256B.0625 COVERED SERVICES.
Subdivision 1. Inpatient hospital services.
Medical assistance covers inpatient hospital
services. A second medical opinion is required prior to reimbursement for elective surgeries
requiring a second opinion. The commissioner shall publish in the State Register a list of elective
surgeries that require a second medical opinion prior to reimbursement, and the criteria and
standards for deciding whether an elective surgery should require a second medical opinion. The
list and the criteria and standards are not subject to the requirements of sections
The commissioner's decision whether a second medical opinion is required, made in accordance
with rules governing that decision, is not subject to administrative appeal.
Subd. 1a. Services provided in a hospital emergency room.
Medical assistance does
not cover visits to a hospital emergency room that are not for emergency and emergency
poststabilization care or urgent care, and does not pay for any services provided in a hospital
emergency room that are not for emergency and emergency poststabilization care or urgent care.
Subd. 2. Skilled and intermediate nursing care.
Medical assistance covers skilled nursing
home services and services of intermediate care facilities, including training and habilitation
services, as defined in section
252.41, subdivision 3
, for persons with developmental disabilities
who are residing in intermediate care facilities for persons with developmental disabilities.
Medical assistance must not be used to pay the costs of nursing care provided to a patient in a
swing bed as defined in section
, unless (a) the facility in which the swing bed is located
is eligible as a sole community provider, as defined in Code of Federal Regulations, title 42,
, or the facility is a public hospital owned by a governmental entity with 15 or
fewer licensed acute care beds; (b) the Centers for Medicare and Medicaid Services approves
the necessary state plan amendments; (c) the patient was screened as provided by law; (d) the
patient no longer requires acute care services; and (e) no nursing home beds are available within
25 miles of the facility. The commissioner shall exempt a facility from compliance with the
sole community provider requirement in clause (a) if, as of January 1, 2004, the facility had an
agreement with the commissioner to provide medical assistance swing bed services. Medical
assistance also covers up to ten days of nursing care provided to a patient in a swing bed if: (1)
the patient's physician certifies that the patient has a terminal illness or condition that is likely to
result in death within 30 days and that moving the patient would not be in the best interests of the
patient and patient's family; (2) no open nursing home beds are available within 25 miles of the
facility; and (3) no open beds are available in any Medicare hospice program within 50 miles of
the facility. The daily medical assistance payment for nursing care for the patient in the swing bed
is the statewide average medical assistance skilled nursing care per diem as computed annually
by the commissioner on July 1 of each year.
Subd. 2a. Skilled nursing facility and hospice services for dual eligibles.
assistance covers skilled nursing facility services for individuals eligible for both medical
assistance and Medicare who have waived the Medicare skilled nursing facility room and board
benefit and have enrolled in the Medicare hospice program. Medical assistance covers skilled
nursing facility services regardless of whether an individual enrolled in the Medicare hospice
program prior to, on, or after the date of the hospitalization that qualified the individual for
Medicare skilled nursing facility services.
Subd. 3. Physicians' services.
Medical assistance covers physicians' services. Rates paid
for anesthesiology services provided by physicians shall be according to the formula utilized
in the Medicare program and shall use a conversion factor "at percentile of calendar year set
Subd. 3a. Sex reassignment surgery.
Sex reassignment surgery is not covered.
Subd. 3b. Telemedicine consultations.
Medical assistance covers telemedicine consultations.
Telemedicine consultations must be made via two-way, interactive video or store-and-forward
technology. Store-and-forward technology includes telemedicine consultations that do not occur
in real time via synchronous transmissions, and that do not require a face-to-face encounter with
the patient for all or any part of any such telemedicine consultation. The patient record must
include a written opinion from the consulting physician providing the telemedicine consultation.
A communication between two physicians that consists solely of a telephone conversation is not a
telemedicine consultation. Coverage is limited to three telemedicine consultations per recipient
per calendar week. Telemedicine consultations shall be paid at the full allowable rate.
Subd. 3c. Health Services Policy Committee.
The commissioner, after receiving
recommendations from professional physician associations, professional associations representing
licensed nonphysician health care professionals, and consumer groups, shall establish a
13-member Health Services Policy Committee, which consists of 12 voting members and one
nonvoting member. The Health Services Policy Committee shall advise the commissioner
regarding health services pertaining to the administration of health care benefits covered under the
medical assistance, general assistance medical care, and MinnesotaCare programs. The Health
Services Policy Committee shall meet at least quarterly. The Health Services Policy Committee
shall annually elect a physician chair from among its members, who shall work directly with the
commissioner's medical director, to establish the agenda for each meeting.
Subd. 3d. Health Services Policy Committee members.
The Health Services Policy
Committee consists of:
(1) seven voting members who are licensed physicians actively engaged in the practice
of medicine in Minnesota, one of whom must be actively engaged in the treatment of persons
with mental illness, and three of whom must represent health plans currently under contract to
serve medical assistance recipients;
(2) two voting members who are physician specialists actively practicing their specialty in
(3) two voting members who are nonphysician health care professionals licensed or registered
in their profession and actively engaged in their practice of their profession in Minnesota;
(4) one consumer who shall serve as a voting member; and
(5) the commissioner's medical director who shall serve as a nonvoting member.
Members of the Health Services Policy Committee shall not be employed by the Department
of Human Services, except for the medical director.
Subd. 3e. Health Services Policy Committee terms and compensation.
members shall serve staggered three-year terms, with one-third of the voting members' terms
expiring annually. Members may be reappointed by the commissioner. The commissioner may
require more frequent Health Services Policy Committee meetings as needed. An honorarium of
$200 per meeting and reimbursement for mileage and parking shall be paid to each committee
member in attendance except the medical director. The Health Services Policy Committee does
not expire as provided in section
15.059, subdivision 6
Subd. 3f. Circumcision for newborns.
Newborn circumcision is not covered, unless the
procedure is medically necessary or required because of a well-established religious practice.
Subd. 4. Outpatient and physician-directed clinic services.
Medical assistance covers
outpatient hospital or physician-directed clinic services. The physician-directed clinic staff shall
include at least two physicians and all services shall be provided under the direct supervision of a
physician. Hospital outpatient departments are subject to the same limitations and reimbursements
as other enrolled vendors for all services, except initial triage, emergency services, and services
not provided or immediately available in clinics, physicians' offices, or by other enrolled providers.
"Emergency services" means those medical services required for the immediate diagnosis and
treatment of medical conditions that, if not immediately diagnosed and treated, could lead to
serious physical or mental disability or death or are necessary to alleviate severe pain. Neither
the hospital, its employees, nor any physician or dentist, shall be liable in any action arising out
of a determination not to render emergency services or care if reasonable care is exercised in
determining the condition of the person, or in determining the appropriateness of the facilities, or
the qualifications and availability of personnel to render these services consistent with this section.
Subd. 4a. Second medical opinion for surgery.
Certain surgeries require a second medical
opinion to confirm the necessity of the procedure, in order for reimbursement to be made. The
commissioner shall publish in the State Register a list of surgeries that require a second medical
opinion and the criteria and standards for deciding whether a surgery should require a second
medical opinion. The list and the criteria and standards are not subject to the requirements of
. The commissioner's decision about whether a second medical opinion is
required, made according to rules governing that decision, is not subject to administrative appeal.
Subd. 5. Community mental health center services.
Medical assistance covers community
mental health center services provided by a community mental health center that meets the
requirements in paragraphs (a) to (j).
(a) The provider is licensed under Minnesota Rules, parts 9520.0750
(b) The provider provides mental health services under the clinical supervision of a
mental health professional who is licensed for independent practice at the doctoral level or by
a board-certified psychiatrist or a psychiatrist who is eligible for board certification. Clinical
supervision has the meaning given in Minnesota Rules, part 9505.0323
, subpart 1, item F.
(c) The provider must be a private nonprofit corporation or a governmental agency and have
a community board of directors as specified by section
(d) The provider must have a sliding fee scale that meets the requirements in section
, and agree to serve within the limits of its capacity all individuals residing in its service
(e) At a minimum, the provider must provide the following outpatient mental health services:
diagnostic assessment; explanation of findings; family, group, and individual psychotherapy,
including crisis intervention psychotherapy services, multiple family group psychotherapy,
psychological testing, and medication management. In addition, the provider must provide or be
capable of providing upon request of the local mental health authority day treatment services and
professional home-based mental health services. The provider must have the capacity to provide
such services to specialized populations such as the elderly, families with children, persons who
are seriously and persistently mentally ill, and children who are seriously emotionally disturbed.
(f) The provider must be capable of providing the services specified in paragraph (e) to
individuals who are diagnosed with both mental illness or emotional disturbance, and chemical
dependency, and to individuals dually diagnosed with a mental illness or emotional disturbance
and developmental disability.
(g) The provider must provide 24-hour emergency care services or demonstrate the capacity
to assist recipients in need of such services to access such services on a 24-hour basis.
(h) The provider must have a contract with the local mental health authority to provide one
or more of the services specified in paragraph (e).
(i) The provider must agree, upon request of the local mental health authority, to enter into a
contract with the county to provide mental health services not reimbursable under the medical
(j) The provider may not be enrolled with the medical assistance program as both a hospital
and a community mental health center. The community mental health center's administrative,
organizational, and financial structure must be separate and distinct from that of the hospital.
Subd. 5a. Services for children with autism spectrum disorders.
