256B.037 PROSPECTIVE PAYMENT OF DENTAL SERVICES.
Subdivision 1. Contract for dental services.
The commissioner may conduct a
demonstration project to contract, on a prospective per capita payment basis, with an organization
or organizations licensed under chapter 62C, 62D, or 62N for the provision of all dental care
services beginning July 1, 1994, under the medical assistance, general assistance medical care,
and MinnesotaCare programs, or when necessary waivers are granted by the secretary of health
and human services, whichever occurs later. The commissioner shall identify a geographic area or
areas, including both urban and rural areas, where access to dental services has been inadequate,
in which to conduct demonstration projects. The commissioner shall seek any federal waivers or
approvals necessary to implement this section from the secretary of health and human services.
The commissioner may exclude from participation in the demonstration project any or all
groups currently excluded from participation in the prepaid medical assistance program under
. Except for persons excluded from participation in the demonstration project, all
persons who have been determined eligible for medical assistance, general assistance medical
care and, if applicable, MinnesotaCare and reside in the designated geographic areas are required
to enroll in a dental plan to receive their dental care services. Except for emergency services or
out-of-plan services authorized by the dental plan, recipients must receive their dental services
from dental care providers who are part of the dental plan provider network.
The commissioner shall select either multiple dental plans or a single dental plan in a
designated area. A dental plan under contract with the department must serve both medical
assistance recipients and general assistance medical care recipients in a designated geographic
area and may serve MinnesotaCare recipients. The commissioner may limit the number of dental
plans with which the department contracts within a designated geographic area, taking into
consideration the number of recipients within the designated geographic area; the number of
potential dental plan contractors; the size of the provider network offered by dental plans; the
dental care services offered by a dental plan; qualifications of dental plan personnel; accessibility
of services to recipients; dental plan assurances of recipient confidentiality; dental plan marketing
and enrollment activities; dental plan compliance with this section; dental plan performance under
other contracts with the department to serve medical assistance, general assistance medical care,
or MinnesotaCare recipients; or any other factors necessary to provide the most economical care
consistent with high standards of dental care.
For purposes of this section, "dental plan" means an organization licensed under chapter
62C, 62D, or 62N that contracts with the department to provide covered dental care services to
recipients on a prepaid capitation basis. "Emergency services" has the meaning given in section
256B.0625, subdivision 4
. "Multiple dental plan area" means a designated area in which more
than one dental plan is offered. "Participating provider" means a dentist or dental clinic who is
employed by or under contract with a dental plan to provide dental care services to recipients.
"Single dental plan area" means a designated area in which only one dental plan is available.
Subd. 1a. Multiple dental plan areas.
After the department has executed contracts with
dental plans to provide covered dental care services in a multiple dental plan area, the department
(1) inform applicants and recipients, in writing, of available dental plans, when written
notice of dental plan selection must be submitted to the department, and when dental plan
(2) assign to a dental plan recipients who fail to notify the department in writing of their
dental plan choice; and
(3) notify recipients, in writing, of their assigned dental plan before the effective date of the
recipient's dental plan participation.
Subd. 1b. Single dental plan areas.
After the department has executed a contract with a
dental plan to provide covered dental care services as the sole dental plan in a geographic area,
the provisions in paragraphs (a) to (c) apply.
(a) The department shall assure that applicants and recipients are informed, in writing, of
participating providers in the dental plan and when dental plan participation begins.
(b) The dental plan may require the recipient to select a specific dentist or dental clinic and
may assign to a specific dentist or dental clinic recipients who fail to notify the dental plan of
(c) The dental plan shall notify recipients in writing of their assigned providers before
the effective date of dental plan participation.
Subd. 1c. Dental choice.
(a) In multiple dental plan areas, recipients may change dental
plans once within the first year the recipient participates in a dental plan. After the first year of
dental plan participation, recipients may change dental plans during the annual 30-day open
(b) In single dental plan areas, recipients may change their specific dentist or clinic at
least once during the first year of dental plan participation. After the first year of dental plan
participation, recipients may change their specific dentist or clinic at least once annually. The
dental plan shall notify recipients of this change option.
