1.1                          A bill for an act
  1.2             relating to human services; modifying personal care 
  1.3             assistant services under the medical assistance 
  1.4             program; amending Minnesota Statutes 1994, section 
  1.5             256B.0627, subdivisions 1, as amended, 4, as amended, 
  1.6             and 5, as amended; and Minnesota Statutes 1995 
  1.7             Supplement, section 256B.0625, subdivision 19a.  
  1.8   BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MINNESOTA: 
  1.9      Section 1.  Minnesota Statutes 1995 Supplement, section 
  1.10  256B.0625, subdivision 19a, is amended to read:  
  1.11     Subd. 19a.  [PERSONAL CARE SERVICES.] Medical assistance 
  1.12  covers personal care services in a recipient's home.  To qualify 
  1.13  for personal care services, recipients or responsible parties 
  1.14  must be able to identify ~~their~~ recipient needs, direct and 
  1.15  evaluate task accomplishment, and ~~assure their~~ provide for 
  1.16  health and safety.  Approved hours may be used outside the home 
  1.17  when normal life activities take them outside the home and when, 
  1.18  without the provision of personal care, their health and safety 
  1.19  would be jeopardized.  Total hours for services, whether 
  1.20  actually performed inside or outside the recipient's home, 
  1.21  cannot exceed that which is otherwise allowed for personal care 
  1.22  services in an in-home setting according to section 256B.0627.  
  1.23  Medical assistance does not cover personal care services for 
  1.24  residents of a hospital, nursing facility, intermediate care 
  1.25  facility, health care facility licensed by the commissioner of 
  1.26  health, or unless a resident who is otherwise eligible is on 
  2.1   leave from the facility and the facility either pays for the 
  2.2   personal care services or forgoes the facility per diem for the 
  2.3   leave days that personal care services are used.  All personal 
  2.4   care services must be provided according to section 256B.0627.  
  2.5   Personal care services may not be reimbursed if the personal 
  2.6   care assistant is the spouse or legal guardian of the recipient 
  2.7   or the parent of a recipient under age 18, the responsible party 
  2.8   or the foster care provider of a recipient who cannot direct the 
  2.9   recipient's own care unless, in the case of a foster provider, a 
  2.10  county or state case manager visits the recipient as needed, but 
  2.11  not less than every six months, to monitor the health and safety 
  2.12  of the recipient and to ensure the goals of the care plan are 
  2.13  met.  Parents of adult recipients, adult children of the 
  2.14  recipient or adult siblings of the recipient may be reimbursed 
  2.15  for personal care services if they are not the recipient's legal 
  2.16  guardian and are granted a waiver under section 256B.0627.  
  2.17     Sec. 2.  Minnesota Statutes 1994, section 256B.0627, 
  2.18  subdivision 1, as amended by Laws 1995, chapter 207, article 6, 
  2.19  sections 52 and 125, subdivision 9, is amended to read: 
  2.20     Subdivision 1.  [DEFINITION.] (a) "Assessment" means a 
  2.21  review and evaluation of a recipient's need for home care 
  2.22  services conducted in person.  Assessments for private duty 
  2.23  nursing shall be conducted by a private duty nurse.  Assessments 
  2.24  for home health agency services shall be conducted by a home 
  2.25  health agency nurse.  Assessments for personal care services 
  2.26  shall be conducted by the county public health nurse or a 
  2.27  certified public health nurse under contract with the county.  
  2.28  Assessments must be completed on forms provided by the 
  2.29  commissioner within 30 days of a request for home care services 
  2.30  by a recipient or responsible party. 
  2.31     (b) "Care plan" means a written description of personal 
  2.32  care assistant services developed by the agency nurse with the 
  2.33  recipient or responsible party to be used by the personal care 
  2.34  assistant with a copy provided to the recipient or responsible 
  2.35  party. 
  2.36     (c) "Home care services" means a health service, determined 
  3.1   by the commissioner as medically necessary, that is ordered by a 
  3.2   physician and documented in a care plan that is reviewed by the 
  3.3   physician at least once every 60 days for the provision of home 
  3.4   health services, or private duty nursing, or at least once every 
  3.5   365 days for personal care.  Home care services are provided to 
  3.6   the recipient at the recipient's residence that is a place other 
  3.7   than a hospital or long-term care facility or as specified in 
  3.8   section 256B.0625.  
