2006 Minnesota Statutes

CHAPTER 256L. MINNESOTACARE

256L.01 DEFINITIONS.
    Subdivision 1. Scope. For purposes of sections 256L.01 to 256L.18, the following terms
shall have the meanings given them.
    Subd. 1a. Child. "Child" means an individual under 21 years of age, including the unborn
child of a pregnant woman, an emancipated minor, and an emancipated minor's spouse.
    Subd. 2. Commissioner. "Commissioner" means the commissioner of human services.
    Subd. 3. Eligible providers. "Eligible providers" means those health care providers who
provide covered health services to medical assistance recipients under rules established by the
commissioner for that program.
    Subd. 3a. Family with children. (a) "Family with children" means:
(1) parents and their children residing in the same household; or
(2) grandparents, foster parents, relative caretakers as defined in the medical assistance
program, or legal guardians; and their wards who are children residing in the same household.
(b) The term includes children who are temporarily absent from the household in settings
such as schools, camps, or parenting time with noncustodial parents.
    Subd. 4. Gross individual or gross family income. (a) "Gross individual or gross family
income" for nonfarm self-employed means income calculated for the six-month period of
eligibility using the net profit or loss reported on the applicant's federal income tax form for
the previous year and using the medical assistance families with children methodology for
determining allowable and nonallowable self-employment expenses and countable income.
(b) "Gross individual or gross family income" for farm self-employed means income
calculated for the six-month period of eligibility using as the baseline the adjusted gross income
reported on the applicant's federal income tax form for the previous year and adding back in
reported depreciation amounts that apply to the business in which the family is currently engaged.
(c) "Gross individual or gross family income" means the total income for all family members,
calculated for the six-month period of eligibility.
    Subd. 5. Income. (a) "Income" has the meaning given for earned and unearned income for
families and children in the medical assistance program, according to the state's aid to families
with dependent children plan in effect as of July 16, 1996. The definition does not include medical
assistance income methodologies and deeming requirements. The earned income of full-time
and part-time students under age 19 is not counted as income. Public assistance payments and
supplemental security income are not excluded income.
(b) For purposes of this subdivision, and unless otherwise specified in this section, the
commissioner shall use reasonable methods to calculate gross earned and unearned income
including, but not limited to, projecting income based on income received within the past 30
days, the last 90 days, or the last 12 months.
History: 1986 c 444; 1987 c 403 art 2 s 63; 1988 c 689 art 2 s 137; 1989 c 282 art 3 s 33;
1990 c 568 art 3 s 14; 1992 c 549 art 4 s 2,19; 1993 c 345 art 9 s 1; 1998 c 407 art 5 s 7; 2000 c
444 art 2 s 5; 2002 c 374 art 10 s 13; 2005 c 98 art 2 s 15; 1Sp2005 c 4 art 8 s 55,56

NOTE: The amendment to subdivision 4 by Laws 2005, First Special Session chapter 4,
article 8, section 55, is effective August 1, 2007, or upon HealthMatch implementation, whichever
is later. Laws 2005, First Special Session chapter 4, article 8, section 55, the effective date.

256L.02 PROGRAM ADMINISTRATION.
    Subdivision 1. Purpose. The MinnesotaCare program is established to promote access to
appropriate health care services to assure healthy children and adults.
    Subd. 2. Commissioner's duties. The commissioner shall establish an office for the state
administration of this plan. The plan shall be used to provide covered health services for eligible
persons. Payment for these services shall be made to all eligible providers. The commissioner
shall adopt rules to administer the MinnesotaCare program. The commissioner shall establish
marketing efforts to encourage potentially eligible persons to receive information about the
program and about other medical care programs administered or supervised by the Department
of Human Services. A toll-free telephone number must be used to provide information about
medical programs and to promote access to the covered services.
    Subd. 3. Financial management. (a) The commissioner shall manage spending for the
MinnesotaCare program in a manner that maintains a minimum reserve. As part of each state
revenue and expenditure forecast, the commissioner must make an assessment of the expected
expenditures for the covered services for the remainder of the current biennium and for the
following biennium. The estimated expenditure, including the reserve, shall be compared to
an estimate of the revenues that will be available in the health care access fund. Based on this
comparison, and after consulting with the chairs of the house Ways and Means Committee and
the senate Finance Committee, and the Legislative Commission on Health Care Access, the
commissioner shall, as necessary, make the adjustments specified in paragraph (b) to ensure that
expenditures remain within the limits of available revenues for the remainder of the current
biennium and for the following biennium. The commissioner shall not hire additional staff using
appropriations from the health care access fund until the commissioner of finance makes a
determination that the adjustments implemented under paragraph (b) are sufficient to allow
MinnesotaCare expenditures to remain within the limits of available revenues for the remainder
of the current biennium and for the following biennium.
(b) The adjustments the commissioner shall use must be implemented in this order: first, stop
enrollment of single adults and households without children; second, upon 45 days' notice, stop
coverage of single adults and households without children already enrolled in the MinnesotaCare
program; third, upon 90 days' notice, decrease the premium subsidy amounts by ten percent for
families with gross annual income above 200 percent of the federal poverty guidelines; fourth,
upon 90 days' notice, decrease the premium subsidy amounts by ten percent for families with
gross annual income at or below 200 percent; and fifth, require applicants to be uninsured for
at least six months prior to eligibility in the MinnesotaCare program. If these measures are
insufficient to limit the expenditures to the estimated amount of revenue, the commissioner shall
further limit enrollment or decrease premium subsidies.
    Subd. 4.[Repealed, 1Sp2001 c 9 art 2 s 76; 2002 c 277 s 31]
History: 1986 c 444; 1987 c 403 art 2 s 63; 1988 c 689 art 2 s 137; 1989 c 282 art 3 s
34; 1992 c 549 art 4 s 3,19; 1993 c 4 s 28; 1993 c 247 art 4 s 11; 1993 c 345 art 9 s 2; 1994
c 625 art 8 s 72; art 13 s 1; 1995 c 234 art 6 s 3; 1997 c 225 art 3 s 3; 1998 c 407 art 5 s 8,9;
1Sp2001 c 5 art 14 s 1