(a) Medical assistance
covers home-based intensive early intervention behavior therapy for children with autism
spectrum disorders, effective July 1, 2007. Children with autism spectrum disorder, and their
custodial parents or foster parents, may access other covered services to treat autism spectrum
disorder, and are not required to receive intensive early intervention behavior therapy services
under this subdivision.
(b) Intensive early intervention behavior therapy does not include coverage for services to
treat developmental disorders of language, early onset psychosis, Rett's disorder, selective mutism,
social anxiety disorder, stereotypic movement disorder, dementia, obsessive compulsive disorder,
schizoid personality disorder, avoidant personality disorder, or reactive attachment disorder.
(c) If a child with autism spectrum disorder is diagnosed to have one or more of these
conditions, intensive early intervention behavior therapy includes coverage only for services
necessary to treat the autism spectrum disorder.
Subd. 5b. Purpose of intensive early intervention behavior therapy services (IEIBTS).
The purpose of IEIBTS is to improve the child's behavioral functioning, to prevent development
of challenging behaviors, to eliminate autistic behaviors, to reduce the risk of out-of-home
placement, and to establish independent typical functioning in language and social behavior. The
procedures used to accomplish these goals are based upon research in applied behavior analysis.
Subd. 5c. Eligible children.
A child is eligible to initiate IEIBTS if, the child meets the
additional eligibility criteria in paragraph (d) and in a diagnostic assessment by a mental health
professional who is not under the employ of the service provider, the child:
(1) is found to have an autism spectrum disorder;
(2) has a current IQ of either untestable, or at least 30;
(3) if nonverbal, initiated behavior therapy by 42 months of age;
(4) if verbal, initiated behavior therapy by 48 months of age; or
(5) if having an IQ of at least 50, initiated behavior therapy by 84 months of age.
To continue after six-month individualized treatment plan (ITP) reviews, at least one of the
child's custodial parents or foster parents must participate in an average of at least five hours of
documented behavior therapy per week for six months, and consistently implement behavior
therapy recommendations 24 hours a day. To continue after six-month individualized treatment
plan (ITP) reviews, the child must show documented progress toward mastery of six-month
benchmark behavior objectives. The maximum number of months during which services may be
billed is 54, or up to the month of August in the first year in which the child completes first grade,
whichever comes last. If significant progress towards treatment goals has not been achieved after
24 months of treatment, treatment must be discontinued.
Subd. 5d. Additional eligibility criteria.
A child is eligible to initiate IEIBTS if:
(1) in medical and diagnostic assessments by medical and mental health professionals, it is
determined that the child does not have severe or profound developmental disabilities;
(2) an accurate assessment of the child's hearing has been performed, including audiometry
if the brain stem auditory evokes response;
(3) a blood lead test has been performed prior to initiation of treatment; and
(4) an EEG or neurologic evaluation is done, prior to initiation of treatment, if the child has a
history of staring spells or developmental regression.
Subd. 5e. Covered services.
The focus of IEIBTS must be to treat the principal diagnostic
features of the autism spectrum disorder. All IEIBTS must be delivered by a team of practitioners
under the consistent supervision of a single clinical supervisor. A mental health professional must
develop the ITP for IEIBTS. The ITP must include six-month benchmark behavior objectives. All
behavior therapy must be based upon research in applied behavior analysis, with an emphasis
upon positive reinforcement of carefully task-analyzed skills for optimum rates of progress. All
behavior therapy must be consistently applied and generalized throughout the 24-hour day and
seven-day week by all of the child's regular care providers. When placing the child in school
activities, a majority of the peers must have no mental health diagnosis, and the child must have
sufficient social skills to succeed with 80 percent of the school activities. Reactive consequences,
such as redirection, correction, positive practice, or time-out, must be used only when necessary
to improve the child's success when proactive procedures alone have not been effective. IEIBTS
must be delivered by a team of behavior therapy practitioners who are employed under the
direction of the same agency. The team may deliver up to 200 billable hours per year of direct
clinical supervisor services, up to 700 billable hours per year of senior behavior therapist services,
and up to 1,800 billable hours per year of direct behavior therapist services. A one-hour clinical
review meeting for the child, parents, and staff must be scheduled 50 weeks a year, at which
behavior therapy is reviewed and planned. At least one-quarter of the annual clinical supervisor
billable hours shall consist of on-site clinical meeting time. At least one-half of the annual senior
behavior therapist billable hours shall consist of direct services to the child or parents. All of the
behavioral therapist billable hours shall consist of direct on-site services to the child or parents.
None of the senior behavior therapist billable hours or behavior therapist billable hours shall
consist of clinical meeting time. If there is any regression of the autistic spectrum disorder after
12 months of therapy, a neurologic consultation must be performed.
Subd. 5f. Provider qualifications.
The provider agency must be capable of delivering
consistent applied behavior analysis (ABA) based behavior therapy in the home. The site director
of the agency must be a mental health professional and a board certified behavior analyst certified
by the Behavior Analyst Certification Board. Each clinical supervisor must be a certified associate
behavior analyst certified by the Behavior Analyst Certification Board or have equivalent
experience in applied behavior analysis.
Subd. 5g. Supervision requirements.
(a) Each behavior therapist practitioner must be
continuously supervised while in the home until the practitioner has mastered competencies for
independent practice. Each behavior therapist must have mastered three credits of academic
content and practice in an applied behavior analysis sequence at an accredited university before
providing more than 12 months of therapy. A college degree or minimum hours of experience are
not required. Each behavior therapist must continue training through weekly direct observation by
the senior behavior therapist, through demonstrated performance in clinical meetings with the
clinical supervisor, and annual training in applied behavior analysis.
(b) Each senior behavior therapist practitioner must have mastered the senior behavior
therapy competencies, completed one year of practice as a behavior therapist, and six months
of co-therapy training with another senior behavior therapist or have an equivalent amount of
experience in applied behavior analysis. Each senior behavior therapist must have mastered 12
credits of academic content and practice in an applied behavior analysis sequence at an accredited
university before providing more than 12 months of senior behavior therapy. Each senior behavior
therapist must continue training through demonstrated performance in clinical meetings with the
clinical supervisor, and annual training in applied behavior analysis.
(c) Each clinical supervisor practitioner must have mastered the clinical supervisor and
family consultation competencies, completed two years of practice as a senior behavior therapist
and one year of co-therapy training with another clinical supervisor, or equivalent experience
in applied behavior analysis. Each clinical supervisor must continue training through annual
training in applied behavior analysis.
Subd. 5h. Place of service.
IEIBTS are provided primarily in the child's home and
community. Services may be provided in the child's natural school or preschool classroom, home
of a relative, natural recreational setting, or day care.
Subd. 5i. Prior authorization requirements.
Prior authorization shall be required for
services provided after 200 hours of clinical supervisor, 700 hours of senior behavior therapist, or
1,800 hours of behavior therapist services per year.
Subd. 5j. Payment rates.
The following payment rates apply:
(1) for an IEIBTS clinical supervisor practitioner under supervision of a mental health
professional, the lower of the submitted charge or $67 per hour unit;
(2) for an IEIBTS senior behavior therapist practitioner under supervision of a mental health
professional, the lower of the submitted charge or $37 per hour unit; or
(3) for an IEIBTS behavior therapist practitioner under supervision of a mental health
professional, the lower of the submitted charge or $27 per hour unit.
An IEIBTS practitioner may receive payment for travel time which exceeds 50 minutes one-way.
The maximum payment allowed will be $0.51 per minute for up to a maximum of 300 hours per
For any week during which the above charges are made to medical assistance, payments
for the following services are excluded: supervising mental health professional hours and
personal care attendant, home-based mental health, family-community support, or mental health
behavioral aide hours.
Subd. 5k. Report.
The commissioner shall collect evidence of the effectiveness of intensive
early intervention behavior therapy services and present a report to the legislature by July 1, 2010.
Subd. 6.[Repealed, 1991 c 292 art 7 s 26
Subd. 6a. Home health services.
Home health services are those services specified in
Minnesota Rules, part 9505.0295
. Medical assistance covers home health services at a recipient's
home residence. Medical assistance does not cover home health services for residents of a
hospital, nursing facility, or intermediate care facility, unless the commissioner of human services
has prior authorized skilled nurse visits for less than 90 days for a resident at an intermediate care
facility for persons with developmental disabilities, to prevent an admission to a hospital or
nursing facility or unless a resident who is otherwise eligible is on leave from the facility and
the facility either pays for the home health services or forgoes the facility per diem for the leave
days that home health services are used. Home health services must be provided by a Medicare
certified home health agency. All nursing and home health aide services must be provided
according to sections
Subd. 7. Private duty nursing.
Medical assistance covers private duty nursing services in a
recipient's home. Recipients who are authorized to receive private duty nursing services in their
home may use approved hours outside of the home during hours when normal life activities
take them outside of their home. To use private duty nursing services at school, the recipient or
responsible party must provide written authorization in the care plan identifying the chosen
provider and the daily amount of services to be used at school. Medical assistance does not cover
private duty nursing services for residents of a hospital, nursing facility, intermediate care facility,
or a health care facility licensed by the commissioner of health, except as authorized in section
for ventilator-dependent recipients in hospitals or unless a resident who is otherwise
eligible is on leave from the facility and the facility either pays for the private duty nursing
services or forgoes the facility per diem for the leave days that private duty nursing services are
used. Total hours of service and payment allowed for services outside the home cannot exceed that
which is otherwise allowed in an in-home setting according to sections
. All private duty nursing services must be provided according to the limits
established under sections
. Private duty nursing services
may not be reimbursed if the nurse is the foster care provider of a recipient who is under age 18.