  3.9      (d) "Medically necessary" has the meaning given in 
  3.10  Minnesota Rules, parts 9505.0170 to 9505.0475.  
  3.11     (e) "Personal care assistant" means a person who:  (1) is 
  3.12  at least 18 years old, except for persons 16 to 18 years of age 
  3.13  who participated in a school-based job training program or have 
  3.14  completed other comparable training approved by the personal 
  3.15  care provider organization; (2) is able to ~~read, write, and~~ 
  3.16  ~~speak English, or communicate with sign language, as well as~~ 
  3.17  communicate effectively with the recipient and the personal care 
  3.18  provider organization; (3) effective July 1, 1996, has completed 
  3.19  one of the training requirements as specified in Minnesota 
  3.20  Rules, part 9505.0335, subpart 3, items A to D; (4) has the 
  3.21  ability to, and provides covered personal care services 
  3.22  according to the recipient's care plan; (5) is not a consumer of 
  3.23  personal care services; and (6) is subject to criminal 
  3.24  background checks.  An individual who has ever been convicted of 
  3.25  a crime specified in Minnesota Rules, part 4668.0020, subpart 
  3.26  14, or a comparable crime in another jurisdiction is 
  3.27  disqualified from being a personal care assistant unless the 
  3.28  provisions of Minnesota Rules, part 4668.0020, subpart 15, have 
  3.29  been met. 
  3.30     (f) "Personal care provider organization" means an 
  3.31  organization enrolled to provide personal care services under 
  3.32  the medical assistance program that complies with the 
  3.33  following:  (1) owners who have a five percent interest or 
  3.34  more and managerial officials are subject to a criminal ~~history~~ 
  3.35  background check as provided in section 245A.04 at the time of 
  3.36  application.  An organization will be barred from enrollment if 
  4.1   an owner or managerial official of the organization has ever 
  4.2   been convicted of a crime specified in Minnesota Rules, part 
  4.3   4668.0020, subpart 14, or a comparable crime in another 
  4.4   jurisdiction unless the provisions of Minnesota Rules, part 
  4.5   4668.0020, subpart 15, have been met; (2) the organization must 
  4.6   maintain a surety bond and liability insurance throughout the 
  4.7   duration of enrollment and provides proof thereof.  The insurer 
  4.8   must notify the department of human services of the cancellation 
  4.9   or lapse of policy; and (3) the organization must maintain 
  4.10  documentation of services as specified in Minnesota Rules, part 
  4.11  9505.2175, subpart 7, as well as evidence of compliance with 
  4.12  personal care assistant training requirements. 
  4.13     (g) "Service plan" means a written description of the 
  4.14  services needed based on the assessment developed by the nurse 
  4.15  who conducts the assessment together with the recipient or 
  4.16  responsible party.  The service plan shall include a description 
  4.17  of the covered home care services, frequency and duration of 
  4.18  services, and expected outcomes and goals.  The recipient and 
  4.19  the provider chosen by the recipient or responsible party must 
  4.20  be given a copy of the completed service plan within 30 calendar 
  4.21  days of the request for home care services by the recipient or 
  4.22  responsible party. 
  4.23     Sec. 3.  Minnesota Statutes 1994, section 256B.0627, 
  4.24  subdivision 4, as amended by Laws 1995, chapter 207, article 6, 
  4.25  sections 54 and 125, subdivision 11, is amended to read:  
  4.26     Subd. 4.  [PERSONAL CARE SERVICES.] (a) The personal care 
  4.27  services that are eligible for payment are the following:  
  4.28     (1) bowel and bladder care; 
  4.29     (2) skin care to maintain the health of the skin; 
  4.30     (3) repetitive maintenance range of motion ~~and~~, muscle 
  4.31  strengthening exercises, and other tasks specific to maintaining 
  4.32  a recipient's optimal level of function; 
  4.33     (4) respiratory assistance; 
  4.34     (5) transfers and ambulation; 
  4.35     (6) bathing, grooming, and hairwashing necessary for 
  4.36  personal hygiene; 
  5.1      (7) turning and positioning; 
  5.2      (8) assistance with furnishing medication that is 
  5.3   self-administered; 
  5.4      (9) application and maintenance of prosthetics and 
  5.5   orthotics; 
  5.6      (10) cleaning medical equipment; 
  5.7      (11) dressing or undressing; 
  5.8      (12) assistance with eating and meal preparation and 
  5.9   necessary grocery shopping; 
  5.10     (13) accompanying a recipient to obtain medical diagnosis 
  5.11  or treatment; and 
  5.12     (14) incidental household services that are an integral 
  5.13  part of a personal care service described in clauses (1) to (13).