256L.03 COVERED HEALTH SERVICES.
    Subdivision 1. Covered health services. For individuals under section 256L.04, subdivision
7 , with income no greater than 75 percent of the federal poverty guidelines or for families
with children under section 256L.04, subdivision 1, all subdivisions of this section apply.
"Covered health services" means the health services reimbursed under chapter 256B, with the
exception of inpatient hospital services, special education services, private duty nursing services,
adult dental care services other than services covered under section 256B.0625, subdivision 9,
orthodontic services, nonemergency medical transportation services, personal care assistant
and case management services, nursing home or intermediate care facilities services, inpatient
mental health services, and chemical dependency services. Outpatient mental health services
covered under the MinnesotaCare program are limited to diagnostic assessments, psychological
testing, explanation of findings, mental health telemedicine, psychiatric consultation, medication
management by a physician, day treatment, partial hospitalization, and individual, family, and
group psychotherapy.
No public funds shall be used for coverage of abortion under MinnesotaCare except where
the life of the female would be endangered or substantial and irreversible impairment of a
major bodily function would result if the fetus were carried to term; or where the pregnancy is
the result of rape or incest.
Covered health services shall be expanded as provided in this section.
    Subd. 1a. 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. A pregnant
woman enrolled in MinnesotaCare is eligible for coverage of all services provided under the
medical assistance program according to chapter 256B retroactive to the date of conception.
Co-payments totaling $30 or more, paid after the date of conception, shall be refunded.
    Subd. 2. Alcohol and drug dependency. Beginning July 1, 1993, covered health services
shall include individual outpatient treatment of alcohol or drug dependency by a qualified health
professional or outpatient program.
Persons who may need chemical dependency services under the provisions of this chapter
shall be assessed by a local agency as defined under section 254B.01, and under the assessment
provisions of section 254A.03, subdivision 3. A local agency or managed care plan under contract
with the Department of Human Services must place a person in need of chemical dependency
services as provided in Minnesota Rules, parts 9530.6600 to 9530.6660. Persons who are
recipients of medical benefits under the provisions of this chapter and who are financially eligible
for consolidated chemical dependency treatment fund services provided under the provisions of
chapter 254B shall receive chemical dependency treatment services under the provisions of
chapter 254B only if:
(1) they have exhausted the chemical dependency benefits offered under this chapter; or
(2) an assessment indicates that they need a level of care not provided under the provisions
of this chapter.
Recipients of covered health services under the children's health plan, as provided in
Minnesota Statutes 1990, section 256.936, and as amended by Laws 1991, chapter 292, article
4, section 17, and recipients of covered health services enrolled in the children's health plan or
the MinnesotaCare program after October 1, 1992, pursuant to Laws 1992, chapter 549, article
4, sections 5 and 17, are eligible to receive alcohol and drug dependency benefits under this
subdivision.
    Subd. 3. Inpatient hospital services. (a) Covered health services shall include inpatient
hospital services, including inpatient hospital mental health services and inpatient hospital and
residential chemical dependency treatment, subject to those limitations necessary to coordinate
the provision of these services with eligibility under the medical assistance spenddown. Prior to
July 1, 1997, the inpatient hospital benefit for adult enrollees is subject to an annual benefit limit
of $10,000. The inpatient hospital benefit for adult enrollees who qualify under section 256L.04,
subdivision 7 , or who qualify under section 256L.04, subdivisions 1 and 2, with family gross
income that exceeds 175 percent of the federal poverty guidelines and who are not pregnant, is
subject to an annual limit of $10,000.
(b) Admissions for inpatient hospital services paid for under section 256L.11, subdivision 3,
must be certified as medically necessary in accordance with Minnesota Rules, parts 9505.0500 to
9505.0540, except as provided in clauses (1) and (2):
(1) all admissions must be certified, except those authorized under rules established under
section 254A.03, subdivision 3, or approved under Medicare; and
(2) payment under section 256L.11, subdivision 3, shall be reduced by five percent for
admissions for which certification is requested more than 30 days after the day of admission.
The hospital may not seek payment from the enrollee for the amount of the payment reduction
under this clause.
    Subd. 3a. Interpreter services. Covered services include sign and spoken language
interpreter services that assist an enrollee in obtaining covered health care services.
    Subd. 4. Coordination with medical assistance. The commissioner shall coordinate the
provision of hospital inpatient services under the MinnesotaCare program with enrollee eligibility
under the medical assistance spenddown.
    Subd. 5. Co-payments and coinsurance. (a) Except as provided in paragraphs (b) and
(c), the MinnesotaCare benefit plan shall include the following co-payments and coinsurance
requirements for all enrollees:
(1) ten percent of the paid charges for inpatient hospital services for adult enrollees, subject
to an annual inpatient out-of-pocket maximum of $1,000 per individual and $3,000 per family;
(2) $3 per prescription for adult enrollees;
(3) $25 for eyeglasses for adult enrollees;
(4) $3 per nonpreventive visit. For purposes of this subdivision, a "visit" means an episode of
service which is required because of a recipient's symptoms, diagnosis, or established illness, and
which is delivered in an ambulatory setting by a physician or physician ancillary, chiropractor,
podiatrist, nurse midwife, advanced practice nurse, audiologist, optician, or optometrist; 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 256.015. For purposes of this subdivision,
"state agency" includes prepaid health plans under contract with the commissioner according
to sections 256B.69, 256D.03, subdivision 4, paragraph (c), and 256L.12; and county-based
purchasing entities under section 256B.692.
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.

256L.035 LIMITED BENEFITS COVERAGE FOR CERTAIN SINGLE ADULTS AND
HOUSEHOLDS WITHOUT CHILDREN.
(a) "Covered health services" for individuals under section 256L.04, subdivision 7, with
income above 75 percent, but not exceeding 175 percent, of the federal poverty guideline means:
(1) inpatient hospitalization benefits with a ten percent co-payment up to $1,000 and subject
to an annual limitation of $10,000;
(2) physician services provided during an inpatient stay; and
(3) physician services not provided during an inpatient stay; outpatient hospital services;
freestanding ambulatory surgical center services; chiropractic services; lab and diagnostic
services; diabetic supplies and equipment; and prescription drugs; subject to the following
co-payments:
(i) $50 co-pay per emergency room visit;
(ii) $3 co-pay per prescription drug; and
(iii) $5 co-pay per nonpreventive visit.
The services covered under this section may be provided by a physician, physician ancillary,
chiropractor, psychologist, or licensed independent clinical social worker if the services are
within the scope of practice of that health care professional.
For purposes of this section, "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 any health care provider identified in this paragraph.
Enrollees are responsible for all co-payments in this section.
(b) Reimbursement to the providers 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 $20 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 paragraph (c).
(c) 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 72; 2004 c 198 s 18; 1Sp2005 c 4 art 8 s 60