Subd. 8. Physical therapy.
Medical assistance covers physical therapy and related services,
including specialized maintenance therapy. Services provided by a physical therapy assistant shall
be reimbursed at the same rate as services performed by a physical therapist when the services
of the physical therapy assistant are provided under the direction of a physical therapist who is
on the premises. Services provided by a physical therapy assistant that are provided under the
direction of a physical therapist who is not on the premises shall be reimbursed at 65 percent of
the physical therapist rate.
Subd. 8a. Occupational therapy.
Medical assistance covers occupational therapy and
related services, including specialized maintenance therapy. Services provided by an occupational
therapy assistant shall be reimbursed at the same rate as services performed by an occupational
therapist when the services of the occupational therapy assistant are provided under the direction
of the occupational therapist who is on the premises. Services provided by an occupational
therapy assistant that are provided under the direction of an occupational therapist who is not on
the premises shall be reimbursed at 65 percent of the occupational therapist rate.
Subd. 8b. Speech language pathology and audiology services.
Medical assistance covers
speech language pathology and related services, including specialized maintenance therapy.
Medical assistance covers audiology services and related services. Services provided by a person
who has been issued a temporary registration under section
shall be reimbursed at the
same rate as services performed by a speech language pathologist or audiologist as long as the
requirements of section
148.5161, subdivision 3
, are met.
Subd. 8c. Care management; rehabilitation services.
(a) Effective July 1, 1999, onetime
thresholds shall replace annual thresholds for provision of rehabilitation services described in
subdivisions 8, 8a, and 8b. The onetime thresholds will be the same in amount and description as
the thresholds prescribed by the Department of Human Services health care programs provider
manual for calendar year 1997, except they will not be renewed annually, and they will include
sensory skills and cognitive training skills.
(b) A care management approach for authorization of services beyond the threshold shall
be instituted in conjunction with the onetime thresholds. The care management approach shall
require the provider and the department rehabilitation reviewer to work together directly through
written communication, or telephone communication when appropriate, to establish a medically
necessary care management plan. Authorization for rehabilitation services shall include approval
for up to 12 months of services at a time without additional documentation from the provider
during the extended period, when the rehabilitation services are medically necessary due to an
ongoing health condition.
(c) The commissioner shall implement an expedited five-day turnaround time to review
authorization requests for recipients who need emergency rehabilitation services and who have
exhausted their onetime threshold limit for those services.
Subd. 9. Dental services.
Medical assistance covers dental services. Dental services
include, with prior authorization, fixed bridges that are cost-effective for persons who cannot use
removable dentures because of their medical condition.
Subd. 10. Laboratory and x-ray services.
Medical assistance covers laboratory and x-ray
Subd. 11. Nurse anesthetist services.
Medical assistance covers nurse anesthetist services.
Rates paid for anesthesiology services provided by certified registered nurse anesthetists shall be
according to the formula utilized in the Medicare program and shall use the conversion factor that
is used by the Medicare program.
Subd. 12. Eyeglasses, dentures, and prosthetic devices.
Medical assistance covers
eyeglasses, dentures, and prosthetic devices if prescribed by a licensed practitioner.
Subd. 13. Drugs.
(a) Medical assistance covers drugs, except for fertility drugs when
specifically used to enhance fertility, if prescribed by a licensed practitioner and dispensed
by a licensed pharmacist, by a physician enrolled in the medical assistance program as a
dispensing physician, or by a physician or a nurse practitioner employed by or under contract
with a community health board as defined in section
145A.02, subdivision 5
, for the purposes
of communicable disease control.
(b) The dispensed quantity of a prescription drug must not exceed a 34-day supply, unless
authorized by the commissioner.
(c) Medical assistance covers the following over-the-counter drugs when prescribed by
a licensed practitioner or by a licensed pharmacist who meets standards established by the
commissioner, in consultation with the board of pharmacy: antacids, acetaminophen, family
planning products, aspirin, insulin, products for the treatment of lice, vitamins for adults with
documented vitamin deficiencies, vitamins for children under the age of seven and pregnant
or nursing women, and any other over-the-counter drug identified by the commissioner, in
consultation with the formulary committee, as necessary, appropriate, and cost-effective
for the treatment of certain specified chronic diseases, conditions, or disorders, and this
determination shall not be subject to the requirements of chapter 14. A pharmacist may prescribe
over-the-counter medications as provided under this paragraph for purposes of receiving
reimbursement under Medicaid. When prescribing over-the-counter drugs under this paragraph,
licensed pharmacists must consult with the recipient to determine necessity, provide drug
counseling, review drug therapy for potential adverse interactions, and make referrals as needed
to other health care professionals.
(d) Effective January 1, 2006, medical assistance shall not cover drugs that are coverable
under Medicare Part D as defined in the Medicare Prescription Drug, Improvement, and
Modernization Act of 2003, Public Law 108-173, section 1860D-2(e), for individuals eligible for
drug coverage as defined in the Medicare Prescription Drug, Improvement, and Modernization
Act of 2003, Public Law 108-173, section 1860D-1(a)(3)(A). For these individuals, medical
assistance may cover drugs from the drug classes listed in United States Code, title 42, section
1396r-8(d)(2), subject to this subdivision and subdivisions 13a to 13g, except that drugs listed in
United States Code, title 42, section 1396r-8(d)(2)(E), shall not be covered.
Subd. 13a. Drug Utilization Review Board.
The commissioner, after receiving
recommendations from professional medical associations, professional pharmacy associations,
and consumer groups shall designate a nine-member Drug Utilization Review Board. The board
shall be comprised of at least three but no more than four licensed physicians actively engaged in
the practice of medicine in Minnesota; at least three licensed pharmacists actively engaged in the
practice of pharmacy in Minnesota; and one consumer representative; the remainder to be made
up of health care professionals who are licensed in their field and have recognized knowledge
in the clinically appropriate prescribing, dispensing, and monitoring of covered outpatient
drugs. The board shall be staffed by an employee of the department who shall serve as an ex
officio nonvoting member of the board. The department's medical director shall also serve as an
ex officio, nonvoting member of the board. The members of the board shall be appointed by
the commissioner and shall serve three-year terms. The commissioner shall appoint the initial
members of the board for terms expiring as follows: three members for terms expiring June 30,
1996; three members for terms expiring June 30, 1997; and three members for terms expiring
June 30, 1998. Members may be reappointed by the commissioner. The board shall annually elect
a chair from among the members.
The commissioner shall, with the advice of the board:
(1) implement a medical assistance retrospective and prospective drug utilization review
program as required by United States Code, title 42, section 1396r-8(g)(3);
(2) develop and implement the predetermined criteria and practice parameters for appropriate
prescribing to be used in retrospective and prospective drug utilization review;
(3) develop, select, implement, and assess interventions for physicians, pharmacists, and
patients that are educational and not punitive in nature;
(4) establish a grievance and appeals process for physicians and pharmacists under this
(5) publish and disseminate educational information to physicians and pharmacists regarding
the board and the review program;
(6) adopt and implement procedures designed to ensure the confidentiality of any information
collected, stored, retrieved, assessed, or analyzed by the board, staff to the board, or contractors to
the review program that identifies individual physicians, pharmacists, or recipients;
(7) establish and implement an ongoing process to (i) receive public comment regarding
drug utilization review criteria and standards, and (ii) consider the comments along with other
scientific and clinical information in order to revise criteria and standards on a timely basis; and
(8) adopt any rules necessary to carry out this section.
The board may establish advisory committees. The commissioner may contract with
appropriate organizations to assist the board in carrying out the board's duties. The commissioner
may enter into contracts for services to develop and implement a retrospective and prospective
The board shall report to the commissioner annually on the date the Drug Utilization Review
Annual Report is due to the Centers for Medicare and Medicaid Services. This report is to cover
the preceding federal fiscal year. The commissioner shall make the report available to the public
upon request. The report must include information on the activities of the board and the program;
the effectiveness of implemented interventions; administrative costs; and any fiscal impact
resulting from the program. An honorarium of $100 per meeting and reimbursement for mileage
shall be paid to each board member in attendance.
Subd. 13b.[Repealed, 1997 c 203 art 4 s 73
Subd. 13c. Formulary committee.
The commissioner, after receiving recommendations
from professional medical associations and professional pharmacy associations, and consumer
groups shall designate a Formulary Committee to carry out duties as described in subdivisions
13 to 13g. The Formulary Committee shall be comprised of four licensed physicians actively
engaged in the practice of medicine in Minnesota one of whom must be actively engaged in the
treatment of persons with mental illness; at least three licensed pharmacists actively engaged
in the practice of pharmacy in Minnesota; and one consumer representative; the remainder to
be made up of health care professionals who are licensed in their field and have recognized
knowledge in the clinically appropriate prescribing, dispensing, and monitoring of covered
outpatient drugs. Members of the Formulary Committee shall not be employed by the Department
of Human Services, but the committee shall be staffed by an employee of the department who
shall serve as an ex officio, nonvoting member of the board. The department's medical director
shall also serve as an ex officio, nonvoting member for the committee. Committee members shall
serve three-year terms and may be reappointed by the commissioner. The Formulary Committee
shall meet at least quarterly. The commissioner may require more frequent Formulary Committee
meetings as needed. An honorarium of $100 per meeting and reimbursement for mileage shall be
paid to each committee member in attendance.