  5.14     (b) The personal care services that are not eligible for 
  5.15  payment are the following:  
  5.16     (1) services not ordered by the physician; 
  5.17     (2) assessments by personal care provider organizations or 
  5.18  by independently enrolled registered nurses; 
  5.19     (3) services that are not in the service plan; 
  5.20     (4) services provided by the recipient's spouse, legal 
  5.21  guardian for an adult or child recipient, or parent of a 
  5.22  recipient under age 18; 
  5.23     (5) services provided by the residential or program license 
  5.24  holder in a residence for more than four persons; 
  5.25     (6) services that are the responsibility of a residential 
  5.26  or program license holder under the terms of a service agreement 
  5.27  and administrative rules; 
  5.28     (7) sterile procedures; 
  5.29     (8) injections of fluids into veins, muscles, or skin; 
  5.30     (9) services provided by parents of adult recipients, adult 
  5.31  children or adult siblings of the recipient, unless these 
  5.32  relatives meet one of the following hardship criteria and the 
  5.33  commissioner waives this requirement: 
  5.34     (i) the relative resigns from a part-time or full-time job 
  5.35  to provide personal care for the recipient; 
  5.36     (ii) the relative goes from a full-time to a part-time job 
  6.1   with less compensation to provide personal care for the 
  6.2   recipient; 
  6.3      (iii) the relative takes a leave of absence without pay to 
  6.4   provide personal care for the recipient; 
  6.5      (iv) the relative incurs substantial expenses by providing 
  6.6   personal care for the recipient; or 
  6.7      (v) because of labor conditions or intermittent hours of 
  6.8   care needed, the relative is needed in order to provide an 
  6.9   adequate number of qualified personal care assistants to meet 
  6.10  the medical needs of the recipient; 
  6.11     (10) homemaker services that are not an integral part of a 
  6.12  personal care services; 
  6.13     (11) home maintenance, or chore services; 
  6.14     (12) services not specified under paragraph (a); ~~and~~ 
  6.15     (13) services not authorized by the commissioner or the 
  6.16  commissioner's designee; and 
  6.17     (14) services provided by a foster care provider of a 
  6.18  recipient who cannot direct their own care, unless monitored by 
  6.19  a county or state case manager under section 256B.0625, 
  6.20  subdivision 19a. 
  6.21     Sec. 4.  Minnesota Statutes 1994, section 256B.0627, 
  6.22  subdivision 5, as amended by Laws 1995, chapter 207, article 6, 
  6.23  sections 55 and 125, subdivision 12, is amended to read: 
  6.24     Subd. 5.  [LIMITATION ON PAYMENTS.] Medical assistance 
  6.25  payments for home care services shall be limited according to 
  6.26  this subdivision.  
  6.27     (a) Limits on services without prior authorization.  A 
  6.28  recipient may receive the following amounts of home care 
  6.29  services during a calendar year: 
  6.30     (1) a total of 40 home health aide visits or skilled nurse 
  6.31  visits under section 256B.0625, subdivision 6a; and 
  6.32     (2) assessments and reassessments done to determine a 
  6.33  recipient's need for personal care services.  