256L.04 ELIGIBLE PERSONS.
    Subdivision 1. Families with children. (a) Families with children with family income equal
to or less than 275 percent of the federal poverty guidelines for the applicable family size shall be
eligible for MinnesotaCare according to this section. All other provisions of sections 256L.01 to
256L.18, including the insurance-related barriers to enrollment under section 256L.07, shall apply
unless otherwise specified.
(b) Parents who enroll in the MinnesotaCare program must also enroll their children, if
the children are eligible. Children may be enrolled separately without enrollment by parents.
However, if one parent in the household enrolls, both parents must enroll, unless other insurance
is available. If one child from a family is enrolled, all children must be enrolled, unless other
insurance is available. If one spouse in a household enrolls, the other spouse in the household
must also enroll, unless other insurance is available. Families cannot choose to enroll only certain
uninsured members.
(c) Beginning October 1, 2003, the dependent sibling definition no longer applies to the
MinnesotaCare program. These persons are no longer counted in the parental household and
may apply as a separate household.
(d) Beginning July 1, 2003, or upon federal approval, whichever is later, parents are not
eligible for MinnesotaCare if their gross income exceeds $50,000.
    Subd. 1a. Social Security number required. (a) Individuals and families applying for
MinnesotaCare coverage must provide a Social Security number.
(b) The commissioner shall not deny eligibility to an otherwise eligible applicant who has
applied for a Social Security number and is awaiting issuance of that Social Security number.
(c) Newborns enrolled under section 256L.05, subdivision 3, are exempt from the
requirements of this subdivision.
(d) Individuals who refuse to provide a Social Security number because of well-established
religious objections are exempt from the requirements of this subdivision. The term
"well-established religious objections" has the meaning given in Code of Federal Regulations,
title 42, section 435.910.
    Subd. 2. Third-party liability, paternity, and other medical support. (a) To be eligible
for MinnesotaCare, individuals and families must cooperate with the state agency to identify
potentially liable third-party payers and assist the state in obtaining third-party payments.
"Cooperation" includes, but is not limited to, complying with the notice requirements in section
256B.056, subdivision 9, identifying any third party who may be liable for care and services
provided under MinnesotaCare to the enrollee, providing relevant information to assist the state in
pursuing a potentially liable third party, and completing forms necessary to recover third-party
payments.
(b) A parent, guardian, relative caretaker, or child enrolled in the MinnesotaCare program
must cooperate with the Department of Human Services and the local agency in establishing the
paternity of an enrolled child and in obtaining medical care support and payments for the child
and any other person for whom the person can legally assign rights, in accordance with applicable
laws and rules governing the medical assistance program. A child shall not be ineligible for or
disenrolled from the MinnesotaCare program solely because the child's parent, relative caretaker,
or guardian fails to cooperate in establishing paternity or obtaining medical support.
    Subd. 2a. Applications for other benefits. To be eligible for MinnesotaCare, individuals
and families must take all necessary steps to obtain other benefits as described in Code of Federal
Regulations, title 42, section 435.608. Applicants and enrollees must apply for other benefits
within 30 days of notification.
    Subd. 3.[Repealed, 1998 c 407 art 5 s 48]
    Subd. 4.[Repealed, 1998 c 407 art 5 s 48]
    Subd. 5.[Repealed, 1998 c 407 art 5 s 48]
    Subd. 6.[Repealed, 1998 c 407 art 5 s 48]
    Subd. 7. Single adults and households with no children. The definition of eligible persons
includes all individuals and households with no children who have gross family incomes that are
equal to or less than 175 percent of the federal poverty guidelines.
    Subd. 7a. Ineligibility. Applicants whose income is greater than the limits established under
this section may not enroll in the MinnesotaCare program.
    Subd. 7b. Annual income limits adjustment. The commissioner shall adjust the income
limits 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. 8. Applicants potentially eligible for medical assistance. (a) Individuals who receive
supplemental security income or retirement, survivors, or disability benefits due to a disability,
or other disability-based pension, who qualify under subdivision 7, but who are potentially
eligible for medical assistance without a spenddown shall be allowed to enroll in MinnesotaCare
for a period of 60 days, so long as the applicant meets all other conditions of eligibility. The
commissioner shall identify and refer the applications of such individuals to their county social
service agency. The county and the commissioner shall cooperate to ensure that the individuals
obtain medical assistance coverage for any months for which they are eligible.
(b) The enrollee must cooperate with the county social service agency in determining
medical assistance eligibility within the 60-day enrollment period. Enrollees who do not cooperate
with medical assistance within the 60-day enrollment period shall be disenrolled from the plan
within one calendar month. Persons disenrolled for nonapplication for medical assistance may not
reenroll until they have obtained a medical assistance eligibility determination. Persons disenrolled
for noncooperation with medical assistance may not reenroll until they have cooperated with the
county agency and have obtained a medical assistance eligibility determination.
(c) Beginning January 1, 2000, counties that choose to become MinnesotaCare enrollment
sites shall consider MinnesotaCare applications to also be applications for medical assistance.
Applicants who are potentially eligible for medical assistance, except for those described in
paragraph (a), may choose to enroll in either MinnesotaCare or medical assistance.
(d) The commissioner shall redetermine provider payments made under MinnesotaCare
to the appropriate medical assistance payments for those enrollees who subsequently become
eligible for medical assistance.
    Subd. 9. General assistance medical care. A person cannot have coverage under
both MinnesotaCare and general assistance medical care in the same month. Eligibility for
MinnesotaCare cannot be replaced by eligibility for general assistance medical care, and
eligibility for general assistance medical care cannot be replaced by eligibility for MinnesotaCare.
    Subd. 10. Citizenship requirements. Eligibility for MinnesotaCare is limited to citizens
or nationals of the United States, qualified noncitizens, and other persons residing lawfully in
the United States as described in section 256B.06, subdivision 4, paragraphs (a) to (e) and (j).
Undocumented noncitizens and nonimmigrants are ineligible for MinnesotaCare. For purposes of
this subdivision, a nonimmigrant is an individual in one or more of the classes listed in United
States Code, title 8, section 1101(a)(15), and an undocumented noncitizen is an individual
who resides in the United States without the approval or acquiescence of the Immigration and
Naturalization Service. Families with children who are 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.
    Subd. 10a. Sponsor's income and resources deemed available; documentation. When
determining eligibility for any federal or state benefits under sections 256L.01 to 256L.18, the
income and resources of all noncitizens whose sponsor signed an affidavit of support as defined
under United States Code, title 8, section 1183a, shall be deemed to include their sponsors' income
and resources as defined in 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. To be eligible for the program, noncitizens must provide documentation of their
immigration status.
    Subd. 11.[Repealed, 1Sp2005 c 4 art 8 s 88]
    Subd. 12. Persons in detention. Beginning January 1, 1999, an applicant residing in a
correctional or detention facility is not eligible for MinnesotaCare. An enrollee residing in a
correctional or detention facility is not eligible at renewal of eligibility under section 256L.05,
subdivision 3b .
    Subd. 13. Families with relative caretakers, foster parents, or legal guardians. Beginning
January 1, 1999, in families that include a relative caretaker as defined in the medical assistance
program, foster parent, or legal guardian, the relative caretaker, foster parent, or legal guardian
may apply as a family or may apply separately for the children. If the caretaker applies separately
for the children, only the children's income is counted and the provisions of subdivision 1,
paragraph (b), do not apply. If the relative caretaker, foster parent, or legal guardian applies with
the children, their income is included in the gross family income for determining eligibility
and premium amount.
History: 1986 c 444; 1992 c 549 art 4 s 5,19; 1993 c 247 art 4 s 5; 1993 c 345 art 9 s 4-6;
1994 c 625 art 8 s 52-55,72; art 13 s 2; 1995 c 234 art 6 s 6-9; 1997 c 85 art 3 s 9; 1997 c 203 art
12 s 1; 1997 c 225 art 1 s 4-8; 1998 c 407 art 5 s 17-25; 1999 c 245 art 4 s 91-94; 1Sp2003 c 14
art 12 s 73,74; 2005 c 98 art 2 s 16; 1Sp2005 c 4 art 8 s 61-63; 2006 c 282 art 17 s 35

NOTE: Subdivisions 1a and 2a, as added by Laws 2005, First Special Session chapter 4,
article 8, sections 61 and 63, are effective August 1, 2007, or upon HealthMatch implementation,
whichever is later. Laws 2005, First Special Session chapter 4, article 8, sections 61 and 63, the
effective dates.

