Current through Register Vol. 49, No. 13, September 23, 2024
Subpart
1.
Required participation.
As a condition of participating in the other state health
care programs listed in part
9505.5210, subpart 14, a vendor
other than a health maintenance organization must:
A. participate as a provider in the
department health care programs; and
B. except as provided in subparts
3 and
4, accept on a continuous
basis new patients who are recipients, and use the same acceptance criteria
applied to new patients who are not recipients.
Subp. 2.
Exclusion from other state
health care programs.
A vendor that fails to comply with the requirements of this
part is excluded from participating in other state health care programs listed
in part
9505.5210, subpart 14, except as
provided in items A to C.
A. In
geographic areas where provider participation in department health care
programs is limited by department managed care contracts, a vendor that fails
to comply is not excluded from participating in insurance plans offered to
local government employees.
B. A
vendor who enrolls as a provider at the request of the department for the sole
purpose of ensuring continuity of care for recipients who are temporarily
ineligible for the vendor's health plan is not subject to the requirements of
this part unless the vendor provides health services on a fee for service basis
to patients not covered by department health care programs.
C. An independently owned physical therapy
agency or occupational therapy agency, other than a Medicare-certified
rehabilitation agency is not subject to the requirements of this part if:
(1) the agency is owned by at least one
physical therapist or occupational therapist who is individually
Medicare-certified and enrolled as a provider in the department health care
programs;
(2) the agency accepts
recipients on a continuous basis; and
(3) all health services provided recipients
are provided by a therapist who is individually Medicare-certified.
This item does not require an agency to provide services to
recipients that the agency does not provide other clients.
Subp. 3.
Limiting
acceptance of recipients; 20 percent threshold.
A provider may limit acceptance of new patients who are
recipients, only as provided in items A to D.
A. The provider, at least annually, shall
determine annual active patient caseload. Annual active patient caseload means:
(1) the total number of patient encounters
that result in a billing during the provider's most recent fiscal year;
or
(2) if enrolled as a provider
for less than a year, the total number of patient encounters that result in a
billing during the period between enrollment and the end of the provider's
fiscal year.
B. A
provider may include, in the determination, patient encounters from all service
sites enrolled under the provider's number but shall count only one patient
encounter per patient per day regardless of the number of service sites
involved in the patient's health care. A provider may count recipients
receiving health services on a fee-for-service basis and under a prepaid
contract.
C. If at least 20 percent
of the provider's annual active patient case load are and continue to be
recipients, the provider may refuse to accept new patients who are recipients
for the remainder of the provider's fiscal year.
D. The provider shall notify the department
in writing at least ten days before limiting acceptance of new patients who are
recipients. The notice must include the active patient caseload data upon which
the provider relied in calculating the percentage of patients who are
recipients. The provider shall provide any other information required by the
commissioner to verify compliance with parts
9505.5200 to
9505.5240.
Subp. 4.
Waiver.
A vendor may request a waiver from the participation
requirements of this part in writing from the commissioner. The commissioner
shall grant a waiver for up to one year and shall include the vendor on the
list of participating providers in part
9505.5240 if:
A. the vendor is a provider who is not
accepting new patients, regardless of payer source; or
B. the vendor is ineligible to enroll as a
provider in the department health care programs because the vendor does not
provide a covered health service.
Statutory Authority: MS s
256B.0644