Subd. 13d. Drug formulary.
The commissioner shall establish a drug formulary. Its
establishment and publication shall not be subject to the requirements of the Administrative
Procedure Act, but the Formulary Committee shall review and comment on the formulary
The formulary shall not include:
(1) drugs or products for which there is no federal funding;
(2) over-the-counter drugs, except as provided in subdivision 13;
(3) drugs used for weight loss, except that medically necessary lipase inhibitors may be
covered for a recipient with type II diabetes;
(4) drugs when used for the treatment of impotence or erectile dysfunction;
(5) drugs for which medical value has not been established; and
(6) drugs from manufacturers who have not signed a rebate agreement with the Department
of Health and Human Services pursuant to section 1927 of title XIX of the Social Security Act.
Subd. 13e. Payment rates.
(a) The basis for determining the amount of payment shall be
the lower of the actual acquisition costs of the drugs plus a fixed dispensing fee; the maximum
allowable cost set by the federal government or by the commissioner plus the fixed dispensing
fee; or the usual and customary price charged to the public. The amount of payment basis must be
reduced to reflect all discount amounts applied to the charge by any provider/insurer agreement
or contract for submitted charges to medical assistance programs. The net submitted charge
may not be greater than the patient liability for the service. The pharmacy dispensing fee shall
be $3.65, except that the dispensing fee for intravenous solutions which must be compounded
by the pharmacist shall be $8 per bag, $14 per bag for cancer chemotherapy products, and $30
per bag for total parenteral nutritional products dispensed in one liter quantities, or $44 per bag
for total parenteral nutritional products dispensed in quantities greater than one liter. Actual
acquisition cost includes quantity and other special discounts except time and cash discounts. The
actual acquisition cost of a drug shall be estimated by the commissioner, at average wholesale
price minus 12 percent. The actual acquisition cost of antihemophilic factor drugs shall be
estimated at the average wholesale price minus 30 percent. The maximum allowable cost of a
multisource drug may be set by the commissioner and it shall be comparable to, but no higher
than, the maximum amount paid by other third-party payors in this state who have maximum
allowable cost programs. Establishment of the amount of payment for drugs shall not be subject
to the requirements of the Administrative Procedure Act.
(b) An additional dispensing fee of $.30 may be added to the dispensing fee paid to
pharmacists for legend drug prescriptions dispensed to residents of long-term care facilities
when a unit dose blister card system, approved by the department, is used. Under this type of
dispensing system, the pharmacist must dispense a 30-day supply of drug. The National Drug
Code (NDC) from the drug container used to fill the blister card must be identified on the claim
to the department. The unit dose blister card containing the drug must meet the packaging
standards set forth in Minnesota Rules, part 6800.2700
, that govern the return of unused drugs
to the pharmacy for reuse. The pharmacy provider will be required to credit the department
for the actual acquisition cost of all unused drugs that are eligible for reuse. Over-the-counter
medications must be dispensed in the manufacturer's unopened package. The commissioner may
permit the drug clozapine to be dispensed in a quantity that is less than a 30-day supply.
(c) Whenever a generically equivalent product is available, payment shall be on the basis of
the actual acquisition cost of the generic drug, or on the maximum allowable cost established
by the commissioner.
(d) The basis for determining the amount of payment for drugs administered in an outpatient
setting shall be the lower of the usual and customary cost submitted by the provider or the amount
established for Medicare by the United States Department of Health and Human Services pursuant
to title XVIII, section 1847a of the federal Social Security Act.
(e) The commissioner may negotiate lower reimbursement rates for specialty pharmacy
products than the rates specified in paragraph (a). The commissioner may require individuals
enrolled in the health care programs administered by the department to obtain specialty pharmacy
products from providers with whom the commissioner has negotiated lower reimbursement
rates. Specialty pharmacy products are defined as those used by a small number of recipients
or recipients with complex and chronic diseases that require expensive and challenging drug
regimens. Examples of these conditions include, but are not limited to: multiple sclerosis,
HIV/AIDS, transplantation, hepatitis C, growth hormone deficiency, Crohn's Disease, rheumatoid
arthritis, and certain forms of cancer. Specialty pharmaceutical products include injectable and
infusion therapies, biotechnology drugs, high-cost therapies, and therapies that require complex
care. The commissioner shall consult with the formulary committee to develop a list of specialty
pharmacy products subject to this paragraph. In consulting with the formulary committee in
developing this list, the commissioner shall take into consideration the population served by
specialty pharmacy products, the current delivery system and standard of care in the state, and
access to care issues. The commissioner shall have the discretion to adjust the reimbursement
rate to prevent access to care issues.
Subd. 13f. Prior authorization.
(a) The Formulary Committee shall review and recommend
drugs which require prior authorization. The Formulary Committee shall establish general criteria
to be used for the prior authorization of brand-name drugs for which generically equivalent drugs
are available, but the committee is not required to review each brand-name drug for which a
generically equivalent drug is available.
(b) Prior authorization may be required by the commissioner before certain formulary drugs
are eligible for payment. The Formulary Committee may recommend drugs for prior authorization
directly to the commissioner. The commissioner may also request that the Formulary Committee
review a drug for prior authorization. Before the commissioner may require prior authorization
for a drug:
(1) the commissioner must provide information to the Formulary Committee on the impact
that placing the drug on prior authorization may have on the quality of patient care and on
program costs, information regarding whether the drug is subject to clinical abuse or misuse, and
relevant data from the state Medicaid program if such data is available;
(2) the Formulary Committee must review the drug, taking into account medical and clinical
data and the information provided by the commissioner; and
(3) the Formulary Committee must hold a public forum and receive public comment for
an additional 15 days.
The commissioner must provide a 15-day notice period before implementing the prior
(c) Prior authorization shall not be required or utilized for any atypical antipsychotic drug
prescribed for the treatment of mental illness if:
(1) there is no generically equivalent drug available; and
(2) the drug was initially prescribed for the recipient prior to July 1, 2003; or
(3) the drug is part of the recipient's current course of treatment.
This paragraph applies to any multistate preferred drug list or supplemental drug rebate program
established or administered by the commissioner. Prior authorization shall automatically be
granted for 60 days for brand name drugs prescribed for treatment of mental illness within 60
days of when a generically equivalent drug becomes available, provided that the brand name
drug was part of the recipient's course of treatment at the time the generically equivalent drug
(d) Prior authorization shall not be required or utilized for any antihemophilic factor drug
prescribed for the treatment of hemophilia and blood disorders where there is no generically
equivalent drug available if the prior authorization is used in conjunction with any supplemental
drug rebate program or multistate preferred drug list established or administered by the
(e) The commissioner may require prior authorization for brand name drugs whenever a
generically equivalent product is available, even if the prescriber specifically indicates "dispense
as written-brand necessary" on the prescription as required by section
151.21, subdivision 2
(f) Notwithstanding this subdivision, the commissioner may automatically require prior
authorization, for a period not to exceed 180 days, for any drug that is approved by the United
States Food and Drug Administration on or after July 1, 2005. The 180-day period begins no
later than the first day that a drug is available for shipment to pharmacies within the state. The
Formulary Committee shall recommend to the commissioner general criteria to be used for the
prior authorization of the drugs, but the committee is not required to review each individual drug.
In order to continue prior authorizations for a drug after the 180-day period has expired, the
commissioner must follow the provisions of this subdivision.
Subd. 13g. Preferred drug list.
(a) The commissioner shall adopt and implement a preferred
drug list by January 1, 2004. The commissioner may enter into a contract with a vendor or one or
more states for the purpose of participating in a multistate preferred drug list and supplemental
rebate program. The commissioner shall ensure that any contract meets all federal requirements
and maximizes federal financial participation. The commissioner shall publish the preferred
drug list annually in the State Register and shall maintain an accurate and up-to-date list on
the agency Web site.
(b) The commissioner may add to, delete from, and otherwise modify the preferred drug list,
after consulting with the Formulary Committee and appropriate medical specialists and providing
public notice and the opportunity for public comment.
(c) The commissioner shall adopt and administer the preferred drug list as part of the
administration of the supplemental drug rebate program. Reimbursement for prescription drugs
not on the preferred drug list may be subject to prior authorization, unless the drug manufacturer
signs a supplemental rebate contract.
(d) For purposes of this subdivision, "preferred drug list" means a list of prescription drugs
within designated therapeutic classes selected by the commissioner, for which prior authorization
based on the identity of the drug or class is not required.
(e) The commissioner shall seek any federal waivers or approvals necessary to implement
Subd. 13h. Medication therapy management services.
(a) Medical assistance and general
assistance medical care cover medication therapy management services for a recipient taking four
or more prescriptions to treat or prevent two or more chronic medical conditions, or a recipient
with a drug therapy problem that is identified or prior authorized by the commissioner that has
resulted or is likely to result in significant nondrug program costs. The commissioner may cover
medical therapy management services under MinnesotaCare if the commissioner determines this
is cost-effective. For purposes of this subdivision, "medication therapy management" means the
provision of the following pharmaceutical care services by a licensed pharmacist to optimize the
therapeutic outcomes of the patient's medications:
(1) performing or obtaining necessary assessments of the patient's health status;
(2) formulating a medication treatment plan;
(3) monitoring and evaluating the patient's response to therapy, including safety and
(4) performing a comprehensive medication review to identify, resolve, and prevent
medication-related problems, including adverse drug events;
(5) documenting the care delivered and communicating essential information to the patient's
other primary care providers;
(6) providing verbal education and training designed to enhance patient understanding and
appropriate use of the patient's medications;
(7) providing information, support services, and resources designed to enhance patient
adherence with the patient's therapeutic regimens; and
(8) coordinating and integrating medication therapy management services within the broader
health care management services being provided to the patient.