256L.05 APPLICATION PROCEDURES.
    Subdivision 1. Application and information availability. Applications and other
information must be made available to provider offices, local human services agencies, school
districts, public and private elementary schools in which 25 percent or more of the students
receive free or reduced price lunches, community health offices, and Women, Infants and
Children (WIC) program sites. These sites may accept applications and forward the forms to the
commissioner. Otherwise, applicants may apply directly to the commissioner. Beginning January
1, 2000, MinnesotaCare enrollment sites will be expanded to include local county human services
agencies which choose to participate.
    Subd. 1a. Person authorized to apply on applicant's behalf. Beginning January 1, 1999, a
family member who is age 18 or over or who is an authorized representative, as defined in the
medical assistance program, may apply on an applicant's behalf.
    Subd. 1b. MinnesotaCare enrollment by county agencies. Beginning September 1, 2006,
county agencies shall enroll single adults and households with no children formerly enrolled in
general assistance medical care in MinnesotaCare according to section 256D.03, subdivision 3.
County agencies shall perform all duties necessary to administer the MinnesotaCare program
ongoing for these enrollees, including the redetermination of MinnesotaCare eligibility at
six-month renewal.
    Subd. 2. Commissioner's duties. (a) 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. In addition, the commissioner shall perform random audits to
verify reported income and eligibility. The commissioner may execute data sharing arrangements
with the Department of Revenue and any other governmental agency in order to perform income
verification related to eligibility and premium payment under the MinnesotaCare program.
(b) In determining eligibility for MinnesotaCare, the commissioner shall require applicants
and enrollees seeking renewal of eligibility to verify both earned and unearned income. The
commissioner shall also require applicants and enrollees to submit the names of their employers
and a contact name with a telephone number for each employer for purposes of verifying whether
the applicant or enrollee, and any dependents, are eligible for employer-subsidized coverage. Data
collected is nonpublic data as defined in section 13.02, subdivision 9.
    Subd. 3. Effective date of coverage. (a) The effective date of coverage is the first day of the
month following the month in which eligibility is approved and the first premium payment has
been received. As provided in section 256B.057, coverage for newborns is automatic from the
date of birth and must be coordinated with other health coverage. The effective date of coverage
for eligible newly adoptive children added to a family receiving covered health services is the
month of placement. The effective date of coverage for other new members added to the family is
the first day of the month following the month in which the change is reported. All eligibility
criteria must be met by the family at the time the new family member is added. The income of the
new family member is included with the family's gross income and the adjusted premium begins
in the month the new family member is added.
(b) The initial premium must be received by the last working day of the month for coverage
to begin the first day of the following month.
(c) Benefits are not available until the day following discharge if an enrollee is hospitalized
on the first day of coverage.
(d) Notwithstanding any other law to the contrary, benefits under sections 256L.01 to
256L.18 are secondary to a plan of insurance or benefit program under which an eligible
person may have coverage and the commissioner shall use cost avoidance techniques to ensure
coordination of any other health coverage for eligible persons. The commissioner shall identify
eligible persons who may have coverage or benefits under other plans of insurance or who
become eligible for medical assistance.
(e) The effective date of coverage for single adults and households with no children formerly
enrolled in general assistance medical care and enrolled in MinnesotaCare according to section
256D.03, subdivision 3, is the first day of the month following the last day of general assistance
medical care coverage.
    Subd. 3a. Renewal of eligibility. (a) Beginning January 1, 1999, an enrollee's eligibility
must be renewed every 12 months. The 12-month period begins in the month after the month
the application is approved.
(b) Beginning October 1, 2004, an enrollee's eligibility must be renewed every six months.
The first six-month period of eligibility begins the month the application is received by the
commissioner. The effective date of coverage within the first six-month period of eligibility is
as provided in subdivision 3. Each new period of eligibility must take into account any changes
in circumstances that impact eligibility and premium amount. An enrollee must provide all the
information needed to redetermine eligibility by the first day of the month that ends the eligibility
period. The premium for the new period of eligibility must be received as provided in section
256L.06 in order for eligibility to continue.
(c) For single adults and households with no children formerly enrolled in general assistance
medical care and enrolled in MinnesotaCare according to section 256D.03, subdivision 3, the
first six-month period of eligibility begins the month the enrollee submitted the application or
renewal for general assistance medical care.
    Subd. 3b. Reapplication. Beginning January 1, 1999, families and individuals must reapply
after a lapse in coverage of one calendar month or more and must meet all eligibility criteria.
    Subd. 3c. Retroactive coverage. Notwithstanding subdivision 3, the effective date of
coverage shall be the first day of the month following termination from medical assistance or
general assistance medical care for families and individuals who are eligible for MinnesotaCare
and who submitted a written request for retroactive MinnesotaCare coverage with a completed
application within 30 days of the mailing of notification of termination from medical assistance or
general assistance medical care. The applicant must provide all required verifications within 30
days of the written request for verification. For retroactive coverage, premiums must be paid in full
for any retroactive month, current month, and next month within 30 days of the premium billing.
    Subd. 4. Application processing. The commissioner of human services shall determine an
applicant's eligibility for MinnesotaCare no more than 30 days from the date that the application
is received by the Department of Human Services. Beginning January 1, 2000, this requirement
also applies to local county human services agencies that determine eligibility for MinnesotaCare.
    Subd. 5. Availability of private insurance. The commissioner, in consultation with the
commissioners of health and commerce, shall provide information regarding the availability of
private health insurance coverage and the possibility of disenrollment under section 256L.07,
subdivision 1 , paragraphs (b) and (c), to all: (1) families enrolled in the MinnesotaCare program
whose gross family income is equal to or more than 225 percent of the federal poverty guidelines;
and (2) single adults and households without children enrolled in the MinnesotaCare program
whose gross family income is equal to or more than 165 percent of the federal poverty guidelines.
This information must be provided upon initial enrollment and annually thereafter. The
commissioner shall also include information regarding the availability of private health insurance
coverage in the notice of ineligibility provided to persons subject to disenrollment under section
256L.07, subdivision 1, paragraphs (b) and (c).
History: 1986 c 444; 1987 c 403 art 2 s 63; 1988 c 689 art 2 s 137; 1992 c 549 art 4 s 6,19;
1993 c 247 art 4 s 6; 1994 c 625 art 8 s 72; art 13 s 3; 1995 c 234 art 6 s 10; 1996 c 451 art 5 s
10; 1997 c 225 art 1 s 9-11; 1997 c 251 s 26; 1998 c 407 art 5 s 26-31; 1999 c 245 art 4 s 95,96;
2000 c 488 art 9 s 27; 1Sp2001 c 9 art 2 s 61; 2002 c 277 s 28; 2002 c 379 art 1 s 113; 1Sp2003 c
14 art 12 s 75,76; 1Sp2005 c 4 art 8 s 64-67

NOTE: The amendments to subdivisions 3, paragraph (a), and 3a, paragraph (b), by Laws
2005, First Special Session chapter 4, article 8, sections 66 and 67, are effective August 1, 2007,
or upon HealthMatch implementation, whichever is later. Laws 2005, First Special Session
chapter 4, article 8, sections 66 and 67, the effective dates.

256L.06 PREMIUM ADMINISTRATION.
    Subdivision 1.[Repealed, 1998 c 407 art 5 s 48]
    Subd. 2.[Repealed, 1998 c 407 art 5 s 48]
    Subd. 3. Commissioner's duties and payment. (a) Premiums are dedicated to the
commissioner for MinnesotaCare.
(b) The commissioner shall develop and implement procedures to: (1) require enrollees to
report changes in income; (2) adjust sliding scale premium payments, based upon both increases
and decreases in enrollee income, at the time the change in income is reported; and (3) disenroll
enrollees from MinnesotaCare for failure to pay required premiums. Failure to pay includes
payment with a dishonored check, a returned automatic bank withdrawal, or a refused credit
card or debit card payment. The commissioner may demand a guaranteed form of payment,
including a cashier's check or a money order, as the only means to replace a dishonored, returned,
or refused payment.
(c) Premiums are calculated on a calendar month basis and may be paid on a monthly,
quarterly, or semiannual basis, with the first payment due upon notice from the commissioner of
the premium amount required. The commissioner shall inform applicants and enrollees of these
premium payment options. Premium payment is required before enrollment is complete and to
maintain eligibility in MinnesotaCare. Premium payments received before noon are credited the
same day. Premium payments received after noon are credited on the next working day.
(d) Nonpayment of the premium will result in disenrollment from the plan effective for the
calendar month for which the premium was due. Persons disenrolled for nonpayment or who
voluntarily terminate coverage from the program may not reenroll until four calendar months
have elapsed. Persons disenrolled for nonpayment who pay all past due premiums as well as
current premiums due, including premiums due for the period of disenrollment, within 20 days
of disenrollment, shall be reenrolled retroactively to the first day of disenrollment. Persons
disenrolled for nonpayment or who voluntarily terminate coverage from the program may not
reenroll for four calendar months unless the person demonstrates good cause for nonpayment.
Good cause does not exist if a person chooses to pay other family expenses instead of the
premium. The commissioner shall define good cause in rule.
History: 1986 c 444; 1987 c 403 art 2 s 63; 1988 c 689 art 2 s 137; 1989 c 282 art 3 s 35;
1992 c 549 art 4 s 7,19; 1993 c 247 art 4 s 7; 1993 c 345 art 9 s 7; 1994 c 625 art 13 s 4; 1995 c
234 art 8 s 56; 1998 c 407 art 5 s 32; 1999 c 245 art 4 s 97; 1Sp2001 c 9 art 2 s 62; 2002 c 277 s
29; 2002 c 379 art 1 s 113; 1Sp2003 c 14 art 12 s 77; 1Sp2005 c 4 art 8 s 68

