SF 71

Subd. 4.

General assistance medical care; services.

(a)(i) For a person who is
eligible under subdivision 3, paragraph (a), clause (2), item (i), general assistance medical
care covers, except as provided in paragraph (c):

(1) inpatient hospital services;

(2) outpatient hospital services;

(3) services provided by Medicare certified rehabilitation agencies;

(4) prescription drugs and other products recommended through the process
established in section 256B.0625, subdivision 13;

(5) equipment necessary to administer insulin and diagnostic supplies and equipment
for diabetics to monitor blood sugar level;

(6) eyeglasses and eye examinations provided by a physician or optometrist;

(7) hearing aids;

(8) prosthetic devices;

(9) laboratory and X-ray services;

(10) physician's services;

(11) medical transportation except special transportation;

(12) chiropractic services as covered under the medical assistance program;

(13) podiatric services;

(14) dental services as covered under the medical assistance program;

(15) outpatient services provided by a mental health center or clinic that is under
contract with the county board and is established under section 245.62;

(16) day treatment services for mental illness provided under contract with the
county board;

(17) prescribed medications for persons who have been diagnosed as mentally ill as
necessary to prevent more restrictive institutionalization;

(18) psychological services, medical supplies and equipment, and Medicare
premiums, coinsurance and deductible payments;

(19) medical equipment not specifically listed in this paragraph when the use of
the equipment will prevent the need for costlier services that are reimbursable under
this subdivision;

(20) 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 is otherwise covered under this
chapter as a physician service, (2) the service provided on an inpatient basis is not included
as part of the cost for inpatient services included in the operating payment rate, and (3) the
service is within the scope of practice of the nurse practitioner's license as a registered
nurse, as defined in section 148.171;

(21) 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 nurse's license as a registered nurse, as defined in section 148.171;

(22) telemedicine consultations, to the extent they are covered under section
256B.0625, subdivision 3b; and

(23) mental health telemedicine and psychiatric consultation as covered under
section 256B.0625, subdivisions 46 and 48.

(ii) Effective October 1, 2003, for a person who is eligible under subdivision 3,
paragraph (a), clause (2), item (ii), general assistance medical care coverage is limited
to inpatient hospital services, including physician services provided during the inpatient
hospital stay. A $1,000 deductible is required for each inpatient hospitalization.

(b) Effective August 1, 2005, sex reassignment surgery is not covered under this
subdivision.

(c) In order to contain costs, the commissioner of human services shall select
vendors of medical care who can provide the most economical care consistent with high
medical standards and shall where possible contract with organizations on a prepaid
capitation basis to provide these services. The commissioner shall consider proposals by
counties and vendors for prepaid health plans, competitive bidding programs, block grants,
or other vendor payment mechanisms designed to provide services in an economical
manner or to control utilization, with safeguards to ensure that necessary services are
provided. Before implementing prepaid programs in counties with a county operated or
affiliated public teaching hospital or a hospital or clinic operated by the University of
Minnesota, the commissioner shall consider the risks the prepaid program creates for the
hospital and allow the county or hospital the opportunity to participate in the program in a
manner that reflects the risk of adverse selection and the nature of the patients served by
the hospital, provided the terms of participation in the program are competitive with the
terms of other participants considering the nature of the population served. Payment for
services provided pursuant to this subdivision shall be as provided to medical assistance
vendors of these services under sections 256B.02, subdivision 8, and 256B.0625. For
payments made during fiscal year 1990 and later years, the commissioner shall consult
with an independent actuary in establishing prepayment rates, but shall retain final control
over the rate methodology.

deleted text begin (d) Recipients eligible under subdivision 3, paragraph (a), shall pay the following
co-payments for services provided on or after October 1, 2003:
deleted text end

deleted text begin (1) $25 for eyeglasses;
deleted text end

deleted text begin (2) $25 for nonemergency visits to a hospital-based emergency room;
deleted text end

deleted text begin (3) $3 per brand-name drug prescription and $1 per generic drug prescription,
subject to a $12 per month maximum for prescription drug co-payments. No co-payments
shall apply to antipsychotic drugs when used for the treatment of mental illness; and
deleted text end

deleted text begin (4) 50 percent coinsurance on restorative dental services.
deleted text end

deleted text begin (e) Co-payments shall be limited to one per day per provider for nonpreventive visits,
eyeglasses, and nonemergency visits to a hospital-based emergency room. Recipients of
general assistance medical care are responsible for all co-payments in this subdivision.
The general assistance medical care reimbursement to the provider shall be reduced by
the amount of the co-payment, except that reimbursement for prescription drugs shall not
be reduced once a recipient has reached the $12 per month maximum for prescription
drug co-payments. The provider collects the co-payment from the recipient. Providers
may not deny services to recipients who are unable to pay the co-payment, except as
provided in paragraph (f).
deleted text end

deleted text begin (f) If it is the routine business practice of a provider to refuse service to an individual
with uncollected debt, the provider may include uncollected co-payments under this
section. A provider must give advance notice to a recipient with uncollected debt before
services can be denied.
deleted text end

deleted text begin (g)deleted text end new text begin (d) new text end Any county may, from its own resources, provide medical payments for
which state payments are not made.

deleted text begin (h)deleted text end new text begin (e) new text end Chemical dependency services that are reimbursed under chapter 254B must
not be reimbursed under general assistance medical care.

deleted text begin (i)deleted text end new text begin (f) new text end The maximum payment for new vendors enrolled in the general assistance
medical care program after the base year shall be determined from the average usual and
customary charge of the same vendor type enrolled in the base year.

deleted text begin (j)deleted text end new text begin (g) new text end The conditions of payment for services under this subdivision are the same
as the conditions specified in rules adopted under chapter 256B governing the medical
assistance program, unless otherwise provided by statute or rule.

deleted text begin (k)deleted text end new text begin (h)new text end Inpatient and outpatient payments shall be reduced by five percent, effective
July 1, 2003. This reduction is in addition to the five percent reduction effective July 1,
2003, and incorporated by reference in paragraph (i).

deleted text begin (l)deleted text end new text begin (i) new text end Payments for all other health services except inpatient, outpatient, and
pharmacy services shall be reduced by five percent, effective July 1, 2003.

deleted text begin (m)deleted text end new text begin (j) new text end Payments to managed care plans shall be reduced by five percent for services
provided on or after October 1, 2003.

deleted text begin (n)deleted text end new text begin (k) new text end A hospital receiving a reduced payment as a result of this section may apply
the unpaid balance toward satisfaction of the hospital's bad debts.

deleted text begin (o) Fee-for-service payments for nonpreventive visits shall be reduced by $3
for services provided on or after January 1, 2006. For purposes of this subdivision, a
visit means an episode of service which is required because of a recipient's symptoms,
diagnosis, or established illness, and which is delivered in an ambulatory setting by
a physician or physician ancillary, chiropractor, podiatrist, advance practice nurse,
audiologist, optician, or optometrist.
deleted text end

deleted text begin (p) Payments to managed care plans shall not be increased as a result of the removal
of the $3 nonpreventive visit co-payment effective January 1, 2006.
deleted text end