Nothing in this subdivision shall be construed to expand or modify the scope of practice of the
pharmacist as defined in section
151.01, subdivision 27
(b) To be eligible for reimbursement for services under this subdivision, a pharmacist must
meet the following requirements:
(1) have a valid license issued under chapter 151;
(2) have graduated from an accredited college of pharmacy on or after May 1996, or
completed a structured and comprehensive education program approved by the Board of Pharmacy
and the American Council of Pharmaceutical Education for the provision and documentation of
pharmaceutical care management services that has both clinical and didactic elements;
(3) be practicing in an ambulatory care setting as part of a multidisciplinary team or have
developed a structured patient care process that is offered in a private or semiprivate patient care
area that is separate from the commercial business that also occurs in the setting; and
(4) make use of an electronic patient record system that meets state standards.
(c) For purposes of reimbursement for medication therapy management services, the
commissioner may enroll individual pharmacists as medical assistance and general assistance
medical care providers. The commissioner may also establish contact requirements between
the pharmacist and recipient, including limiting the number of reimbursable consultations per
(d) The commissioner, after receiving recommendations from professional medical
associations, professional pharmacy associations, and consumer groups, shall convene an
11-member Medication Therapy Management Advisory Committee to advise the commissioner
on the implementation and administration of medication therapy management services. The
committee shall be comprised of: two licensed physicians; two licensed pharmacists; two
consumer representatives; two health plan company representatives; and three members with
expertise in the area of medication therapy management, who may be licensed physicians or
licensed pharmacists. The committee is governed by section
, except that committee
members do not receive compensation or reimbursement for expenses. The advisory committee
expires on June 30, 2007.
(e) The commissioner shall evaluate the effect of medication therapy management on quality
of care, patient outcomes, and program costs, and shall include a description of any savings
generated in the medical assistance and general assistance medical care programs that can be
attributable to this coverage. The evaluation shall be submitted to the legislature by December 15,
2007. The commissioner may contract with a vendor or an academic institution that has expertise
in evaluating health care outcomes for the purpose of completing the evaluation.
Subd. 14. Diagnostic, screening, and preventive services.
(a) Medical assistance covers
diagnostic, screening, and preventive services.
(b) "Preventive services" include services related to pregnancy, including:
(1) services for those conditions which may complicate a pregnancy and which may be
available to a pregnant woman determined to be at risk of poor pregnancy outcome;
(2) prenatal HIV risk assessment, education, counseling, and testing; and
(3) alcohol abuse assessment, education, and counseling on the effects of alcohol usage
while pregnant. Preventive services available to a woman at risk of poor pregnancy outcome
may differ in an amount, duration, or scope from those available to other individuals eligible
for medical assistance.
(c) "Screening services" include, but are not limited to, blood lead tests.
Subd. 15. Health plan premiums and co-payments.
(a) Medical assistance covers health
care prepayment plan premiums, insurance premiums, and co-payments if determined to be
cost-effective by the commissioner. For purposes of obtaining Medicare Part A and Part B, and
co-payments, expenditures may be made even if federal funding is not available.
(b) Effective for all premiums due on or after June 30, 1997, medical assistance does not
cover premiums that a recipient is required to pay under a qualified or Medicare supplement
plan issued by the Minnesota comprehensive health association. Medical assistance shall
continue to cover premiums for recipients who are covered under a plan issued by the Minnesota
Comprehensive Health Association on June 30, 1997, for a period of six months following receipt
of the notice of termination or until December 31, 1997, whichever is later.
Subd. 16. Abortion services.
Medical assistance covers abortion services, but only if one
of the following conditions is met:
(a) The abortion is a medical necessity. "Medical necessity" means (1) the signed written
statement of two physicians indicating the abortion is medically necessary to prevent the death of
the mother, and (2) the patient has given her consent to the abortion in writing unless the patient is
physically or legally incapable of providing informed consent to the procedure, in which case
consent will be given as otherwise provided by law;
(b) The pregnancy is the result of criminal sexual conduct as defined in section
clauses (c), (d), (e)(i), and (f), and the incident is reported within 48 hours after the incident
occurs to a valid law enforcement agency for investigation, unless the victim is physically unable
to report the criminal sexual conduct, in which case the report shall be made within 48 hours after
the victim becomes physically able to report the criminal sexual conduct; or
(c) The pregnancy is the result of incest, but only if the incident and relative are reported to a
valid law enforcement agency for investigation prior to the abortion.
Subd. 17. Transportation costs.
(a) Medical assistance covers transportation costs incurred
solely for obtaining emergency medical care or transportation costs incurred by eligible persons
in obtaining emergency or nonemergency medical care when paid directly to an ambulance
company, common carrier, or other recognized providers of transportation services.
(b) Medical assistance covers special transportation, as defined in Minnesota Rules, part
, subpart 1, item F, if the recipient has a physical or mental impairment that would
prohibit the recipient from safely accessing and using a bus, taxi, other commercial transportation,
or private automobile.
The commissioner may use an order by the recipient's attending physician to certify that the
recipient requires special transportation services. Special transportation includes driver-assisted
service to eligible individuals. Driver-assisted service includes passenger pickup at and return to
the individual's residence or place of business, assistance with admittance of the individual to the
medical facility, and assistance in passenger securement or in securing of wheelchairs or stretchers
in the vehicle. Special transportation providers must obtain written documentation from the health
care service provider who is serving the recipient being transported, identifying the time that the
recipient arrived. Special transportation providers may not bill for separate base rates for the
continuation of a trip beyond the original destination. Special transportation providers must take
recipients to the nearest appropriate health care provider, using the most direct route available.
The maximum medical assistance reimbursement rates for special transportation services are:
(1) $17 for the base rate and $1.35 per mile for services to eligible persons who need a
(2) $11.50 for the base rate and $1.30 per mile for services to eligible persons who do not
need a wheelchair-accessible van; and
(3) $60 for the base rate and $2.40 per mile, and an attendant rate of $9 per trip, for services
to eligible persons who need a stretcher-accessible vehicle.
Subd. 17a. Payment for ambulance services.
Effective for services rendered on or after
July 1, 2001, medical assistance payments for ambulance services shall be paid at the Medicare
reimbursement rate or at the medical assistance payment rate in effect on July 1, 2000, whichever
Subd. 18. Bus or taxicab transportation.
To the extent authorized by rule of the state
agency, medical assistance covers costs of the most appropriate and cost-effective form of
transportation incurred by any ambulatory eligible person for obtaining nonemergency medical
Subd. 18a. Access to medical services.
(a) Medical assistance reimbursement for meals for
persons traveling to receive medical care may not exceed $5.50 for breakfast, $6.50 for lunch,
or $8 for dinner.
(b) Medical assistance reimbursement for lodging for persons traveling to receive medical
care may not exceed $50 per day unless prior authorized by the local agency.
(c) Medical assistance direct mileage reimbursement to the eligible person or the eligible
person's driver may not exceed 20 cents per mile.
(d) Medical assistance covers oral language interpreter services when provided by an
enrolled health care provider during the course of providing a direct, person-to-person covered
health care service to an enrolled recipient with limited English proficiency.
Subd. 19.[Repealed, 1991 c 292 art 7 s 26
Subd. 19a. Personal care assistant services.
Medical assistance covers personal care
assistant services in a recipient's home. To qualify for personal care assistant services, recipients
or responsible parties must be able to identify the recipient's needs, direct and evaluate task
accomplishment, and provide for health and safety. Approved hours may be used outside the home
when normal life activities take them outside the home. To use personal care assistant services
at school, the recipient or responsible party must provide written authorization in the care plan
identifying the chosen provider and the daily amount of services to be used at school. Total hours
for services, whether actually performed inside or outside the recipient's home, cannot exceed that
which is otherwise allowed for personal care assistant services in an in-home setting according to
. Medical assistance does not cover personal
care assistant services for residents of a hospital, nursing facility, intermediate care facility,
health care facility licensed by the commissioner of health, or unless a resident who is otherwise
eligible is on leave from the facility and the facility either pays for the personal care assistant
services or forgoes the facility per diem for the leave days that personal care assistant services are
used. All personal care assistant services must be provided according to sections
. Personal care assistant services may not be reimbursed if the personal
care assistant is the spouse or legal guardian of the recipient or the parent of a recipient under
age 18, or the responsible party or the foster care provider of a recipient who cannot direct the
recipient's own care unless, in the case of a foster care provider, a county or state case manager
visits the recipient as needed, but not less than every six months, to monitor the health and safety
of the recipient and to ensure the goals of the care plan are met. Parents of adult recipients, adult
children of the recipient or adult siblings of the recipient may be reimbursed for personal care
assistant services, if they are granted a waiver under sections
. Notwithstanding the provisions of section
256B.0655, subdivision 2
, paragraph (b),
clause (4), the noncorporate legal guardian or conservator of an adult, who is not the responsible
party and not the personal care provider organization, may be granted a hardship waiver under
, to be reimbursed to provide personal care
assistant services to the recipient, and shall not be considered to have a service provider interest
for purposes of participation on the screening team under section
256B.092, subdivision 7
Subd. 19b. No automatic adjustment.