  6.34     (b) Prior authorization; exceptions.  All home care 
  6.35  services above the limits in paragraph (a) must receive the 
  6.36  commissioner's prior authorization, except when: 
  7.1      (1) the home care services were required to treat an 
  7.2   emergency medical condition that if not immediately treated 
  7.3   could cause a recipient serious physical or mental disability, 
  7.4   continuation of severe pain, or death.  The provider must 
  7.5   request retroactive authorization no later than five working 
  7.6   days after giving the initial service.  The provider must be 
  7.7   able to substantiate the emergency by documentation such as 
  7.8   reports, notes, and admission or discharge histories; 
  7.9      (2) the home care services were provided on or after the 
  7.10  date on which the recipient's eligibility began, but before the 
  7.11  date on which the recipient was notified that the case was 
  7.12  opened.  Authorization will be considered if the request is 
  7.13  submitted by the provider within 20 working days of the date the 
  7.14  recipient was notified that the case was opened; 
  7.15     (3) a third-party payor for home care services has denied 
  7.16  or adjusted a payment.  Authorization requests must be submitted 
  7.17  by the provider within 20 working days of the notice of denial 
  7.18  or adjustment.  A copy of the notice must be included with the 
  7.19  request; or 
  7.20     (4) the commissioner has determined that a county or state 
  7.21  human services agency has made an error. 
  7.22     (c) Retroactive authorization.  A request for retroactive 
  7.23  authorization will be evaluated according to the same criteria 
  7.24  applied to prior authorization requests.  
  7.25     (d) Assessment and service plan.  Assessments under section 
  7.26  256B.0627, subdivision 1, paragraph (a), shall be conducted 
  7.27  initially, and at least annually thereafter, in person with the 
  7.28  recipient and result in a completed service plan using forms 
  7.29  specified by the commissioner.  Within 30 days of recipient or 
  7.30  responsible party request for home care services, the 
  7.31  assessment, the service plan, and other information necessary to 
  7.32  determine medical necessity such as diagnostic or testing 
  7.33  information, social or medical histories, and hospital or 
  7.34  facility discharge summaries shall be submitted to the 
  7.35  commissioner.  For personal care services: 
  7.36     (1) The amount and type of service authorized based upon 
  8.1   the assessment and service plan will follow the recipient if the 
  8.2   recipient chooses to change providers.  
  8.3      (2) If the recipient's medical need changes, the 
  8.4   recipient's provider may assess the need for a change in service 
  8.5   authorization and request the change from the county public 
  8.6   health nurse.  Within 30 days of the request, the public health 
  8.7   nurse will determine whether to request the change in services 
  8.8   based upon the provider assessment, or conduct a home visit to 
  8.9   assess the need and determine whether the change is appropriate. 
  8.10     (3) To continue to receive personal care services when the 
  8.11  recipient displays no significant change, the county public 
  8.12  health nurse has the option to review with the commissioner, or 
  8.13  the commissioner's designee, the service plan on record and 
  8.14  receive authorization for up to an additional 12 months at a 
  8.15  time for up to five years. 
  8.16     (e) Prior authorization.  The commissioner, or the 
  8.17  commissioner's designee, shall review the assessment, the 
  8.18  service plan, and any additional information that is submitted.  
  8.19  The commissioner shall, within 30 days after receiving a 
  8.20  complete request, assessment, and service plan, authorize home 
  8.21  care services as follows:  
  8.22     (1) Home health services.  All home health services 
  8.23  provided by a nurse or a home health aide that exceed the limits 
  8.24  established in paragraph (a) must be prior authorized by the 
  8.25  commissioner or the commissioner's designee.  Prior 
  8.26  authorization must be based on medical necessity and 
  8.27  cost-effectiveness when compared with other care options.  When 
  8.28  home health services are used in combination with personal care 
  8.29  and private duty nursing, the cost of all home care services 
  8.30  shall be considered for cost-effectiveness.  The commissioner 
  8.31  shall limit nurse and home health aide visits to no more than 
  8.32  one visit each per day. 
