Subdivision 1.Definitions.
(a) For the purposes of sections256B.0651to256B.0654and256B.0659, the terms in paragraphs (b) to (g) have the meanings given.
(b) "Activities of daily living" has the meaning given in section256B.0659, subdivision 1, paragraph (b).
(c) "Assessment" means a review and evaluation of a recipient's need for home care services conducted in person.
(d) "Home care services" means medical assistance covered services that are home health agency services, including skilled nurse visits; home health aide visits; physical therapy, occupational therapy, respiratory therapy, and language-speech pathology therapy; home care nursing; and personal care assistance.
(e) "Home residence," effective January 1, 2010, means a residence owned or rented by the recipient either alone, with roommates of the recipient's choosing, or with an unpaid responsible party or legal representative; or a family foster home where the license holder lives with the recipient and is not paid to provide home care services for the recipient except as allowed under sections256B.0652, subdivision 10, and256B.0654, subdivision 4.
(f) "Medically necessary" has the meaning given in Minnesota Rules, parts9505.0170to9505.0475.
(g) "Ventilator-dependent" means an individual who receives mechanical ventilation for life support at least six hours per day and is expected to be or has been dependent on a ventilator for at least 30 consecutive days.
Subd. 2.Services covered.
Home care services covered under this section and sections256B.0652to256B.0654and256B.0659include:
(1) nursing services under sections256B.0625, subdivision 6a, and 256B.0653;
(2) home care nursing services under sections256B.0625, subdivision 7, and256B.0654;
(3) home health services under sections256B.0625, subdivision 6a, and 256B.0653;
(4) personal care assistance services under sections256B.0625, subdivision 19a, and256B.0659;
(5) supervision of personal care assistance services provided by a qualified professional under sections256B.0625, subdivision 19a, and256B.0659;
(6) face-to-face assessments by county public health nurses for services under sections256B.0625, subdivision 19a, and256B.0659; and
(7) service updates and review of temporary increases for personal care assistance services by the county public health nurse for services under sections256B.0625, subdivision 19a, and256B.0659.
Subd. 3.Noncovered home care services.
The following home care services are not eligible for payment under medical assistance:
(1) services provided in a nursing facility, hospital, or intermediate care facility with exceptions in section256B.0653;
(2) services for the sole purpose of monitoring medication compliance with an established medication program for a recipient;
(3) home care services for covered services under the Medicare program or any other insurance held by the recipient;
(4) services to other members of the recipient's household;
(5) any home care service included in the daily rate of the community-based residential facility where the recipient is residing;
(6) nursing and rehabilitation therapy services that are reasonably accessible to a recipient outside the recipient's place of residence, excluding the assessment, counseling and education, and personal assistance care; or
(7) Medicare evaluation or administrative nursing visits on dual-eligible recipients that do not qualify for Medicare visit billing.
Subd. 4.
MS 2008 [Renumbered256B.0652, subd 14]
Subd. 5.
[Repealed by amendment,2009 c 79 art 8 s 23]
Subd. 6.
MS 2008 [Paragraph (a) renumbered256B.0652, subd 3a]
[Paragraph (b) renumbered256B.0652, subd 4]
[Paragraph (c) renumbered256B.0652, subd 7]
Subd. 7.
MS 2008 [Paragraph (a) renumbered256B.0652, subd 8]
[Paragraph (b) renumbered256B.0652, subd 8]
[Paragraph (c) renumbered256B.0652, subd 13]
Subd. 8.
MS 2008 [Renumbered256B.0652, subd 9]
Subd. 9.
MS 2008 [Renumbered256B.0652, subd 10]
Subd. 10.
[Repealed by amendment,2009 c 79 art 8 s 23]
Subd. 11.
MS 2008 [Renumbered256B.0652, subd 11]
Subd. 12.Approval of home care services.
The commissioner or the commissioner's designee shall determine the medical necessity of home care services, the level of caregiver according to subdivision 2, and the institutional comparison according to this subdivision and sections256B.0652, subdivisions 3a, 4 to 11, 13, and 14, and256B.0659, the cost-effectiveness of services, and the amount, scope, and duration of home care services reimbursable by medical assistance, based on the assessment, primary payer coverage determination information as required, the service plan, the recipient's age, the cost of services, the recipient's medical condition, and diagnosis or disability. The commissioner may publish additional criteria for determining medical necessity according to section256B.04.
Subd. 13.Recovery of excessive payments.
The commissioner shall seek monetary recovery from providers of payments made for services which exceed the limits established in this section and sections256B.0653,256B.0654, and256B.0659. This subdivision does not apply to services provided to a recipient at the previously authorized level pending an appeal under section256.045, subdivision 10.
Subd. 14.Referrals to Medicare providers required.
Home care providers that do not participate in or accept Medicare assignment must refer and document the referral of dual-eligible recipients to Medicare providers when Medicare is determined to be the appropriate payer for services and supplies and equipment. Providers must be terminated from participation in the medical assistance program for failure to make these referrals.
Subd. 15.Quality assurance for program integrity.
The commissioner shall establish an ongoing quality assurance process for home care services to monitor program integrity, including provider standards and training, consumer surveys, and random reviews of documentation.
Subd. 16.Oversight of enrolled providers.
The commissioner has the authority to request proof of documentation of meeting provider standards, quality standards of care, correct billing practices, and other information. Failure to comply with or to provide access and information to demonstrate compliance with laws, rules, or policies may result in suspension, denial, or termination of the provider agency's enrollment with the department.
Subd. 17.Recipient protection.
(a) Providers of home care services must provide each recipient with a copy of the home care bill of rights under section144A.44at least 30 days prior to terminating services to a recipient, if the termination results from provider sanctions under section256B.064, such as a payment withhold, a suspension of participation, or a termination of participation. If a home care provider determines it is unable to continue providing services to a recipient, the provider must notify the recipient, the recipient's responsible party, and the commissioner 30 days prior to terminating services to the recipient because of an action under section256B.064, and must assist the commissioner and lead agency in supporting the recipient in transitioning to another home care provider of the recipient's choice.
(b) In the event of a payment withhold from a home care provider, a suspension of participation, or a termination of participation of a home care provider under section256B.064, the commissioner may inform the Office of Ombudsman for Long-Term Care and the lead agencies for all recipients with active service agreements with the provider. At the commissioner's request, the lead agencies must contact recipients to ensure that the recipients are continuing to receive needed care, and that the recipients have been given free choice of provider if they transfer to another home care provider. In addition, the commissioner or the commissioner's delegate may directly notify recipients who receive care from the provider that payments have been or will be withheld or that the provider's participation in medical assistance has been or will be suspended or terminated, if the commissioner determines that notification is necessary to protect the welfare of the recipients. For purposes of this subdivision, "lead agencies" means counties, tribes, and managed care organizations.