 14 art 12 s 71; 2004 c 228 art
1 s 75; 1Sp2005 c 4 art 2 s 17; art 8 s 57-59; 2006 c 282 art 16 s 12
NOTE: The amendment to subdivision 5 by Laws 2006, chapter 282, article 16, section 12,
is effective July 1, 2007. Laws 2006, chapter 282, article 16, section 12, the effective date.