Minnesota Administrative Rules
Agency 196 - Human Services Department
Chapter 9500 - ASSISTANCE PAYMENTS PROGRAMS
ADMINISTRATION OF THE PREPAID MEDICAL ASSISTANCE PROGRAM
Part 9500.1451 - DEFINITIONS

Subpart 1. Scope.

For the purposes of parts 9500.1450 to 9500.1464, the following terms have the meanings given them in this part.

Subp. 2. [Repealed, 16 SR 1086]

Subp. 2a. Appeal.

"Appeal" means an enrollee's written request for a hearing, filed with the commissioner according to Minnesota Statutes, section 256.045, related to the delivery of health services or participation in a health plan.

Subp. 2b. Authorization.

"Authorization" means a participating provider's written referral for health services provided by a nonparticipating provider. Authorization includes an admission request by a participating provider, on behalf of a PMAP enrollee, following the established health plan admission procedures for inpatient health services.

Subp. 2c. Authorized representative.

"Authorized representative" means a person authorized in writing by a PMAP consumer to act on the PMAP consumer's behalf in matters involving the prepaid medical assistance program.

Subp. 3. [Repealed, 16 SR 1086]

Subp. 4. Capitation.

"Capitation" means a method of payment for health services that involves a monthly per person rate paid on a prospective basis to a health plan.

Subp. 4a. Case management.

"Case management" means a method of providing health care in which the health plan coordinates the provision of health services to an enrollee.

Subp. 4b. Commissioner.

"Commissioner" means the commissioner of the Minnesota Department of Human Services or the commissioner's designated representative.

Subp. 4c. Complaint.

"Complaint" means an enrollee's written or oral communication to a health plan expressing dissatisfaction with the provision of health services. The subject of the complaint may include, but is not limited to, the scope of covered services, quality of care, or administrative operations.

Subp. 5. [Repealed, 16 SR 1086]

Subp. 6. Department.

"Department" means the Department of Human Services.

Subp. 7. Enrollee.

"Enrollee" means a PMAP consumer who is enrolled in a health plan.

Subp. 7a. Health plan.

"Health plan" means an organization contracting with the state to provide medical assistance health services to enrollees in exchange for a monthly capitation payment.

Subp. 8. Health services.

"Health services" means the services and supplies given to a recipient by a provider for a health related purpose under Minnesota Statutes, section 256B.0625.

Subp. 9. Insolvency.

"Insolvency" means the condition in which a health plan is financially unable to meet the financial and health care service delivery obligations in the contract between the department and the health plan.

Subp. 10. Local agency.

"Local agency" means a county or multicounty agency that is authorized under Minnesota Statutes, sections 393.01, subdivision 7, and 393.07, subdivision 2, as the agency responsible for determining recipient eligibility for the medical assistance program.

Subp. 11. [Repealed, 16 SR 1086]

Subp. 12. [Repealed, 16 SR 1086]

Subp. 13. Medical assistance or MA.

"Medical assistance" or "MA" means the program established under title XIX of the Social Security Act and Minnesota Statutes, chapter 256B.

Subp. 14. Medical assistance population or MA population.

"Medical assistance population" or "MA population" means a category of eligibility for the medical assistance program, the eligibility standards for which are in parts 9505.0010 to 9505.0150 and Minnesota Statutes, section 256B.055.

Subp. 14a. Multiple health plan model.

"Multiple health plan model" means a health services delivery system that allows PMAP consumers to enroll in one of two or more health plans.

Subp. 14b. Nonparticipating provider.

"Nonparticipating provider" means a provider who is not employed by or under contract with a health plan to provide health services.

Subp. 14c. Ombudsperson.

"Ombudsperson" means an individual designated by the commissioner under Minnesota Statutes, section 256B.031, subdivision 6, to advocate for PMAP consumers and enrollees and to assist them in obtaining necessary health services.

Subp. 14d. Open enrollment.

"Open enrollment" means the annual 30-day period during which PMAP enrollees in a multiple health plan model may change to another health plan.

Subp. 14e. Participating provider.

"Participating provider" means a provider who is employed by or under contract with a health plan to provide health services.

Subp. 14f. Personal care assistant.

"Personal care assistant" means a provider of personal care services prescribed by a physician, supervised by a registered nurse, and provided to a medical assistance recipient under Minnesota Statutes, section 256B.0659. A personal care assistant must not be the recipient's spouse, legal guardian, or parent if the recipient is a minor child.

Subp. 14g. Personal care services.

"Personal care services" has the meaning given it in Minnesota Statutes, section 256B.0655, subdivision 2.

Subp. 14h. Prepaid medical assistance program or PMAP.

"Prepaid medical assistance program" or "PMAP" means the prepaid medical assistance program authorized under Minnesota Statutes, section 256B.69.

Subp. 14i. PMAP consumer.

"PMAP consumer" means a medical assistance recipient who is selected to participate in PMAP.

Subp. 14j. Prepayment coordinator.

"Prepayment coordinator" means the individual designated by the local agency under Minnesota Statutes, section 256B.031, subdivision 9.

Subp. 14k. Primary care provider health plan model.

"Primary care provider health plan model" means a health services delivery system that allows PMAP consumers to select a primary care physician and primary care dentist from a list of physicians and dentists under contract with the state or a county to provide health services to PMAP consumers.

Subp. 15. Provider.

"Provider" means a person or entity providing health services.

Subp. 16. Rate cell.

"Rate cell" means a grouping of recipients by demographic characteristics, established by the commissioner for use in determining capitation rates. The following are deemed to be demographic characteristics: a recipient's age, sex, medicare status, basis of medical assistance eligibility, county of residence, and residence in a long-term care facility.

Subp. 16a. Rate cell year.

"Rate cell year" means the period beginning on the date of enrollment in the health plan and ending on the date of the annual eligibility review or the date of enrollment in a new plan, whichever occurs sooner, and thereafter the 12-month period between eligibility reviews during which an enrollee's rate cell assignment is fixed.

Subp. 17. Recipient.

"Recipient" means a person who has been determined by the local agency to be eligible for the medical assistance program.

Subp. 17a. Spenddown.

"Spenddown" means the process by which a person who has income in excess of the medical assistance income standard becomes eligible for medical assistance by incurring health services expenses, other than nursing home facility per diem charges, that are not covered by a liable third party and that reduce the excess income to zero.

Subp. 17b. State institution.

"State institution" means all regional treatment centers as defined in Minnesota Statutes, section 245.0312, and all state operated facilities as defined in Minnesota Statutes, section 252.50.

Subp. 18. [Repealed, 16 SR 1086]