256L.07 ELIGIBILITY FOR MINNESOTACARE.
    Subdivision 1. General requirements. (a) Children enrolled in the original children's
health plan as of September 30, 1992, children who enrolled in the MinnesotaCare program
after September 30, 1992, pursuant to Laws 1992, chapter 549, article 4, section 17, and
children who have family gross incomes that are equal to or less than 150 percent of the federal
poverty guidelines are eligible without meeting the requirements of subdivision 2 and the
four-month requirement in subdivision 3, as long as they maintain continuous coverage in the
MinnesotaCare program or medical assistance. Children who apply for MinnesotaCare on or
after the implementation date of the employer-subsidized health coverage program as described
in Laws 1998, chapter 407, article 5, section 45, who have family gross incomes that are equal
to or less than 150 percent of the federal poverty guidelines, must meet the requirements of
subdivision 2 to be eligible for MinnesotaCare.
(b) Families enrolled in MinnesotaCare under section 256L.04, subdivision 1, whose income
increases above 275 percent of the federal poverty guidelines, are no longer eligible for the
program and shall be disenrolled by the commissioner. Individuals enrolled in MinnesotaCare
under section 256L.04, subdivision 7, whose income increases above 175 percent of the
federal poverty guidelines are no longer eligible for the program and shall be disenrolled by
the commissioner. For persons disenrolled under this subdivision, MinnesotaCare coverage
terminates the last day of the calendar month following the month in which the commissioner
determines that the income of a family or individual exceeds program income limits.
(c) Notwithstanding paragraph (b), children may remain enrolled in MinnesotaCare if
ten percent of their gross individual or gross family income as defined in section 256L.01,
subdivision 4 , is less than the premium for a six-month policy with a $500 deductible available
through the Minnesota Comprehensive Health Association. Children who are no longer eligible
for MinnesotaCare under this clause shall be given a 12-month notice period from the date that
ineligibility is determined before disenrollment. The premium for children remaining eligible
under this clause shall be the maximum premium determined under section 256L.15, subdivision
2 , paragraph (b).
(d) Notwithstanding paragraphs (b) and (c), parents are not eligible for MinnesotaCare if
gross household income exceeds $25,000 for the six-month period of eligibility.
    Subd. 2. Must not have access to employer-subsidized coverage. (a) To be eligible, a
family or individual must not have access to subsidized health coverage through an employer and
must not have had access to employer-subsidized coverage through a current employer for 18
months prior to application or reapplication. A family or individual whose employer-subsidized
coverage is lost due to an employer terminating health care coverage as an employee benefit
during the previous 18 months is not eligible.
(b) This subdivision does not apply to a family or individual who was enrolled
in MinnesotaCare within six months or less of reapplication and who no longer has
employer-subsidized coverage due to the employer terminating health care coverage as an
employee benefit.
(c) For purposes of this requirement, subsidized health coverage means health coverage
for which the employer pays at least 50 percent of the cost of coverage for the employee or
dependent, or a higher percentage as specified by the commissioner. Children are eligible for
employer-subsidized coverage through either parent, including the noncustodial parent. The
commissioner must treat employer contributions to Internal Revenue Code Section 125 plans and
any other employer benefits intended to pay health care costs as qualified employer subsidies
toward the cost of health coverage for employees for purposes of this subdivision.
    Subd. 2a. Access to health coverage; postsecondary education student. To be eligible,
an individual under 21 years of age who is enrolled in a program of study at a postsecondary
education institution, including an emancipated minor and an emancipated minor's spouse, must
not have access to health coverage through the postsecondary education institution.
    Subd. 3. Other health coverage. (a) Families and individuals enrolled in the MinnesotaCare
program must have no health coverage while enrolled or for at least four months prior to
application and renewal. Children enrolled in the original children's health plan and children in
families with income equal to or less than 150 percent of the federal poverty guidelines, who have
other health insurance, are eligible if the coverage:
(1) lacks two or more of the following:
(i) basic hospital insurance;
(ii) medical-surgical insurance;
(iii) prescription drug coverage;
(iv) dental coverage; or
(v) vision coverage;
(2) requires a deductible of $100 or more per person per year; or
(3) lacks coverage because the child has exceeded the maximum coverage for a particular
diagnosis or the policy excludes a particular diagnosis.
The commissioner may change this eligibility criterion for sliding scale premiums in order
to remain within the limits of available appropriations. The requirement of no health coverage
does not apply to newborns.
(b) Medical assistance, general assistance medical care, and the Civilian Health and Medical
Program of the Uniformed Service, CHAMPUS, or other coverage provided under United States
Code, title 10, subtitle A, part II, chapter 55, are not considered insurance or health coverage for
purposes of the four-month requirement described in this subdivision.
(c) For purposes of this subdivision, an applicant or enrollee who is entitled to Medicare Part
A or enrolled in Medicare Part B coverage under title XVIII of the Social Security Act, United
States Code, title 42, sections 1395c to 1395w-152, is considered to have health coverage. An
applicant or enrollee who is entitled to premium-free Medicare Part A may not refuse to apply for
or enroll in Medicare coverage to establish eligibility for MinnesotaCare.
(d) Applicants who were recipients of medical assistance or general assistance medical care
within one month of application must meet the provisions of this subdivision and subdivision 2.
(e) Cost-effective health insurance that was paid for by medical assistance is not considered
health coverage for purposes of the four-month requirement under this section, except if the
insurance continued after medical assistance no longer considered it cost-effective or after
medical assistance closed.
    Subd. 4. Families with children in need of chemical dependency treatment. Premiums for
families with children when a parent has been determined to be in need of chemical dependency
treatment pursuant to an assessment conducted by the county under section 626.556, subdivision
10 , or a case plan under section 260C.201, subdivision 6, or 260C.212, who are eligible for
MinnesotaCare under section 256L.04, subdivision 1, may be paid by the county of residence of
the person in need of treatment for one year from the date the family is determined to be eligible
or if the family is currently enrolled in MinnesotaCare from the date the person is determined to
be in need of chemical dependency treatment. Upon renewal, the family is responsible for any
premiums owed under section 256L.15. If the family is not currently enrolled in MinnesotaCare,
the local county human services agency shall determine whether the family appears to meet the
eligibility requirements and shall assist the family in applying for the MinnesotaCare program.
    Subd. 5. Voluntary disenrollment for members of military. Notwithstanding section
256L.05, subdivision 3b, MinnesotaCare enrollees who are members of the military and their
families, who choose to voluntarily disenroll from the program when one or more family members
are called to active duty, may reenroll during or following that member's tour of active duty.
Those individuals and families shall be considered to have good cause for voluntary termination
under section 256L.06, subdivision 3, paragraph (d). Income and asset increases reported at the
time of reenrollment shall be disregarded. All provisions of sections 256L.01 to 256L.18 shall
apply to individuals and families enrolled under this subdivision upon six-month renewal.
    Subd. 6. Exception for certain adults. Single adults and households with no children
formerly enrolled in general assistance medical care and enrolled in MinnesotaCare according to
section 256D.03, subdivision 3, are eligible without meeting the requirements of this section until
six-month renewal.
History: 1986 c 444; 1992 c 549 art 4 s 8,19; 1993 c 345 art 9 s 8; 1994 c 625 art 8 s
56,72; 1995 c 234 art 6 s 11-13; 1997 c 187 art 1 s 18; 1997 c 225 art 1 s 12; 1998 c 407 art 5
s 33; 1999 c 139 art 4 s 2; 1999 c 245 art 4 s 98; 1Sp2001 c 9 art 2 s 63; 2002 c 220 art 15 s
21,22; 2002 c 277 s 30; 2002 c 379 art 1 s 113; 1Sp2003 c 14 art 12 s 78,79; 2005 c 10 art 1 s
56; 2005 c 59 s 1; 1Sp2005 c 4 art 8 s 69-72

NOTE: The amendment to subdivision 1 by Laws 2005, First Special Session chapter 4,
article 8, section 69, is effective August 1, 2007, or upon HealthMatch implementation, whichever
is later. Laws 2005, First Special Session chapter 4, article 8, section 69, the effective date.

NOTE: Subdivision 2a, as added by Laws 2005, First Special Session chapter 4, article 8,
section 70, is effective September 1, 2005, or upon federal approval, whichever is later. Laws
2005, First Special Session chapter 4, article 8, section 70, the effective date.

256L.08 [Repealed, 1998 c 407 art 5 s 48]