  8.33     (2) Personal care services.  (i) All personal care services 
  8.34  and registered nurse supervision must be prior authorized by the 
  8.35  commissioner or the commissioner's designee except for the 
  8.36  assessments established in paragraph (a).  The amount of 
  9.1   personal care services authorized must be based on the 
  9.2   recipient's home care rating.  A child may not be found to be 
  9.3   dependent in an activity of daily living if because of the 
  9.4   child's age an adult would either perform the activity for the 
  9.5   child or assist the child with the activity and the amount of 
  9.6   assistance needed is similar to the assistance appropriate for a 
  9.7   typical child of the same age.  Based on medical necessity, the 
  9.8   commissioner may authorize: 
  9.9      (A) up to ~~1.75~~ two times the average number of direct care 
  9.10  hours provided in nursing facilities for the recipient's 
  9.11  comparable case mix level; or 
  9.12     (B) up to ~~2.625~~ three times the average number of direct 
  9.13  care hours provided in nursing facilities for recipients who 
  9.14  have complex medical needs or are dependent in at least seven 
  9.15  activities of daily living and need physical assistance with 
  9.16  eating or have a neurological diagnosis ~~but in no case shall the~~ 
  9.17  ~~dollar amount authorized exceed the statewide weighted average~~ 
  9.18  ~~nursing facility payment rate for fiscal year 1995~~; or 
  9.19     (C) up to 60 percent of the average reimbursement rate, as 
  9.20  of July 1, 1991, plus any inflation adjustment provided, for 
  9.21  care provided in a regional treatment center for recipients who 
  9.22  have Level I behavior; or 
  9.23     (D) up to the amount the commissioner would pay, as of July 
  9.24  1, 1991, plus any inflation adjustment provided for home care 
  9.25  services, for care provided in a regional treatment center for 
  9.26  recipients referred to the commissioner by a regional treatment 
  9.27  center preadmission evaluation team.  For purposes of this 
  9.28  clause, home care services means all services provided in the 
  9.29  home or community that would be included in the payment to a 
  9.30  regional treatment center; or 
  9.31     ~~(D)~~ (E) up to the amount medical assistance would reimburse 
  9.32  for facility care for recipients referred to the commissioner by 
  9.33  a preadmission screening team established under section 
  9.34  256B.0911 or 256B.092; and 
  9.35     ~~(E)~~ (F) a reasonable amount of time for the necessary 
  9.36  provision of nursing supervision of personal care services.  
 10.1      (ii) The number of direct care hours shall be determined 
 10.2   according to the annual cost report submitted to the department 
 10.3   by nursing facilities.  The average number of direct care hours, 
 10.4   ~~for the report year 1993,~~ as established by ~~July 11, 1994~~ May 1, 
 10.5   1992, shall be calculated and incorporated into the home care 
 10.6   limits on July 1, ~~1996~~ 1992.  These limits shall be calculated 
 10.7   to the nearest quarter hour. 
 10.8      (iii) The home care rating shall be determined by the 
 10.9   commissioner or the commissioner's designee based on information 
 10.10  submitted to the commissioner by the county public health nurse 
 10.11  on forms specified by the commissioner.  The home care rating 
 10.12  shall be a combination of current assessment tools developed 
 10.13  under sections 256B.0911 and 256B.501 with an addition for 
 10.14  seizure activity that will assess the frequency and severity of 
 10.15  seizure activity and with adjustments, additions, and 
 10.16  clarifications that are necessary to reflect the needs and 
 10.17  conditions of recipients who need home care including children 
 10.18  and adults under 65 years of age.  The commissioner shall 
 10.19  establish these forms and protocols under this section and shall 
 10.20  use an advisory group, including representatives of recipients, 
 10.21  providers, and counties, for consultation in establishing and 
 10.22  revising the forms and protocols. 
 10.23     (iv) A recipient shall qualify as having complex medical 
 10.24  needs if the care required is difficult to perform and because 
 10.25  of recipient's medical condition requires more time than 
 10.26  community-based standards allow or requires more skill than 
 10.27  would ordinarily be required and the recipient needs or has one 
 10.28  or more of the following: 
 10.29     (A) daily tube feedings; 
 10.30     (B) daily parenteral therapy; 
 10.31     (C) wound or decubiti care; 
 10.32     (D) postural drainage, percussion, nebulizer treatments, 
 10.33  suctioning, tracheotomy care, oxygen, mechanical ventilation; 
 10.34     (E) catheterization; 
 10.35     (F) ostomy care; 
 10.36     (G) quadriplegia; or 
 11.1      (H) other comparable medical conditions or treatments the 
 11.2   commissioner determines would otherwise require institutional 
 11.3   care.  
