The commissioner shall supervise the coordination of the prior authorization and review of home care services that are reimbursed by medical assistance.
(a) The commissioner may contract with or employ qualified registered nurses and necessary support staff, or contract with qualified agencies, to provide home care prior authorization and review services for medical assistance recipients who are receiving home care services.
(b) Reimbursement for the prior authorization function shall be made through the medical assistance administrative authority. The state shall pay the nonfederal share. The functions will be to:
(1) assess the recipient's individual need for services required to be cared for safely in the community;
(2) ensure that a service plan that meets the recipient's needs is developed by the appropriate agency or individual;
(3) ensure cost-effectiveness of medical assistance home care services;
(4) recommend the approval or denial of the use of medical assistance funds to pay for home care services;
(5) reassess the recipient's need for and level of home care services at a frequency determined by the commissioner; and
(6) conduct on-site assessments when determined necessary by the commissioner and recommend changes to care plans that will provide more efficient and appropriate home care.
(c) In addition, the commissioner or the commissioner's designee may:
(1) review service plans and reimbursement data for utilization of services that exceed community-based standards for home care, inappropriate home care services, medical necessity, home care services that do not meet quality of care standards, or unauthorized services and make appropriate referrals within the department or to other appropriate entities based on the findings;
(2) assist the recipient in obtaining services necessary to allow the recipient to remain safely in or return to the community;
(3) coordinate home care services with other medical assistance services under section 256B.0625;
(4) assist the recipient with problems related to the provision of home care services;
(5) assure the quality of home care services; and
(6) assure that all liable third-party payers including Medicare have been used prior to medical assistance for home care services, including but not limited to, home health agency, elected hospice benefit, waivered services, alternative care program services, and personal care services.
(d) For the purposes of this section, "home care services" means medical assistance services defined under section 256B.0625, subdivisions 6a, 7, and 19a.
Effective January 1, 1996, for purposes of providing informed choice, coordinating of local planning decisions, and streamlining administrative requirements, the assessment and prior authorization process for persons receiving both home care and home and community-based waivered services for persons with developmental disabilities shall meet the requirements of sections 256B.0651 and 256B.0653 to 256B.0656 with the following exceptions:
(a) Upon request for home care services and subsequent assessment by the public health nurse under sections 256B.0651 and 256B.0653 to 256B.0656, the public health nurse shall participate in the screening process, as appropriate, and, if home care services are determined to be necessary, participate in the development of a service plan coordinating the need for home care and home and community-based waivered services with the assigned county case manager, the recipient of services, and the recipient's legal representative, if any.
(b) The public health nurse shall give prior authorization for home care services to the extent that home care services are:
(1) medically necessary;
(2) chosen by the recipient and their legal representative, if any, from the array of home care and home and community-based waivered services available;
(3) coordinated with other services to be received by the recipient as described in the service plan; and
(4) provided within the county's reimbursement limits for home care and home and community-based waivered services for persons with developmental disabilities.
(c) If the public health agency is or may be the provider of home care services to the recipient, the public health agency shall provide the commissioner of human services with a written plan that specifies how the assessment and prior authorization process will be held separate and distinct from the provision of services.
Official Publication of the State of Minnesota
Revisor of Statutes