256L.09 RESIDENCY.
    Subdivision 1. Findings and purpose. The legislature finds that the enactment of a
comprehensive health plan for uninsured Minnesotans creates a risk that persons needing medical
care will migrate to the state for the primary purpose of obtaining medical care subsidized by the
state. The risk of migration undermines the state's ability to provide to legitimate state residents a
valuable and necessary health care program which is an important component of the state's
comprehensive cost containment and health care system reform plan. Intent-based residency
requirements, which are expressly authorized under decisions of the United States Supreme Court,
are an unenforceable and ineffective method of denying benefits to those persons the Supreme
Court has stated may legitimately be denied eligibility for state programs. If the state is unable to
limit eligibility to legitimate permanent residents of the state, the state faces a significant risk that
it will be forced to reduce the eligibility and benefits it would otherwise provide to Minnesotans.
The legislature finds that a durational residence requirement is a legitimate, objective, enforceable
standard for determining whether a person is a permanent resident of the state. The legislature also
finds low-income persons who have not lived in the state for the required time period will have
access to necessary health care services through the general assistance medical care program, the
medical assistance program, and public and private charity care programs.
    Subd. 2. Residency requirement. (a) To be eligible for health coverage under the
MinnesotaCare program, adults without children must be permanent residents of Minnesota.
(b) To be eligible for health coverage under the MinnesotaCare program, pregnant women,
families, and children must meet the residency requirements as provided by Code of Federal
Regulations, title 42, section 435.403, except that the provisions of section 256B.056, subdivision
1 , shall apply upon receipt of federal approval.
    Subd. 3.[Repealed, 1998 c 407 art 5 s 48]
    Subd. 4. Eligibility as Minnesota resident. (a) For purposes of this section, a permanent
Minnesota resident is a person who has demonstrated, through persuasive and objective evidence,
that the person is domiciled in the state and intends to live in the state permanently.
(b) To be eligible as a permanent resident, an applicant must demonstrate the requisite intent
to live in the state permanently by:
(1) showing that the applicant maintains a residence at a verified address other than a place
of public accommodation, through the use of evidence of residence described in section 256D.02,
subdivision 12a , clause (1);
(2) demonstrating that the applicant has been continuously domiciled in the state for no less
than 180 days immediately before the application; and
(3) signing an affidavit declaring that (A) the applicant currently resides in the state and
intends to reside in the state permanently; and (B) the applicant did not come to the state for the
primary purpose of obtaining medical coverage or treatment.
(c) A person who is temporarily absent from the state does not lose eligibility for
MinnesotaCare. "Temporarily absent from the state" means the person is out of the state for a
temporary purpose and intends to return when the purpose of the absence has been accomplished.
A person is not temporarily absent from the state if another state has determined that the person
is a resident for any purpose. If temporarily absent from the state, the person must follow the
requirements of the health plan in which the person is enrolled to receive services.
    Subd. 5. Persons excluded as permanent residents. An individual or family that moved to
Minnesota primarily to obtain medical treatment or health coverage for a preexisting condition is
not a permanent resident.
    Subd. 6. 12-month preexisting exclusion. If the 180-day requirement in subdivision 4,
paragraph (b), clause (2), is determined by a court to be unconstitutional, the commissioner of
human services shall impose a 12-month preexisting condition exclusion on coverage for persons
who have been domiciled in the state for less than 180 days.
    Subd. 7. Effect of a court determination. If any paragraph, sentence, clause, or phrase of
this section is for any reason determined by a court to be unconstitutional, the decision shall not
affect the validity of the remaining portions of the section. The legislature declares that it would
have passed each paragraph, sentence, clause, and phrase in this section, irrespective of the fact
that any one or more paragraphs, sentences, clauses, or phrases is declared unconstitutional.
History: 1986 c 444; 1992 c 549 art 4 s 10,19; 1993 c 247 art 4 s 11; 1994 c 625 art 8 s 72;
1997 c 225 art 1 s 14; 1998 c 407 art 5 s 34-36

256L.10 APPEALS.
If the commissioner suspends, reduces, or terminates eligibility for the MinnesotaCare
program, or services provided under the MinnesotaCare program, the commissioner must provide
notification according to the laws and rules governing the medical assistance program. A
MinnesotaCare program applicant or enrollee aggrieved by a determination of the commissioner
has the right to appeal the determination according to section 256.045.
History: 1986 c 444; 1991 c 292 art 4 s 17; 1992 c 549 art 4 s 11,19; 1993 c 247 art 4 s
11; 1994 c 625 art 8 s 72

256L.11 PROVIDER PAYMENT.
    Subdivision 1. Medical assistance rate to be used. Payment to providers under sections
256L.01 to 256L.11 shall be at the same rates and conditions established for medical assistance,
except as provided in subdivisions 2 to 6.
    Subd. 2. Payment of certain providers. Services provided by federally qualified health
centers, rural health clinics, and facilities of the Indian health service shall be paid for according
to the same rates and conditions applicable to the same service provided by providers that are not
federally qualified health centers, rural health clinics, or facilities of the Indian health service.
    Subd. 2a. Payment rates; services for families and children under the MinnesotaCare
health care reform waiver. Subdivision 2 shall not apply to services provided to families with
children who are eligible according to section 256L.04, subdivision 1, paragraph (a).
    Subd. 3. Inpatient hospital services. Inpatient hospital services provided under section
256L.03, subdivision 3, shall be paid for as provided in subdivisions 4 to 6.
    Subd. 4. Definition of medical assistance rate for inpatient hospital services. The
"medical assistance rate," as used in this section to apply to rates for providing inpatient hospital
services, means the rates established under sections 256.9685 to 256.9695 for providing inpatient
hospital services to medical assistance recipients who receive Minnesota family investment
program assistance.
    Subd. 5. Enrollees younger than 18. Payment for inpatient hospital services provided to
MinnesotaCare enrollees who are younger than 18 years old on the date of admission to the
inpatient hospital shall be at the medical assistance rate.
    Subd. 6. Enrollees 18 or older. Payment by the MinnesotaCare program for inpatient
hospital services provided to MinnesotaCare enrollees eligible under section 256L.04, subdivision
7 , or who qualify under section 256L.04, subdivisions 1 and 2, with family gross income that
exceeds 175 percent of the federal poverty guidelines and who are not pregnant, who are 18
years old or older on the date of admission to the inpatient hospital must be in accordance with
paragraphs (a) and (b). Payment for adults who are not pregnant and are eligible under section
256L.04, subdivisions 1 and 2, and whose incomes are equal to or less than 175 percent of the
federal poverty guidelines, shall be as provided for under paragraph (c).
(a) If the medical assistance rate minus any co-payment required under section 256L.03,
subdivision 4 , is less than or equal to the amount remaining in the enrollee's benefit limit
under section 256L.03, subdivision 3, payment must be the medical assistance rate minus any
co-payment required under section 256L.03, subdivision 4. The hospital must not seek payment
from the enrollee in addition to the co-payment. The MinnesotaCare payment plus the co-payment
must be treated as payment in full.
(b) If the medical assistance rate minus any co-payment required under section 256L.03,
subdivision 4 , is greater than the amount remaining in the enrollee's benefit limit under section
256L.03, subdivision 3, payment must be the lesser of:
(1) the amount remaining in the enrollee's benefit limit; or
(2) charges submitted for the inpatient hospital services less any co-payment established
under section 256L.03, subdivision 4.
The hospital may seek payment from the enrollee for the amount by which usual and
customary charges exceed the payment under this paragraph. If payment is reduced under section
256L.03, subdivision 3, paragraph (b), the hospital may not seek payment from the enrollee for
the amount of the reduction.
(c) For admissions occurring during the period of July 1, 1997, through June 30, 1998,
for adults who are not pregnant and are eligible under section 256L.04, subdivisions 1 and 2,
and whose incomes are equal to or less than 175 percent of the federal poverty guidelines, the
commissioner shall pay hospitals directly, up to the medical assistance payment rate, for inpatient
hospital benefits in excess of the $10,000 annual inpatient benefit limit.
    Subd. 7. Critical access dental providers. Effective for dental services provided to
MinnesotaCare enrollees on or after January 1, 2007, the commissioner shall increase payment
rates to dentists and dental clinics deemed by the commissioner to be critical access providers
under section 256B.76, paragraph (c), by 50 percent above the payment rate that would otherwise
be paid to the provider. The commissioner shall adjust the rates paid on or after January 1, 2007,
to prepaid health plans under contract with the commissioner to reflect this rate increase. The
prepaid health plan must pass this rate increase to providers who have been identified by the
commissioner as critical access dental providers under section 256B.76, paragraph (c).
History: 1993 c 345 art 9 s 9; 1994 c 625 art 8 s 57; 1995 c 234 art 6 s 21; 1997 c 225
art 1 s 15; 1998 c 407 art 5 s 37,47; 1999 c 159 s 106; 1Sp2001 c 9 art 2 s 66; 2002 c 379
art 1 s 113; 2006 c 282 art 16 s 13