 11.4      (v) A recipient shall qualify as having Level I behavior if 
 11.5   there is reasonable supporting evidence that the recipient 
 11.6   exhibits, or that without supervision, observation, or 
 11.7   redirection would exhibit, one or more of the following 
 11.8   behaviors that cause, or have the potential to cause: 
 11.9      (A) injury to his or her own body; 
 11.10     (B) physical injury to other people; or 
 11.11     (C) destruction of property. 
 11.12     (vi) Time authorized for personal care relating to Level I 
 11.13  behavior in subclause (v), items (A) to (C), shall be based on 
 11.14  the predictability, frequency, and amount of intervention 
 11.15  required. 
 11.16     (vii) A recipient shall qualify as having Level II behavior 
 11.17  if the recipient exhibits on a daily basis one or more of the 
 11.18  following behaviors that interfere with the completion of 
 11.19  personal care services under subdivision 4, paragraph (a): 
 11.20     (A) unusual or repetitive habits; 
 11.21     (B) withdrawn behavior; or 
 11.22     (C) offensive behavior. 
 11.23     (viii) A recipient with a home care rating of Level II 
 11.24  behavior in subclause (vii), items (A) to (C), shall be rated as 
 11.25  comparable to a recipient with complex medical needs under 
 11.26  subclause (iv).  If a recipient has both complex medical needs 
 11.27  and Level II behavior, the home care rating shall be the next 
 11.28  complex category up to the maximum rating under subclause (i), 
 11.29  item (B). 
 11.30     (3) Private duty nursing services.  All private duty 
 11.31  nursing services shall be prior authorized by the commissioner 
 11.32  or the commissioner's designee.  Prior authorization for private 
 11.33  duty nursing services shall be based on medical necessity and 
 11.34  cost-effectiveness when compared with alternative care options.  
 11.35  The commissioner may authorize medically necessary private duty 
 11.36  nursing services in quarter-hour units when: 
 12.1      (i) the recipient requires more individual and continuous 
 12.2   care than can be provided during a nurse visit; or 
 12.3      (ii) the cares are outside of the scope of services that 
 12.4   can be provided by a home health aide or personal care assistant.
 12.5      The commissioner may authorize: 
 12.6      (A) up to two times the average amount of direct care hours 
 12.7   provided in nursing facilities statewide for case mix 
 12.8   classification "K" as established by the annual cost report 
 12.9   submitted to the department by nursing facilities in May 1992; 
 12.10     (B) private duty nursing in combination with other home 
 12.11  care services up to the total cost allowed under clause (2); 
 12.12     (C) up to 16 hours per day if the recipient requires more 
 12.13  nursing than the maximum number of direct care hours as 
 12.14  established in item (A) and the recipient meets the hospital 
 12.15  admission criteria established under Minnesota Rules, parts 
 12.16  9505.0500 to 9505.0540.  
 12.17     The commissioner may authorize up to 16 hours per day of 
 12.18  medically necessary private duty nursing services or up to 24 
 12.19  hours per day of medically necessary private duty nursing 
 12.20  services until such time as the commissioner is able to make a 
 12.21  determination of eligibility for recipients who are 
 12.22  cooperatively applying for home care services under the 
 12.23  community alternative care program developed under section 
 12.24  256B.49, or until it is determined by the appropriate regulatory 
 12.25  agency that a health benefit plan is or is not required to pay 
 12.26  for appropriate medically necessary health care services.  
 12.27  Recipients or their representatives must cooperatively assist 
 12.28  the commissioner in obtaining this determination.  Recipients 
 12.29  who are eligible for the community alternative care program may 
 12.30  not receive more hours of nursing under this section than would 
 12.31  otherwise be authorized under section 256B.49. 
 12.32     (4) Ventilator-dependent recipients.  If the recipient is 
 12.33  ventilator-dependent, the monthly medical assistance 
 12.34  authorization for home care services shall not exceed what the 
 12.35  commissioner would pay for care at the highest cost hospital 
 12.36  designated as a long-term hospital under the Medicare program.  
 13.1   For purposes of this clause, home care services means all 
 13.2   services provided in the home that would be included in the 
 13.3   payment for care at the long-term hospital.  