For fiscal years beginning on or after July 1, 1993,
the commissioner of human services shall not provide automatic annual inflation adjustments
for home care services. The commissioner of finance shall include as a budget change request
in each biennial detailed expenditure budget submitted to the legislature under section
annual adjustments in reimbursement rates for home care services.
Subd. 19c. Personal care.
Medical assistance covers personal care assistant services
provided by an individual who is qualified to provide the services according to subdivision 19a
, where the services have a statement of
need by a physician, provided in accordance with a plan, and are supervised by the recipient or a
qualified professional. The physician's statement of need for personal care assistant services shall
be documented on a form approved by the commissioner and include the diagnosis or condition
of the person that results in a need for personal care assistant services and be updated when
the person's medical condition requires a change, but at least annually if the need for personal
care assistant services is ongoing.
"Qualified professional" means a mental health professional as defined in section
245.4871, subdivision 27
; or a registered nurse as defined in sections
, or a licensed social worker as defined in section
. As part of the assessment,
the county public health nurse will assist the recipient or responsible party to identify the most
appropriate person to provide supervision of the personal care assistant. The qualified professional
shall perform the duties described in Minnesota Rules, part 9505.0335
, subpart 4.
Subd. 20. Mental health case management.
(a) To the extent authorized by rule of the
state agency, medical assistance covers case management services to persons with serious and
persistent mental illness and children with severe emotional disturbance. Services provided under
this section must meet the relevant standards in sections
, the Comprehensive
Adult and Children's Mental Health Acts, Minnesota Rules, parts
, excluding subpart 10.
(b) Entities meeting program standards set out in rules governing family community support
services as defined in section
245.4871, subdivision 17
, are eligible for medical assistance
reimbursement for case management services for children with severe emotional disturbance
when these services meet the program standards in Minnesota Rules, parts
, excluding subparts 6 and 10.
(c) Medical assistance and MinnesotaCare payment for mental health case management shall
be made on a monthly basis. In order to receive payment for an eligible child, the provider must
document at least a face-to-face contact with the child, the child's parents, or the child's legal
representative. To receive payment for an eligible adult, the provider must document:
(1) at least a face-to-face contact with the adult or the adult's legal representative; or
(2) at least a telephone contact with the adult or the adult's legal representative and document
a face-to-face contact with the adult or the adult's legal representative within the preceding two
(d) Payment for mental health case management provided by county or state staff shall be
based on the monthly rate methodology under section
256B.094, subdivision 6
, paragraph (b),
with separate rates calculated for child welfare and mental health, and within mental health,
separate rates for children and adults.
(e) Payment for mental health case management provided by Indian health services or
by agencies operated by Indian tribes may be made according to this section or other relevant
federally approved rate setting methodology.
(f) Payment for mental health case management provided by vendors who contract with a
county or Indian tribe shall be based on a monthly rate negotiated by the host county or tribe.
The negotiated rate must not exceed the rate charged by the vendor for the same service to other
payers. If the service is provided by a team of contracted vendors, the county or tribe may
negotiate a team rate with a vendor who is a member of the team. The team shall determine how
to distribute the rate among its members. No reimbursement received by contracted vendors shall
be returned to the county or tribe, except to reimburse the county or tribe for advance funding
provided by the county or tribe to the vendor.
(g) If the service is provided by a team which includes contracted vendors, tribal staff, and
county or state staff, the costs for county or state staff participation in the team shall be included
in the rate for county-provided services. In this case, the contracted vendor, the tribal agency, and
the county may each receive separate payment for services provided by each entity in the same
month. In order to prevent duplication of services, each entity must document, in the recipient's
file, the need for team case management and a description of the roles of the team members.
(h) The commissioner shall calculate the nonfederal share of actual medical assistance and
general assistance medical care payments for each county, based on the higher of calendar year
1995 or 1996, by service date, project that amount forward to 1999, and transfer one-half of
the result from medical assistance and general assistance medical care to each county's mental
health grants under section
for calendar year 1999. The annualized minimum amount
added to each county's mental health grant shall be $3,000 per year for children and $5,000
per year for adults. The commissioner may reduce the statewide growth factor in order to fund
these minimums. The annualized total amount transferred shall become part of the base for
future mental health grants for each county.
(i) Notwithstanding section
256B.19, subdivision 1
, the nonfederal share of costs for mental
health case management shall be provided by the recipient's county of responsibility, as defined
, from sources other than federal funds or funds used to match
other federal funds. If the service is provided by a tribal agency, the nonfederal share, if any, shall
be provided by the recipient's tribe.
(j) The commissioner may suspend, reduce, or terminate the reimbursement to a provider that
does not meet the reporting or other requirements of this section. The county of responsibility, as
defined in sections
, or, if applicable, the tribal agency, is responsible for
any federal disallowances. The county or tribe may share this responsibility with its contracted
(k) The commissioner shall set aside a portion of the federal funds earned under this section
to repay the special revenue maximization account under section
256.01, subdivision 2
(15). The repayment is limited to:
(1) the costs of developing and implementing this section; and
(2) programming the information systems.
(l) Payments to counties and tribal agencies for case management expenditures under this
section shall only be made from federal earnings from services provided under this section.
Payments to county-contracted vendors shall include both the federal earnings and the county
(m) Notwithstanding section
, county payments for the cost of mental health case
management services provided by county or state staff shall not be made to the commissioner
of finance. For the purposes of mental health case management services provided by county or
state staff under this section, the centralized disbursement of payments to counties under section
consists only of federal earnings from services provided under this section.
(n) Case management services under this subdivision do not include therapy, treatment,
legal, or outreach services.
(o) If the recipient is a resident of a nursing facility, intermediate care facility, or hospital,
and the recipient's institutional care is paid by medical assistance, payment for case management
services under this subdivision is limited to the last 180 days of the recipient's residency in that
facility and may not exceed more than six months in a calendar year.
(p) Payment for case management services under this subdivision shall not duplicate
payments made under other program authorities for the same purpose.
(q) By July 1, 2000, the commissioner shall evaluate the effectiveness of the changes
required by this section, including changes in number of persons receiving mental health case
management, changes in hours of service per person, and changes in caseload size.
(r) For each calendar year beginning with the calendar year 2001, the annualized amount
of state funds for each county determined under paragraph (h) shall be adjusted by the county's
percentage change in the average number of clients per month who received case management
under this section during the fiscal year that ended six months prior to the calendar year in
question, in comparison to the prior fiscal year.
(s) For counties receiving the minimum allocation of $3,000 or $5,000 described in
paragraph (h), the adjustment in paragraph (s) shall be determined so that the county receives
the higher of the following amounts:
(1) a continuation of the minimum allocation in paragraph (h); or
(2) an amount based on that county's average number of clients per month who received
case management under this section during the fiscal year that ended six months prior to the
calendar year in question, times the average statewide grant per person per month for counties not
receiving the minimum allocation.
(t) The adjustments in paragraphs (s) and (t) shall be calculated separately for children
Subd. 20a. Case management; developmental disabilities.
To the extent defined in the state
Medicaid plan, case management service activities for persons with developmental disabilities
as defined in section
, and rules promulgated thereunder, are covered services under
Subd. 21.[Repealed, 1989 c 282 art 3 s 98
Subd. 22. Hospice care.
Medical assistance covers hospice care services under Public Law
99-272, section 9505, to the extent authorized by rule.
Subd. 23. Day treatment services.
Medical assistance covers day treatment services as
specified in sections
245.462, subdivision 8
245.4871, subdivision 10
, that are provided
under contract with the county board. Notwithstanding Minnesota Rules, part 9505.0323
15, the commissioner may set authorization thresholds for day treatment for adults according
256B.0625, subdivision 25
. Effective July 1, 2004, medical assistance covers day
treatment services for children as specified under section
Subd. 24. Other medical or remedial care.
Medical assistance covers any other medical
or remedial care licensed and recognized under state law unless otherwise prohibited by law,
except licensed chemical dependency treatment programs or primary treatment or extended
care treatment units in hospitals that are covered under chapter 254B. The commissioner shall
include chemical dependency services in the state medical assistance plan for federal reporting
purposes, but payment must be made under chapter 254B. The commissioner shall publish in the
State Register a list of elective surgeries that require a second medical opinion before medical
assistance reimbursement, and the criteria and standards for deciding whether an elective surgery
should require a second medical opinion. The list and criteria and standards are not subject to
the requirements of sections
Subd. 25. Prior authorization required.
The commissioner shall publish in the State
Register a list of health services that require prior authorization, as well as the criteria and
standards used to select health services on the list. The list and the criteria and standards used to
formulate it are not subject to the requirements of sections
. The commissioner's
decision whether prior authorization is required for a health service is not subject to administrative
Subd. 26. Special education services.
(a) Medical assistance covers medical services
identified in a recipient's individualized education plan and covered under the medical assistance
state plan. Covered services include occupational therapy, physical therapy, speech-language
therapy, clinical psychological services, nursing services, school psychological services, school
social work services, personal care assistants serving as management aides, assistive technology
devices, transportation services, health assessments, and other services covered under the medical
assistance state plan. Mental health services eligible for medical assistance reimbursement must
be provided or coordinated through a children's mental health collaborative where a collaborative
exists if the child is included in the collaborative operational target population. The provision
or coordination of services does not require that the individual education plan be developed
by the collaborative.