256L.12 MANAGED CARE.
    Subdivision 1. Selection of vendors. In order to contain costs, the commissioner of human
services shall select vendors of medical care who can provide the most economical care consistent
with high medical standards and shall, where possible, contract with organizations on a prepaid
capitation basis to provide these services. The commissioner shall consider proposals by counties
and vendors for managed care plans which may include: prepaid capitation programs, competitive
bidding programs, or other vendor payment mechanisms designed to provide services in an
economical manner or to control utilization, with safeguards to ensure that necessary services are
provided.
    Subd. 2. Geographic area. The commissioner shall designate the geographic areas in which
eligible individuals must receive services through managed care plans.
    Subd. 3. Limitation of choice. Persons enrolled in the MinnesotaCare program who reside
in the designated geographic areas must enroll in a managed care plan to receive their health care
services. Enrollees must receive their health care services from health care providers who are part
of the managed care plan provider network, unless authorized by the managed care plan, in cases
of medical emergency, or when otherwise required by law or by contract.
If only one managed care option is available in a geographic area, the managed care plan may
require that enrollees designate a primary care provider from which to receive their health care.
Enrollees will be permitted to change their designated primary care provider upon request to the
managed care plan. Requests to change primary care providers may be limited to once annually. If
more than one managed care plan is offered in a geographic area, enrollees will be enrolled in
a managed care plan for up to one year from the date of enrollment, but shall have the right to
change to another managed care plan once within the first year of initial enrollment. Enrollees
may also change to another managed care plan during an annual 30-day open enrollment period.
Enrollees shall be notified of the opportunity to change to another managed care plan before the
start of each annual open enrollment period.
Enrollees may change managed care plans or primary care providers at other than the above
designated times for cause as determined through an appeal pursuant to section 256.045.
    Subd. 4. Exemptions to limitations on choice. All contracts between the Department of
Human Services and prepaid health plans to serve medical assistance, general assistance medical
care, and MinnesotaCare recipients must comply with the requirements of United States Code,
title 42, section 1396a (a)(23)(B), notwithstanding any waivers authorized by the United States
Department of Health and Human Services pursuant to United States Code, title 42, section 1315.
    Subd. 5. Eligibility for other state programs. MinnesotaCare enrollees who become
eligible for medical assistance or general assistance medical care will remain in the same managed
care plan if the managed care plan has a contract for that population. Effective January 1, 1998,
MinnesotaCare enrollees who were formerly eligible for general assistance medical care pursuant
to section 256D.03, subdivision 3, within six months of MinnesotaCare enrollment and were
enrolled in a prepaid health plan pursuant to section 256D.03, subdivision 4, paragraph (c), must
remain in the same managed care plan if the managed care plan has a contract for that population.
Managed care plans must participate in the MinnesotaCare and general assistance medical care
programs under a contract with the Department of Human Services in service areas where they
participate in the medical assistance program.
    Subd. 6. Co-payments and benefit limits. Enrollees are responsible for all co-payments in
sections 256L.03, subdivision 5, and 256L.035, and shall pay co-payments to the managed care
plan or to its participating providers. The enrollee is also responsible for payment of inpatient
hospital charges which exceed the MinnesotaCare benefit limit.
    Subd. 7. Managed care plan vendor requirements. The following requirements apply to all
counties or vendors who contract with the Department of Human Services to serve MinnesotaCare
recipients. Managed care plan contractors:
(1) shall authorize and arrange for the provision of the full range of services listed in section
256L.03 in order to ensure appropriate health care is delivered to enrollees;
(2) shall accept the prospective, per capita payment or other contractually defined payment
from the commissioner in return for the provision and coordination of covered health care services
for eligible individuals enrolled in the program;
(3) may contract with other health care and social service practitioners to provide services to
enrollees;
(4) shall provide for an enrollee grievance process as required by the commissioner and
set forth in the contract with the department;
(5) shall retain all revenue from enrollee co-payments;
(6) shall accept all eligible MinnesotaCare enrollees, without regard to health status or
previous utilization of health services;
(7) shall demonstrate capacity to accept financial risk according to requirements specified in
the contract with the department. A health maintenance organization licensed under chapter 62D,
or a nonprofit health plan licensed under chapter 62C, is not required to demonstrate financial risk
capacity, beyond that which is required to comply with chapters 62C and 62D; and
(8) shall submit information as required by the commissioner, including data required for
assessing enrollee satisfaction, quality of care, cost, and utilization of services.
    Subd. 8. Chemical dependency assessments. The managed care plan shall be responsible
for assessing the need and placement for chemical dependency services according to criteria set
forth in Minnesota Rules, parts 9530.6600 to 9530.6660.
    Subd. 9. Rate setting; performance withholds. (a) Rates will be prospective, per capita,
where possible. The commissioner may allow health plans to arrange for inpatient hospital
services on a risk or nonrisk basis. The commissioner shall consult with an independent actuary to
determine appropriate rates.
(b) For services rendered on or after January 1, 2003, to December 31, 2003, the
commissioner shall withhold .5 percent of managed care plan payments under this section pending
completion of performance targets. The withheld funds must be returned no sooner than July 1
and no later than July 31 of the following year if performance targets in the contract are achieved.
A managed care plan may include as admitted assets under section 62D.044 any amount withheld
under this paragraph that is reasonably expected to be returned.
(c) For services rendered on or after January 1, 2004, the commissioner shall withhold five
percent of managed care plan payments under this section pending completion of performance
targets. Each performance target must be quantifiable, objective, measurable, and reasonably
attainable, except in the case of a performance target based on a federal or state law or rule.
Criteria for assessment of each performance target must be outlined in writing prior to the
contract effective date. The withheld funds must be returned no sooner than July 1 and no later
than July 31 of the following calendar year if performance targets in the contract are achieved.
A managed care plan or a county-based purchasing plan under section 256B.692 may include
as admitted assets under section 62D.044 any amount withheld under this paragraph that is
reasonably expected to be returned.
    Subd. 9a. Rate setting; ratable reduction. For services rendered on or after October 1,
2003, the total payment made to managed care plans under the MinnesotaCare program is
reduced 1.0 percent.
    Subd. 9b. Rate setting; ratable reduction. In addition to the reduction in subdivision
9a, the total payment made to managed care plans under the MinnesotaCare program shall be
reduced for services provided on or after January 1, 2006, to reflect a 6.0 percent reduction in
reimbursement for inpatient hospital services.
    Subd. 10. Childhood immunization. Each managed care plan contracting with the
Department of Human Services under this section shall collaborate with the local public health
agencies to ensure childhood immunization to all enrolled families with children. As part of this
collaboration the plan must provide the families with a recommended immunization schedule.
    Subd. 11. Coverage at Indian health service facilities. For American Indian enrollees of
MinnesotaCare, MinnesotaCare shall cover health care services provided at Indian health service
facilities 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 Act, Public Law 93-638, if those services would otherwise be covered under section
256L.03. Payments for services provided under this subdivision shall be made on a fee-for-service
basis, and may, at the option of the tribe or organization, be made at the rates authorized under
sections 256.969, subdivision 16, and 256B.0625, subdivision 34, for those MinnesotaCare
enrollees eligible for coverage at medical assistance rates. 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.
History: 1993 c 345 art 9 s 10; 1994 c 625 art 8 s 58-60; 1995 c 234 art 6 s 17; 1997 c
225 art 1 s 16; art 2 s 56,62; 1998 c 407 art 5 s 38; 1Sp2001 c 9 art 2 s 64; 2002 c 220 art 15
s 23; 2002 c 375 art 2 s 46; 2002 c 379 art 1 s 113; 1Sp2003 c 14 art 12 s 80-82; 2004 c 228
art 1 s 75; 1Sp2005 c 4 art 8 s 73

256L.13 [Repealed, 1998 c 407 art 5 s 48]

256L.14 [Repealed, 1998 c 407 art 5 s 48]