 13.4   "Ventilator-dependent" means an individual who receives 
 13.5   mechanical ventilation for life support at least six hours per 
 13.6   day and is expected to be or has been dependent for at least 30 
 13.7   consecutive days.  
 13.8      (f) Prior authorization; time limits. +c The commissioner 
 13.9   or the commissioner's designee shall determine the time period 
 13.10  for which a prior authorization shall be effective. If the 
 13.11  recipient continues to require home care services beyond the 
 13.12  duration of the prior authorization, the home care provider must 
 13.13  request a new prior authorization.  Under no circumstances, 
 13.14  other than the exceptions in paragraph (b), shall a prior 
 13.15  authorization be valid prior to the date the commissioner 
 13.16  receives the request or for more than 12 months.  A recipient 
 13.17  who appeals a reduction in previously authorized home care 
 13.18  services may continue previously authorized services, other than 
 13.19  temporary services under paragraph (h), pending an appeal under 
 13.20  section 256.045.  The commissioner must provide a detailed 
 13.21  explanation of why the authorized services are reduced in amount 
 13.22  from those requested by the home care provider.  
 13.23     (g) Approval of home care services.  The commissioner or 
 13.24  the commissioner's designee shall determine the medical 
 13.25  necessity of home care services, the level of caregiver 
 13.26  according to subdivision 2, and the institutional comparison 
 13.27  according to this subdivision, the cost-effectiveness of 
 13.28  services, and the amount, scope, and duration of home care 
 13.29  services reimbursable by medical assistance, based on the 
 13.30  assessment, the care plan, the recipient's age, the cost of 
 13.31  services, the recipient's medical condition, and diagnosis or 
 13.32  disability.  The commissioner may publish additional criteria 
 13.33  for determining medical necessity according to section 256B.04. 
 13.34     (h) Prior authorization requests; temporary services. The 
 13.35  agency nurse, the independently enrolled private duty nurse, or 
 13.36  county public health nurse may request a temporary authorization 
 14.1   for home care services by telephone.  The commissioner may 
 14.2   approve a temporary level of home care services based on the 
 14.3   assessment and service or care plan information.  Authorization 
 14.4   for a temporary level of home care services including nurse 
 14.5   supervision is limited to the time specified by the 
 14.6   commissioner, but shall not exceed 45 days, unless extended 
 14.7   because the county public health nurse has not completed the 
 14.8   required assessment and service plan, or the commissioner's 
 14.9   determination has not been made.  The level of services 
 14.10  authorized under this provision shall have no bearing on a 
 14.11  future prior authorization. 
 14.12     (i) Prior authorization required in foster care setting.  
 14.13  Home care services provided in an adult or child foster care 
 14.14  setting must receive prior authorization by the department 
 14.15  according to the limits established in paragraph (a). 
 14.16     The commissioner may not authorize: 
 14.17     (1) home care services that are the responsibility of the 
 14.18  foster care provider under the terms of the foster care 
 14.19  placement agreement and administrative rules; 
 14.20     (2) personal care services when the foster care license 
 14.21  holder is also the personal care provider or personal care 
 14.22  assistant unless the recipient can direct the recipient's own 
 14.23  care, or case management is provided as required in section 
 14.24  256B.0625, subdivision 19a; 
 14.25     (3) personal care services when the responsible party is an 
 14.26  employee of, or under contract with, or has any direct or 
 14.27  indirect financial relationship with the personal care provider 
 14.28  or personal care assistant, unless case management is provided 
 14.29  as required in section 256B.0625, subdivision 19a; 
 14.30     (4) home care services when the number of foster care 
 14.31  residents is greater than four unless the county responsible for 
 14.32  the recipient's foster placement made the placement prior to 
 14.33  April 1, 1992, requests that home care services be provided, and 
 14.34  case management is provided as required in section 256B.0625, 
 14.35  subdivision 19a; or 
 14.36     ~~(3)~~ (5) home care services when combined with foster care 
 15.1   payments, other than room and board payments that exceed the 
 15.2   total amount that public funds would pay for the recipient's 
 15.3   care in a medical institution. 
 15.4      Sec. 5.  [EFFECTIVE DATE.] 
 15.5      Sections 1 to 4 are effective July 1, 1996.