256L.03 Covered health services. 

    Subdivision 1.    Covered health services.  "Covered 
 health services" means the health services reimbursed under 
 chapter 256B, with the exception of inpatient hospital services, 
 special education services, private duty nursing services, adult 
 dental care services other than preventive services, orthodontic 
 services, nonemergency medical transportation services, personal 
 care assistant and case management services, nursing home or 
 intermediate care facilities services, inpatient mental health 
 services, and chemical dependency services.  Effective July 1, 
 1998, adult dental care for nonpreventive services with the 
 exception of orthodontic services is available to persons who 
 qualify under section 256L.04, subdivisions 1 to 7, or 256L.13, 
 with family gross income equal to or less than 175 percent of 
 the federal poverty guidelines.  Outpatient mental health 
 services covered under the MinnesotaCare program are limited to 
 diagnostic assessments, psychological testing, explanation of 
 findings, medication management by a physician, day treatment, 
 partial hospitalization, and individual, family, and group 
 psychotherapy. 

    No public funds shall be used for coverage of abortion 
 under MinnesotaCare except where the life of the female would be 
 endangered or substantial and irreversible impairment of a major 
 bodily function would result if the fetus were carried to term; 
 or where the pregnancy is the result of rape or incest. 

    Covered health services shall be expanded as provided in 
 this section. 

    Subd. 2.    Alcohol and drug dependency.  Beginning July 
 1, 1993, covered health services shall include individual 
 outpatient treatment of alcohol or drug dependency by a 
 qualified health professional or outpatient program.  

    Persons who may need chemical dependency services under the 
 provisions of this chapter shall be assessed by a local agency 
 as defined under section 254B.01, and under the assessment 
 provisions of section 254A.03, subdivision 3.  A local agency or 
 managed care plan under contract with the department of human 
 services must place a person in need of chemical dependency 
 services as provided in Minnesota Rules, parts 9530.6600 to 
 9530.6660.  Persons who are recipients of medical benefits under 
 the provisions of this chapter and who are financially eligible 
 for consolidated chemical dependency treatment fund services 
 provided under the provisions of chapter 254B shall receive 
 chemical dependency treatment services under the provisions of 
 chapter 254B only if: 

    (1) they have exhausted the chemical dependency benefits 
 offered under this chapter; or 

    (2) an assessment indicates that they need a level of care 
 not provided under the provisions of this chapter. 

    Recipients of covered health services under the children's 
 health plan, as provided in Minnesota Statutes 1990, section 
 256.936, and as amended by Laws 1991, chapter 292, article 4, 
 section 17, and recipients of covered health services enrolled 
 in the children's health plan or the MinnesotaCare program after 
 October 1, 1992, pursuant to Laws 1992, chapter 549, article 4, 
 sections 5 and 17, are eligible to receive alcohol and drug 
 dependency benefits under this subdivision. 

    Subd. 3.    Inpatient hospital services.  (a) Beginning 
 July 1, 1993, covered health services shall include inpatient 
 hospital services, including inpatient hospital mental health 
 services and inpatient hospital and residential chemical 
 dependency treatment, subject to those limitations necessary to 
 coordinate the provision of these services with eligibility 
 under the medical assistance spenddown.  Prior to July 1, 1997, 
 the inpatient hospital benefit for adult enrollees is subject to 
 an annual benefit limit of $10,000.  Effective July 1, 1997, the 
 inpatient hospital benefit for adult enrollees who qualify under 
 section 256L.04, subdivision 7, or who qualify under section 
 256L.04, subdivisions 1 to 6, or 256L.13 with family gross 
 income that exceeds 175 percent of the federal poverty 
 guidelines and who are not pregnant, is subject to an annual 
 limit of $10,000.  

    (b) Enrollees who qualify under section 256L.04, 
 subdivision 7, or who qualify under section 256L.04, 
 subdivisions 1 to 6, or 256L.13 with family gross income that 
 exceeds 175 percent of the federal poverty guidelines and who 
 are not pregnant, and are determined by the commissioner to have 
 a basis of eligibility for medical assistance shall apply for 
 and cooperate with the requirements of medical assistance by the 
 last day of the third month following admission to an inpatient 
 hospital.  If an enrollee fails to apply for medical assistance 
 within this time period, the enrollee and the enrollee's family 
 shall be disenrolled from the plan and they may not reenroll 
 until 12 calendar months have elapsed.  Enrollees and enrollees' 
 families disenrolled for not applying for or not cooperating 
 with medical assistance may not reenroll. 