256L.15 PREMIUMS.
    Subdivision 1. Premium determination. (a) Families with children and individuals shall
pay a premium determined according to subdivision 2.
(b) Pregnant women and children under age two are exempt from the provisions of section
256L.06, subdivision 3, paragraph (b), clause (3), requiring disenrollment for failure to pay
premiums. For pregnant women, this exemption continues until the first day of the month
following the 60th day postpartum. Women who remain enrolled during pregnancy or the
postpartum period, despite nonpayment of premiums, shall be disenrolled on the first of the month
following the 60th day postpartum for the penalty period that otherwise applies under section
256L.06, unless they begin paying premiums.
    Subd. 1a. Payment options. The commissioner may offer the following payment options
to an enrollee:
(1) payment by check;
(2) payment by credit card;
(3) payment by recurring automatic checking withdrawal;
(4) payment by onetime electronic transfer of funds;
(5) payment by wage withholding with the consent of the employer and the employee; or
(6) payment by using state tax refund payments.
At application or reapplication, a MinnesotaCare applicant or enrollee may authorize the
commissioner to use the Revenue Recapture Act in chapter 270A to collect funds from the
applicant's or enrollee's refund for the purposes of meeting all or part of the applicant's or enrollee's
MinnesotaCare premium obligation. The applicant or enrollee may authorize the commissioner to
apply for the state working family tax credit on behalf of the applicant or enrollee. The setoff due
under this subdivision shall not be subject to the $10 fee under section 270A.07, subdivision 1.
    Subd. 1b. Payments nonrefundable. Only MinnesotaCare premiums paid for future months
of coverage for which a health plan capitation fee has not been paid may be refunded.
    Subd. 2. Sliding fee scale; monthly gross individual or family income. (a) The
commissioner shall establish a sliding fee scale to determine the percentage of monthly gross
individual or family income that households at different income levels must pay to obtain
coverage through the MinnesotaCare program. The sliding fee scale must be based on the
enrollee's monthly gross individual or family income. The sliding fee scale must contain separate
tables based on enrollment of one, two, or three or more persons. The sliding fee scale begins
with a premium of 1.5 percent of monthly gross individual or family income for individuals
or families with incomes below the limits for the medical assistance program for families and
children in effect on January 1, 1999, and proceeds through the following evenly spaced steps:
1.8, 2.3, 3.1, 3.8, 4.8, 5.9, 7.4, and 8.8 percent. These percentages are matched to evenly spaced
income steps ranging from the medical assistance income limit for families and children in effect
on January 1, 1999, to 275 percent of the federal poverty guidelines for the applicable family size,
up to a family size of five. The sliding fee scale for a family of five must be used for families of
more than five. Effective October 1, 2003, the commissioner shall increase each percentage by
0.5 percentage points for enrollees with income greater than 100 percent but not exceeding 200
percent of the federal poverty guidelines and shall increase each percentage by 1.0 percentage
points for families and children with incomes greater than 200 percent of the federal poverty
guidelines. The sliding fee scale and percentages are not subject to the provisions of chapter 14.
If a family or individual reports increased income after enrollment, premiums shall be adjusted
at the time the change in income is reported.
(b) Children in families whose gross income is above 275 percent of the federal poverty
guidelines shall pay the maximum premium. The maximum premium is defined as a base charge
for one, two, or three or more enrollees so that if all MinnesotaCare cases paid the maximum
premium, the total revenue would equal the total cost of MinnesotaCare medical coverage and
administration. In this calculation, administrative costs shall be assumed to equal ten percent of
the total. The costs of medical coverage for pregnant women and children under age two and
the enrollees in these groups shall be excluded from the total. The maximum premium for two
enrollees shall be twice the maximum premium for one, and the maximum premium for three or
more enrollees shall be three times the maximum premium for one.
(c) After calculating the percentage of premium each enrollee shall pay under paragraph (a),
eight percent shall be added to the premium.
    Subd. 3. Exceptions to sliding scale. Children in families with income at or below 150
percent of the federal poverty guidelines pay a monthly premium of $4.
    Subd. 4. Exception for transitioned adults. County agencies shall pay premiums for single
adults and households with no children formerly enrolled in general assistance medical care and
enrolled in MinnesotaCare according to section 256D.03, subdivision 3, until six-month renewal.
The county agency has the option of continuing to pay premiums for these enrollees past the first
six-month renewal period.
History: 1995 c 234 art 6 s 20; 1998 c 407 art 5 s 39; 1999 c 245 art 4 s 99-101; 2001 c 203
s 16; 1Sp2001 c 9 art 2 s 65; 2002 c 220 art 15 s 24,25; 2002 c 379 art 1 s 113; 1Sp2003 c 14 art
12 s 83-85; 2005 c 10 art 1 s 57; 1Sp2005 c 4 art 8 s 74-76

NOTE: The amendment to subdivision 2, paragraph (a), by Laws 2005, First Special
Session chapter 4, article 8, section 74, changing gross family or individual income to monthly
gross family or individual income is effective August 1, 2007, or upon implementation of
HealthMatch, whichever is later. The amendment to subdivision 2, paragraph (a), related to
premium adjustments and changes of income and subdivision 2, paragraph (c), are effective
September 1, 2005, or upon federal approval, whichever is later. Laws 2005, First Special Session
chapter 4, article 8, section 74, the effective date.

NOTE: The amendment to subdivision 3 by Laws 2005, First Special Session chapter 4,
article 8, section 75, is effective August 1, 2007, or upon HealthMatch implementation, whichever
is later. Laws 2005, First Special Session chapter 4, article 8, section 75, the effective date.

256L.16 [Renumbered 256L.11, subd 2a]

256L.17 ASSET REQUIREMENT FOR MINNESOTACARE.
    Subdivision 1. Definitions. For purposes of this section, the following definitions apply.
(a) "Asset" means cash and other personal property, as well as any real property, that a family
or individual owns which has monetary value.
(b) "Homestead" means the home that is owned by, and is the usual residence of, the family
or individual, together with the surrounding property which is not separated from the home by
intervening property owned by others. Public rights-of-way, such as roads that run through the
surrounding property and separate it from the home, will not affect the exemption of the property.
"Usual residence" includes the home from which the family or individual is temporarily absent
due to illness, employment, or education, or because the home is temporarily not habitable due to
casualty or natural disaster.
(c) "Net asset" means the asset's fair market value minus any encumbrances including, but
not limited to, liens and mortgages.
    Subd. 2. Limit on total assets. (a) Effective July 1, 2002, or upon federal approval,
whichever is later, in order to be eligible for the MinnesotaCare program, 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.
(b) For purposes of this subdivision, assets are determined according to section 256B.056,
subdivision 3c .
(c) State-funded MinnesotaCare is not available for applicants or enrollees who are otherwise
eligible for medical assistance but fail to verify assets. Enrollees who become eligible for
federally funded medical assistance shall be terminated from state-funded MinnesotaCare and
transferred to medical assistance.
    Subd. 3. Documentation. (a) The commissioner of human services shall require individuals
and families, at the time of application or renewal, to indicate on a checkoff form developed by
the commissioner whether they satisfy the MinnesotaCare asset requirement. This form must
include the following or similar language: "To be eligible for MinnesotaCare, individuals and
families must not own net assets in excess of $30,000 for a household of two or more persons or
$15,000 for a household of one person, not including a homestead, household goods and personal
effects, assets owned by children, vehicles used for employment, court-ordered settlements up to
$10,000, individual retirement accounts, and capital and operating assets of a trade or business up
to $200,000. Do you and your household own net assets in excess of these limits?"
(b) The commissioner may require individuals and families to provide any information
the commissioner determines necessary to verify compliance with the asset requirement, if the
commissioner determines that there is reason to believe that an individual or family has assets that
exceed the program limit.
    Subd. 4. Penalties. Individuals or families who are found to have knowingly misreported the
amount of their assets as described in this section shall be subject to the penalties in section 256.98.
The commissioner shall present recommendations on additional penalties to the 1998 legislature.
    Subd. 5. Exemption. This section does not apply to pregnant women. For purposes of this
subdivision, a woman is considered pregnant for 60 days postpartum.
    Subd. 6. Waiver of maintenance of effort requirement. Unless a federal waiver of the
maintenance of effort requirements 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, this section does not apply
to children. The commissioner shall publish a notice in the State Register upon receipt of a
federal waiver.
    Subd. 7. Exception for certain adults. Single adults and households with no children
formerly enrolled in general assistance medical care and enrolled in MinnesotaCare according
to section 256D.03, subdivision 3, are exempt from the requirements of this section until
six-month renewal.
History: 1997 c 225 art 1 s 17; 1998 c 407 art 5 s 40; 1Sp2001 c 9 art 2 s 67; 2002 c 379 art
1 s 113; 1Sp2003 c 14 art 12 s 86; 1Sp2005 c 4 art 8 s 77; 2006 c 282 art 16 s 14

256L.18 PENALTIES.
Whoever obtains or attempts to obtain, or aids or abets any person to obtain by means of a
willfully false statement or representation, or by the intentional withholding or concealment of a
material fact, or by impersonation, or other fraudulent device:
(1) benefits under the MinnesotaCare program to which the person is not entitled; or
(2) benefits under the MinnesotaCare program greater than that to which the person is
reasonably entitled;
shall be considered to have violated section 256.98, and shall be subject to both the criminal
and civil penalties provided under that section.
History: 1997 c 225 art 1 s 18