The services may be provided by a Minnesota school district that is enrolled as a medical
assistance provider or its subcontractor, and only if the services meet all the requirements
otherwise applicable if the service had been provided by a provider other than a school
district, in the following areas: medical necessity, physician's orders, documentation, personnel
qualifications, and prior authorization requirements. The nonfederal share of costs for services
provided under this subdivision is the responsibility of the local school district as provided in
. Services listed in a child's individual education plan are eligible for medical
assistance reimbursement only if those services meet criteria for federal financial participation
under the Medicaid program.
(b) Approval of health-related services for inclusion in the individual education plan does not
require prior authorization for purposes of reimbursement under this chapter. The commissioner
may require physician review and approval of the plan not more than once annually or upon any
modification of the individual education plan that reflects a change in health-related services.
(c) Services of a speech-language pathologist provided under this section are covered
notwithstanding Minnesota Rules, part 9505.0390
, subpart 1, item L, if the person:
(1) holds a masters degree in speech-language pathology;
(2) is licensed by the Minnesota Board of Teaching as an educational speech-language
(3) either has a certificate of clinical competence from the American Speech and Hearing
Association, has completed the equivalent educational requirements and work experience
necessary for the certificate or has completed the academic program and is acquiring supervised
work experience to qualify for the certificate.
(d) Medical assistance coverage for medically necessary services provided under other
subdivisions in this section may not be denied solely on the basis that the same or similar services
are covered under this subdivision.
(e) The commissioner shall develop and implement package rates, bundled rates, or per diem
rates for special education services under which separately covered services are grouped together
and billed as a unit in order to reduce administrative complexity.
(f) The commissioner shall develop a cost-based payment structure for payment of these
(g) Effective July 1, 2000, medical assistance services provided under an individual
education plan or an individual family service plan by local school districts shall not count against
medical assistance authorization thresholds for that child.
(h) Nursing services as defined in section
148.171, subdivision 15
, and provided as an
individual education plan health-related service, are eligible for medical assistance payment if
they are otherwise a covered service under the medical assistance program. Medical assistance
covers the administration of prescription medications by a licensed nurse who is employed by
or under contract with a school district when the administration of medications is identified in
the child's individualized education plan. The simple administration of medications alone is not
covered under medical assistance when administered by a provider other than a school district or
when it is not identified in the child's individualized education plan.
Subd. 27. Organ and tissue transplants.
All organ transplants must be performed at
transplant centers meeting united network for organ sharing criteria or at Medicare-approved
organ transplant centers. Stem cell or bone marrow transplant centers must meet the standards
established by the Foundation for the Accreditation of Hematopoietic Cell Therapy.
Subd. 28. Certified nurse practitioner services.
Medical assistance covers services
performed by a certified pediatric nurse practitioner, a certified family nurse practitioner, a
certified adult nurse practitioner, a certified obstetric/gynecological nurse practitioner, a certified
neonatal nurse practitioner, or a certified geriatric nurse practitioner in independent practice, if:
(1) the service provided on an inpatient basis is not included as part of the cost for inpatient
services included in the operating payment rate;
(2) the service is otherwise covered under this chapter as a physician service; and
(3) the service is within the scope of practice of the nurse practitioner's license as a registered
nurse, as defined in section
Subd. 28a. Registered physician assistant services.
Medical assistance covers services
performed by a registered physician assistant if the service is otherwise covered under this chapter
as a physician service and if the service is within the scope of practice of a registered physician
assistant as defined in section
Subd. 29. Public health nursing clinic services.
Medical assistance covers the services of
a certified public health nurse or a registered nurse practicing in a public health nursing clinic
that is a department of, or that operates under the direct authority of, a unit of government, if
the service is within the scope of practice of the public health or registered nurse's license as a
registered nurse, as defined in section
Subd. 30. Other clinic services.
(a) Medical assistance covers rural health clinic services,
federally qualified health center services, nonprofit community health clinic services, public
health clinic services, and the services of a clinic meeting the criteria established in rule by the
commissioner. Rural health clinic services and federally qualified health center services mean
services defined in United States Code, title 42, section 1396d(a)(2)(B) and (C). Payment for rural
health clinic and federally qualified health center services shall be made according to applicable
federal law and regulation.
(b) A federally qualified health center that is beginning initial operation shall submit an
estimate of budgeted costs and visits for the initial reporting period in the form and detail required
by the commissioner. A federally qualified health center that is already in operation shall submit
an initial report using actual costs and visits for the initial reporting period. Within 90 days of
the end of its reporting period, a federally qualified health center shall submit, in the form and
detail required by the commissioner, a report of its operations, including allowable costs actually
incurred for the period and the actual number of visits for services furnished during the period,
and other information required by the commissioner. Federally qualified health centers that file
Medicare cost reports shall provide the commissioner with a copy of the most recent Medicare
cost report filed with the Medicare program intermediary for the reporting year which support the
costs claimed on their cost report to the state.
(c) In order to continue cost-based payment under the medical assistance program according
to paragraphs (a) and (b), a federally qualified health center or rural health clinic must apply for
designation as an essential community provider within six months of final adoption of rules
by the Department of Health according to section
62Q.19, subdivision 7
. For those federally
qualified health centers and rural health clinics that have applied for essential community provider
status within the six-month time prescribed, medical assistance payments will continue to be
made according to paragraphs (a) and (b) for the first three years after application. For federally
qualified health centers and rural health clinics that either do not apply within the time specified
above or who have had essential community provider status for three years, medical assistance
payments for health services provided by these entities shall be according to the same rates and
conditions applicable to the same service provided by health care providers that are not federally
qualified health centers or rural health clinics.
(d) Effective July 1, 1999, the provisions of paragraph (c) requiring a federally qualified
health center or a rural health clinic to make application for an essential community provider
designation in order to have cost-based payments made according to paragraphs (a) and (b)
no longer apply.
(e) Effective January 1, 2000, payments made according to paragraphs (a) and (b) shall be
limited to the cost phase-out schedule of the Balanced Budget Act of 1997.
(f) Effective January 1, 2001, each federally qualified health center and rural health clinic
may elect to be paid either under the prospective payment system established in United States
Code, title 42, section 1396a(aa), or under an alternative payment methodology consistent with
the requirements of United States Code, title 42, section 1396a(aa), and approved by the Centers
for Medicare and Medicaid Services. The alternative payment methodology shall be 100 percent
of cost as determined according to Medicare cost principles.
Subd. 31. Medical supplies and equipment.
Medical assistance covers medical supplies
and equipment. Separate payment outside of the facility's payment rate shall be made for
wheelchairs and wheelchair accessories for recipients who are residents of intermediate care
facilities for the developmentally disabled. Reimbursement for wheelchairs and wheelchair
accessories for ICF/MR recipients shall be subject to the same conditions and limitations as
coverage for recipients who do not reside in institutions. A wheelchair purchased outside of the
facility's payment rate is the property of the recipient.
Subd. 31a. Augmentative and alternative communication systems.
(a) Medical assistance
covers augmentative and alternative communication systems consisting of electronic or
nonelectronic devices and the related components necessary to enable a person with severe
expressive communication limitations to produce or transmit messages or symbols in a manner
that compensates for that disability.
(b) Until the volume of systems purchased increases to allow a discount price, the
commissioner shall reimburse augmentative and alternative communication manufacturers
and vendors at the manufacturer's suggested retail price for augmentative and alternative
communication systems and related components. The commissioner shall separately reimburse
providers for purchasing and integrating individual communication systems which are unavailable
as a package from an augmentative and alternative communication vendor.
(c) Reimbursement rates established by this purchasing program are not subject to Minnesota
Rules, part 9505.0445
, item S or T.
Subd. 32. Nutritional products.
Medical assistance covers nutritional products needed for
nutritional supplementation because solid food or nutrients thereof cannot be properly absorbed
by the body or needed for treatment of phenylketonuria, hyperlysinemia, maple syrup urine
disease, a combined allergy to human milk, cow's milk, and soy formula, or any other childhood
or adult diseases, conditions, or disorders identified by the commissioner as requiring a similarly
necessary nutritional product. Nutritional products needed for the treatment of a combined allergy
to human milk, cow's milk, and soy formula require prior authorization. Separate payment shall
not be made for nutritional products for residents of long-term care facilities. Payment for dietary
requirements is a component of the per diem rate paid to these facilities.
Subd. 33. Child welfare targeted case management.
Medical assistance, subject to federal
approval, covers child welfare targeted case management services as defined in section
to children under age 21 who have been assessed and determined in accordance with section
(1) at risk of placement or in placement as defined in section
260C.212, subdivision 1
(2) at risk of maltreatment or experiencing maltreatment as defined in section
(3) in need of protection or services as defined in section
260C.007, subdivision 6
Subd. 34. Indian health services facilities.
Medical assistance payments and MinnesotaCare
payments to facilities of the Indian health service and facilities operated by a tribe or tribal
organization under funding authorized by United States Code, title 25, sections 450f to 450n, or
title III of the Indian Self-Determination and Education Assistance Act, Public Law 93-638, for
enrollees who are eligible for federal financial participation, shall be at the option of the facility in
accordance with the rate published by the United States Assistant Secretary for Health under the
authority of United States Code, title 42, sections 248(a) and 249(b). General assistance medical
care payments to facilities of the Indian health services and facilities operated by a tribe or tribal
organization for the provision of outpatient medical care services billed after June 30, 1990, must
be in accordance with the general assistance medical care rates paid for the same services when
provided in a facility other than a facility of the Indian health service or a facility operated by a
tribe or tribal organization. MinnesotaCare payments for enrollees who are not eligible for federal
financial participation at facilities of the Indian health service and facilities operated by a tribe or
tribal organization for the provision of outpatient medical services must be in accordance with the
medical assistance rates paid for the same services when provided in a facility other than a facility
of the Indian health service or a facility operated by a tribe or tribal organization.