    (c) Admissions for inpatient hospital services paid for 
 under section 256L.11, subdivision 3, must be certified as 
 medically necessary in accordance with Minnesota Rules, parts 
 9505.0500 to 9505.0540, except as provided in clauses (1) and 
 (2): 

    (1) all admissions must be certified, except those 
 authorized under rules established under section 254A.03, 
 subdivision 3, or approved under Medicare; and 

    (2) payment under section 256L.11, subdivision 3, shall be 
 reduced by five percent for admissions for which certification 
 is requested more than 30 days after the day of admission.  The 
 hospital may not seek payment from the enrollee for the amount 
 of the payment reduction under this clause. 

    (d) Any enrollee or family member of an enrollee who has 
 previously been permanently disenrolled from MinnesotaCare for 
 not applying for and cooperating with medical assistance shall 
 be eligible to reenroll if 12 calendar months have elapsed since 
 the date of disenrollment. 

    Subd. 4.    Coordination with medical assistance.  The 
 commissioner shall coordinate the provision of hospital 
 inpatient services under the MinnesotaCare program with enrollee 
 eligibility under the medical assistance spenddown, and shall 
 apply to the secretary of health and human services for any 
 necessary federal waivers or approvals. 

    Subd. 5.    Copayments and coinsurance.  The 
 MinnesotaCare benefit plan shall include the following 
 copayments and coinsurance requirements:  

    (1) ten percent of the paid charges for inpatient hospital 
 services for adult enrollees not eligible for medical 
 assistance, subject to an annual inpatient out-of-pocket maximum 
 of $1,000 per individual and $3,000 per family; 

    (2) $3 per prescription for adult enrollees; 

    (3) $25 for eyeglasses for adult enrollees; and 

    (4) effective July 1, 1998, 50 percent of the 
 fee-for-service rate for adult dental care services other than 
 preventive care services for persons eligible under section 
 256L.04, subdivisions 1 to 7, or 256L.13, with income equal to 
 or less than 175 percent of the federal poverty guidelines. 

    Prior to July 1, 1997, enrollees who are not eligible for 
 medical assistance with or without a spenddown shall be 
 financially responsible for the coinsurance amount and amounts 
 which exceed the $10,000 benefit limit.  Effective July 1, 1997, 
 adult enrollees who qualify under section 256L.04, subdivision 
 7, or who qualify under section 256L.04, subdivisions 1 to 6, or 
 256L.13 with family gross income that exceeds 175 percent of the 
 federal poverty guidelines and who are not pregnant, and who are 
 not eligible for medical assistance with or without a spenddown, 
 shall be financially responsible for the coinsurance amount and 
 amounts which exceed the $10,000 inpatient hospital benefit 
 limit. 

    When a MinnesotaCare enrollee becomes a member of a prepaid 
 health plan, or changes from one prepaid health plan to another 
 during a calendar year, any charges submitted towards the 
 $10,000 annual inpatient benefit limit, and any out-of-pocket 
 expenses incurred by the enrollee for inpatient services, that 
 were submitted or incurred prior to enrollment, or prior to the 
 change in health plans, shall be disregarded. 

    Subd. 6.    Lien.  When the state agency provides, pays 
 for, or becomes liable for covered health services, the agency 
 shall have a lien for the cost of the covered health services 
 upon any and all causes of action accruing to the enrollee, or 
 to the enrollee's legal representatives, as a result of the 
 occurrence that necessitated the payment for the covered health 
 services.  All liens under this section shall be subject to the 
 provisions of section 256.015.  For purposes of this 
 subdivision, "state agency" includes authorized agents of the 
 state agency. 

    HIST: 1986 c 444; 1992 c 549 art 4 s 4,19; 1992 c 603 s 31; 
 1993 c 247 art 4 s 2-4,11; 1993 c 345 art 9 s 3; 1993 c 366 s 
 26; 1994 c 625 art 8 s 50,51,72; 1995 c 207 art 6 s 12; 1995 c 
 234 art 6 s 4,5; 1997 c 225 art 1 s 1-3 

*   NOTE:  The amendment to subdivision 7, clause (1), now 
*renumbered as subdivision 5, clause (1), by Laws 1997, chapter 
*225, article 1, section 3, is effective July 1, 1998.  Laws 
*1997, chapter 225, article 1, section 22.