Subpart
1.
Covered services; additional health services.
Except as provided in subparts
2 and
3, a health plan must provide
and pay for all covered health services listed in Minnesota Statutes, section
256L.03.
A health plan may offer enrollees additional health services that are not
covered by MinnesotaCare.
Subp.
2.
Payment for inpatient hospital services.
The commissioner may contract with a health plan for inpatient
hospital services for enrollees on either a risk or a nonrisk basis.
A. If the commissioner contracts with a
health plan for inpatient hospital services on a nonrisk basis:
(1) except as authorized under subpart
3, the health plan must
require enrollees to receive inpatient hospital services from participating
providers;
(2) the health plan must
comply with units (a) to (c) when arranging inpatient hospital services for
enrollees:
(a) parts
9500.1090 to
9500.1140 and Minnesota Statutes,
sections
256.9685,
256.9686,
256.969, and
256.9695
governing inpatient hospital payment rates for medical assistance;
(b) parts
9505.0170 to
9505.0475 and Minnesota Statutes,
section
256L.03,
subdivisions 1 to 5, establishing standards for services covered by medical
assistance; and
(c) part
9506.0080, subpart
3, governing hospital
admission certification;
(3) the department shall pay for inpatient
hospital services according to part
9506.0080, subpart
2, and shall make payment to
the health plan to pass through to the hospital;
(4) the hospital shall collect from adult
enrollees required MinnesotaCare copayments and costs not covered by
MinnesotaCare or medical assistance; and
(5) the health plan must report enrollee
inpatient hospital admissions to the department within 30 days after the
admission date, in a form prescribed by the department.
B. If the commissioner contracts with a
health plan for inpatient hospital services on a risk basis:
(1) except as authorized under subpart
3, the health plan must
require enrollees to receive inpatient hospital services from participating
providers;
(2) the health plan
shall pay for all inpatient hospital services for children and up to the annual
benefit limit established for adult enrollees;
(3) the hospital shall collect from adult
enrollees required MinnesotaCare copayments and costs not covered by
MinnesotaCare or medical assistance; and
(4) the health plan must report enrollee
inpatient hospital admissions to the department within 30 days after the
admission date, in a form prescribed by the department.
Subp. 3.
Payment for
out-of-plan services.
A. A health plan
is not liable for payment for health services provided enrollees by providers
not participating in the health plan, except, a health plan must pay for:
(1) enrollee emergency services, as defined
in Minnesota Statutes, section
256B.0625,
subdivision 4;
(2) any other health
services required under the contract with the department or by law;
and
(3) out-of-plan services
authorized by the health plan or a participating provider; the health plan is
not required to pay more than the rate under part
9506.0090, subpart
2, for authorized out-of-plan
services unless another payment rate is required by law.
B. The department is not liable to
nonparticipating providers for payment for health services.
Subp. 4.
Enrollee
costs.
Except for copayments required under Minnesota Statutes,
section
256L.03,
subdivision 5, and inpatient hospital charges that exceed the MinnesotaCare
benefit limit, enrollees are not liable for any costs for covered services or
for authorized out-of-plan services.
Subp. 5.
Payment to health
plans.
A. Payments to health plans for
covered health services for enrollees shall be prospective, per capita
payments, made on an actuarially sound basis as determined by the commissioner;
except, the commissioner may allow health plans to arrange for inpatient
hospital services on a risk or nonrisk basis as provided in subpart
2.
B. By the tenth day of each month, the
commissioner shall prepay the health plan the capitation rate specified in the
contract.
C. The department shall
make payment rates and contracts with health plans available to the public upon
request.