Subd. 35.[Repealed, 1Sp2003 c 14 art 4 s 24
Subd. 35a. Children's mental health crisis response services.
Medical assistance covers
children's mental health crisis response services according to section
Subd. 35b. Children's therapeutic services and supports.
Medical assistance covers
children's therapeutic services and supports according to section
Subd. 36.[Repealed, 1Sp2003 c 14 art 4 s 24
Subd. 37. Individualized rehabilitation services.
Medical assistance covers individualized
rehabilitation services as defined in section
245.492, subdivision 23
, that are provided by a
collaborative, county, or an entity under contract with a county through an integrated service
system, as described in section
, that is approved by the state coordinating council,
subject to federal approval.
Subd. 38. Payments for mental health services.
Payments for mental health services
covered under the medical assistance program that are provided by masters-prepared mental health
professionals shall be 80 percent of the rate paid to doctoral-prepared professionals. Payments
for mental health services covered under the medical assistance program that are provided by
masters-prepared mental health professionals employed by community mental health centers shall
be 100 percent of the rate paid to doctoral-prepared professionals. For purposes of reimbursement
of mental health professionals under the medical assistance program, all social workers who:
(1) have received a master's degree in social work from a program accredited by the Council
on Social Work Education;
(2) are licensed at the level of graduate social worker or independent social worker; and
(3) are practicing clinical social work under appropriate supervision, as defined by chapter
148D; meet all requirements under Minnesota Rules, part 9505.0323
, subpart 24, and shall be
Subd. 39. Childhood immunizations.
Providers who administer pediatric vaccines within
the scope of their licensure, and who are enrolled as a medical assistance provider, must enroll in
the pediatric vaccine administration program established by section 13631 of the Omnibus Budget
Reconciliation Act of 1993. Medical assistance shall pay an $8.50 fee per dose for administration
of the vaccine to children eligible for medical assistance. Medical assistance does not pay for
vaccines that are available at no cost from the pediatric vaccine administration program.
Subd. 40. Tuberculosis related services.
(a) For persons infected with tuberculosis,
medical assistance covers case management services and direct observation of the intake of
drugs prescribed to treat tuberculosis.
(b) "Case management services" means services furnished to assist persons infected with
tuberculosis in gaining access to needed medical services. Case management services include
at a minimum:
(1) assessing a person's need for medical services to treat tuberculosis;
(2) developing a care plan that addresses the needs identified in clause (1);
(3) assisting the person in accessing medical services identified in the care plan; and
(4) monitoring the person's compliance with the care plan to ensure completion of
tuberculosis therapy. Medical assistance covers case management services under this subdivision
only if the services are provided by a certified public health nurse who is employed by a
community health board as defined in section
145A.02, subdivision 5
(c) To be covered by medical assistance, direct observation of the intake of drugs prescribed
to treat tuberculosis must be provided by a community outreach worker, licensed practical nurse,
registered nurse who is trained and supervised by a public health nurse employed by a community
health board as defined in section
145A.02, subdivision 5
, or a public health nurse employed by a
community health board.
Subd. 41. Residential services for children with severe emotional disturbance.
assistance covers rehabilitative services in accordance with section
that are provided
by a county through a residential facility, for children who have been diagnosed with severe
emotional disturbance and have been determined to require the level of care provided in a
Subd. 42. Mental health professional.
Notwithstanding Minnesota Rules, part 9505.0175
subpart 28, the definition of a mental health professional shall include a person who is qualified as
specified in section
245.462, subdivision 18
, clause (5); or
245.4871, subdivision 27
, clause (5),
for the purpose of this section and Minnesota Rules, parts 9505.0170
Subd. 43. Mental health provider travel time.
Medical assistance covers provider travel
time if a recipient's individual treatment plan requires the provision of mental health services
outside of the provider's normal place of business. This does not include any travel time which
is included in other billable services, and is only covered when the mental health service being
provided to a recipient is covered under medical assistance.
Subd. 44. Targeted case management services.
Medical assistance covers case management
services for vulnerable adults and adults with developmental disabilities, as provided under
Subd. 45. Subacute psychiatric care for persons under 21 years of age.
covers subacute psychiatric care for person under 21 years of age when:
(1) the services meet the requirements of Code of Federal Regulations, title 42, section
(2) the facility is accredited as a psychiatric treatment facility by the Joint Commission on
Accreditation of Healthcare Organizations, the Commission on Accreditation of Rehabilitation
Facilities, or the Council on Accreditation; and
(3) the facility is licensed by the commissioner of health under section
Subd. 46. Mental health telemedicine.
Effective January 1, 2006, and subject to federal
approval, mental health services that are otherwise covered by medical assistance as direct
face-to-face services may be provided via two-way interactive video. Use of two-way interactive
video must be medically appropriate to the condition and needs of the person being served.
Reimbursement is at the same rates and under the same conditions that would otherwise apply
to the service. The interactive video equipment and connection must comply with Medicare
standards in effect at the time the service is provided.
Subd. 47. Treatment foster care services.
Effective July 1, 2006, and subject to federal
approval, medical assistance covers treatment foster care services according to section
Subd. 48. Psychiatric consultation to primary care practitioners.
Effective January 1,
2006, medical assistance covers consultation provided by a psychiatrist via telephone, e-mail,
facsimile, or other means of communication to primary care practitioners, including pediatricians.
The need for consultation and the receipt of the consultation must be documented in the patient
record maintained by the primary care practitioner. If the patient consents, and subject to federal
limitations and data privacy provisions, the consultation may be provided without the patient
History: Ex1967 c 16 s 2; 1969 c 395 s 1; 1973 c 717 s 17; 1975 c 247 s 9; 1975 c 384 s 1;
1975 c 437 art 2 s 3; 1976 c 173 s 56; 1976 c 236 s 1; 1976 c 312 s 1; 1978 c 508 s 2; 1978 c 560
s 10; 1981 c 360 art 2 s 26,54; 1Sp1981 c 2 s 12; 1Sp1981 c 4 art 4 s 22; 3Sp1981 c 2 art 1 s 31;
1982 c 562 s 2; 1983 c 151 s 1,2; 1983 c 312 art 1 s 27; art 5 s 10; art 9 s 4; 1984 c 654 art 5 s 58;
1985 c 21 s 52-54; 1985 c 49 s 41; 1985 c 252 s 19,20; 1Sp1985 c 3 s 19; 1986 c 394 s 17; 1986 c
444; 1987 c 309 s 24; 1987 c 370 art 1 s 3; art 2 s 4; 1987 c 374 s 1; 1987 c 403 art 2 s 73,74; art
5 s 16; 1988 c 689 art 2 s 141,268; 1989 c 282 art 3 s 54-58; 1990 c 422 s 10; 1990 c 568 art 3 s
43-50,104; 1991 c 199 art 2 s 1; 1991 c 292 art 4 s 41-49; art 6 s 45; art 7 s 5,9-11; 1992 c 391 s
1,2; 1992 c 513 art 7 s 43-49; art 9 s 25; 1993 c 246 s 1,2; 1993 c 247 art 4 s 11; 1993 c 345 art
13 s 1; 1Sp1993 c 1 art 3 s 23; art 5 s 36-49; art 7 s 41-44; art 9 s 71; 1Sp1993 c 6 s 10; 1994 c
465 art 3 s 52; 1994 c 625 art 8 s 72; 1995 c 178 art 2 s 26; 1995 c 207 art 6 s 38-51; art 8 s 33;
1995 c 234 art 6 s 38; 1995 c 263 s 10; 1996 c 451 art 2 s 20; art 5 s 15,16; 1997 c 203 art 2 s 25;
art 4 s 25,26; 1997 c 225 art 4 s 3; art 6 s 5,8; 1998 c 398 art 2 s 46; 1998 c 407 art 4 s 20-28;
1999 c 86 art 2 s 4; 1999 c 139 art 4 s 2; 1999 c 245 art 4 s 37-49,121; art 5 s 20; art 8 s 5,87; art
10 s 10; 2000 c 298 s 3; 2000 c 347 s 1; 2000 c 474 s 6,7; 2000 c 488 art 9 s 16; 2001 c 178 art 1
s 44; 2001 c 203 s 9; 1Sp2001 c 9 art 2 s 30-38; art 3 s 16-19; art 9 s 41,42; 2002 c 220 art 15 s
13; 2002 c 277 s 12-14,32; 2002 c 294 s 6; 2002 c 375 art 2 s 13-16; 2002 c 379 art 1 s 113; 2003
c 112 art 2 s 50; 1Sp2003 c 14 art 3 s 25; art 4 s 4-7; art 11 s 11; art 12 s 33-36; 2004 c 288 art 5
s 3; art 6 s 22; 2005 c 10 art 1 s 48; 2005 c 56 s 1; 2005 c 98 art 2 s 3,4; 2005 c 147 art 1 s 67;
2005 c 155 art 3 s 2-6; 1Sp2005 c 4 art 2 s 8-10; art 7 s 13,14; art 8 s 29-40; 2006 c 282 art 16 s 6