(c) If a dental plan's contract with the department is terminated for any reason, recipients in
that dental plan shall select a new dental plan and may change dental plans or a specific dentist or
clinic within the first 60 days of participation in the second dental plan.
(d) Recipients may change dental plans or a specific dentist or clinic at any time as follows:
(1) in multiple dental plan areas, if the travel time from the recipient's residence to a general
practice dentist is over 30 minutes, the recipient may change dental plans;
(2) in single dental plan areas, if the travel time from the recipient's residence to the
recipient's specific dentist or clinic is over 30 minutes, the recipient may change providers; or
(3) if the recipient's dental plan or specific dentist or clinic was incorrectly designated due
to department or dental plan error.
(e) Requests for change under this subdivision must be submitted to the department or dental
plan in writing. The department or dental plan shall notify recipients whether the request is
approved or denied within 30 days after receipt of the written request.
Subd. 2. Establishment of prepayment rates.
The commissioner shall consult with an
independent actuary to establish prepayment rates, but shall retain final authority over the
methodology used to establish the rates. The prepayment rates shall not result in payments that
exceed the per capita expenditures that would have been made for dental services by the programs
under a fee-for-service reimbursement system. The package of dental benefits provided to
individuals under this subdivision shall not be less than the package of benefits provided under the
medical assistance fee-for-service reimbursement system for dental services.
Subd. 3. Appeals.
All recipients of services under this section have the right to appeal to the
commissioner under section
. A recipient participating in a dental plan may utilize the
dental plan's internal complaint procedure but is not required to exhaust the internal complaint
procedure before appealing to the commissioner. The appeal rights and procedures in Minnesota
Rules, part 9500.1463
, apply to recipients who enroll in dental plans.
Subd. 4. Information required by commissioner.
A contractor shall submit
encounter-specific information as required by the commissioner, including, but not limited to,
information required for assessing client satisfaction, quality of care, and cost and utilization of
services. Dental plans and participating providers must provide the commissioner access to
recipient dental records to monitor compliance with the requirements of this section.
Subd. 5. Other contracts permitted.
Nothing in this section prohibits the commissioner
from contracting with an organization for comprehensive health services, including dental
services, under section
256D.03, subdivision 4
, paragraph (c).
Subd. 6. Recipient costs.
A dental plan and its participating providers or nonparticipating
providers who provide emergency services or services authorized by the dental plan shall not
charge recipients for any costs for covered services.
Subd. 7. Financial accountability.
A dental plan is accountable to the commissioner for the
fiscal management of covered dental care services. The state of Minnesota and recipients shall
be held harmless for the payment of obligations incurred by a dental plan if the dental plan or
a participating provider becomes insolvent and the department has made the payments due to
the dental plan under the contract.
Subd. 8. Quality improvement.
A dental plan shall have an internal quality improvement
system. A dental plan shall permit the commissioner or the commissioner's agents to evaluate the
quality, appropriateness, and timeliness of covered dental care services through inspections, site
visits, and review of dental records.
Subd. 9. Third-party liability.
To the extent required under section
Rules, part 9506.0080
, a dental plan shall coordinate benefits for or recover the cost of dental
care services provided recipients who have other dental care coverage. Coordination of benefits
includes the dental plan paying applicable co-payments or deductibles on behalf of a recipient.
Subd. 10. Financial capacity.
A dental plan shall demonstrate that its financial risk
capacity is acceptable to its participating providers; except, an organization licensed as a health
maintenance organization under chapter 62D, a nonprofit health service plan under chapter 62C,
or a community integrated service network under chapter 62N, is not required to demonstrate
financial risk capacity beyond the requirements in those chapters for licensure or a certificate of
Subd. 11. Data privacy.
The contract between the commissioner and the dental plan must
specify that the dental plan is an agent of the welfare system and shall have access to welfare
data on recipients to the extent necessary to carry out the dental plan's responsibilities under
the contract. The dental plan shall comply with chapter 13, the Minnesota Government Data
History: 1Sp1993 c 1 art 5 s 27; 1995 c 234 art 6 s 22-33; 1997 c 203 art 9 s 9; 1997 c
225 art 2 s 62